本文選題：急性心肌梗死 + 阿托伐他汀��； 參考：《河北醫(yī)科大學》2013年碩士論文

【摘要】：目的：近年來，多個研究相繼證實冠心病擇期PCI術前給予大劑量阿托伐他汀治療能夠降低PCI圍手術期心肌損傷，從而改善預后，降低短期內心臟不良事件發(fā)生率，尤其是對于穩(wěn)定型心絞痛或急性冠脈綜合征患者。然而對于急性ST段抬高型心肌梗死（STEMI）患者急診PCI術前大劑量他汀治療的相關研究卻很少，因此本研究對STEMI患者急診PCI術前給予負荷劑量的阿托伐他汀進行干預，旨在探討STEMI患者急診PCI圍手術期強化阿托伐他汀治療的長期臨床療效。 方法：從2010年5月1日至2012年7月31日連續(xù)入選發(fā)病12小時內擬急診行PCI治療的STEMI患者，隨機分為A、B、C組，A組（術前給予阿托伐他汀80mg，術后給予40mg/日，1月后改為20mg/日），B組（術前未服用阿托伐他汀，術后給予40mg/日，1月后改為20mg/日），C組（術前未服用阿托伐他汀，術后給予20mg/日），測定指標：1分別測定術前、術后7天、術后1個月、術后6月血清高敏C反應蛋白（hs-CRP）、基質金屬蛋白酶9（MMP-9）及B型鈉酸肽（BNP）水平。2分別測定術后2天、術后3個月及術后6月左室射血分數(shù)（LVEF）、左室舒張末期內徑（LVEDD）。3觀察術后1月及術后1年MACE事件(死亡、非致死性心肌梗死及靶血管血運重建)發(fā)生率。4藥物安全性觀察包括肝酶升高（超過正常值上限3倍），肌痛及橫紋肌溶解，還包括胃腸道反應及皮疹等。 結果：試驗期間初步共篩選204例STEMI患者，符合入選標準的共181例，其中6例患者造影后未進一步行PCI治療，12例患者拒絕參加臨床試驗，最終入組患者163例，其中A組54例，B組51例，C組58例。 1三組患者入院時一般情況無明顯差異。 2三組患者hs-CRP比較:三組患者術前hs-CRP測定值兩兩比較均無統(tǒng)計學差異（P＞0.05）；術后7天hs-CRP測定值分別為6.21±1.31mg/L，7.37±1.74mg/L及7.24±1.70mg/L，A組明顯低于B組、C組（P均＜0.05），B組較C組比較無統(tǒng)計學差異（P＞0.05）；術后1月hs-CRP測定值分別為3.06±1.49mg/L，4.14±1.40mg/L及4.95±1.43mg/L，三組間差別具有統(tǒng)計學意義（P＜0.05）。與C組相比較，A和B組的值明顯降低（P均＜0.05），而A組又明顯低于B組（P＜0.05）；術后6月hs-CRP測定值分別為1.96±0.98mg/L，2.10±0.82mg/L及2.54±0.71mg/L，三組間差別具有統(tǒng)計學意義（P＜0.05）。與C組相比較，A組和B組的值明顯降低（P均＜0.05），而A組又明顯低于B組（P＜0.05）。 3三組患者MMP-9比較：三組患者術前MMP-9兩兩比較均無統(tǒng)計學差異（P＞0.05）；術后7天MMP-9在三組分別為1.05±0.37ng/mL，1.13±0.62ng/mL及1.28±0.45ng/mL，A組明顯低于C組（P＜0.05），而A組較B組、B組較C組無統(tǒng)計學差異（P＞0.05）；術后1月MMP-9在三組分別為0.86±0.34ng/mL，0.87±0.25ng/mL及1.05±0.35ng/mL，與C組相比較，A組和B組的值明顯降低（P均＜0.05），而A組較B組無統(tǒng)計學差異（P＞0.05）；術后6月MMP-9在三組分別為0.63±0.28ng/mL，0.73±0.20ng/mL及0.93±0.26ng/mL，與C組相比較，A組和B組的值明顯降低（P均＜0.05），而A組較B組無統(tǒng)計學差異（P＞0.05）。 4三組患者BNP比較:三組患者術前BNP兩兩比較均無統(tǒng)計學差異（P＞0.05）。術后7天BNP測定分別為555.62±122.82pg/mL,653.41±167.36pg/mL及658.03±206.47pg/mL， A組明顯低于B組及C組（P＜0.05），，B組較C組無統(tǒng)計學差異（P＞0.05）。術后1月BNP測定值分別為397.71±87.98pg/mL，502.52±131.52pg/mL及579.59±182.42pg/mL，三組間差別具有統(tǒng)計學意義（P＜0.05）。與C組相比較，A和B組的值明顯降低（P均＜0.05），而A組又明顯低于B組（P＜0.05）；術后6月BNP測定值分別為320.72±47.45pg/mL，371.92±80.92pg/mL及433.95±124.23pg/mL，三組間差別具有統(tǒng)計學意義（P＜0.05）。與C組相比較，A和B組的值明顯降低（P均＜0.05），而A組又明顯低于B組（P＜0.05）。 5三組患者術后超聲結果組間比較：三組患者術后2天、3個月LVEF組間比較無統(tǒng)計學差異（P＞0.05），術后6個月LVEF值分別54.95±6.50%，55.10±6.51%及50.95±5.67%,與C組相比，A組和B組值明顯升高（P均＜0.05），A組較B組無統(tǒng)計學差異（P＞0.05）。三組患者術后2天、術后3月、術后6月LVEDD組間比較均無統(tǒng)計學差異（P＞0.05）。 三組患者超聲結果組內比較：A組術后3月及術后6個月LVEF顯著高于術后2天（P＜0.05），而術后3個月與術后6個月比無統(tǒng)計學差異（P＞0.05）。B組術后6個月高于術后2天LVEF（47.15±7.84%vs55.10±6.50%）為差異有統(tǒng)計學意義（P＜0.05），術后2天與3月、術后3個月與6個月比無統(tǒng)計學差異（P＞0.05）。C組組間兩兩比較均無統(tǒng)計學差異（P＞0.05）。A組術后6個月LVEDD低于術后2天（51.05±7.38mmvs47.50±3.83mm），為差異有統(tǒng)計學意義（P＜0.05）。B組組內及C組組內自身前后對照比較均無統(tǒng)計學差異（P＞0.05）。 6術后MACE事件隨訪:住院及出院1月期間三組MACE事件發(fā)生率A、B、C三組分別是3.70%，5.88%，6.89%，P＞0.05無統(tǒng)計學差異；1年總體不良事件發(fā)生率在A、B、C三組分別為11.11%、25.49%、25.86%，P=0.098＞0.05無統(tǒng)計學差異，但是A組MACE事件發(fā)生率有下降的趨勢。 7藥物安全性觀察：三組患者肝酶、肌酶比較：三組患者術前、術后7天、術后1月及術后6月谷丙轉氨酶（ALT）、谷草轉氨酶（AST）及肌酸激酶（CK）兩兩比較均無統(tǒng)計學差異（P＞0.05）。 結論：STEMI患者急診PCI術前80mg阿托伐他汀聯(lián)合術后40mg阿托伐他汀治療： 1可明顯降低炎癥反應程度，增加斑塊的穩(wěn)定性。 2可明顯改善患者左室收縮功能，逆轉心室重構。 3未顯著降低術后1月及1年的MACE事件的發(fā)生率，但有降低術后1年MACE事件發(fā)生率的趨勢。
