本文選題：急性ST段抬高心肌梗死 + 慢性完全閉塞病變��； 參考：《首都醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的探討對(duì)接受急診介入治療(percutaneous coronary intervention,PCI)的急性ST段抬高心肌梗死(ST-segment elevation myocardial infarction,STEMI)患者非梗死相關(guān)血管慢性完全閉塞病變(non-infarct-related artery,non-IRA-CTO)擇期血運(yùn)重建對(duì)臨床預(yù)后影響,并識(shí)別可能影響其臨床預(yù)后的因素,以期為該類患者尋找一種安全、可行的血運(yùn)重建策略,為臨床提供進(jìn)一步的循證醫(yī)學(xué)依據(jù)。方法對(duì)我院急診科2005年1月至2013年6月行急診PCI的患者進(jìn)行篩選,符合入組標(biāo)準(zhǔn)的STEMI合并non-IRA-CTO的共226例患者,擇期non-IRA-CTO手術(shù)成功組82例患者,手術(shù)失敗組36例患者,未行手術(shù)組108例患者。記錄患者一般臨床資料、藥物使用情況、超聲心動(dòng)圖及化驗(yàn)檢查結(jié)果等,收集并閱讀介入治療光盤及手術(shù)記錄等資料,電話隨訪3年內(nèi)主要心血管事件(major adverse cardiac events,MACE)的發(fā)生情況,MACE事件包括心源性死亡,再次血運(yùn)重建,心肌梗死,大出血,卒中。所有數(shù)據(jù)以均值±標(biāo)準(zhǔn)差(Mean±SD)表示,組間比較采用t檢驗(yàn)或非參數(shù)檢驗(yàn)。計(jì)數(shù)資料采用χ2檢驗(yàn)。根據(jù)隨訪結(jié)果,臨床終點(diǎn)通過Log-rank進(jìn)行分析,生存分析應(yīng)用Kaplan-Meier方法,并且通過多元Cox回歸分析各組之間調(diào)整風(fēng)險(xiǎn)后的長(zhǎng)期生存差異,P0.05為差異有顯著統(tǒng)計(jì)學(xué)意義。結(jié)果擇期non-IRA-CTO手術(shù)成功組,手術(shù)失敗組及未手術(shù)組患者的基線資料、PCI相關(guān)指標(biāo)差異無統(tǒng)計(jì)學(xué)意義。手術(shù)成功組患者術(shù)后1月超聲結(jié)果提示射血分?jǐn)?shù)較術(shù)前有改善(P0.05),手術(shù)失敗組及未行手術(shù)組射血分?jǐn)?shù)未見明顯改善。3年內(nèi)MACE事件手術(shù)成功組發(fā)生12例(14.6%),手術(shù)失敗組15例(41.7%),未手術(shù)組為45例(41.7%),差異有顯著統(tǒng)計(jì)學(xué)差異(P0.001);其中,心源性死亡發(fā)生分別為1例(1.2%)、3例(8.3%)、16例(14.8%),差異有統(tǒng)計(jì)學(xué)差異(P0.05);Kaplan-Meier生存分析發(fā)現(xiàn):手術(shù)成功組心源性死亡(1.2%vs.8.3%,p=0.036)及主要MACE事件(14.6%vs.41.7%,p0.001)較手術(shù)失敗組均明顯降低;手術(shù)失敗組與未行手術(shù)組在心源性死亡及主要MACE事件無差異;手術(shù)成功組心源性死亡(1.6%vs.13.6%,p=0.001)及主要MACE事件(14.6%vs.41.7%,p0.001)較未開通組(手術(shù)失敗組及為未行手術(shù)組)均顯著降低;多元Cox回歸分析發(fā)現(xiàn):手術(shù)成功是患者3年無心源性死亡(HR:0.035,95%CI:0.003-0.42,p=0.008)及無主要心血管事件(HR:0.344,95%CI:0.16-0.73,p=0.005)的獨(dú)立預(yù)測(cè)因素。結(jié)論成功的non-IRA-CTO擇期血運(yùn)重建可以增加接受急診PCI的STEMI患者擇期手術(shù)后1個(gè)月的射血分?jǐn)?shù),減少患者3年的MACE事件,從而改善患者的臨床預(yù)后。未來還需要更多的大規(guī)模、隨機(jī)對(duì)照試驗(yàn)來全面衡量non-IRA-CTO擇期血運(yùn)重建在該類患者的臨床預(yù)后價(jià)值。
[Abstract]:Objective to investigate the prognostic effects of selective revascularization of non-infraction related chronic total occlusive lesions in patients with ST-segment elevation myocardial infraction (ST-segment elevation myocardial inflexion) in patients with acute ST-segment elevation myocardial infarction (ST-segment elevation myocardial occlusion) undergoing emergency interventional therapy. In order to find a safe and feasible strategy of revascularization and provide further evidence-based medicine basis for clinical practice, we can identify the factors that may affect the clinical prognosis. Methods from January 2005 to June 2013, 226 patients with STEMI combined with non-IRA-CTO were selected from emergency department of our hospital, 82 patients were selected for successful non-IRA-CTO operation, 36 patients were failed operation group. 108 patients were treated without operation. To record patients' general clinical data, drug use, echocardiography and laboratory examination results, and to collect and read the data of interventional therapy CD and operation records, etc. The occurrence of major adverse cardiac events (Mace) during 3 years of telephone follow-up included cardiac death, re-revascularization, myocardial infarction, massive hemorrhage and stroke. All the data were expressed as mean 鹵standard deviation (mean 鹵SDN). T test or nonparametric test were used to compare the data between groups. The count data were analyzed by 蠂 2 test. According to the follow-up results, the clinical end point was analyzed by Log-rank, the survival analysis was performed by Kaplan-Meier method, and the long-term survival difference after adjusting risk was statistically significant by multivariate Cox regression analysis. Results there was no significant difference in baseline data between successful group, failed group and non-operative group. One month after operation, the ultrasonic results of successful operation group showed that the ejection fraction was improved compared with that before operation (P 0.05), but the ejection fraction in the failed operation group and the non-operation group was not significantly improved. Within 3 years, 12 patients in the successful MACE event group had 14. 6 and 12 patients in the failed operation group. There were significant differences between 15 cases (41.7%) and 45 cases (41.7%) in the unoperated group (P 0.001). The incidence of cardiac death in 1 case (1.2%) and 3 cases (8.3%) were significantly lower than that in the failed group (P 0.05). Kaplan-Meier survival analysis showed that the cardiac death rate of the successful group was 1.2vs.8.3% (0.036) and the main MACE events were 14.6vs.41.7p0.001) significantly lower than that of the failed group. There was no significant difference in cardiac death and major MACE events between the failed group and the non-operative group, the cardiac death score 1.6vs.13.6p0.001 and the main MACE event 14.6vs.41.7p0.001 in the successful group were significantly lower than those in the unopened group (the failed group and the non-operative group). Multivariate Cox regression analysis showed that the success of the operation was an independent predictor of the patient's 3-year non-cardiac death (HR: 0.035 / 95 CI: 0.003-0.42p0.008) and no major cardiovascular events (HR0.344 / 95CI0.16-0.73p0.005). Conclusion successful elective revascularization of non-IRA-CTO can increase ejection fraction of 1 month after elective operation in STEMI patients undergoing emergency PCI, reduce MACE events in 3 years, and improve the clinical prognosis of patients. In the future, more large-scale, randomized controlled trials are needed to evaluate the clinical prognostic value of elective revascularization of non-IRA-CTO in this group of patients.
【學(xué)位授予單位】：首都醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R542.22

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