本文選題：重組人腦利鈉肽　切入點：老年　出處：《河北醫(yī)科大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：目的:研究重組人腦利鈉肽(recombinant human brain natriuretic peptide,rh BNP)對老年患者急性前壁心肌梗死直接PCI術(shù)后患者心功能的影響。方法:連續(xù)選取2015年1月-2016年12月在我院心血管內(nèi)五科住院治療的符合急性前壁心肌梗死診斷標(biāo)準(zhǔn)且接受急診PCI的老年患者63例為研究對象,年齡≥65歲,平均年齡為69.09±2.93歲。依據(jù)數(shù)字化隨機表隨機分為靜脈應(yīng)用重組人腦利鈉肽(rh BNP)組32例(男性25例,女性7例)和硝酸甘油治療組(nitroglycerin,NIT組)31例(男性25例,女性6例)。兩組患者在術(shù)前均給予阿司匹林片300mg、硫酸氫氯吡格雷300mg嚼服,阿托伐他汀鈣片40mg口服,行急診PCI后繼續(xù)常規(guī)應(yīng)用抗凝、抗血小板聚集、降脂、血管緊張素轉(zhuǎn)換酶抑制劑(Angoitensin converting enzyme inhibitor,ACEI)或血管緊張素受體拮抗劑(angiotensin receptor blocker,ARB)、β受體阻滯劑等藥物治療。rh BNP組在常規(guī)治療的基礎(chǔ)上,PCI術(shù)后血流動力學(xué)穩(wěn)定、血壓允許(收縮壓≥90mm Hg)的情況下給予rh BNP(新活素,康哲藥業(yè))負(fù)荷量1.5ug/kg靜脈注射,以0.0075ug/kg/min為起始劑量靜脈泵入,用藥期間保證收縮壓≥85mm Hg,平均動脈壓≥65mm Hg,根據(jù)患者臨床癥狀及血壓情況,調(diào)整rh BNP劑量范圍(0.0075ug/kg/min-0.03ug/kg/min),并在6小時內(nèi)調(diào)至患者能耐受的合適劑量,共維持72小時靜脈泵點。NIT組在基礎(chǔ)治療的前提下,PCI術(shù)后血流動力學(xué)穩(wěn)定、血壓允許(收縮壓≥90mm Hg)的情況下給予硝酸甘油10ug/min靜脈泵點,用藥期間保證收縮壓≥85mm Hg,平均動脈壓≥65mm Hg,根據(jù)患者臨床癥狀及血壓情況,調(diào)整硝酸甘油的用量(10ug/min-100ug/min泵入),并在6小時內(nèi)調(diào)至患者可耐受的合適劑量,共維持72小時靜脈泵入。通過觀察兩組患者在治療前后心率、呼吸頻率、收縮壓、血NT-pro BNP水平、24小時出入量差值、肌酸激酶同工酶(CK-MB)和肌鈣蛋白I(c Tn I)峰值、左室射血分?jǐn)?shù)(left ventricular ejection fraction,LVEF)、二尖瓣舒張早期血流峰值(E)與二尖瓣環(huán)舒張早期運動速度(e,)比值(E/e,)、左室舒張末內(nèi)徑(left ventricular end diastolic diameter,LVEDD),左室收縮末內(nèi)徑(left ventricular end systolic diameter,LVESD),探討rh BNP對老年患者急性前壁心肌梗死直接PCI治療術(shù)后心功能的影響。通過觀察應(yīng)用過程中低血壓、過敏、頭痛、急性腎功能異常、惡性心律失常等不良事件發(fā)生率及主要心血管不良事件(MACE事件)(包括:梗死后心絞痛、院外心衰加重、惡性室性心律失常、心源性猝死),來評價rh BNP在老年患者急性前壁心肌梗死直接PCI術(shù)后應(yīng)用的有效性及安全性。兩組患者均應(yīng)用SPSS 20.0統(tǒng)計軟件對數(shù)據(jù)進行統(tǒng)計分析。統(tǒng)計結(jié)果將P0.05(雙側(cè))作為有差異并具有統(tǒng)計學(xué)意義。結(jié)果:1兩組患者基線資料:年齡、性別、吸煙、高血壓、高血脂、糖尿病、收縮壓、舒張壓、呼吸頻率、心率、首次醫(yī)療接觸時間(first medical contact time,FMC)、發(fā)病至血管開通時間、血漿NT-pro BNP濃度、腎肌酐清除率、Killip分級上均無統(tǒng)計學(xué)差異(P0.05)。兩組患者在應(yīng)用鹽酸替羅非班治療及常規(guī)藥物治療上均無統(tǒng)計學(xué)差異(P0.05)。2兩組患者呼吸頻率在治療后24h、72h呼吸情況較前有所降低(P0.05),且rh BNP組較NIT組降低更顯著(P0.05)[(22.92±1.31)次/分vs(24.86±1.38)次/分,P0.01;(17.25±1.09)次/分vs(22.75±1.48)次/分,P0.01];兩組患者的心率在治療后24h、72h較治療前均降低(P0.05),且rh BNP組較NIT組降低更為顯著[(80.79±5.15)次/分vs(85.26±4.83)次/分,P=0.001;(65.25±4.28)次/分vs(71.97±5.93)次/分,P0.01];兩組患者收縮壓在治療24h、72h后較前均明顯降低(P0.05),且rh BNP組較NIT組降低更為明顯[(120.45±9.93)mm Hg vs(126.94±10.04)mm Hg,P=0.012;(104.12±5.45)mm Hg vs(111.09±5.75)mm Hg,P0.01]。兩組患者治療后第一個、第三個24小時出入量差值均有統(tǒng)計學(xué)差異(P0.05),且rh BNP組較NIT組升高明顯[(731.55±124.51)ml vs(657.14±155.01)ml,P=0.04;(964.06±189.51)mlvs(799.83±146.91)ml,P0.01]。3通過對兩組CK-MB、c Tn I峰值的測定,rh BNP組較NIT組減低,有統(tǒng)計學(xué)意義(P0.05)[CK-MB(195.30±89.71)u/L vs(227.06±88.27)u/L,P0.01;c Tn I(55.29±15.36)ng/ml vs(66.76±16.45)ng/ml,P=0.006]。4兩組患者在治療72h、7天后血NT-pro BNP水平較治療前明顯降低,且rh BNP組較NIT降低更為明顯,有統(tǒng)計學(xué)意義(P0.05)[(1391.09±50.62)pg/ml vs(1505.72±60.69)pg/ml,P0.01;(849.01±50.96)pg/ml vs(947.04±47.12)pg/ml,P0.01]。