本文選題：缺血后處理 + 急性心肌梗死��； 參考：《天津醫(yī)科大學》2013年碩士論文

【摘要】：背景： 以溶栓療法和經(jīng)皮冠狀動脈介入治療(percutaneous coronary intervention,PCI)為代表的早期再灌注治療(Reperfusion therapy, RT)能及時開通梗死相關(guān)動脈(infarction related artery, IRA),限制梗死面積(infarct size, IS),是急性心肌梗死(acute myocardial infarction, AMI)的主要救治措施。然而,RT又可以矛盾性的造成新的心肌損傷,這稱之為缺血再灌注損傷(ischemia reperfusion injury,IRI)。在接受成功血運重建治療的AMI患者中,有40%的心肌IS來源于IRI。如何減少RT過程中的IRI是近幾十年來的研究重點。 1986年,Murry等提出缺血預處理(ischemic preconditioning, IPreC)的概念并指出IPreC可以減輕IRI,限制IS,這一效應先后在多種缺血再灌注動物模型上得到證實,心外科醫(yī)生在擇期的心臟手術(shù)中也觀察到了IPreC的保護作用。然而,由于AMI事件的不可預知性限制了IPreC的臨床應用。在2000年和2003年,陶凌和Zhao等先后提出了缺血后處理(Ischemic postconditioning, IPostC)的概念并發(fā)現(xiàn)IPostC同樣可以減輕再灌注治療時的IRI,限制IS。此后,大量的基礎(chǔ)研究證實IPostC可以減輕不同動物心肌缺血再灌注模型的IRI并對其心肌保護作用機制進行了深入而廣泛的探討。由于IPostC可以很容易的在AMI患者的直接PCI治療中實現(xiàn),人們對其臨床效果寄予厚望。小樣本的“概念證明研究”表明IPostC可以縮小接受直接PCI治療的AMI患者的IS,但IPostC在臨床應用中的心肌保護作用仍存在爭議。 目的： 觀察IPostC對接受直接PCI治療的AMI患者再灌注心律失常(reperfusion arrhythmia, RA)、冠狀動脈及心肌灌注、IS、左室結(jié)構(gòu)和功能改變以及臨床事件和炎癥標志物水平的影響,探索預防心肌IRI的方法。 方法： 自2010年6月至2012年6月,于天津醫(yī)科大學寶坻臨床學院心血管內(nèi)科住院,發(fā)病12小時內(nèi)且接受直接PCI治療的急性ST段抬高型心肌梗死患者106例,隨機進入對照組(56例)或IPostC組(50例)。兩組均接受規(guī)范的藥物治療,再此基礎(chǔ)上對照組以標準技術(shù)行PCI治療,IPostC組于IRA開通后30秒內(nèi)給予3輪30秒／次的IPostC后再給予持續(xù)再灌注治療并繼續(xù)完成PCI治療操作。記錄PCI過程中RA發(fā)生情況,測定術(shù)中、術(shù)后冠狀動脈TIMI血流、校正的TIMI血流幀數(shù)計數(shù)(corrected TIMI frame count, cTFC)、心肌染色顯影分級(myocardial blush grade, MBG)和術(shù)后即刻ST段回落率(ST segment recovery,STR),并于入院即刻和發(fā)病8小時、10小時、12小時、14小時、16小時、18小時、24小時、48小時取靜脈血1次,分別測定血清肌酸激酶同工酶MB(creatine kinase isoenzyme-MB, CK-MB)、高敏肌鈣蛋白T (high sensitivity troponin T,hs-TnT)和高敏C反應蛋白(high sensitivity C reactive protein, hs-CRP)水平,于發(fā)病90天時行經(jīng)胸二維超聲心動圖檢查,測定左室舒張末期內(nèi)徑(left ventricular end diastolic diameter, LVED), Simpson法測定左室射血分數(shù)(Left Ventricular Ejection Fractions, LVEF),檢測并計算室壁節(jié)段運動指數(shù)(wall motion score index, WMSI),同時觀察90天時死亡、再梗死、腦卒中、梗死后心絞痛及心力衰竭等臨床事件發(fā)生率。 結(jié)果： 兩組患者基線臨床情況、冠脈病變及PCI治療情況一致,術(shù)中IPostC組頻發(fā)室性期前收縮、室性心動過速等室性RA發(fā)生率少于對照組(24.0%vs42.9%,P=0.041;2.0%vs14.3%,P=0.034)；IPostC組術(shù)中冠脈無復流(no reflow, NRF)發(fā)生率低于對照組(8.0%vs23.2%,P=0.033)：術(shù)后ST段完全回落率高于對照組(96.0%vs83.9%,P=0.042)；盡管術(shù)畢時IRA的TIMI血流無差異,但cTFC及MBG優(yōu)于對照組(P0.05);IPostC組術(shù)后CK-MB和Hs-TnT均低于對照組(258.3±87.8U/L vs306.6±94.4U/L,P=0.008；3582.08±1731.40ng/L vs4501.34±1554.4ng/L,.P=0.005)同樣,術(shù)后IPostC組的hs-CRP水平亦低于對照組(13.65(4.36,32.76) mg/Lvs17.25(9.58,36.35) mg/L, P=0.048);90天時IPostC組LVED小于對照組(52.02±3.28mm vs55.11±4.08mm, P0.0001), LVEF高于對照組(55.92%±2.87%vs48.96%±3.19%,P0.0001),WMSI低于對照組(1.34±0.21vs1.49±0.24,P=0.0001);兩組患者90天時心力衰竭發(fā)生率在IPostC組低于對照組(10.0%vs25.0%,P=0.044)。 結(jié)論： 在標準PCI操作基礎(chǔ)上,3輪30秒/次的IPostC操作可以減輕急性ST段抬高型心肌梗死患者的IRI,降低術(shù)中RA和冠狀動脈NRF發(fā)生率及術(shù)后心肌壞死標志物水平,限制IS,減輕AMI后心室重塑,改善室壁運動,提高LVEF和心臟泵血能力,從而改善臨床預后。
[Abstract]:Background:
Early reperfusion therapy (Reperfusion therapy, RT), represented by thrombolytic therapy and percutaneous coronary intervention (percutaneous coronary intervention, PCI), can open the infarct related artery (infarction related artery, IRA) in time, and limit the infarct area (infarct), which is acute myocardial infarction. AMI) major treatment. However, RT can also create a contradictory new myocardial injury, which is called ischemia reperfusion injury (IRI). In AMI patients receiving successful revascularization, 40% of cardiac IS originates from how IRI. reduces RT process, and is the focus of recent research.
