本文選題：急救綠色通道 + 急性ST段抬高型心肌梗死�。� 參考：《蘇州大學(xué)》2015年博士論文

【摘要】：第一部分:特色的優(yōu)化的始自院前急救綠色通道對(duì)ST段抬高型心肌梗死搶救流程時(shí)間參數(shù)以及急診冠脈介入治療預(yù)后的影響目的:比較傳統(tǒng)通道、綠色通道、優(yōu)化的綠色通道這3種臨床途徑行直接經(jīng)皮冠狀動(dòng)脈介入(PCI)治療對(duì)急性ST段抬氋型心肌梗死(STEMI)患者搶救流程時(shí)間參數(shù)以及急診PCI治療預(yù)后的影響,驗(yàn)證本中心以派駐�？漆t(yī)生隨診120、自制的心梗搶救包等一系列措施為特色的優(yōu)化的綠色通道模式在STEMI救治中的優(yōu)勢(shì)。方法:入選由救護(hù)車送入,發(fā)病12 h之內(nèi)接受直接PCI的STEMI患者180例,分為傳統(tǒng)通道組(由120急救系統(tǒng)→急診室→CCU病房→導(dǎo)管室)45例、綠色通道組(120急救系統(tǒng)→急診室→導(dǎo)管室)62例、優(yōu)化的綠色通道組73例(簡(jiǎn)稱優(yōu)化通道組,在綠色通道基礎(chǔ)上進(jìn)一步優(yōu)化,包括120救護(hù)車上由本中心派駐的隨診�？漆t(yī)生完成首份心電圖→通過遠(yuǎn)程系統(tǒng)傳輸心電圖和病人信息至急診大廳→急診內(nèi)科醫(yī)生接到信息→通知心內(nèi)科值班醫(yī)生(攜帶心梗搶救包)等待病人→通知PCI團(tuán)隊(duì);或者120救護(hù)車隨診專科醫(yī)生完成首份心電圖→通過遠(yuǎn)程系統(tǒng)傳輸心電圖和病人信息至急診大廳(同時(shí)通知PCI團(tuán)隊(duì))→急診內(nèi)科醫(yī)生接到信息→通知心內(nèi)科值班醫(yī)生(攜帶心梗搶救包)等待病人),主要的研究指標(biāo)為首次醫(yī)療接觸至球囊擴(kuò)張(FMC2B)時(shí)間、首次醫(yī)療接觸至抗血小板治療(FMC2A)時(shí)間、首次醫(yī)療接觸至簽署介入治療同意書(FMC2S)時(shí)間、就診至球囊擴(kuò)張(D2B)時(shí)間、住院期間再次非致命性心梗、腦血管意外、心力衰竭發(fā)生、全因和心源性死亡及隨訪期間主要心血管事件發(fā)生率,比較三組無事件生存率,Logistic回歸分析測(cè)定影響STEMI患者PCI術(shù)后住院和1年隨訪期間臨床預(yù)后的相關(guān)因素。結(jié)果:1.三組患者基線特征無顯著性差異(均P0.05)。FMC2B時(shí)間、FMC2A時(shí)間、FMC2S時(shí)間、D2B時(shí)間在傳統(tǒng)通道組、綠色通道組、優(yōu)化通道組依次縮短(除傳統(tǒng)通道組與綠色通道組FMC2A時(shí)間、傳統(tǒng)通道組與綠色通道組FMC2S時(shí)間比較外,均P0.05);首次醫(yī)療接觸120min內(nèi)完成球囊擴(kuò)張的比例及D2B90 min的比例在傳統(tǒng)通道組、綠色通道組、優(yōu)化通道組依次增加(均P0.05)。2.三組住院期間再次非致命性心梗、腦血管意外、心力衰竭發(fā)生無顯著差異(均P0.05),綠色通道組、優(yōu)化通道組住院期間心血管疾病死亡及各種原因死亡率較傳統(tǒng)通道組低(均P0.05),優(yōu)化通道組住院期間心血管疾病死亡及各種原因死亡率較綠色通道組低,但無顯著性差異(均P0.05);隨訪期間三組患者心絞痛復(fù)發(fā)率、再次非致命性心梗、靶血管再次的血管化、嚴(yán)重心律失常的發(fā)生均無差異(P0.05),但綠色通道組、優(yōu)化通道組心力衰竭、再次因心源性疾病入院、全因死亡及心源性死亡率均明顯低于傳統(tǒng)通道組(P0.05)。3.通過對(duì)三組心血管事件相關(guān)危險(xiǎn)因素的回歸分析,發(fā)現(xiàn)年齡(P=0.025)、吸煙(P=0.013)、糖尿病(P=0.031)、雙支病變(P=0.007)、三支病變(P=0.011)、FMC2B時(shí)間(P=0.034)、FMC2A時(shí)間(P=0.028),FMC2S時(shí)間(P=0.046),D2B時(shí)間(P=0.025)是心血管相關(guān)事件發(fā)生的危險(xiǎn)因素,并進(jìn)一步得出FMC2B時(shí)間、FMC2A時(shí)間、FMC2S時(shí)間、D2B時(shí)間、年齡是PCI后心血管相關(guān)事件發(fā)生的獨(dú)立危險(xiǎn)因素。結(jié)論:本中心以派駐�？漆t(yī)生隨診120、自制的心梗搶救包等一系列措施為特色的優(yōu)化的綠色通道模式可顯著縮短首次醫(yī)療接觸至球囊擴(kuò)張時(shí)間、首次醫(yī)療接觸至抗血小板治療時(shí)間、首次醫(yī)療接觸至簽署介入治療同意書時(shí)間、就診至球囊擴(kuò)張時(shí)間,并改善急診PCI術(shù)后住院和1年隨訪期間的臨床預(yù)后。第二部分:急性ST段抬高型心肌梗死急診PCI后非梗死相關(guān)血管不同治療策略對(duì)血炎癥因子、主要心血管事件的影響目的:急性ST段抬高型心肌梗死(STEMI)多支血管病變急診經(jīng)皮冠脈介入(PCI)治療后非梗死相關(guān)血管采用標(biāo)準(zhǔn)藥物或標(biāo)準(zhǔn)藥物+PCI治療后1年主要心血管事件發(fā)生率、血炎癥因子(hs CRP、s CD40L、IL-6、TNF-a)變化以及冠脈造影結(jié)果的比較。方法:入選2011年6月至2014年6月接受急診PCI的131例STEMI多支病變患者,根據(jù)對(duì)非梗死相關(guān)血管是否再次PCI治療將患者分為兩組,其中藥物+PCI治療組51例(占39%),藥物治療組80例(占61%)。隨訪兩組1年的臨床終點(diǎn)事件,術(shù)后一年復(fù)查冠脈造影,再次檢測(cè)入選患者血中炎癥因子(hs CRP、s CD40L、IL-6、TNF-α)水平。結(jié)果:1.兩組患者性別、年齡、病因構(gòu)成比、冠心病易患因素、冠心病家族史、心功能分級(jí)、肝腎功能指標(biāo)、治療用藥、癥狀發(fā)作至球囊擴(kuò)張時(shí)間、就診至球囊擴(kuò)張時(shí)間等在內(nèi)的兩組的基線特征以及急診冠脈造影及直接PCI的相關(guān)數(shù)據(jù)均無顯著差異(P0.05)。2.PCI組患者遠(yuǎn)期(3-12月)心絞痛復(fù)發(fā)率、再次因心源性疾病入院率均明顯低于藥物治療組(P0.05)。兩組心力衰竭、再發(fā)心梗、再次血運(yùn)重建、嚴(yán)重心律失常的發(fā)生、全因死亡及心源性死亡率等均無差異(P0.05)。3.