【摘要】：背景 急性心肌梗死(AMI)的預(yù)后,與治療是否及時(shí)、梗死范圍的大小以及是否有側(cè)枝循環(huán)的建立等因素有關(guān)。AMI患者絕大多數(shù)有一支以上的冠狀動(dòng)脈嚴(yán)重受累,一定數(shù)量的患者三支主要血管均存在有臨床意義的狹窄。梗死相關(guān)血管(IRA)斑塊破裂和繼發(fā)血栓形成是導(dǎo)致AMI的主要機(jī)制,雖然非梗死相關(guān)血管不作為發(fā)病的主要原因,但合并存在其他非梗死相關(guān)血管是否會(huì)增加患者的死亡率或不良事件的發(fā)生率尚不完全確定。本文就以冠脈造影結(jié)果出發(fā),探討病變血管數(shù)量對(duì)AMI患者預(yù)后的影響。 方法 選取浙江大學(xué)附屬邵逸夫醫(yī)院2009年1月至2011年11月所有行冠脈造影檢查的AMI患者。收集患者住院期間資料并通過(guò)門診或電話兩種方式隨訪1年(12±3月)。隨訪聯(lián)合終點(diǎn)為主要心腦血管不良事件(MACCE)。根據(jù)病變血管數(shù)量將所有患者分為冠脈造影陰性組、單支病變組、兩支病變組和三支病變組。通過(guò)Kaplan-Meier法描述1年隨訪無(wú)MACCE發(fā)生率曲線,Cox回歸模型分析患者1年預(yù)后的獨(dú)立預(yù)測(cè)因子。 結(jié)果 493名患者中累及左主干(LM)的有39人(7.9%),累及左冠狀動(dòng)脈前降支(LAD)的有421人(85.4%),累及左冠狀動(dòng)脈回旋支(CX)的有270人(54.8%),累及右冠狀動(dòng)脈(RCA)的有305人(61.9%)。所有患者中有279人(56.6%)患高血壓,132人(26.8%)患糖尿病。多支病變比單支病變：年齡(64.1vs.59.2,P=0.000)、高血壓(59.9%vs.48.9%,P=0.031)、糖尿病(30.6%vs.17.3%,P=0.003)、既往卒中病史(8.1%vs.1.4%,P=0.006)、糖化血紅蛋白(6.6vs.6.2,P=0.044)、低密度脂蛋白(2.00vs.1.83,P=0.044)。1年中72人(16.5%)發(fā)生MACCE事件。多支病變vs.單支病變：1年累積MACCE發(fā)生率(19.5%vs.10.1%,P=0.013)、再次血運(yùn)重建(11.8%vs.5.8%, P=0.049). COX多因素回歸提示以下三個(gè)變量對(duì)1年預(yù)后有陽(yáng)性預(yù)測(cè)意義：多支病變(HR:2.445,95%CI:1.028-5.815, P=0.043)、術(shù)后eGFR60ml·min-1·1.73m-2(HR:4.245,95%CI:1.405-12.827, P=0.010)、既往卒中史(HR:3.250,95%CI:1.202-8.787, P=0.020) 腎功能方面術(shù)后eGFR60ml·min-1·1.73m-2的患者比術(shù)后eGFR≥60ml·min-1·1.73m2的患者：1年MACCE發(fā)生率(37.9%vs.13.4%,P=0.000)、1年全因死亡(25.9%vs.2.2%,P=0.000)、致死性心梗(19.0%vs.1.6%,P=0.000)。 結(jié)論 1)56.6%的AMI患者合并高血壓,26.8%患者合并糖尿病。各支血管中前降支最易受累,其次為右冠、回旋支和左主干。 2)多支病變的患者年齡較大、有較多的心血管危險(xiǎn)因素及既往卒中病史、糖化血紅蛋白高、低密度脂蛋白高。 3)多支血管病變和術(shù)后eGFR水平為AMI患者1年隨訪MACCE的獨(dú)立預(yù)測(cè)因子。 4)冠造陽(yáng)性患者1年MACCE發(fā)生率為16.5%,多支病變患者1年累積MACCE發(fā)生率更高,更多的患者需要再次血運(yùn)重建。 5)術(shù)后eGFR60ml·min-1·1.73m-2的患者1年MACCE發(fā)生率更高,1年全因死亡率尤其是發(fā)生致死性心梗的比例高。
[Abstract]:Background the prognosis of acute myocardial infarction (AMI) is related to the timeliness of treatment, the size of infarction size and the establishment of collateral circulation. Most patients with acute myocardial infarction have more than one coronary artery seriously involved. A certain number of patients have clinical stenosis of the three main vessels. The rupture of (IRA) plaques and secondary thrombosis of infarction-related vessels are the main mechanisms leading to AMI, although non-infarction-related vessels are not the main causes of AMI. However, it is not entirely certain whether the presence of other non-infarction-related vessels will increase the mortality or the incidence of adverse events. Based on the results of coronary angiography, the effect of the number of diseased vessels on the prognosis of patients with AMI was discussed. Methods from January 2009 to November 2011, all AMI patients who underwent coronary angiography in Shaw Hospital affiliated to Zhejiang University were selected. The data were collected during hospitalization and followed up for 1 year (12 鹵3 months) by outpatient or telephone. The combined end point of follow-up was (MACCE)., the main cardiovascular and cerebrovascular adverse events. According to the number of diseased vessels, all patients were divided into three groups: coronary angiography negative group, single vessel lesion group, two vessel lesion group and three vessel lesion group. Kaplan-Meier method was used to describe the incidence curve of one-year follow-up without MACCE. Cox regression model was used to analyze the independent predictors of 1-year prognosis. Results among 493 patients, 39 (7.9%) were involved in left main coronary artery (LM), 421 (85.4%) involved left anterior descending coronary artery (LAD), and 270 (54.8%) involved left coronary artery circumflex (CX). (RCA) of the right coronary artery was involved in 305 patients (61.9%). 279 (56.6%) of all patients had hypertension and 132 (26.8%) had diabetes. Compared with single vessel lesion, age (64.1 vs.59.2, P 鈮，

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