In 1986, Murry and so on proposed the concept of ischemic preconditioning (IPreC) and pointed out that IPreC could reduce IRI and restrict IS. This effect has been confirmed in a variety of ischemic reperfusion animal models, and the cardiac surgeon also observed the protection of IPreC during elective cardiac surgery. However, because of the inability of AMI events Predictability restricts the clinical application of IPreC. In 2000 and 2003, Tao and Zhao proposed the concept of Ischemic postconditioning (IPostC) successively and found that IPostC also alleviated IRI during reperfusion treatment, limiting IS., and a large number of basic studies confirmed that IPostC could reduce myocardial ischemia and reperfusion in different animals. IRI and the mechanism of myocardial protection are extensively discussed. Since IPostC can be easily implemented in the direct PCI treatment of AMI patients, people have great expectations for its clinical effects. The "conceptual proof study" of small samples shows that IPostC can reduce the IS of AMI patients receiving direct PCI treatment, but IPostC The myocardial protective effect in clinical application is still controversial.
Objective:
To observe the effect of IPostC on reperfusion arrhythmia (reperfusion arrhythmia, RA), coronary artery and myocardial perfusion, IS, left ventricular structure and function changes, the level of clinical events and inflammatory markers in AMI patients receiving direct PCI treatment, and to explore the methods of preventing cardiac IRI.
Method:
From June 2010 to June 2012, 106 patients with acute ST segment myocardial infarction (56 cases) or group IPostC (56 cases) or IPostC (50 cases) were hospitalized in the cardiovascular medicine department of the Baodi Clinical College of Medical University Of Tianjin and received direct PCI treatment. The two groups were treated with standardized drug treatment, and then the control group was based on the standard. The technique was treated with PCI, and group IPostC was given 3 rounds of 30 seconds / times of IPostC in 30 seconds after the opening of IRA, and followed by continuous reperfusion therapy and continuing to complete PCI treatment. Record the occurrence of RA in the PCI process, determine the coronary artery TIMI blood flow in the operation, the corrected number of TIMI blood flow frames (corrected TIMI frame), and myocardial staining Myocardial blush grade (MBG) and immediate ST segment drop rate (ST segment recovery, STR) after operation, and 8 hours, 10 hours, 12 hours, 12 hours, 14 hours, 16 hours, 18 hours, 24 hours and 48 hours for 1, respectively, to determine the serum creatine kinase isoenzyme MB (creatine kinase), Gao Minji. The T (high sensitivity troponin T, hs-TnT) and the high sensitive C reactive protein (high sensitivity C reactive protein) were measured at the 90 day of the onset, and the left ventricular end diastolic diameter was measured. Icular Ejection Fractions, LVEF), detect and calculate the ventricular wall segment motion index (wall motion score index, WMSI), and observe the incidence of death, re infarction, stroke, post infarction angina and heart failure at the same time in 90 days.
Result:
The baseline clinical conditions, coronary lesions and PCI treatment in the two groups were consistent. The incidence of ventricular RA in IPostC group was less than that in the control group (24.0%vs42.9%, P=0.041; 2.0%vs14.3%, P=0.034), and the incidence of coronary artery free flow (no reflow, NRF) in group IPostC was lower than that of the control group (8.0%vs23.2%,) After the operation, the total fall rate of ST segment was higher than that of the control group (96.0%vs83.9%, P=0.042), although the TIMI blood flow of IRA was no difference at the time of operation, but cTFC and MBG were superior to the control group (P0.05), and the CK-MB and Hs-TnT in group IPostC were lower than those of the control group (258.3 +). The level of hs-CRP in the post IPostC group was also lower than that of the control group (13.65 (4.36,32.76) mg/Lvs17.25 (9.58,36.35) mg/L, P=0.048), and at the 90 day IPostC group LVED was less than the control group (52.02 + 3.28mm vs55.11 + 4.08mm,), which was higher than that of the control group (55.92% + 3.19% + 3.19%, 1.34 + 0.24, 1.34); The incidence of heart failure was lower in the IPostC group than in the control group on the 90 day (10.0%vs25.0%, P=0.044).
Conclusion:
On the basis of standard PCI operation, 3 rounds of 30 seconds / 30 seconds can reduce the IRI in patients with acute ST segment elevation myocardial infarction, reduce the incidence of RA and coronary NRF in operation and the level of postoperative myocardial necrosis markers, restrict IS, reduce ventricular remodeling after AMI, improve ventricular wall movement, improve LVEF and cardiac pump blood ability, thus improving clinical preclinical. After.
【學位授予單位】：天津醫(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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