本文選題：紅細(xì)胞體積分布寬度 + 血小板計(jì)數(shù)��； 參考：《河北醫(yī)科大學(xué)》2016年碩士論文

【摘要】：目的:本研究旨在評(píng)估紅細(xì)胞體積分布寬度(Red Cell Distribution Width,PDW)與血小板計(jì)數(shù)(Platelet Count,PLT)的比值(Red Cell Distribution Width to Platelet ratio,RPR)對(duì)急性ST段抬高性型心肌梗死(ST-segment Elevation Myocardial Infarction,STEMI)行直接經(jīng)皮冠狀動(dòng)脈介入治療(Percutaneous Coronary Intervention,PCI)患者心肌灌注水平的預(yù)測(cè)意義及其與無(wú)復(fù)流現(xiàn)象(No-Reflow Phenomenon,NR)發(fā)生的相關(guān)性。方法:本研究前瞻性入組2013年9月-2015年12月明確診斷為STEMI、就診于河北省邢臺(tái)市第一醫(yī)院心血管內(nèi)并接受急診PCI的患者�；颊呷脒x標(biāo)準(zhǔn):(1)符合2015年中華醫(yī)學(xué)會(huì)心血管病學(xué)分會(huì)《急性ST段抬高型心肌梗死診斷和治療指南》中關(guān)于STEMI的診斷標(biāo)準(zhǔn);(2)患者于發(fā)病12小時(shí)內(nèi)就診入院;(3)患者接受急診PCI術(shù)治療;(4)患者及其家屬同意手術(shù),并簽署手術(shù)知情同意書(shū)�；颊吲懦龢�(biāo)準(zhǔn):(1)對(duì)麻醉劑或?qū)Ρ葎┻^(guò)敏;(2)嚴(yán)重肝功能不全(谷丙轉(zhuǎn)氨酶或谷草轉(zhuǎn)氨酶水平大于正常值上限2倍);(3)嚴(yán)重腎功能不全,需行血液或腹部透析治療;(4)主動(dòng)脈夾層;(5)既往曾有心肌梗死病史,曾行冠脈支架置入或冠脈搭橋手術(shù);(6)合并室速、室顫等惡性心律失常,急性心力衰竭或機(jī)械性并發(fā)癥;(7)心原性休克,需應(yīng)用主動(dòng)脈內(nèi)球囊反搏(Intra-Aortic Balloon Pump,IABP);(8)合并抗凝、抗血小板聚集藥物禁忌癥;(9)合并血液系統(tǒng)疾病、自身免疫性疾病、嚴(yán)重創(chuàng)傷及腫瘤;(10)已行溶栓治療;(11)患者或其家屬拒絕參加本研究。所有入組患者均經(jīng)充分的術(shù)前準(zhǔn)備(吸氧、心電監(jiān)護(hù)、鎮(zhèn)靜止痛和抗凝、抗血小板聚集等治療),行冠狀動(dòng)脈造影(Coronary Angiography,CAG)明確梗死相關(guān)動(dòng)脈(Infarction Related Artery,IRA),并予以直接PCI治療。術(shù)中記錄患者癥狀發(fā)作至球囊擴(kuò)張的時(shí)間、心肌梗死溶栓試驗(yàn)血流(Thrombolysis In Myocardial Infarction,TIMI)分級(jí),校正的TIMI血流幀數(shù)(Corrected TIMI Frame Count,CTFC)、TIMI心肌灌注分級(jí)(TIMI myocardial perfusion grade,TMPG)。根據(jù)TMPG結(jié)果,將入組患者分為兩組:A組為無(wú)復(fù)流組,即術(shù)后TMPG分級(jí)為0-2級(jí);B組為正常血流組,即術(shù)后達(dá)到TMPG3級(jí)。兩組患者術(shù)后均給予抗凝、抗血小板聚集治療,同時(shí)應(yīng)用β受體阻滯劑、硝酸酯類(lèi)、血管緊張素轉(zhuǎn)換酶抑制劑(Angiotension Converting Enzyme Inhibitors,ACEI)/血管緊張素Ⅱ受體阻滯劑(AngiotensionⅡReceptor Blocker,ARB)、鈣通道阻滯劑(Calcium Channel Blocker,CCB)、調(diào)脂等常規(guī)藥物治療。比較兩組患者一般基線(xiàn)資料,相關(guān)實(shí)驗(yàn)室指標(biāo)如血常規(guī)、D-Dimer、心肌損傷標(biāo)志物(hs-CRP、心肌酶、肌鈣蛋白I(c Tn I))、隨機(jī)血糖、電解質(zhì)、低密度脂蛋白(LDL-C)、血漿BNP等,術(shù)后病情穩(wěn)定及30天行心臟彩超明確左室射血分?jǐn)?shù)(Left Ventricular Ejection Fraction,LVEF),隨訪(fǎng)比較30天內(nèi)主要心臟不良事件(Major Adverse Cardiac Events,MACEs)的差異,記錄患者心原性再入院情況。所有數(shù)據(jù)均使用統(tǒng)計(jì)軟件SPSS 23.0行數(shù)據(jù)處理分析,將雙側(cè)P0.05定義為有統(tǒng)計(jì)學(xué)意義。結(jié)果:本研究共入選80例患者,其中男性59例,女性21例;A組共入組患者27例(男性20例,平均年齡64.39±11.87歲),B組53例(男性43例,平均年齡57.84±12.44歲);1一般基線(xiàn)資料兩組患者在性別、家族史、吸煙史、高血壓病史、血脂異常、BMI、CRUSADE評(píng)分等方面均無(wú)統(tǒng)計(jì)學(xué)差異(P0.05);A組患者的平均年齡為64.39±11.87歲,B組為57.84±12.44歲,兩組患者年齡差異具有統(tǒng)計(jì)學(xué)意義(P0.001);A組中有10例患者既往有梗死性心絞痛發(fā)作(37.0%),B組中有33例患者曾有梗死性心絞痛發(fā)作(62.3%),兩組數(shù)據(jù)具有統(tǒng)計(jì)學(xué)差異(P=0.032);A組患者TIMI評(píng)分顯著高于B組(10.65±2.98 vs.8.37±3.18,P=0.027),A組患者的GRACE評(píng)分高于B組(144.56±34.78 vs.129.48±30.56,P=0.037);2 PCI治療資料A組患者自胸痛發(fā)作至球囊擴(kuò)張的平均為6.4±2.1h,而B(niǎo)組的再灌注時(shí)間為5.1±2.3h,兩組患者再灌注時(shí)間有差異(P=0.018);行冠脈介入治療時(shí),兩組患者IRA分布比例、置入支架平均直徑和長(zhǎng)度、術(shù)前TIMI3級(jí)血流的比例均無(wú)明顯統(tǒng)計(jì)學(xué)差異(P0.05);術(shù)后A組三支冠脈LAD、LCX、RCA的CTFC大于B組,且差異有統(tǒng)計(jì)學(xué)意義(25.29±5.59 vs.19.81±6.00,P=0.0002;23.50±6.53 vs.18.86±6.67,P=0.004;24.00±6.00 