兩亞組梗死相關(guān)血管支架內(nèi)血栓發(fā)生率及支架內(nèi)再狹窄發(fā)生率無顯著性差異(P0.05),非梗死相關(guān)血管采用PCI治療沒有額外增加支架內(nèi)再狹窄、節(jié)段性再狹窄、支架內(nèi)血栓等事件。4.兩組患者急診PCI術(shù)后基線炎癥因子、1年復(fù)查兩亞組炎癥因子水平比較無統(tǒng)計(jì)學(xué)差異(均P0.05),1年治療后炎癥因子水平較前均有所下降,具有顯著的統(tǒng)計(jì)學(xué)差異(P0.05),但兩亞組患者治療前后炎癥因子水平變化差值比較無統(tǒng)計(jì)學(xué)差異(P0.05)。5.hs CRP、s CD40L水平變化差值是隨訪期間心血管相關(guān)事件發(fā)生的獨(dú)立危險(xiǎn)因素。結(jié)論:1.STEMI多支病變患者急診PCI治療后非梗死相關(guān)血管采用標(biāo)準(zhǔn)藥物+PCI治療與單純標(biāo)準(zhǔn)藥物治療比較,未能進(jìn)一步降低心力衰竭、再發(fā)心梗、再次血運(yùn)重建、嚴(yán)重心律失常、全因死亡及心源性死亡發(fā)生率,但是顯著減少遠(yuǎn)期(3-12月)心絞痛復(fù)發(fā)、再次因心源性疾病入院率。2.STEMI多支病變患者急診PCI治療后非梗死相關(guān)血管采用標(biāo)準(zhǔn)藥物+PCI治療或單純標(biāo)準(zhǔn)藥物治療,梗死相關(guān)血管支架內(nèi)血栓發(fā)生率及支架內(nèi)再狹窄發(fā)生率相似,非梗死相關(guān)血管采用PCI治療沒有額外增加支架內(nèi)再狹窄、節(jié)段性再狹窄、支架內(nèi)血栓等事件。3.STEMI多支病變患者急診PCI治療后非梗死相關(guān)血管采用標(biāo)準(zhǔn)藥物+PCI治療或單純標(biāo)準(zhǔn)藥物治療,均可能降低STEMI后的炎癥因子水平,但兩種治療方法降低炎癥子水平比較無明顯差異。4.STEMI多支病變患者急診PCI治療后檢測(cè)hs CRP、s CD40L水平變化對(duì)患者PCI治療后心血管相關(guān)事件的發(fā)生有一定的預(yù)測(cè)價(jià)值,有助于篩選相對(duì)高危患者。第三部分:急性ST段抬高型心肌梗死同期處理非梗死相關(guān)血管的小樣本回顧性研究目的:急性ST段抬高型心肌梗死(STEMI)多支血管病變急診經(jīng)皮冠脈介入(PCI)治療處理梗死相關(guān)血管后,非梗死相關(guān)血管采取急診同期或擇期PCI處理,比較兩者1年的臨床終點(diǎn)事件及血炎癥因子水平。方法:入選2011年6月至2014年6月接受急診PCI的74例STEMI多支病變患者,根據(jù)對(duì)非梗死相關(guān)血管是否同期PCI或擇期PCI將患者分為兩組,其中同期PCI組24例(占32%),擇期(或稱非同期)PCI組50例(占68%)。隨訪兩組1年的臨床終點(diǎn)事件,術(shù)后一年再次檢測(cè)入選患者血中炎癥因子(hs CRP、s CD40L、IL-6、TNF-α)水平。結(jié)果:1.兩組患者性別、年齡、病因構(gòu)成比、冠心病易患因素、冠心病家族史、心功能分級(jí)、肝腎功能指標(biāo)、治療用藥、癥狀發(fā)作至球囊擴(kuò)張時(shí)間、就診至球囊擴(kuò)張時(shí)間等在內(nèi)的兩組的基線特征以及急診冠脈造影及直接PCI的相關(guān)數(shù)據(jù)均無顯著差異(P0.05)。2.兩組近期(1-3月)、遠(yuǎn)期(3-12月)、1年總的心血管事件發(fā)生率(心絞痛復(fù)發(fā)、再次因心源性疾病入院、心力衰竭、再發(fā)心梗、再次血運(yùn)重建、嚴(yán)重心律失常、全因死亡及心源性死亡率)等均無差異(均P0.05)。3.兩組患者急診PCI術(shù)后基線炎癥因子、1年復(fù)查兩亞組炎癥因子水平比較無統(tǒng)計(jì)學(xué)差異(均P0.05),1年治療后炎癥因子水平較前均有所下降,具有顯著的統(tǒng)計(jì)學(xué)差異(P0.05),但兩亞組患者治療前后炎癥因子水平變化差值比較無統(tǒng)計(jì)學(xué)差異(P0.05)。結(jié)論:1.急性ST段抬高型心肌梗死急診PCI同期干預(yù)非梗死相關(guān)血管與擇期干預(yù)非梗死相關(guān)血管比較,近期(1-3月)、遠(yuǎn)期(3-12月)、1年內(nèi)總的心血管相關(guān)事件發(fā)生率(心絞痛、心源性疾病入院、心力衰竭、再發(fā)心梗、再次血運(yùn)重建、嚴(yán)重心律失常、全因死亡及心源性死亡)相似。STEMI患者急診PCI時(shí)同期干預(yù)非梗死相關(guān)血管是安全的,并沒有額外增加心血管相關(guān)事件的發(fā)生。2.急性ST段抬高型心肌梗死急診PCI同期干預(yù)非梗死相關(guān)血管與擇期干預(yù)非梗死相關(guān)血管,均可能降低STEMI后的炎癥因子水平,但降低炎癥因子水平比較差異無統(tǒng)計(jì)學(xué)意義,進(jìn)一步提示兩種治療方法對(duì)于此類患者遠(yuǎn)期預(yù)后的效果相當(dāng)。
[Abstract]:The first part: the influence of pre hospital first aid green channel on the time parameters of ST segment elevation myocardial infarction and the prognosis of emergency coronary intervention: compare the traditional channel, green channel, and optimized green channel, the 3 clinical approaches of direct percutaneous coronary intervention (PCI) treatment for acute ST segment. The effect of the time parameters for the rescue process of STEMI patients and the prognosis of the emergency PCI treatment, the advantages of the optimized green channel model in the treatment of STEMI were verified by a series of measures, such as a series of specialist doctor follow-up and a series of self-made myocardial infarction rescue packages, and a series of measures for the treatment of STEMI. 