本文關(guān)鍵詞： 急性心肌梗死 無復(fù)流 臨床特點 預(yù)后 直接PCI 強化他汀治療 無復(fù)流 預(yù)后　出處：《安徽醫(yī)科大學(xué)》2015年博士論文　論文類型：學(xué)位論文

【摘要】：第一部分急性心肌梗死患者直接PCI不同階段發(fā)生無復(fù)流的臨床意義背景:直接經(jīng)皮冠狀動脈介入治療(percutaneous coronary intervention,PCI)是恢復(fù)急性心肌梗死(acute myocardial infarction,AMI)患者冠狀動脈前向血流的最有效策略之一。然而,隨之而來的無復(fù)流(No-reflow,NR)現(xiàn)象,降低了PCI的療效以及給患者帶來不良的臨床預(yù)后,當(dāng)前已經(jīng)引起臨床介入醫(yī)師的廣泛重視。對發(fā)生NR患者臨床特征的分析,可以篩選出高危病人;進一步對發(fā)生在直接PCI的不同階段(包括支架植入術(shù)后階段和發(fā)生在球囊預(yù)擴張后至支架植入前的階段)的NR患者臨床特征的分析,可以為心血管介入醫(yī)師提供更多有價值的臨床信息。然而,在PCI術(shù)中不同階段的發(fā)生NR的臨床意義尚未見相關(guān)研究與報道。我們的研究分析比較NR發(fā)生在直接PCI的兩個階段(支架植入術(shù)后階段和發(fā)生在球囊預(yù)擴張后至支架植入前的階段)的AMI患者的臨床和血管造影特征,隨訪上述兩個階段各自的臨床預(yù)后,并探討早期階段無復(fù)流發(fā)生的預(yù)測因素。方法:連續(xù)收集2009年1月至2013年12月在安徽醫(yī)科大學(xué)第一附屬醫(yī)院心內(nèi)科接受直接PCI的420例ST段抬高心肌梗死患者。其中63例(15%)患者發(fā)生NR構(gòu)成我們的研究對象。根據(jù)患者在直接PCI期間發(fā)生無復(fù)流的時間不同分為早期NR組和隨后NR組。比較兩組之間的臨床特征和血管造影結(jié)果。運用Logistic多變量逐步回歸分析確定早期NR的預(yù)測因素,并分析兩組PCI術(shù)后長期的臨床結(jié)果。應(yīng)用SPASS17.0統(tǒng)計軟件對上述資料進行分析。結(jié)果:在直接PCI期間63例無復(fù)流中,早期NR組28例,隨后NR組35例。兩組使用手動血栓抽吸導(dǎo)管的比例沒有明顯差異(53.6%vs 37.1%,P=0.192)。通過與隨后NR組的基線特征比較,我們發(fā)現(xiàn)早期NR組有更高的糖尿病的比例(42.9%vs20%)、更低的入院時SBP(102.2±8.3mm Hg vs 110.5±7.6mm Hg)、更高的Killip分級III級比例(71.4%vs45.7%)和更長的再灌注時間(7.1±2.3 h vs 5.88±2.2 h),差異有統(tǒng)計學(xué)意義(P均0.05)。血管造影特征比較,兩組初始TIMI血流0/1百分比(64.3%vs37.1%)、目標(biāo)病變長度(31.4±13.6mm vs13.6±17.3mm)及血栓積分≥4(67.9%vs 42.9%)有顯著的統(tǒng)計學(xué)差異(P均0.05)。多重Logistc逐步回歸分析表明,入院時SBP100mm Hg(OR=4.580;95%可信區(qū)間1.385-15.150;P=0.0130)、再灌注時間≥6 h(OR=4.978;95%可信區(qū)間1.468-16.882;P=0.010)和血栓評分≥4(OR=2.708;95%可信區(qū)間0.833-8.799;P=0.008)是早期NR發(fā)生的獨立危險因素。在1年的隨訪期間,早期的NR組出現(xiàn)心源性死亡6例和由于出血并發(fā)癥與嚴(yán)重腎功能衰竭所致的非心源性死亡2例,導(dǎo)致全因死亡率28.6%(n=8),隨后NR組的全因死亡率為5.7%(心源性死亡2例)。與隨后NR組比較,早期NR組心源性死亡有增加的趨勢,但是差異無統(tǒng)計學(xué)意義(21.4%比5.7%,P=0.063)。早期NR組的全因死亡率和MACE發(fā)生率顯著高于隨后NR組(分別為28.6%vs 5.7%、35.7%vs 14.3%,P均0.05)。上述兩組分別與基線比較,在1年隨訪結(jié)束時LVEF減少(42.5±4.7mm vs 48.6±3.7mm,48.6±3.7mm vs 50.2±2.9mm,P均0.001),LVEDD增加(56.0±4.0mm vs 49.6±2.8mm,49.6±2.8mm vs 48.3±3.7mm,P均0.001)。此外,在1年隨訪結(jié)束時,早期NR組LVEF明顯低于隨后NR組(42.5±4.7 vs 47.8±3.5,P0.001),而LVEDD顯著高于隨后NR組(56.0±4.0 vs51.5±4.7,P0.001)。結(jié)論:AMI直接PCI患者早期NR組有更嚴(yán)重的基線臨床和血管造影特點以及更差的長期預(yù)后。第二部分直接PCI患者術(shù)前強化他汀治療的臨床觀察目的:強化他汀藥物治療能否改善直接PCI患者術(shù)中無復(fù)流現(xiàn)象當(dāng)前臨床上還存在很大的爭議。我們的研究進一步驗證直接PCI術(shù)前強化阿托伐他汀治療是否減少患者無復(fù)流發(fā)生,并探討其對術(shù)中處理無復(fù)流藥物使用情況的影響。方法:收集施行直接PCI的STEMI患者130例,隨機分為負荷劑量治療組和對照組。負荷劑量治療組60例,在PCI術(shù)前給予80mg首劑負荷劑量阿托伐他汀嚼服,術(shù)后20mg/天口服維持;對照組70例,給予阿托伐他汀20mg/天的標(biāo)準(zhǔn)劑量口服維持治療。記錄患者的基線臨床資料、LVEF、LVEDD及術(shù)中處理無復(fù)流藥物(地爾硫罩、硝普鈉、腺苷、替羅非班)的使用情況。術(shù)中采用心肌梗死溶栓分級(TIMI)血流分級與校正的TIMI血流幀數(shù)(CTFC)評價心肌微循環(huán)灌注,收集冠狀動脈造影及PCI影像資料。隨訪記錄術(shù)后1個月內(nèi)主要不良心臟事件(major adverse cardiovascular events,MACE)發(fā)生;測量1個月時LVEF、LVEDD并檢測hs-CRP水平。結(jié)果:負荷劑量治療組術(shù)中發(fā)生無復(fù)流13例(21.7%),對照組18例(25.7%),兩組間比較,差異無統(tǒng)計學(xué)意義(P=0.589)。