[Abstract]:Objective: in recent years, a number of studies have confirmed that large doses of atorvastatin before PCI for coronary heart disease can reduce myocardial injury in the perioperative period of PCI, thus improving the prognosis and reducing the incidence of adverse cardiac events in the short term, especially for patients with stable angina or acute coronary syndrome. However, acute ST segment elevation There are few studies on the treatment of large dose statins in patients with acute myocardial infarction (STEMI) before the emergency PCI operation. Therefore, this study gave a load dose of atorvastatin before the emergency PCI operation in STEMI patients. The purpose of this study was to explore the long-term clinical efficacy of the intensive atorvastatin treatment in the emergency PCI perioperative period of the patients with STEMI.
Methods: from May 1, 2010 to July 31, 2012, STEMI patients were randomly selected for PCI treatment within 12 hours. They were randomly divided into A, B, C, A group (atorvastatin 80mg before operation, 40mg/ day after operation, January to 20mg/ day), B group (without atorvastatin before operation, 40mg/ day after operation, and 20mg/ day after January). Before operation, atorvastatin was not taken, and 20mg/ days were given after operation. 1 before operation, 7 days after operation, 1 months after operation, serum high sensitivity C reactive protein (hs-CRP), matrix metalloproteinase 9 (MMP-9) and B type natriuretic peptide (BNP) level.2 respectively for 2 days after operation, 3 months after operation and left ventricular ejection fraction (LVEF) and left ventricular systolic function after operation. The incidence of MACE events (death, non fatal myocardial infarction and target vessel blood revascularization) in January and 1 years after operation (death, nonfatal myocardial infarction and target vessel blood revascularization) was observed in the end of the end-stage internal diameter (LVEDD).3, including the elevation of the liver enzyme (over 3 times the upper limit of the normal value), myalgia and rhabdomyolysis, as well as the gastric and intestinal reactions and rashes.
Results: a total of 204 patients with STEMI were screened during the trial. 181 cases were in line with the standard of admission, of which 6 cases were not further treated with PCI, and 12 patients refused to participate in clinical trials, and 163 cases were finally enrolled, including 54 cases in group A, 51 in group B, and 58 in group C.
1 three groups of patients generally have no obvious difference.
