【摘要】：目的：研究急性心肌梗死（Acute myocardial infarction，AMI）患者直接經(jīng)皮冠狀動(dòng)脈介入術(shù)（Percutaneous coronary intervention，PCI）前高負(fù)荷阿托伐他汀80mg對PCI術(shù)中無復(fù)流的預(yù)防作用及短期心功能的影響。 方法：選取2012年9月到2013年12月期間于河北醫(yī)科大學(xué)第三醫(yī)院心血管二科住院，首次診斷為急性心肌梗死并成功行冠脈介入治療的72名患者（年齡在32~79歲）作為研究對象，排除急性心梗合并急性左心衰、心源性休克、活動(dòng)性肝臟疾病及嚴(yán)重肝腎功能不全等影響觀察指標(biāo)患者，其中包括ST段抬高型心肌梗死（ST segment elevation myocardialinfarction，STEIM）54例，非ST段抬高型心肌梗死（Non-ST segment eleva-tion myocardial infarction，NSTIM）患者18例，按隨機(jī)數(shù)字表法隨機(jī)分為兩組，負(fù)荷組（38例），急診PCI術(shù)前嚼服阿托伐他汀（立普妥，20mg/片，輝瑞制藥）80mg，術(shù)后給予20mg每晚一次口服；常規(guī)組（34例）僅術(shù)后給予阿托伐他汀20mg每晚一次，兩組患者術(shù)前均給予嚼服阿司匹林300mg，氯吡格雷600mg；術(shù)后住院期間兩組均給予阿司匹林、氯吡格雷及低分子肝素，根據(jù)患者情況給予IIb/Ⅲa受體拮抗劑、血管緊張素轉(zhuǎn)化酶抑制劑/血管緊張素受體拮抗劑（ACEI/ARB）及β－受體阻滯劑等冠心病基礎(chǔ)藥物治療。記錄所有患者一般情況：性別、年齡、吸煙、飲酒、基礎(chǔ)疾病（包括高血壓、糖尿病、血脂代謝異常）及病變血管數(shù)、梗死相關(guān)動(dòng)脈、胸痛持續(xù)時(shí)間等臨床特點(diǎn)，所有患者在簽署知情同意書后90min內(nèi)開通梗死相關(guān)動(dòng)脈，成功的PCI術(shù)后即刻由兩名有經(jīng)驗(yàn)驗(yàn)的介入醫(yī)師對梗死相關(guān)動(dòng)脈進(jìn)行TIMI（thrombolysis in myocardial infarction）血流分級評估梗死相關(guān)動(dòng)脈心外膜冠脈血流，記錄無復(fù)流發(fā)生率；根據(jù)TIMI心肌灌注分級（TIMI myocardial perfusion grade，TMPG），評估微循環(huán)、心肌灌注情況；記錄入院即刻及術(shù)后第一天空腹血漿BNP（腦利鈉肽，BrainNatriuretic Peptide，BNP）水平，及術(shù)后一個(gè)月心臟彩超心臟左室射血分?jǐn)?shù)（Left ventricular ejection fraction，LVEF）值，評估短期心功能受損及恢復(fù)情況。實(shí)驗(yàn)主要研究終點(diǎn)：兩組術(shù)中無復(fù)流發(fā)生率及心肌灌注水平，次要終點(diǎn)是急診PCI術(shù)前阿托伐他汀高負(fù)荷對患者短期心功能的影響。 結(jié)果：1兩組參數(shù)的比較 兩組患者性別、年齡、吸煙史、飲酒史、高血壓病史、糖尿病病史、血脂代謝異常病史、入院時(shí)BNP水平、發(fā)病時(shí)間、梗死相關(guān)動(dòng)脈、冠脈病變數(shù)等均無統(tǒng)計(jì)學(xué)差異，兩組有可比性。 2TIMI血流結(jié)果 將梗死相關(guān)動(dòng)脈開通后TIMI血流≤II級定義為無復(fù)流，無復(fù)流總發(fā)生率25%，與資料統(tǒng)計(jì)10~30%相符；負(fù)荷組發(fā)生無復(fù)流7例，無復(fù)流發(fā)生率18.4%；常規(guī)組發(fā)生無復(fù)流11例，無復(fù)流發(fā)生率32.3%，負(fù)荷組較常規(guī)組無復(fù)流發(fā)生率低但差異無統(tǒng)計(jì)學(xué)意義（18.4%vs32.3%，P＞0.05）； 3TIMI心肌灌注比較 負(fù)荷組TMPG血流＜3級患者10例，占負(fù)荷組26.3%，常規(guī)組18例，比例52.9%，負(fù)荷組TMPG血流＜3級患者比例顯著低于常規(guī)組（26.3%vs52.9%，P＜0.05），差異有統(tǒng)計(jì)學(xué)意義。 4心功能評價(jià)結(jié)果 兩組患者入院即刻BNP水平，負(fù)荷組101±33pg/ml，常規(guī)組89±45pg/ml，兩組比較（101±33pg/ml vs89±45pg/ml，P＞0.05），差異無統(tǒng)計(jì)學(xué)意義；術(shù)后第一天BNP水平，負(fù)荷組275±212pg/ml，常規(guī)組389±157pg/ml，兩組比較（275±212pg/ml vs389±157pg/ml，P＜0.05）差異有統(tǒng)計(jì)學(xué)意義；術(shù)后1個(gè)月心臟彩超左室射血分?jǐn)?shù)（LVEF）：負(fù)荷組（54±12）%，明顯好于常規(guī)組（49±8）%，兩組比較差異有統(tǒng)計(jì)學(xué)意義（P0.05）。住院及隨訪期間監(jiān)測患者肝酶及肌酸激酶水平，，無一例出現(xiàn)嚴(yán)重肝毒性及肌毒性。 結(jié)論： 1急性心肌梗死患者直接PCI術(shù)前高負(fù)荷他汀能有效改善缺血心肌再灌注，對術(shù)中無復(fù)流現(xiàn)象有一定預(yù)防作用。 2急診PCI術(shù)前高負(fù)荷他汀能減輕缺血、PCI及再灌注等對心肌的損傷，保護(hù)心肌細(xì)胞功能，改善AMI患者心功能。
[Abstract]:AIM: To investigate the effects of high-load atorvastatin 80 mg before percutaneous coronary intervention (PCI) on no-reflow and short-term cardiac function in patients with acute myocardial infarction (AMI).