vs.19.88±3.72,P=0.0003);A組術(shù)中預(yù)擴(kuò)張擴(kuò)張比例高于B組(P0.001),而兩組在后擴(kuò)張比例、術(shù)中球囊釋放壓力、血栓抽吸比例、術(shù)中應(yīng)用替羅非班比例方面均無(wú)統(tǒng)計(jì)學(xué)差異(P0.05);3入院后實(shí)驗(yàn)室檢查結(jié)果PCI術(shù)前兩組患者行實(shí)驗(yàn)室檢查,其中,兩組患者在紅細(xì)胞計(jì)數(shù)、血小板計(jì)數(shù)、血肌酐水平、c Tn I、CK-MB、低密度脂蛋白-C、隨機(jī)血糖等指標(biāo)方面均無(wú)統(tǒng)計(jì)學(xué)差異;A組患者的白細(xì)胞計(jì)數(shù)雖然高于B組患者,然而差異并無(wú)統(tǒng)計(jì)學(xué)意義(P=0.067);中性粒細(xì)胞百分比(%)方面A組高于B組,具有顯著差異(78.30±14.38 vs.67.44±14.73,P=0.002);紅細(xì)胞體積分布寬度(fl)方面A組高于B組,具有統(tǒng)計(jì)學(xué)意義(6.68±1.19 vs.5.38±1.45,P0.001);A組患者紅細(xì)胞分布寬度與血小板計(jì)數(shù)的比值和B組患者相比,有統(tǒng)計(jì)學(xué)意義(6.68±1.19 vs.5.38±1.45,P0.001);A組患者的腎小球?yàn)V過(guò)率(ml/min/1.73m2)高于B組,有統(tǒng)計(jì)學(xué)意義(89.08±12.22 vs.103.94±18.91,P0.001);A組患者的hs-CRP(mg/L)高于B組,具有顯著差異(8.58±1.98 vs.5.11±1.27,P0.001);A組BNP(pg/ml)水平高于B組,具有顯著差異(254.80±87.70 vs.216.03±72.18,P=0.038);A組D-dimer(ug/ml)水平高于B組,具有顯著差異(0.79±0.40 vs.0.60±0.38,P=0.041);4心功能結(jié)果患者術(shù)后基線(xiàn)及術(shù)后30天通過(guò)心臟彩超測(cè)量LVEF。A組基線(xiàn)資料明顯低于B組(44.29±4.14 vs.47.55±3.67,P=0.006);兩組患者術(shù)后30天較入院時(shí)LVEF(%)均有升高,且組間比較差異具有統(tǒng)計(jì)學(xué)意義(44.29±4.14 vs.47.87±8.30,P0.05;47.55±3.67 vs.51.63±4.99,P0.05;47.87±8.3 vs.51.63±4.99,P=0.002);5隨訪(fǎng)MACEs的發(fā)生率術(shù)后隨訪(fǎng)30天內(nèi),A組有4例患者出現(xiàn)心原性死亡,6例患者出現(xiàn)惡性心律失常,14例患者出現(xiàn)不同程度的心力衰竭,2例患者出現(xiàn)非致死性再發(fā)性心梗,1例患者行靶血管重建,4例患者心原性再入院治療。B組有1例患者出現(xiàn)心原性死亡,1例患者出現(xiàn)惡性心律失常,8例患者出現(xiàn)心力衰竭,無(wú)患者出現(xiàn)非致死性再發(fā)性心梗及靶血管重建,2例患者出現(xiàn)心原性再入院治療。兩組MACEs的發(fā)生率均有統(tǒng)計(jì)學(xué)意義(P0.05),兩組患者心原性再入院率無(wú)差異;6多因素logistic回歸分析綜合以上結(jié)果,A組患者年齡、既往心絞痛病史、再灌注時(shí)間、術(shù)前TIMI評(píng)分、GRACE評(píng)分、糖尿病史、中性粒細(xì)胞比例、紅細(xì)胞分布寬度、其與血小板計(jì)數(shù)的比值、hs-CRP、腎小球?yàn)V過(guò)率、BNP水平等方面的指標(biāo)和B組患者具有較為明顯的差異。將既往心絞痛病史、再灌注時(shí)間、中性粒細(xì)胞比例、紅細(xì)胞分布寬度與血小板計(jì)數(shù)的比值、hs-CRP、腎小球?yàn)V過(guò)率等作為自變量,將NR作為因變量,行多因素logistic回歸分析,結(jié)果發(fā)現(xiàn),紅細(xì)胞分布寬度與血小板計(jì)數(shù)的比值是STEMI患者直接PCI術(shù)后NR發(fā)生的獨(dú)立危險(xiǎn)因素(OR=2.104,95%CI=1.343-3.297,P=0.001)。結(jié)論:1.對(duì)于STEMI行急診PCI術(shù)的患者,高齡、合并糖尿病病史、無(wú)梗死性心絞痛發(fā)作、延遲開(kāi)通梗死相關(guān)動(dòng)脈、術(shù)前中性粒細(xì)胞比例升高、紅細(xì)胞體積分布寬度增加、紅細(xì)胞體積分布寬度與血小板計(jì)數(shù)比值升高、高敏C反應(yīng)蛋白計(jì)數(shù)升高、腎小球?yàn)V過(guò)率下降、BNP等指標(biāo)提示無(wú)復(fù)流發(fā)生的可能性較高;2.紅細(xì)胞體積分布寬度與血小板計(jì)數(shù)比值對(duì)STEMI行直接PCI術(shù)患者的心肌灌注具有預(yù)測(cè)價(jià)值,是無(wú)復(fù)流發(fā)生的獨(dú)立危險(xiǎn)因素,需要廣大臨床工作者予以重視。
[Abstract]:Objective: To evaluate the ratio of the Red Cell Distribution Width (PDW) to the platelet count (Platelet Count, PLT) (Red Cell Distribution Width) (Red Cell Distribution Width) for acute segment elevation myocardial infarction. Predictive significance of myocardial perfusion level in patients with Percutaneous Coronary Intervention (PCI) and the correlation with non reflow phenomenon (No-Reflow Phenomenon, NR). Methods: This prospective study was clearly diagnosed as STEMI in December -2015 year September 2013, in the cardiovascular and reception of Xingtai First Hospital in Hebei province. Emergency PCI patients. Patient admission criteria: (1) compliance with the diagnostic and therapeutic guidelines for acute ST elevation myocardial infarction in the Chinese Medical Association of