發(fā)布時(shí)間：2018-05-27 12:17

  本文選題：ST段抬高型心肌梗死 + 手動(dòng)血栓抽吸�。� 參考：《中國人民解放軍醫(yī)學(xué)院》2016年博士論文

【摘要】：第一部分常規(guī)合用手動(dòng)血栓抽吸術(shù)對行PCI術(shù)STEMI患者的有效性和安全性Meta分析更新目的：更新Meta分析是為了探究合用手動(dòng)血栓抽吸術(shù)對行PCI術(shù)STEMI患者的有效性和安全性。方法：在該Meta分析中,一共納入25個(gè)RCT試驗(yàn),入組了21708名患者,其中10829名患者隨機(jī)分配到手動(dòng)血栓抽吸組,10902名患者隨機(jī)分配到PCI-only組,根據(jù)不同的隨訪時(shí)間,我們做了臨床結(jié)局的分析。時(shí)間框架按照從入院到30天為短期隨訪、6-9個(gè)月為中期隨訪、1年及1年以上為長期隨訪來界定。基于不同的隨訪時(shí)間計(jì)算反映心肌灌注終點(diǎn)的RR值,比如TIMI血流3級、心肌顯色分級2-3、ST段回落率≥70%,以及臨床結(jié)局終點(diǎn),包括死亡率、MACE事件、再發(fā)心肌梗死、靶血管重建、支架內(nèi)血栓和卒中。結(jié)果：觀察到TA+PCI組術(shù)后TIMI血流3級增加,有統(tǒng)計(jì)學(xué)意義。[RR=1.05,95%CI(1.02,1.09), P=0.0004],與單純PCI組相比。術(shù)后TA+PCI組MBG2-3級和STR比率明顯增加,RR分別為[RR=1.68,95%CI(1.40,2.00),P0.001],[RR=1.24,95%CI(1.12,1.38),P0.001],沒有發(fā)現(xiàn)在全因死亡率[RR=0.91,95%CI(0.80,1.02),P=0.11]、不同隨訪時(shí)期的死亡率方面存在差別。(RR值分別為[RR=0.85,95%CI(0.72,1.00),P=0.06], [RR=0.90, 95%CI(0.73,1.10),P=0.30]和[RR=0.90,95%CI(0.80,1.02),P=0.12]).在MACE事件復(fù)合終點(diǎn)方面短期和中長期的隨訪沒有統(tǒng)計(jì)學(xué)差異。RR值分別為[RR=0.77,95%CI (0.56,1.07),P=0.12],[RR=0.94,95%CI(0.82,1.08),P=0.38]和[RR=0.92,95%CI (0.82,1.02), P=0.11].RI發(fā)生率短期隨訪在TA+PCI組比單純PCI低[RR=0.60, 95%CI(0.38,0.96),P=0.03].中長期隨訪RI發(fā)生率兩組之間差別無統(tǒng)計(jì)學(xué)意義分別[RR=1.00,95%CI(0.77,1.29),P=0.98]和[RR=0.96,95%CI(0.81,1.15),P=0.69]. TA+PCI治療在不同時(shí)期都不能減少TVR的發(fā)生率,RR分別為[RR=0.82,95%CI(0.63,1.08), P=0.16],[RR=0.99,95%CI(0.84,1.18),P=0.94],[RR=0.98,95%CI(0.87,1.10),P=0.70].沒有發(fā)現(xiàn)與單純PCI組相比,TA+PCI組支架內(nèi)血栓發(fā)生率下降。在中長期隨訪和總的卒中的發(fā)生率明顯增加,有統(tǒng)計(jì)學(xué)意義,分別為[RR=1.60,95%CI(1.08,2.38), P=0.02],[RR=1.43,95%CI(1.03,1.98),P=0.03].結(jié)論：在所有STEMI患者中,常規(guī)血栓抽吸能夠改善心外膜和心肌再灌注的參數(shù)。STEMI患者合并TA治療會增加中長期卒中的風(fēng)險(xiǎn),但短期影響仍存在爭議。早期和中晚期隨訪在TA+PCI組和單純PCI組之間,全因死亡率、死亡、MACE事件、靶血管重建、支架內(nèi)血栓及中長期再發(fā)心肌梗死方面沒有差別。TA+PCI可能和短期再發(fā)心肌梗死減少相關(guān)。第二部分老年STEMI患者行PCI術(shù)中合并手動(dòng)血栓抽吸治療對術(shù)后和30天臨床結(jié)局的影響目的：研究目的是評估老年STEMI患者行PCI術(shù)中合并手動(dòng)血栓抽吸治療對術(shù)后和30天臨床結(jié)局的影響。方法：從2012年11月1日到2014年10月31日一共連續(xù)入組了630名行PCI治療的老年患者(年齡≥65歲,男性為387人,占61.6%；女性為243人,占38.6%,平均年齡為67.14±10.98)進(jìn)行前瞻性隊(duì)列研究。結(jié)果：高齡、最初入院行PCI之前血流動(dòng)力學(xué)不穩(wěn)定、血管管腔直徑2.5mm,由資深心血管介入專家手術(shù)操作的患者接受TA治療的可能性更大,在整個(gè)隊(duì)列中行TA治療的患者PCI術(shù)前TIMI血流0/1級而不是TIMI血流2/3級的情況更常見(95%vs5%,p0.001)。在傾向性分析中矯正混雜因素后,與單純PCI治療相比,TA能夠顯著改善術(shù)后TIMI血流3級水平(93.8%vs 84.3%,P=0.004),降低MACE和MACCE事件發(fā)生率(分別為1.7%vs5.6%,P=0.032;4.4%vs8.1%,p=0.034), TA+PCI治療組大出血的風(fēng)險(xiǎn)增加,盡管沒有統(tǒng)計(jì)學(xué)意義,TA+PCI臺療也不能改善30天的死亡率(2.8%vs 2.9%,P=0.94)。結(jié)論：該連續(xù)入組的老年STMI患者的觀察性研究提示：PCI術(shù)中手動(dòng)血栓抽吸治療和術(shù)后TIMI血流3級和iSTR和MACE、MACCE事件發(fā)生率減少相關(guān),但是不能改善30天死亡率。大出血風(fēng)險(xiǎn)在TA治療組明顯,盡管沒有統(tǒng)計(jì)學(xué)差異。第三部分 手動(dòng)血栓抽吸治療對行PCI術(shù)老年STEMI患者1年預(yù)后的影響目的：評估手動(dòng)血栓抽吸治療對行PCI術(shù)老年STEMI患者1年預(yù)后的影響方法：總共630名行PCI術(shù)的老年患者納入觀察性研究中,隨訪1年。通過傾向性評分矯正,TA+PCI組和單純PCI組各納入178名患者,記錄分析全因死亡率和MACE事件。通過構(gòu)建Cox比例風(fēng)險(xiǎn)模型,篩選1年全因死亡率的獨(dú)立危險(xiǎn)預(yù)測因子.結(jié)果：通過傾向性評分矯正后,TA+PCI組與單純PCI組1年全因死亡率的分別為(5.6.%vs 6.7%,P=0.65),TA+PCI組與單純PCI組1年MACE事件發(fā)生率分別為(7.3.%vs 8.4%，P=0.694),兩組之間沒有統(tǒng)計(jì)學(xué)差別。通過傾向性評分和其它協(xié)變量矯正,構(gòu)建1年全因死亡率的COX比例風(fēng)險(xiǎn)模型,年齡做分類變量,截?cái)嘀禐?5歲,1年的全因死亡率與高齡(≥75歲)密切相關(guān)(P0.001)。還和多支血管病變[HR:1.64,95%CI(1.42,1.89),P=0.02].心源性休克[HR:1.68,95%CI(1.45,2.46), P=0.01]、LVEF35%[HR:1.31,95%CI(1.02,2.99), P0.001]、HBG60g/L[HR: 1.07,95%CI(1.02,2.34), P=0.01]有關(guān)。結(jié)論：本研究提示：手動(dòng)血栓抽吸合并PCI治療和單純PCI治療相比,并沒有改善老年STEMI患者1年的全因死亡率和MACE事件發(fā)生率。高齡(≥75歲)、多支血管病變、重度貧血、心源性休克、LVEF35%可以用來預(yù)測老年STEMI患者的1年全因死亡率結(jié)局。