METHODS: Seventy-two patients (aged 32-79 years) with first acute myocardial infarction and successful coronary intervention were enrolled in the Department of Cardiovascular Disease, Third Hospital of Hebei Medical University from September 2012 to December 2013. All patients were excluded from acute myocardial infarction complicated with acute left heart failure, cardiogenic shock, active liver disease and coronary intervention. Severe hepatorenal insufficiency, including 54 patients with ST-segment Eleva tion myocardial infarction (STEIM) and 18 patients with non-ST-segment Eleva tion myocardial infarction (NSTIM), were randomly divided into two groups according to the random number table method. Atorvastatin was given 80 mg before PCI and 20 mg once a night after PCI. Atorvastatin was given to 34 patients in routine group only 20 mg every night after PCI. Both groups were given 300 mg aspirin and 600 mg clopidogrel before PCI. Both groups were given aspirin and clopidogrel during hospitalization. Gray and low molecular weight heparin were given basic medications for coronary heart disease, such as IIb/III a receptor antagonist, angiotensin-converting enzyme inhibitor/angiotensin receptor antagonist (ACEI/ARB) and beta-blocker, according to the patient's condition. Infarction-related arteries were opened in all patients within 90 minutes after signing informed consent. Two experienced interventional physicians performed TIMI (thrombolysis in myocardial infarction) immediately after successful PCI. Blood flow grading was used to assess the epicardial coronary flow of infarct-related artery and record the incidence of no-reflow; microcirculation and myocardial perfusion were assessed according to TIMI myocardial perfusion grading (TMPG); abdominal plasma BNP (brain natriuretic peptide, BNP) levels were recorded immediately after admission and the first day after surgery; and after surgery. One-month echocardiographic left ventricular ejection fraction (LVEF) was used to assess the short-term impairment and recovery of cardiac function.
Results: 1 Comparison of two groups of parameters
There were no significant differences in gender, age, smoking history, drinking history, hypertension history, diabetes history, abnormal blood lipid metabolism history, BNP level at admission, onset time, infarction-related artery, coronary artery lesions between the two groups.
2TIMI blood flow results
TIMI blood flow (< II) was defined as no-reflow, the total incidence of no-reflow was 25%, which was consistent with the statistical data of 10-30%. No-reflow occurred in 7 cases in load group and the incidence of no-reflow was 18.4%. No-reflow occurred in 11 cases in routine group and the incidence of no-reflow was 32.3%. The incidence of no-reflow in load group was lower than that in routine group, but the difference was not statistically significant. Meaning (18.4%vs32.3%, P > 0.05);
Comparison of 3TIMI myocardial perfusion
Ten patients (26.3%) in load group and 18 patients (52.9%) in routine group, whose TMPG blood flow was less than grade 3 in load group were significantly lower than those in routine group (26.3% vs 52.9%, P < 0.05).
4 cardiac function evaluation results
There was no significant difference in BNP level between the two groups immediately after admission. The BNP level in the load group was 101 + 33pg / ml and that in the routine group was 89 + 45pg / ml. There was no significant difference between the two groups (101 + 33pg / ml vs 89 + 45pg / ml, P > 0.05). The left ventricular ejection fraction (LVEF) of cardiac color Doppler echocardiography at 1 month after operation was significantly better than that of routine echocardiography group (54 65507
Conclusion:
High-load statin before PCI can effectively improve myocardial ischemia-reperfusion in patients with acute myocardial infarction.
High-load statin before emergency PCI can alleviate myocardial injury such as ischemia, PCI and reperfusion, protect myocardial cell function and improve cardiac function in patients with AMI.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R542.22

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