China in 2015; (2) patients were hospitalized within 12 hours of onset; (3) patients received acute PCI surgery; (4) patients and their families agreed to operate, and signed hands. Patient's informed consent. Patient exclusion criteria: (1) allergies to anesthetics or contrast agents; (2) severe liver dysfunction (alanine aminotransferase or cereal transaminase level is 2 times greater than the upper limit of normal value); (3) severe renal insufficiency, need for blood or abdominal dialysis treatment; (4) aortic dissection; (5) previously had a history of myocardial infarction, had coronary stent implantation Or coronary artery bypass surgery; (6) combined ventricular tachycardia, ventricular fibrillation and other malignant arrhythmia, acute heart failure or mechanical complications; (7) cardiogenic shock, Intra-Aortic Balloon Pump, IABP; (8) combined anticoagulant, antiplatelet aggregation drug contraindication; (9) combined blood system disease, autoimmune disease, serious Trauma and tumor; (10) thrombolytic therapy; (11) patients or their families refused to participate in this study. All the patients received adequate preoperative preparation (oxygen inhalation, electrocardiographic monitoring, sedative analgesic and anticoagulant, anti platelet aggregation), and Coronary Angiography (CAG) (Infarction Related Artery, I). RA) and direct PCI treatment. During the operation, the time of symptom onset to balloon dilatation was recorded, the blood flow (Thrombolysis In Myocardial Infarction, TIMI) classification of myocardial infarction thrombolytic test, the number of corrected TIMI flow frames (Corrected TIMI Frame Count), cardiac muscle perfusion classification. The patients were divided into two groups: the group A was no reflow group, that is, the post operation TMPG classification was grade 0-2, and the group B was the normal blood flow group, that is, the TMPG3 level was reached after the operation. The two groups were treated with anticoagulant, antiplatelet aggregation, and the use of beta blockers, nitrates, angiotensin converting enzyme inhibitors (Angiotension Converting Enzyme Inhi). Bitors, ACEI) / angiotensin II receptor blocker (Angiotension II Receptor Blocker, ARB), calcium channel blocker (Calcium Channel Blocker, CCB), and lipid modulation. Compare the general baseline data of two groups of patients, related laboratory indicators such as blood routine, D-Dimer, myocardial damage markers (hs-CRP, myocardial enzymes, troponin proteins) ) random blood sugar, electrolytes, low density lipoprotein (LDL-C), plasma BNP and so on. After operation, the condition was stable and the left ventricular ejection fraction (Left Ventricular Ejection Fraction, LVEF) was determined by color Doppler ultrasound (LVEF) on 30 days. The difference of the major adverse events (Major Adverse Cardiac Events, MACEs) in 30 days was compared, and the cardiogenic readmission of the patients was recorded. All data were analyzed with statistical software SPSS 23 lines. Results: bilateral P0.05 was defined as statistically significant. Results: 80 patients were enrolled in this study, including 