發(fā)布時間：2018-09-09 10:01

【摘要】：目的:了解大連地區(qū)急性ST段抬高型心肌梗死患者的發(fā)病特點、直接經(jīng)皮冠狀動脈介入術(shù)(PCI)治療現(xiàn)狀、住院期間主要不良事件及預(yù)后情況,為大連地區(qū)優(yōu)化STEMI救治提供理論依據(jù)。方法:前瞻性分析2015年10月1日至2016年10月30日在大連市6家醫(yī)院收治的、發(fā)病后行直接PCI并住院的902例STEMI患者。醫(yī)院:選擇大連市首診STEMI能行直接PCI中的6家醫(yī)院(其中1家二甲醫(yī)院和5家三甲醫(yī)院)。收集并記錄研究對象的臨床基線資料、冠脈造影結(jié)果、PCI冠脈開通策略、藥物輔助治療情況及住院期間主要不良事件及預(yù)后情況。住院期間不良事件包括:住院期間的死亡(包括心源性和非心源性死亡)及MACE事件(住院期間的死亡、非致死性再發(fā)心肌梗死、新發(fā)腦卒中、出血事件)。結(jié)果:1.STEMI直接PCI患者入院基線資料:共連續(xù)入選902例STEMI患者,平均年齡(62.4± 12.5歲),其中男性715例(79.3%)、女性187例(20.1%)。冠心病危險因素,其中合并高血壓51.6%、糖尿病27.7%、高脂血癥26.5%、吸煙52.2%。發(fā)病后91.4%主要表現(xiàn)為胸悶、胸痛,其它癥狀(呼吸困難、暈厥、上腹不適)占8.6%。發(fā)病后呼叫120救護車比例為47.5%,選擇出租車或其他方式來院占52.5%。中位"癥狀入門時間"為3.5(2-6)h。2.STEMI直接PCI患者手術(shù)情況:直接PCI前口服抗血小板藥物負荷量阿司匹林99.0%、氯吡格雷/替格瑞洛98.7%。直接PCI時經(jīng)橈動脈路徑791例(87.7%)、經(jīng)股動脈111例(12.3%),應(yīng)用血栓抽吸導(dǎo)管288例(31.9%),應(yīng)用IABP 12例(1.3%)。術(shù)中抗凝藥物比伐盧定580例(64.3%)、普通肝素鈉322例(35.7%);應(yīng)用GPⅡb/Ⅲa受體拮抗劑458例(50.8%)。直接PCI術(shù)中98.5%患者植入支架,中位"入門球囊擴張時間" 76.50(60.00-90.00)min,造影劑用量150.0±48.1ml。梗死相關(guān)動脈前降支占44.2%、右冠狀動脈占41.6%、回旋支13.0%、左主干1.2%。住院期間平均植入支架1.41 ±0.67個,平均支架長度29(21-43)mm。STEMI合并冠脈多支病變494/902(54.8%),多支病變直接PCI治療時血運重建策略:①僅干預(yù)罪犯血管:421例(85.2%)選擇Culprit-only PCI;②完全血運重建:73例(14.8%),其中35例(7.1%)選擇Single-setting PCI,38例(7.7%)選擇Staged PCI。對于STEMI患者住院期間完全血運重建平均植入支架2.51 ±0.80個、支架平均長度62.76±24.89mm。3.STEMI直接PCI患者住院期間用藥及平均住院日:住院期間藥物使用情況:阿司匹林98.1%、氯吡格雷/替格瑞洛99.2%、他汀97.8%、β受體阻滯劑70.1%、ACEI/ARB68.5%、CCB 類 9.8%。平均住院日 7±3 天。4.STEMI患者直接PCI術(shù)后住院期間不良事件:住院期間病死率為4.2%(38例),再發(fā)心肌梗死0.4%(4例)、新發(fā)腦卒中0.9%(8例)、出血事件1.0(9例),MACE事件5.3%(51例)。多因素Binary Logistic回歸分析顯示年齡(OR=1.069,95%CI:1.036～1.114,P0.01),既往腦卒中病史(OR=3.014,95%CI:1.331～6.824,P0.01)為STEMI直接PCI患者住院期間死亡獨立危險因素。同時在校正其他因素后年齡(OR=1.062,95%CI:1.033～1.091,P0.01),既往腦卒中病史(OR=3.105,95%CI:1.512～6.378,P0.01)仍是 STEMI 直接PCI患者住院期間MACE的獨立危險因素。結(jié)論:大連地區(qū)STEMI患者發(fā)病后仍有較高的院前延遲,男性STEMI直接PCI比例、心血管疾病危險因素遠高于女性,直接PCI早期再灌注治療以及住院期間藥物治療與目前指南仍有差距,STEMI直接PCI患者住院期間病死率低于國內(nèi)相關(guān)研究。通過本次研究,初步了解了大連地區(qū)STEMI患者行直接PCI治療的現(xiàn)狀和住院病死率的相關(guān)危險因素。年齡、既往腦卒中病史是STEMI直接PCI患者住院期間MACE的獨立危險因素。
[Abstract]:Objective: To investigate the characteristics of acute ST-segment elevation myocardial infarction (STEMI) in Dalian, the current status of direct percutaneous coronary intervention (PCI), major adverse events and prognosis during hospitalization, and to provide theoretical basis for optimizing the treatment of STEMI in Dalian. Ninety-two STEMI patients received direct PCI and were hospitalized after the onset of the disease. Hospitals: Six hospitals (one second-grade hospital and five third-class hospitals) in Dalian were selected for the first time to undergo direct PCI. Clinical baseline data, coronary angiography results, PCI coronary artery patency strategy, drug-assisted therapy and residence were collected and recorded. Main adverse events and prognosis during hospitalization. Adverse events during hospitalization included death