在治療1個月時再次測定兩組患者血NT-pro BNP水平,無明顯差異[(474.84±46.45)pg/ml vs(481.76±64.58)pg/ml,P=0.626]。5兩組患者在治療7天后LVEDD值與LVESD值,rh BNP組與NIT組相比較無統(tǒng)計學(xué)差異[LVEDD:(53.70±3.99)mm vs(54.13±4.21)mm,P=0.405];[LVESD:(40.64±4.29)mm vs(40.79±4.35)mm,P=0.888];rh BNP組LVEF值與NIT組相比較,無統(tǒng)計學(xué)意義[(46.11±3.41)%vs(45.04±3.21)%,P=0.205];在治療1個月時,LVEDD值、LVESD值rh BNP組與NIT組均比原來縮小,且rh BNP組較NIT組縮小較為明顯,[LVEDD:(49.06±4.37)mm vs(52.68±3.74)mm,P0.01];[LVESD:(36.32±3.66)mm vs(38.74±4.03)mm,P0.01]。LVEF值rh BNP組、NIT組較治療7天時均有升高,且rh BNP組較NIT組升高明顯,有統(tǒng)計學(xué)差異[(51.98±3.03)%vs(47.73±3.71)%,P0.01]。兩組患者E/e,值,在治療7天和1個月時,rh BNP組均比NIT組改善明顯[(13.55±3.45)vs(15.81±4.18),P=0.023;(10.24±2.31)vs(13.04±2.43),P0.01]。6兩組患者在治療過程中均未發(fā)現(xiàn)過敏現(xiàn)象。rh BNP組發(fā)現(xiàn)1例患者出現(xiàn)低血壓現(xiàn)象(收縮壓85mm Hg),NIT組發(fā)現(xiàn)2例,在調(diào)整藥物的劑量后低血壓現(xiàn)象沒有再發(fā)生,兩組患者在發(fā)生低血壓現(xiàn)象上無統(tǒng)計學(xué)差異(P0.05);rh BNP組患者中未出現(xiàn)頭痛病例,NIT組則出現(xiàn)5例,后患者耐受,繼續(xù)給予硝酸甘油靜脈泵點,在頭痛發(fā)生情況上,NIT組較rh BNP組明顯,有統(tǒng)計學(xué)意義(P0.05);在出現(xiàn)室性心律失常上,rh BNP組未出現(xiàn),NIT組出現(xiàn)2例頻發(fā)室性早搏,給予鹽酸利多卡因抗心律失常治療后,未再發(fā)生,兩組相比無統(tǒng)計學(xué)差異(P0.05);兩組患者在治療期間均未發(fā)現(xiàn)急性腎損傷。7兩組患者在出院后1周、1個月、3個月時均行動態(tài)心電圖檢查,通過隨訪在3個月時,rh BNP組出現(xiàn)1例室性心律失常者,NIT組出現(xiàn)2例室性心律失常者,通過比較,兩組患者在室性惡性心律失常發(fā)生率上無統(tǒng)計學(xué)差異(P=0.613)。rh BNP組1例患者出現(xiàn)梗死后心絞痛,NIT組出現(xiàn)3例,兩組再發(fā)心絞痛發(fā)生率無統(tǒng)計學(xué)差異(P=0.286)。出院后rh BNP組無患者再次發(fā)生心衰加重情況,NIT組出現(xiàn)2例患者,在院外心衰發(fā)生上,兩組發(fā)生率無統(tǒng)計學(xué)差異(P=0.238)。兩組患者均未出現(xiàn)心源性猝死事件。結(jié)論:對于急性前壁心肌梗死直接PCI治療的老年患者,靜脈應(yīng)用rh BNP,可明顯緩解臨床癥狀、穩(wěn)定血流動力學(xué)狀態(tài)并顯著改善心功能。
[Abstract]:Objective: To study the effects of recombinant human brain natriuretic peptide (recombinant human brain natriuretic peptide, Rh BNP) effects on cardiac function in elderly patients with acute anterior myocardial infarction after primary PCI. Methods: from January 2015 December -2016 in our hospital in five hospitalized cardiovascular treatment with acute anterior wall myocardial infarction diagnostic criteria and received emergency PCI of 63 cases of elderly patients as the research object, 65 years of age or older. The average age was 69.09 + 2.93 years. On the basis of the digital random table were randomly divided into intravenous recombinant human brain natriuretic peptide (RH BNP) group of 32 cases (25 cases, male 7 cases of female) and nitroglycerin group (nitroglycerin NIT group) 31 cases (25 cases, male 6 cases of female). Two groups of patients were treated with Aspirin Tablets 300mg in the preoperative, clopidogrel 300mg chawing, Atorvastatin Calcium Tablets 40mg orally after undergoing PCI to conventional anticoagulation, antiplatelet poly Set, lipid-lowering, angiotensin converting enzyme inhibitors (Angoitensin converting, enzyme inhibitor, ACEI) or angiotensin receptor antagonist (angiotensin receptor, blocker, ARB), beta blockers and other drugs for the treatment of.Rh BNP group on the basis of conventional treatment, stable