2 three groups of patients with hs-CRP comparison: there was no statistical difference between the three groups before operation (P > 0.05), and the hs-CRP values were 6.21 + 1.31mg/L, 7.37 + 1.74mg/L and 7.24 + 1.70mg/L in the 7 days after the operation, A group was significantly lower than the B group, C group (P < 0.05), B group compared with the group (0.05) in January. The difference between the three groups was 3.06 + 1.49mg/L, 4.14 + 1.40mg/L and 4.95 + 1.43mg/L respectively (P < 0.05). Compared with the C group, the values of A and B groups were significantly lower (P < 0.05), and the A group was obviously lower than the B group (P < 0.05). In June, the hs-CRP measurement values were 1.96 +, 2.10 + and 2.54 +, respectively. There was statistical significance (P < 0.05). Compared with C group, A group and B group significantly decreased (P < 0.05), while the A group was significantly lower than that of group B (P < 0.05).
3 three groups of patients MMP-9 comparison: there was no statistical difference between the three groups before operation MMP-9 22 (P > 0.05), and 7 days after the operation, the three groups were 1.05 + 0.37ng/mL, 1.13 + 0.62ng/mL and 1.28 + 0.45ng/mL, A group was significantly lower than the C group (P < 0.05), while the A group was less than the B group. 0.86 + 0.34ng/mL, 0.87 + 0.25ng/mL and 1.05 + 0.35ng/mL, compared with group C, the value of A group and B group decreased significantly (P < 0.05), but there was no statistical difference between group A and B group (P > 0.05). The value of MMP-9 in the three groups in June was 0.63 + 0.28ng/mL, 0.73 and 0.93 +. ), and A group than in B group showed no significant difference (P > 0.05).
The comparison of BNP in the 4 three groups: there was no statistical difference between the three groups before operation (P > 0.05). The BNP determination was 555.62 + 122.82pg/mL, 653.41 + 167.36pg/mL and 658.03 + 206.47pg/mL in the 7 day postoperatively. The A group was significantly lower than the B group and C group (P < 0.05). The B group was less statistically significant than that of the group (0.05). The value of the determination in January was 397.71 + 87.. 98pg/mL, 502.52 + 131.52pg/mL and 579.59 + 182.42pg/mL, the difference between the three groups was statistically significant (P < 0.05). Compared with the C group, the values of the A and B groups were significantly lower (P < 0.05), and the A group was significantly lower than the B group (P < 0.05). In June, the BNP measurement values were 320.72, 371.92 and 433.95 +, respectively, and three groups were different. With statistical significance (P < 0.05). Compared with C, A and B were significantly decreased (P < 0.05), while the A group was significantly lower than that of group B (P < 0.05).
5 three groups of patients with postoperative ultrasound results group comparison: three groups of patients after 2 days, 3 months of LVEF group had no statistical difference (P > 0.05), 6 months after the operation, LVEF value 54.95 + 6.50%, 55.10 + 6.51% and 50.95 + 5.67%, compared with group C, A and B group values increased significantly (P < <), A group compared with the B group (P >). After 2 days, after March, after June LVEDD between two groups were not statistically significant (P > 0.05).
The comparison of ultrasound results in the three groups: LVEF in group A was significantly higher than that of 2 days after operation (P < 0.05) after operation in March and 6 months postoperatively (P < 0.05), but there was no statistical difference between 3 months after operation and 6 months after operation (P > 0.05), and 6 months after operation in.B group was higher than LVEF (47.15 + 7.84%vs55.10 + 7.84%vs55.10) after operation 2 days after operation (P < 0.05). Postoperative 2 days and March, postoperative 3 There was no statistical difference between 6 months and 6 months (P > 0.05) in group.C (P > 0.05). In group.A, LVEDD was lower than 2 days after operation (51.05 + 7.38mmvs47.50 + 3.83mm), and there was significant difference (P < 0.05) in group.B group and in C group, there was no statistical difference (P > 0.05).
6 postoperative follow-up of MACE events: the incidence of three groups of MACE events in the hospital and hospital in January was A, B, and C three groups were 3.70%, 5.88%, 6.89%, and P > 0.05, respectively. The incidence of 1 years' overall adverse events in A, B, and C three groups were 11.11%, 25.49%, 25.86%, P=0.098 > 0.05, but A group MACE events had a downward trend.
7 drug safety observation: three groups of patients with liver enzyme, muscle enzyme comparison: three groups of patients before operation, 7 days after operation, January and 6 months after the operation, ALT, AST and creatine kinase (CK) 22 compared to no statistical difference (P > 0.05).
Conclusion: STEMI patients before emergency PCI 80mg Atorvastatin Combined with atorvastatin in the treatment of postoperative 40mg:
1 can significantly reduce the degree of inflammatory reaction, increase the stability of the plaque.
2 can be significantly improved in patients with left ventricular systolic function, reverse ventricular remodeling.
3 without a significant reduction after January and 1 years in the MACE event rate, but reduce the postoperative MACE event 1 years incidence trend.
【學位授予單位】：河北醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2013
【分類號】：R542.22

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