本文選題：心肌梗死 + 發(fā)病至首次醫(yī)療接觸��； 參考：《安徽醫(yī)科大學(xué)》2017年碩士論文

【摘要】：背景急性ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)起病急,并發(fā)癥發(fā)生率及病死率高。研究表明缺血時(shí)間與STEMI患者預(yù)后強(qiáng)相關(guān),STEMI患者總?cè)毖獣r(shí)間每延長(zhǎng)30分鐘,其1年病死率增加7.5%[1]。再灌注時(shí)間是衡量急性心肌梗死尤其是STEMI早期救治能力和水平的主要指標(biāo)。而這一時(shí)間包括了多個(gè)時(shí)間段,即患者發(fā)病至首次醫(yī)療接觸、首次醫(yī)療接觸至入門就診、入門就診至首次球囊擴(kuò)張等。20余年來(lái)國(guó)外研究提出了很多救治時(shí)間點(diǎn),比如“胸痛至球囊擴(kuò)張(pain-to-balloon)時(shí)間、入門至球囊擴(kuò)張(door-to-balloon,D2B/DTB)時(shí)間、首次醫(yī)療接觸至球囊擴(kuò)張(first medical contact-to-balloon,FMC-to-B)時(shí)間、發(fā)病至首次醫(yī)療接觸(Symptom Onset-to-First Medical Contact,SO-to-FMC)時(shí)間、發(fā)病至首次球囊擴(kuò)張(Symptom Onset-to-balloon,SO-to-B/S2B/STB)時(shí)間”等(見(jiàn)圖1)。多年來(lái)國(guó)內(nèi)外研究者就這些時(shí)間段與生存率進(jìn)行了大量研究,證明這些救治時(shí)間點(diǎn)可影響STEMI患者的治療和臨床預(yù)后,目前較為推薦認(rèn)可的是歐美指南提出的D2B和FMC-to-B這兩大時(shí)間段。然而,目前針對(duì)STEMI患者的研究中,國(guó)內(nèi)外一致將目光聚焦在患者FMC以后的急救工作上,極少關(guān)注STEMI患者從發(fā)病至首次醫(yī)療接觸(SO-to-FMC)時(shí)間在整個(gè)急救體系中的意義。目的本研究探討STEMI患者發(fā)病至首次醫(yī)療接觸(SO-to-FMC)時(shí)間對(duì)各救治時(shí)間及預(yù)后的影響。方法回顧性研究2011年8月至2016年4月連續(xù)在我院急診并符合入選標(biāo)準(zhǔn)的STEMI患者341例,根據(jù)SO-to-FMC時(shí)間分為≤90 min組(201例)和90 min組(140例),記錄并分析主要救治時(shí)間,統(tǒng)計(jì)患者住院期間心肌損傷相關(guān)生物標(biāo)志物、心肌組織灌注情況,定期隨訪心臟超聲,并通過(guò)門診、再住院以及電話等方式進(jìn)行隨訪,統(tǒng)計(jì)其住院及隨訪期間的病死率、主要不良心腦血管事件(major adverse cardiac and cerebro-vascular events,MACCE)發(fā)生率。采用二分類Logistic回歸模型分析術(shù)后1年病死率及出院后1年MACCE發(fā)生率的影響因素,并采用Cox比例風(fēng)險(xiǎn)回歸模型分析PCI術(shù)后4.5年累計(jì)病死率及出院后4.5年無(wú)MACCE生存率的預(yù)測(cè)因素。結(jié)果1.SO-to-FMC時(shí)間≤90 min組患者的D2B時(shí)間[104(88,125)比111(92,144)min,P=0.023]、FMC-to-B時(shí)間[146(119,197)比177(125,237)min,P=0.005]、S2B時(shí)間[200(170,257)比338(270,474)min,P0.001]均短于SO-to-FMC時(shí)間90min組。2.SO-to-FMC時(shí)間≤90 min組患者術(shù)后30天病死率[2.99%(6/201)比7.86%(11/140),P=0.042]、1年病死率[2.89(5/173)比9.57(11/115),P=0.015]、4.5年累計(jì)病死率(3.00%比11.20%,P=0.007)及出院后1年MACCE發(fā)生率[1.16%(2/173)比6.96%(8/115),P=0.021]均低于SO-to-FMC時(shí)間90 min組,出院后4.5年無(wú)MACCE生存率高于SO-to-FMC時(shí)間90 min組(97.20%比88.80%,P=0.025);兩組之間的院內(nèi)病死率差異無(wú)統(tǒng)計(jì)學(xué)意義[2.49%(5/201)比6.43%(9/140),P=0.071];二分類Logistic回歸分析顯示SO-to-FMC時(shí)間90min是患者術(shù)后1年病死率及出院后1年MACCE發(fā)生率的獨(dú)立危險(xiǎn)因素(OR 2.90,95%CI 1.22~6.92,P=0.016;OR 5.19,95%CI 1.21~22.20,P=0.026);多因素COX回歸分析顯示SO-to-FMC時(shí)間90min是患者4.5年累計(jì)病死率的獨(dú)立危險(xiǎn)因素(HR 2.88,95%CI 1.10~7.53,P=0.031)。3.單因素分析顯示,SO-to-FMC時(shí)間≤90min組患者CTFC值低于90min組[18(13,27)比23(16,33.5),P0.05],CTFC≤28達(dá)標(biāo)率及MBG≥2級(jí)達(dá)標(biāo)率均高于90min組[79.39(131/166)比63.64(77/121),P0.05;67.76(68/166)比46.78(81/121),P0.001],兩組間killip≥Ⅱ級(jí)率及STR差異并無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。二分類Logistic回歸分析結(jié)果顯示,校正基線資料等混雜因素后,SO-to-FMC時(shí)間90min是STEMI患者CTFC28和killip≥Ⅱ級(jí)率的獨(dú)立危險(xiǎn)因素(OR 2.29,95%CI 1.33-3.93,P=0.003;OR=2.03,95%CI 1.08-3.82,P=0.029),然而SO-to-FMC時(shí)間90min并非MBG 0/1級(jí)的獨(dú)立危險(xiǎn)因素(OR 2.07,95%CI0.88-4.89,P=0.098)。結(jié)論1.SO-to-FMC時(shí)間越短,其相應(yīng)D2B時(shí)間、FMC-to-B時(shí)間及S2B時(shí)間越短。2.SO-to-FMC時(shí)間≤90min可有效減少患者心肌組織灌注不良發(fā)生率,改善其心功能。3.SO-to-FMC時(shí)間≤90min可降低患者近遠(yuǎn)期病死率及出院后MACCE發(fā)生率。
[Abstract]:Background acute ST segment elevation myocardial infarction (ST-segment elevation myocardial infarction, STEMI) has an acute onset, a high incidence of complications and high mortality. The study showed that the ischemic time was strongly associated with the prognosis of STEMI patients. The total ischemic time of STEMI patients was prolonged by 30 minutes, and the 1 year fatality rate increased in 7.5%[1]. and reperfusion time was a measure of acute myocardial infarction. Death is especially the main indicator of the ability and level of early treatment of STEMI, which includes multiple time periods, namely, the onset of the first medical contact, the first medical contact to the entrance examination, the first medical treatment to the first balloon dilatation, and the other.20 years for the rest of the year, for example, "chest pain to balloon dilatation (pain-t)" O-balloon) time, entry to balloon dilatation (door-to-balloon, D2B/DTB) time, first medical contact to balloon dilatation (first medical