hemodynamics after PCI, blood pressure (systolic blood pressure was 90mm Hg allowed under the condition of given RH BNP) (Xinhuosu, kangzhe pharmaceutical) load 1.5ug/kg intravenous injection with 0.0075ug/kg/min as initial dose of intravenous infusion, medication period guarantee systolic blood pressure more than 85mm Hg, mean arterial pressure was 65mm Hg, according to the clinical symptoms and blood pressure in patients with the situation, adjust the RH BNP dose range (0.0075ug/kg/min-0.03ug/kg/min). And within 6 hours to the patient can appropriate dose tolerance, were maintained for 72 hours intravenous.NIT group based on the basic treatment, stable hemodynamics after PCI, blood pressure (systolic blood pressure was allowed 90mm Hg) under the condition of given nitroglycerin intravenous medication during 10ug/min, ensure systolic blood pressure than 85mm Hg, mean arterial pressure was 65mm Hg, according to the clinical symptoms and blood pressure, adjust the dosage of nitroglycerin (10ug/min-100ug/min pump), and in 6 hours to patients with appropriate dose tolerance, total maintenance 72 hour intravenous infusion. Through the observation of two groups of patients before and after treatment, heart rate, respiratory rate, systolic blood pressure, serum NT-pro BNP levels, 24 hours of quantity difference, creatine kinase isoenzyme (CK-MB) and troponin I (C Tn I) peak, left ventricular ejection fraction (left ventricular ejection fraction, LVEF), mitral valve the early diastolic peak (E) and early diastolic velocity of mitral annulus (E) ratio (E/e), left ventricular end diastolic diameter (left ventricular end diastolic diameter, LVEDD), left ventricular end systolic diameter (left ventricular end systolic DIAM Eter, LVESD, RH) to investigate the effects of BNP on cardiac function in elderly patients with PCI in acute anterior myocardial infarction after treatment. The blood pressure, the observation in the application process of allergy, headache, acute renal dysfunction, arrhythmia and other adverse events and the incidence of major cardiovascular adverse events (event MACE) (including: outside the hospital after infarction angina, heart failure, malignant ventricular arrhythmia and sudden cardiac death), to evaluate the efficacy and safety of the application of RH BNP direct PCI in elderly patients with acute anterior myocardial infarction after operation. Two patients were used SPSS 20 statistical software for statistical analysis of data. The statistical results of the P0.05 (as there are differences in bilateral) and had statistical significance. Results: 1 patients in two groups: age, gender, baseline smoking, hypertension, hyperlipidemia, diabetes, systolic blood pressure, diastolic blood pressure, respiratory rate, heart rate, the first medical contact time (first medical contact time,FMC),鍙戠梾鑷寵綆″紑閫氭椂闂，

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