180 cases of STEMI patients with direct PCI were divided into 45 cases of traditional channel group (120 first aid system, emergency room to CCU ward to catheter room), 62 cases of green channel group (120 first aid system, emergency room to catheter room), and 73 optimized green channel group (optimized channel group, further optimized on the basis of green color channel, including 120 ambulance by Ben. " The medical specialist stationed at the center completed the first electrocardiogram - the transmission of electrocardiogram and the patient information through the remote system to the emergency Hall - the emergency physician received the information - to notify the doctor on duty in the Department of Cardiology (carrying the myocardial infarction rescue package) to wait for the patient and notify the PCI team; or the 120 ambulance specialist completed the first electrocardiogram. The main research index is the first medical contact to the balloon dilatation (FMC2B), the first medical contact to the antiplatelet therapy (FM). The primary medical contact is the first medical contact to the balloon dilatation (FMC2B), and the first medical contact to the antiplatelet therapy (FM C2A) time, the first medical contact to sign the intervention therapy agreement (FMC2S) time, the time to visit the balloon dilatation (D2B), the non fatal myocardial infarction, cerebrovascular accident, heart failure, all cause and cardiogenic death and the incidence of major cardiovascular events during the period of hospitalization, and compare the three groups of non event survival rates and Logistic regression analysis. The related factors affecting the clinical prognosis of STEMI patients after PCI operation and 1 year follow-up were measured. Results there was no significant difference in baseline characteristics between 1. and three groups (P0.05).FMC2B time, FMC2A time, FMC2S time, and D2B time in the traditional channel group, green channel group, and optimized channel group shortened (except for the traditional channel group and the green channel group FMC2A). Between the traditional channel group and the green channel group FMC2S, P0.05); the proportion of balloon dilatation in the first medical contact with 120min and the proportion of D2B90 min in the traditional channel group, the green channel group, the optimized channel group increased (all P0.05) in the group.2. three, and the non fatal myocardial infarction, cerebrovascular accident, and heart failure occurred during the hospitalization. The significant difference (all P0.05), the green channel group, the mortality of cardiovascular disease and the mortality of various reasons in the optimal channel group were lower than that of the traditional channel group (P0.05). The mortality of cardiovascular disease and the mortality of various causes were lower in the optimal channel group than that in the green channel group, but there was no significant difference (all P0.05). During the follow-up period, three