during hospitalization (including cardiogenic and non-cardiogenic deaths) and MACE events (death during hospitalization, non-fatal recurrent myocardial infarction, new stroke, hemorrhagic events). Results: 1. Baseline admission data of STEMI patients with direct PCI: 902 consecutive patients were enrolled. The average age of STEMI patients was 62.4 (+ 12.5 years), 715 males (79.3%) and 187 females (20.1%). The risk factors of coronary heart disease were hypertension 51.6%, diabetes 27.7%, hyperlipidemia 26.5%, smoking 52.2%. 91.4% of the patients were mainly manifested as chest tightness, chest pain, and other symptoms (dyspnea, syncope, epigastric discomfort) 8.6%. The median "symptom entry time" was 3.5 (2-6) h.2. STEMI for direct PCI: oral antiplatelet drug loading aspirin 99.0%, clopidogrel / tigrilol 98.7% before direct PCI; radial route 791 (87.7%) during direct PCI; femoral artery 111 (12.7%). Among them, 288 (31.9%) were treated with thrombus aspiration catheter, 12 (1.3%) with IABP, 580 (64.3%) with bivalirudin, 322 (35.7%) with heparin sodium, 458 (50.8%) with GP II b/III a receptor antagonist, 98.5% with stent implantation during direct PCI, and the median "entry balloon dilation time" of 76.50 (60.00-90.00) minutes with contrast agent dosage of 150.0%. 44.2% of the patients had anterior descending branch of infarction-related artery, 41.6% of the right coronary artery, 13.0% of the circumflex coronary artery and 1.2% of the left main coronary artery. Culprit-only PCI was selected in 5.2%. Complete revascularization was performed in 73 patients (14.8%). Single-set PCI was used in 35 patients (7.1%) and Staged PCI was used in 38 patients (7.7%). Hospital Days: Drug Use: Aspirin 98.1%, Clopidogrel / Tigrilol 99.2%, Statin 97.8%, Beta-blockers 70.1%, ACEI / ARB 68.5%, CCB class 9.8%. Average length of stay: Adverse events after direct PCI in STEMI patients: In-hospital mortality was 4.2% (38 cases), recurrent myocardial infarction 0.4% (4 cases), new onset Multivariate Binary Logistic regression analysis showed that age (OR = 1.069, 95% CI: 1.036-1.114, P 0.01) and previous stroke history (OR = 3.014, 95% CI: 1.331-6.824, P 0.01) were independent risk factors for death in STEMI patients with direct PCI. Age (OR = 1.062, 95% CI: 1.033-1.091, P 0.01) and previous stroke history (OR = 3.105, 95% CI: 1.512-6.378, P 0.01) were still independent risk factors for MACE in STEMI patients during hospitalization. The mortality of STEMI patients during hospitalization was lower than that of domestic related studies. Through this study, we preliminarily understood the current status of direct PCI in Dalian area and the related risk factors of hospitalization mortality. Intermediate history is an independent risk factor for MACE in patients with STEMI direct PCI.
【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R542.22

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