前組手術(shù)結(jié)束前無復(fù)流者持續(xù)存在2例(3.3%),對照組4例(5.7%)(P=0.976)。負荷劑量治療組術(shù)中地爾硫罩重復(fù)使用率、硝普鈉重復(fù)使用率、腺苷重復(fù)使用率均分別低于對照組(8.3%vs21.4%,5%vs18.6%,5%vs 17.1%,P均0.05),兩組替羅非班使用率比較,差異無統(tǒng)計學(xué)意義(3.3%vs 11.4%,P=0.084)。前組1個月內(nèi)MACE事件發(fā)生率低于后組(8.3%vs 22.9%,P=0.023)。負荷劑量治療組LVEF略高于對照組,LVEDD略低于對照組,但差異無統(tǒng)計學(xué)意義(P均0.05)。與對照組比較,在1個月的隨訪時負荷劑量治療組hs-CRP水平顯著下降[7.8(6.2-18.3)vs 10.3(8.6-20.6),P0.05]。與基線比較,負荷劑量治療組明顯下降[7.8(6.2-18.3)vs16.5(13.4-25.4),P0.05];對照組明顯下降[10.3(8.6-20.6)vs15.9(12.5-24.3),P均0.05]。結(jié)論:盡管術(shù)前強化他汀治療未能顯示改善直接PCI患者術(shù)中無復(fù)流的發(fā)生率,但是其可以減少術(shù)中血管擴張劑的使用,改善患者術(shù)后近期臨床預(yù)后,并進一步下調(diào)hs-CRP水平。
[Abstract]:The first part of the direct PCI in patients with acute myocardial infarction in different stages of background and clinical significance of no reflow: direct percutaneous coronary intervention (percutaneous coronary, intervention, PCI) is the recovery of acute myocardial infarction (acute myocardial, infarction, AMI) of coronary artery in patients with anterior to the one of the most effective strategies for blood flow. However, it no longer flow (No-reflow, NR), reduced the efficacy of PCI as well as to patients with poor clinical prognosis, the current has attracted wide attention of interventional cardiologist. Analysis of the clinical features of NR patients, selected high-risk patients; further to occur in different stages of PCI (including direct stent implantation and stage in balloon dilation after stent implantation before the stage) analysis of the clinical characteristics of patients with NR, can provide more valuable for clinical interventional cardiologists The information in the PCI. However, during different stages of the clinical significance of NR has been studied and reported. The two stage of comparative analysis we NR occurred in PCI (direct stenting and balloon dilation occurred in the stage to the stage before stent implantation) clinical and angiographic characteristics of AMI patients the clinical prognosis of the above two stages respectively, and to explore the early stages of no reflow predictors of the occurrence. Methods: from January 2009 to December 2013 to accept direct PCI in the Department of Cardiology of the First Affiliated Hospital of Medical University Of Anhui, 420 cases of patients with ST elevation myocardial infarction. 63 cases (15%) patients with NR constitute the object of our study according to the patients. No reflow time were divided into early NR group and NR group in PCI during the subsequent direct comparison between the two groups. The clinical characteristics and angiographic results using Logistic. Multivariate stepwise regression analysis to determine predictors of early NR, and to analyze the long term results of PCI two groups after operation. The data were analyzed by SPASS17.0 