[Abstract]:The first part is the efficacy and safety of routine combined manual thrombectomy for patients with PCI STEMI. Meta analysis is updated to update the Meta analysis to explore the effectiveness and safety of combined manual thrombectomy for patients with PCI STEMI. In this Meta analysis, a total of 25 RCT trials were included in a total of 21708 patients. 10829 patients were randomly assigned to the manual thrombus aspiration group, and 10902 patients were randomly assigned to the PCI-only group. According to the different follow-up time, we did the analysis of the clinical outcome. The time frame was followed up from admission to 30 days, 6-9 months was followed up, and 1 years and more than 1 years were defined for long-term follow-up. The follow-up time calculated the RR value of the endpoint of myocardial perfusion, such as the 3 level of TIMI blood flow, the color classification of the myocardium 2-3, the ST segment fall rate more than 70%, and the end point of the clinical outcome, including the mortality, the MACE event, the re infarction, the reconstruction of the target vessel, the stent thrombosis and the stroke. Results: the TIMI blood flow in the TA+PCI group was observed to be increased in 3 levels, and the statistical significance was observed. .[RR=1.05,95%CI (1.02,1.09), P=0.0004], compared with the simple PCI group. The MBG2-3 level and STR ratio in TA+PCI group increased significantly after the operation, RR was [RR=1.68,95%CI (1.40,2.00), P0.001], [RR=1.24,95%CI. (RR values are [RR=0.85,95%CI (0.72,1.00), P=0.06], [RR=0.90, 95%CI (0.73,1.10), P=0.30] and [RR=0.90,95%CI (0.80,1.02), P=0.12]). The incidence of 95%CI (0.82,1.02) and P=0.11].RI in the short-term follow-up of the TA+PCI group was lower than that of PCI, [RR=0.60, 95%CI (0.38,0.96), and P=0.03]. in the long term follow-up. There was no statistical difference between the two groups. The incidence of RR was [RR=0.82,95%CI (0.63,1.08), P=0.16], [RR=0.99,95%CI (0.84,1.18), P=0.94], [RR=0.98,95%CI (0.87,1.10). P=0.70]. did not find a decrease in the incidence of thrombus in the scaffold of TA+PCI group compared with that of the simple PCI group. CI (1.08,2.38), P=0.02], [RR=1.43,95%CI (1.03,1.98), P=0.03]. conclusion: in all STEMI patients, conventional thrombus aspiration can improve the parameters of the epicardium and myocardial reperfusion in patients with.STEMI patients combined with TA treatment to increase the risk of middle and long term stroke, but the short-term effects are still in dispute. Early and middle and late follow-up in TA+PCI and simple PCI groups There is no difference in mortality, death, death, MACE events, target vascular reconstruction, stent thrombosis, and middle and long term recurrent myocardial infarction, and there is no correlation between.TA+PCI and short term recurrent myocardial infarction. Second the effect of PCI combined with manual thrombus aspiration on postoperative and 30 day clinical outcomes in the second part of the elderly patients The objective was to assess the effect of PCI combined with manual thrombus aspiration on postoperative and 30 day clinical outcomes in elderly STEMI patients. Methods: from November 1, 2012 to October 31, 2014, a total of 630 elderly patients treated with PCI (age 65 years old, 387 men, 61.6%, 243 women, 38.6%, and average age 6) were evaluated. 