contact-to-balloon, FMC-to-B) time, onset to first medical contact (Symptom Onset-to-First Medical Contact, SO-to-FMC) time, onset to the first balloon dilatation 2B/STB) time "et al. (see Figure 1). Over the years, researchers at home and abroad have conducted a large number of studies on these periods and survival rates, proving that these treatment time points can affect the treatment and clinical prognosis of STEMI patients. At present, it is recommended that the two periods of time, D2B and FMC-to-B, proposed by the European and American guidelines. However, at present, the STEMI patients are present. In the study, the first aid work after the patient's FMC was focused both at home and abroad, and little attention was paid to the significance of the time of STEMI patients from onset to first medical contact (SO-to-FMC) in the whole emergency system. The purpose of this study was to explore the effect of the onset of the onset of STEMI patients to the first medical contact (SO-to-FMC) on the treatment time and prognosis. A retrospective study was made to retrospective study 341 cases of STEMI patients in our hospital from August 2011 to April 2016. They were divided into 90 min groups (201 cases) and 90 min group (140 cases) according to SO-to-FMC time. The main treatment time was recorded and analyzed. Follow up echocardiography was followed up in outpatients, rehospitalization and telephone, and the mortality rate during hospitalization and follow-up, the incidence of major adverse cardiac and cerebrovascular events (major adverse cardiac and cerebro-vascular events, MACCE). The two classification Logistic regression model was used to analyze the mortality rate of 1 years after the operation and 1 year after discharge. The influencing factors of the incidence and the Cox proportional risk regression model were used to analyze the cumulative morbidity of 4.5 years after PCI and the predictive factors for no MACCE survival after 4.5 years after discharge. Results the D2B time of the patients with 1.SO-to-FMC time less than 90 min was [104 (88125), 111 (92144) min, P=0.023], FMC-to-B time [146 (119197) than 177 (125237) min. Time [200 (170257) was more than 338 (270474) min, P0.001] was shorter than SO-to-FMC time 90min group.2.SO-to-FMC time < 90 min > 30 days' mortality [2.99% (6/201) ratio 7.86% (11/140), P=0.042], 1 year fatality ratio 9.57 (3%), 4.5 years' cumulative mortality (3% / 11.20%,) and 1 years after discharge. .16% (2/173) ratio 6.96% (8/115), P=0.021] were lower than SO-to-FMC time 90 min group, 4.5 years after discharge, no MACCE survival rate was higher than SO-to-FMC time 90 min group (97.20% ratio 88.80%, P=0.025); the difference of hospital mortality between two groups was not statistically significant [2.49% (5/201) ratio 6.43% 90min was an independent risk factor (OR 2.90,95%CI 1.22~6.92, P=0.016; OR 5.19,95%CI 1.21~22.20, P=0.026) at 1 years postoperatively and 1 years after discharge (OR 5.19,95%CI 1.21~22.20, P=0.026). Multiple factor COX regression analysis showed that SO-to-FMC time was an independent risk factor for patients with 4.5 years' cumulative mortality. The analysis showed that the CTFC value of the patients with SO-to-FMC time less than 90min was lower than that of group 90min [18 (13,27) 23 (16,33.5), P0.05], CTFC < 28, and MBG > 2 level were higher than that of 90min group [79.39 (46.78), 67.76 (46.78), two groups had no statistical significance. Two classified Logistic regression analysis showed that SO-to-FMC time 90min was an independent risk factor for STEMI patients (OR 2.29,95%CI 1.33-3.93, P=0.003; OR=2.03,95%CI 1.08-3.82) after correction of baseline data and other confounding factors (OR 2.29,95%CI 1.33-3.93, P=0.003; OR=2.03,95%CI 1.08-3.82). 95%CI0.88-4.89, P=0.098). Conclusion the shorter the time of 1.SO-to-FMC, the corresponding D2B time, FMC-to-B time and the shorter S2B time,.2.SO-to-FMC time less than 90min can effectively reduce the incidence of poor myocardial perfusion, and improve the cardiac function.3.SO-to-FMC time less than 90min can reduce the mortality in the near and long term and the MACCE incidence after discharge.