groups of patients were twisted. The rate of pain recurrence, again non fatal myocardial infarction, again the vascularization of the target vessel and the occurrence of serious arrhythmia (P0.05), but the green channel group, the optimal channel group heart failure, the cardiac disease again, all the death and cardiac mortality were lower than the traditional channel group (P0.05).3. through the three groups of cardiovascular events The regression analysis of risk factors showed that age (P=0.025), smoking (P=0.013), diabetes (P=0.031), double branch lesion (P=0.007), three lesions (P=0.011), FMC2B time (P=0.034), FMC2A time (P=0.028), FMC2S time (P=0.046), and D2B time were the risk factors of cardiovascular related events. Interval, FMC2S time, D2B time and age are independent risk factors for cardiovascular events after PCI. Conclusion: the optimal green channel model with a series of measures, such as 120, self-made myocardial infarction rescue package, and so on, can significantly shorten the first medical contact to the balloon dilatation time. The time of platelet therapy, the first medical contact to sign the agreement time of interventional therapy, the time of diagnosis to balloon dilatation, and the improvement of the clinical prognosis in the hospital after emergency PCI operation and 1 year follow-up. The second part: the different treatment strategies of non infarct related blood tube after acute ST segment elevation myocardial infarction in the emergency PCI The effects of tube events: acute ST segment elevation myocardial infarction (STEMI) multiple vascular lesions in emergency percutaneous coronary intervention (PCI) after percutaneous coronary intervention (PCI), the incidence of major cardiovascular events, changes in blood inflammatory factors (HS CRP, s CD40L, IL-6, TNF-a), and the results of coronary angiography after percutaneous coronary intervention (PCI) for non infarct related vessels were treated with standard drugs or standard drug +PCI Methods: 131 patients with STEMI multibranch disease received emergency PCI from June 2011 to June 2014 were divided into two groups according to the re PCI treatment of non infarct related vessels, of which 51 cases (39%) were treated with drug +PCI and 80 cases (61%) in the drug treatment group. The clinical endpoint events of the two group 1 years were reviewed and the coronary artery was reviewed one year after the operation. Results: the levels of HS CRP, s CD40L, IL-6, TNF- a in the blood of the selected patients were re examined. Results: 1. the sex, age, cause of cause of disease, family history of coronary heart disease, family history of coronary heart disease, heart function classification, liver and kidney function index, treatment medication, symptomatic attack to balloon dilatation time, treatment to balloon dilatation time, and so on were two in the two groups. The baseline characteristics of the group, the emergency coronary angiography and the related data of direct PCI were not significantly different (P0.05) the recurrence rate of angina pectoris in group.2.PCI patients (3-12 months), and the admission rate of cardiac disease was significantly lower than that of the drug treatment group (P0.05). The two groups of heart failure, re infarction, revascularization, serious arrhythmia, and all causes There was no difference in death and cardiac death rate (P0.05) in the.3. two subgroup, there was no significant difference in the incidence of thrombosis in the infarct related vascular stent and the incidence of restenosis in the stent (P0.05). The non infarct related blood vessels did not add to the stent restenosis, segmental restenosis, and stent thrombosis in the two group of patients with.4. in the emergency PCI. There was no statistical difference in the level of inflammatory factors in the 1 year reexamination of the two subgroup (all P0.05). The level of inflammatory factors decreased after 1 years of treatment, and there was a significant difference (P0.05), but there was no significant difference (P0.05).5.hs CRP, s CD40L water before and after treatment in the two subgroup. The difference is an independent risk factor for the occurrence of cardiovascular events during follow-up. Conclusion: the non infarct related blood vessels of 1.STEMI patients with multiple vessel diseases after emergency PCI treatment were compared with standard drug +PCI treatment and simple standard drug treatment, and failed to further reduce heart failure, re infarction, re revascularization, and serious arrhythmia. The incidence of all causes of death and cardiac death, but significantly reduced the recurrence of long term (3-12 months) angina pectoris, again due to the admission rate of cardiac disease.2.STEMI multiple disease patients after emergency PCI treatment of non infarct related blood vessels using standard drug +PCI treatment or simple standard drug treatment, infarct related vascular stent thrombosis and stent thrombosis The incidence of restenosis was similar. Non infarct related blood vessels were treated with PCI therapy without additional stent restenosis, segmental restenosis, stent thrombosis and other events in patients with.3.STEMI. Non infarct related blood vessels were treated with standard drug +PCI or simple standard drug treatment after PCI treatment, which could reduce the cause of inflammation after STEMI. Sublevel, but there is no significant difference between the two treatment methods to reduce the sublevel of inflammation, HS CRP was detected after emergency PCI treatment in patients with.4.STEMI multi branch lesions. The changes of s CD40L level have certain predictive value for the occurrence of cardiovascular related events after PCI treatment. It is helpful to screen relative high risk patients. The third part: acute ST segment elevation myocardium A retrospective study of non infarct related vessels for the simultaneous treatment of infarct Objective: acute ST segment elevation myocardial infarction (STEMI) multiple vascular lesions in emergency percutaneous coronary