59 males and 21 females, 27 cases in group A (20 men, 64.39 + 11.87 years old), 53 in group B (43 males, 57.84, 12.44 years of age); 1 General There were no significant differences in gender, family history, smoking history, hypertension history, dyslipidemia, BMI, CRUSADE score in the two groups of patients (P0.05). The average age of the A group was 64.39 + 11.87 years, the B group was 57.84 + 12.44 years, and the two groups had statistical significance (P0.001); 10 patients in the A group had previous infarct sex. Angina pectoris (37%), 33 patients in group B had infarct angina (62.3%), and the two groups had statistical difference (P=0.032). The TIMI score in group A was significantly higher than that in group B (10.65 + 2.98 vs.8.37 + 3.18, P=0.027), and the GRACE score of group A was higher than that of B group (144.56 + 34.78 vs.129.48 + 30.56, P=0.037). The averages from the onset of chest pain to balloon dilatation were 6.4 2.1h, while the reperfusion time of group B was 5.1 2.3h, and the time of reperfusion was different in the two groups (P=0.018). The proportion of IRA distribution in the two groups, the average diameter and length of the stent, and the proportion of the TIMI3 grade blood flow before operation were not significantly different (P0.05), and A group after operation (P0.05). The CTFC of LAD, LCX and RCA in three coronary arteries was greater than that in group B, and the difference was statistically significant (25.29 + 5.59 vs.19.81 + 6, P=0.0002; 23.50 + 6.53 vs.18.86 + 6.67, P=0.004; 24 + 6 vs.19.88 + 3.72, P=0.0003); the proportion of predilatation in the A group was higher than that in the posterior expansion ratio, the pressure of balloon release, the ratio of thrombus aspiration, There was no statistical difference in the proportion of tirofiban in the operation (P0.05); 3 the results of laboratory examination in the two groups before the admission were performed in the laboratory. Among the two groups, there were no significant differences in red blood cell count, platelet count, serum creatinine, C Tn I, CK-MB, low density lipoprotein -C, and random blood sugar, and A patients. Although the white blood cell count was higher than the B group, the difference was not statistically significant (P=0.067); the percentage of neutrophils (%) in A group was higher than that in group B (78.30 + 14.38 vs.67.44 + 14.73, P=0.002); A group of erythrocyte volume distribution width (FL) was higher than that of B group, and had statistical significance (6.68 + 1.19 vs.5.38 + 1.45, P0.001); A Compared with the B group, the ratio of erythrocyte distribution width to platelet count was statistically significant (6.68 + 1.19 vs.5.38 + 1.45, P0.001), and the glomerular filtration rate (ml/min/1.73m2) in group A was higher than that in group B (89.08 + 12.22 vs.103.94 + 18.91, P0.001), and hs-CRP (mg/L) in group A was higher than that in B group, 8 (8). .58 + 1.98 vs.5.11 + 1.27, P0.001); BNP (pg/ml) level in group A was higher than that in B group (254.80 + 87.70 vs.216.03 + 72.18, P=0.038); D-dimer (ug/ml) level in A group was higher than that in the group (0.79 + 0.40 + 0.38,); 4 cardiac function results were measured after baseline and 30 days after operation by cardiac color Doppler ultrasound The data were significantly lower than that of the B group (44.29 + 4.14 vs.47.55 + 3.67, P=0.006), and the two groups were higher than the admission LVEF (%) after 30 days of operation, and the difference between the groups was statistically significant (44.29 + 4.14 vs.47.87 + 8.30, P0.05; 47.55 + 3.67 vs.51.63 + 4.99, P0.05; 47.87 + 8.3 vs.51.63 +, P=0.002). In group A, there were 4 patients with cardiogenic death, 6 patients with malignant arrhythmia, 14 patients with different degrees of heart failure, 2 patients with non fatal recurrent myocardial infarction, 1 patients with target vascular reconstruction, 4 patients with cardiogenic readmission and 1 patients with cardiogenic death in group.B, and 1 patients with malignant heart rhythm. Abnormal, 8 cases of patients with heart failure, no patients with non fatal recurrent myocardial infarction and target vascular reconstruction, 2 cases of cardiogenic readmission. The two groups of MACEs were statistically significant (P0.05), two groups of patients with cardiogenic readmission rate of no difference; 6 multifactorin logistic regression analysis of the comprehensive results, the A group of patients age, The history of angina, the time of reperfusion, the preoperative TIMI score, the GRACE score, the diabetes history, the ratio of neutrophils, the width of the red blood cell, the ratio of the platelet count, the hs-CRP, the glomerular filtration rate, the BNP level, and the B group were significantly different. The history of angina, reperfusion time, neutrophils The ratio of cells, the ratio of red blood cell width to platelet count, hs-CRP and glomerular filtration rate were used as independent variables, and NR was used as a dependent variable, and multiple factor Logistic regression analysis was performed. The results showed that the ratio of red blood cell width to platelet count was an independent risk factor for NR in STEMI patients after direct PCI (OR=2.104,95%CI=1.34). 3-3.297, P=0.001) conclusion: 1. for the patients with STEMI for emergency PCI, the age of the elderly, the history of the diabetes, the onset of the infarction, the delayed opening of the infarct related artery, the increase in the proportion of neutrophils before the operation, the increase in the width of the red blood cell volume, the increase of the volume distribution width of the red blood cell and the ratio of the platelet count, and the high sensitive C reaction protein meter The rate of glomerular filtration rate decreased, BNP and other indicators suggested that the possibility of no reflow was higher, and the ratio of 2. red cell volume distribution width to platelet count was of predictive value for myocardial perfusion in patients with STEMI direct PCI, which was an independent risk factor for no reflow. It is necessary for clinical workers to pay attention to it.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類(lèi)號(hào)】：R542.22

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