7.14 + 10.98) prospective cohort study. Results: elderly patients were initially admitted to hospital with hemodynamic instability before PCI, 2.5mm of the vascular lumen, and more likely to receive TA for patients operated by senior cardiovascular interventional experts. In the whole cohort, TA patients were treated with TIMI blood flow 0/1 level before PCI instead of TIMI blood flow 2/3. The level of the situation was more common (95%vs5%, p0.001). Compared with the simple PCI treatment in the tendency analysis, TA significantly improved the level of TIMI blood flow 3 (93.8%vs 84.3%, P=0.004), and reduced the incidence of MACE and MACCE events (1.7%vs5.6%, P= 0.032, 4.4%vs8.1%,), and increased the risk of bleeding in the treatment group. Although there was no statistical significance, TA+PCI treatment could not improve the mortality rate of 30 days (2.8%vs 2.9%, P=0.94). Conclusion: the observational study of the elderly STMI patients in this continuous group suggests that manual thrombus aspiration and postoperative TIMI blood flow 3 in PCI are associated with a decrease in the iSTR and MACE, the decrease in the MACCE event rate, but can not improve the mortality rate of 30 days. The risk of massive hemorrhage in the TA treatment group, although there is no statistical difference. The effect of third part manual thrombus aspiration on the 1 year prognosis of elderly STEMI patients undergoing PCI surgery: evaluation of the effect of manual thrombus aspiration on the 1 year prognosis of the elderly STEMI patients undergoing PCI surgery: a total of 630 elderly patients with PCI In the study, 1 years were followed up. Through the tendency score correction, the TA+PCI group and the simple PCI group were included in 178 patients, and the total cause mortality and MACE events were recorded and analyzed. The independent risk predictors for the 1 year total cause of mortality were screened by constructing the Cox proportional hazard model. Results: after the correction of the tendency score, the TA+PCI group and the simple PCI group were all 1 years of cause. The mortality rate was (5.6.%vs 6.7%, P=0.65), and the incidence of MACE events in group TA+PCI and PCI group was respectively (7.3.%vs 8.4%, P=0.694), and there was no statistical difference between the two groups. Through the tendency score and other covariate correction, the COX ratio risk model of the 1 year all cause mortality was constructed, the age was classified as the classification variable, the truncated value was 75 years, 1 years. All cause mortality is closely related to older age (P0.001) (P0.001). It is also associated with multiple vascular lesions [HR:1.64,95%CI (1.42,1.89), P=0.02]. cardiogenic shock [HR:1.68,95%CI (1.45,2.46), P=0.01], LVEF35%[HR:1.31,95%CI (1.02,2.99), P0.001], HBG60g/L[HR: 1.07,95. Conclusion: This study suggests: manual thrombus extraction Compared with PCI therapy and simple PCI treatment, the total cause of mortality and the incidence of MACE events in the aged STEMI patients were not improved. Age (75 years old), multiple vessel disease, severe anemia, cardiogenic shock, and LVEF35% could be used to predict the 1 year total mortality outcome of elderly patients with STEMI.
【學(xué)位授予單位】：中國人民解放軍醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R54

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