intervention (PCI) treatment of infarct related vessels. Non infarct related vessels were treated with emergency or elective PCI treatment, compared with 1 years of clinical endpoint events and blood inflammation Methods: 74 patients with STEMI multiple lesions from June 2011 to June 2014 were divided into two groups according to whether the non infarct related blood vessels were PCI or elective PCI, including 24 cases (32%) in group PCI and 50 cases (68%) in group PCI at elective (or non synchronous) period. The clinical endpoint events of the two groups and 1 years were followed up. The level of inflammatory factors (HS CRP, s CD40L, IL-6, TNF- alpha) in blood of the selected patients was re tested one year. Results: 1. the sex, age, etiology, family history of coronary heart disease, family history of coronary heart disease, heart function classification, liver and kidney function index, treatment medication, symptomatic attack to balloon dilatation time, and the time of balloon dilatation, and so on were two in the two groups. There were no significant differences in baseline characteristics, emergency coronary angiography and direct PCI (P0.05).2. two (1-3 months), long term (3-12 months), 1 years of total cardiovascular events (recrudescence of angina pectoris, relapse of heart disease, heart failure, re infarction, re revascularization, severe arrhythmia, all cause death and heart) There was no difference (P0.05) in the.3. two group with baseline inflammatory factors after emergency PCI operation, and there was no significant difference in the level of inflammatory factors in the 1 year reexamination two subgroups (all P0.05). The level of inflammatory factors decreased after 1 years of treatment, with significant statistical difference (P0.05), but the inflammatory factor water before and after treatment in the two subgroup There was no statistical difference (P0.05). Conclusion: 1. acute ST segment elevation myocardial infarction was compared with non infarct related blood vessels during the same period of emergency PCI intervention. The short-term (1-3 months), long term (3-12 months), 1 years of total cardiovascular related events (angina, cardiogenic disease admission, heart failure, recurrence) Myocardial infarction, revascularization, severe arrhythmias, all causes of death and cardiac death in.STEMI patients, non infarct related vessels were safe during the same period of emergency PCI, and no additional cardiovascular related events were added to.2. acute ST segment myocardial infarction in emergency PCI intervention for non infarct related vessels and selective intervention Infarct related blood vessels may reduce the level of inflammatory factors after STEMI, but there is no statistical difference in reducing the level of inflammatory factors. Further hints that the two treatments are effective for the long-term prognosis of these patients.
【學(xué)位授予單位】：蘇州大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R542.22

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