statistical software. Results: in 63 cases of direct PCI during no reflow, NR group of 28 cases of early, and 35 cases in NR group. There was no significant difference between two groups the use of manual thrombus aspiration catheter ratio (53.6%vs 37.1%, P=0.192). By comparing with the baseline characteristics of subsequent NR group, we found that the early NR group had a higher proportion of diabetes mellitus (42.9%vs20%), lower admission SBP (102.2 + 8.3mm Hg vs + 7.6mm 110.5 Hg), higher Killip class III the ratio (71.4%vs45.7%) and the longer time of reperfusion (7.1 H + 2.3 vs 5.88 + 2.2 h), the difference was statistically significant (P < 0.05). Angiographic features comparison, two groups of initial TIMI blood 0/1 (64.3%vs37.1%), the percentage of target lesion length (31.4 + 13.6mm and vs13.6 + 17.3mm) The thrombus integral is greater than or equal to 4 (67.9%vs 42.9%) there is a statistically significant difference (P < 0.05). Multiple Logistc regression analysis showed that admission SBP100mm Hg (OR=4.580; 95% CI 1.385-15.150; P=0.0130), reperfusion time was greater than 6 h (OR=4.978; 95% Ci, 1.468-16.882; P=0.010 = 4) and thrombus score (OR=2.708 95% confidence interval; 0.833-8.799; P=0.008) is an independent risk factor for early NR. During 1 years of follow-up, the early NR group appeared 6 cases of cardiac death and 2 cases with non cardiac complications of hemorrhage and severe renal failure caused by death, resulting in all-cause mortality 28.6% (n=8), and NR group the all-cause mortality was 5.7% (2 cases of cardiac death). And then compared with NR group, NR group had an increasing trend of early cardiac death, but the difference was not statistically significant (21.4% vs 5.7%, P=0.063). Early NR group of all-cause mortality and the incidence of MACE significantly Then higher than NR group (28.6%vs 5.7%, 35.7%vs 14.3%, P 0.05). The two groups were compared with the baseline, LVEF decreased after 1 years of follow-up (42.5 + 4.7MM vs 48.6 + 3.7mm, 48.6 + 3.7mm vs 50.2 + 2.9mm, P 0.001), LVEDD (56 + 4.0mm vs 49.6 + 2.8mm, 49.6 + 2.8mm vs 48.3 + 3.7mm, P 0.001). In addition, at the end of the 1 years of follow-up, early NR group LVEF was significantly lower than that of the NR group (42.5 + 4.7 vs 47.8 + 3.5, P0.001), while LVEDD was significantly higher than that of group NR (56 + 4 and vs51.5 + 4.7, P0.001). Conclusion: AMI PCI patients in NR group with baseline clinical and angiographic characteristics of more serious and long-term prognosis. The second part of PCI patients before intensive statin therapy clinical observation Objective: intensive statin therapy can improve PCI directly in patients with no reflow phenomenon in the clinic is still controversial our study. To further verify the direct PCI preoperative atorvastatin treatment is reduced in patients with no reflow, and