本文選題：首次醫(yī)療接觸　切入點：急性ST段抬高型心肌梗死　出處：《鄭州大學》2017年博士論文

【摘要】：目的明確鄭州周邊縣市內發(fā)病至首次醫(yī)療接觸在3-6小時的急性ST段抬高心肌梗死靜脈溶栓和轉診PCI患者的臨床特點、30天和1年的預后及其影響因素。材料與方法收集2013年1月至2014年1月隸屬于鄭州市的6家縣級醫(yī)院確診為急性ST段抬高心肌梗死的患者999例,排除發(fā)病至首次醫(yī)療接觸在3小時內或6小時以上者共653例,346例發(fā)病至首次醫(yī)療接觸在3-6小時內患者符合入選標準,排除有溶栓禁忌癥者6例、既不接受溶栓也不接受轉診PPCI者7例后,最終接受在當?shù)乜h醫(yī)院急診靜脈溶栓者192例,拒絕溶栓要求轉診至我院行PCI者141例。對192例當?shù)仂o脈溶栓及141例轉診PPCI患者的臨床資料和特征進行分析,分別記錄兩組患者從癥狀發(fā)作至溶栓或轉診行PPCI治療期間各時間點(段)的時間,分析影響各時間點(段)的因素,并對兩組患者30天和1年的預后進行對比分析,同時分析其影響因素。結果1.轉運PCI組較溶栓組患者年齡偏大、男性居多,且既往有短暫性腦缺血發(fā)作或腦卒中的比例偏高,但無明顯統(tǒng)計學差異;兩組患者在吸煙史、高血壓、糖尿病、血脂異常、心血管疾病史、心肌梗死部位、病變血管支數(shù)、發(fā)生心臟驟停、充血性心力衰竭和心源性休克例數(shù)等方面均無明顯差異。2.兩組患者整個救治過程都有不同程度的時間延擱,但發(fā)病至首次院內醫(yī)療接觸時間、疾病診斷時間和總缺血時間無明顯差別。3.就地溶栓治療組和轉運PCI治療組患者30天全因死亡率無明顯差異,而1年的預后分析顯示轉運PCI組患者明顯好于就地溶栓治療組。4.單因素分析顯示:心源性休克及需要通氣支持的心臟驟停是30天和1年死亡的兩個強力預測因子。既往短暫性腦缺血發(fā)作(TIA)和(或)卒中史始終與患者30天和1年死亡有明顯相關性。左心室射血分數(shù)40%、前壁心肌梗死、糖尿病、既往心肌梗死病史、高血壓及年齡均與患者30天的全因死亡明顯相關。外周動脈疾病影響患者1年的預后。多因素回歸分析顯示:既往TIA或卒中史,需要通氣支持的心臟驟停、心源性休克、LVEF0.40、多支病變或主干病變與30天和1年死亡均相關。經多因素校正后結果顯示:糖尿病與30天死亡相關,而轉運PPCI明顯提高患者1年的生存率且轉運PCI時間是PPCI組生存的獨立預測因素。結論1.基層醫(yī)院院內溶栓治療仍然是目前較為安全有效的再灌注治療手段之一,但整個溶栓過程有不同程度的時間延遲。2.發(fā)病至首次醫(yī)療接觸在3-6小時內的STEMI患者,盡管轉運PCI時間大于2小時,但其總的預后明顯好于就地靜脈溶栓患者。3.盡管轉診PCI組患者轉運時間有較長的延遲,兩組患者最終的總缺血時間無明顯統(tǒng)計學差異,轉診PCI的最終獲益明顯抵消了其轉運時間超過2小時的時間延遲。
[Abstract]:Objective to determine the clinical features of patients with acute ST-segment elevation myocardial infarction (ST-elevation) treated with intravenous thrombolytic therapy and referral to PCI for 30 days and 1 year from onset to first medical exposure in Zhengzhou surrounding counties and cities. Materials and methods were used to study the prognostic factors of patients with acute ST-segment elevation myocardial infarction for 30 days and 1 year. From January 2013 to January 2014, 999 patients with acute ST-segment elevation myocardial infarction in 6 county-level hospitals affiliated to Zhengzhou were collected. The total of 653 patients who were excluded from the first medical exposure within 3 hours or more or more than 6 hours from the onset of the disease to the first medical exposure within 3 to 6 hours met the inclusion criteria, and 6 patients with thrombolytic contraindications were excluded. After neither thrombolytic therapy nor referral of PPCI was accepted in 7 patients, 192 patients received intravenous thrombolysis in the emergency department of the local county hospital. There were 141 patients who refused to be referred to our hospital for PCI. The clinical data and characteristics of 192 local venous thrombolytic patients and 141 referrals to PPCI were analyzed. The time from symptom onset to thrombolytic therapy or referral to PPCI treatment was recorded, and the factors affecting each time point (segment) were analyzed, and the prognosis of 30 days and 1 year were compared between the two groups. At the same time, the influencing factors were analyzed. 1. The patients in PCI group were older than those in thrombolytic group, and the proportion of patients with transient ischemic attack or stroke was higher than that of thrombolytic group, but there was no significant difference between the two groups. 2. Hypertension, diabetes, dyslipidemia, history of cardiovascular disease, location of myocardial infarction, number of diseased vessels, cardiac arrest, There was no significant difference in the number of cases of congestive heart failure and cardiogenic shock. 2. The whole treatment process of the two groups was delayed in varying degrees, but the time from onset to first in-hospital medical contact was delayed. There was no significant difference between the time of diagnosis and the time of total ischemia. 3. There was no significant difference in the 30-day all-cause mortality between the thrombolytic therapy group and the PCI transport treatment group. One-year prognostic analysis showed that patients in the PCI group were significantly better than those in the in-situ thrombolytic therapy group .4. univariate analysis showed that cardiogenic shock and cardiac arrest requiring ventilation support were two powerful predictors of 30-day and 1-year mortality. There was a significant correlation between TIA and / or stroke history in 30 days and 1 year of death in patients with transient ischemic attack. Left ventricular ejection fraction (LVEF), anterior wall myocardial infarction, left ventricular ejection fraction (LVEF), left ventricular ejection fraction (LVEF), anterior wall myocardial infarction (AMI), Diabetes mellitus, myocardial infarction history, hypertension and age were significantly associated with 30 days of all-cause death. Peripheral artery disease affected the prognosis of patients for one year. Multivariate regression analysis showed that: previous TIA or stroke history. For cardiac arrest requiring ventilation support, LVEF 0.40 for cardiogenic shock, multivessel lesions or trunk lesions were associated with 30 days and 1 year of death. The results of multifactorial adjustment showed that diabetes was associated with 30 days of death. The transport of PPCI significantly improved the 1-year survival rate of patients and the time of transporting PCI was an independent predictor of survival in PPCI group. Conclusion 1.Inhospital thrombolytic therapy in primary hospitals is still one of the more safe and effective methods of reperfusion therapy at present. However, the whole thrombolytic process was delayed in varying degrees. 2.The onset of thrombolysis occurred in patients with STEMI within 3-6 hours of initial medical exposure, although the PCI transport time was longer than 2 hours. However, the overall prognosis was significantly better than that of intravenous thrombolytic patients in situ .3.Although there was a long delay in the transit time of the patients in the referred PCI group, there was no significant difference in the final total ischemic time between the two groups. The ultimate benefit of referral PCI significantly offset the delay of more than 2 hours of transit time.
【學位授予單位】：鄭州大學
【學位級別】：博士
【學位授予年份】：2017
【分類號】：R542.22

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