【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R542.22

【參考文獻(xiàn)】

相關(guān)期刊論文 前10條

1 陳偉偉;高潤(rùn)霖;劉力生;朱曼璐;王文;王擁軍;吳兆蘇;李惠君;顧東風(fēng);楊躍進(jìn);鄭哲;蔣立新;胡盛壽;;《中國(guó)心血管病報(bào)告2015》概要[J];中國(guó)循環(huán)雜志;2016年06期

2 魏騰飛;趙蓓;王守力;;急性心肌梗死救治時(shí)間節(jié)點(diǎn)研究進(jìn)展[J];臨床軍醫(yī)雜志;2016年05期

3 伏蕊;楊躍進(jìn);竇克非;楊進(jìn)剛;高曉津;許海燕;吳元;李衛(wèi);王楊;賈艷玲;金辰;;中國(guó)不同年齡段急性心肌梗死患者臨床癥狀和誘發(fā)因素的差異分析[J];中華心血管病雜志;2016年04期

4 ;急性ST段抬高型心肌梗死診斷和治療指南[J];中華心血管病雜志;2015年05期

5 韓雅玲;王海昌;陳韻岱;黃嵐;丁世芳;吳宗貴;祝之明;向定成;姜鐵民;趙仙先;楊麗霞;王冬梅;劉惠亮;宋治遠(yuǎn);曹雪濱;荊全民;李毅;柏書軼;徐凱;;急性ST段抬高心肌梗死患者院內(nèi)死亡發(fā)生率的相關(guān)因素分析:冠心病介入治療數(shù)據(jù)庫(kù)資料[J];解放軍醫(yī)學(xué)雜志;2015年04期

6 王守力;趙蓓;劉佩林;馮雪瑤;劉莉;趙京濤;劉利峰;劉瑛琪;宋洪勇;毛帥;周莉;夏會(huì)會(huì);;急性ST段抬高型心�；颊咧苯庸跔顒�(dòng)脈介入救治時(shí)間布局分析[J];解放軍醫(yī)學(xué)雜志;2015年03期

7 劉佩林;劉莉;趙京濤;宋洪勇;趙蓓;馮雪瑤;劉利峰;劉瑛琪;毛帥;周莉;夏會(huì)會(huì);高鐵山;王守力;;發(fā)病至首次醫(yī)療接觸時(shí)間對(duì)急性ST段抬高型心肌梗死患者進(jìn)門至球囊擴(kuò)張時(shí)間的影響研究[J];中國(guó)實(shí)用內(nèi)科雜志;2014年11期

8 秦偉毅;錢洪津;周偉梁;盧勇;曾凡杰;彭雄;段天兵;;胸痛中心對(duì)ST段抬高型心肌梗死急診介入治療的影響[J];中國(guó)老年學(xué)雜志;2013年15期

9 向定成;段天兵;秦偉毅;羅望勝;張金霞;易紹東;阮云軍;肖華;;建立規(guī)范化胸痛中心對(duì)直接經(jīng)皮冠狀動(dòng)脈介入治療患者進(jìn)門-球囊擴(kuò)張時(shí)間及預(yù)后的影響[J];中華心血管病雜志;2013年07期

10 ;NT-proBNP臨床應(yīng)用中國(guó)專家共識(shí)[J];中國(guó)心血管病研究雜志;2011年06期

，

本文編號(hào)：1886942