investigate the effect of no reflow on drug use during treatment. Methods: 130 patients with STEMI were collected for direct PCI patients were randomly divided into treatment group and control group loading dose. Loading dose of 60 cases in the treatment group give first dose, 80mg loading dose of atorvastatin chewing before PCI, maintain 20mg/ orally days after operation; 70 cases in control group were given standard oral dose of atorvastatin 20mg/ day maintenance therapy. Clinical data, patients with baseline LVEF, LVEDD and the operative treatment of no reflow (diltiazem drug cover. Sodium nitroprusside, adenosine, tirofiban). The use of intraoperative use of thrombolysis in myocardial infarction (TIMI) grading flow classification and correction TIMI frame (CTFC) in evaluation of myocardial microcirculation perfusion, collecting coronary angiography and PCI images were recorded. After 1 months of major adverse cardiac events (major adverse cardiovascular events, MACE); measured at 1 months of LVEF, LVEDD and hs-CRP level detection. Results: loading dose treated group was no reflow in 13 cases (21.7%), the control group of 18 cases (25.7%), were compared between the two groups. There was no statistically significant difference (P=0.589). The former group before the end of surgery, no reflow were persistent in 2 cases (3.3%), 4 cases in the control group (5.7%) (P=0.976). The treatment group was loading dose of diltiazem cover repeated use rate, rate of repeated use of sodium nitroprusside, adenosine repeated use rate were significantly lower than those of control group (8.3%vs21.4% 17.1%, 5%vs18.6%, 5%vs, P 0.05), two groups of tirofiban use rate comparison, the difference was not statistically significant (3.3%vs 11.4%, P=0.084). The MACE group before the event occurred within 1 months after the rate is lower than the group (8.3%vs 22.9%, P=0.023). Loading dose LVEF in treatment group was slightly higher than the control group, LVEDD but lower than that of control group There was no statistically significant difference (P < 0.05). Compared with the control group, after 1 months of follow-up loading dose hs-CRP in treatment group was significantly decreased by [7.8 (6.2-18.3) vs 10.3 (8.6-20.6), P0.05]. compared with the baseline, the loading dose treatment group significantly decreased [7.8 (6.2-18.3) vs16.5 (13.4-25.4), P0.05] control group; decreased [10.3 (8.6-20.6) vs15.9 (12.5-24.3), P was 0.05]. conclusion: Although preoperative intensive statin therapy failed to show improvement in patients with direct PCI incidence of no reflow, but it can reduce the use of vasodilators in patients, improve the postoperative prognosis, and further lowered the level of hs-CRP.

【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R542.22

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