【摘要】：急性心肌梗死(Acute myocardial infarction,AMI)是我國(guó)人口死亡主要原因之一。在心肌梗死急性期患者各項(xiàng)生命體征指標(biāo)均會(huì)出現(xiàn)不同程度變化,其中電解質(zhì)變化尤為明顯,以往的研究表明,急性心肌梗死后會(huì)出現(xiàn)不同水平鉀、鈉、鈣、鎂失衡,其中鉀穩(wěn)態(tài)失衡與心血管疾病事件和死亡率顯著相關(guān)。鉀離子廣泛存在于細(xì)胞內(nèi)液,僅2.00%分布于細(xì)胞外液,是心肌細(xì)胞功能的關(guān)鍵因素。既往的研究提示低鉀血癥與心律失常和心源性猝死有關(guān),據(jù)此相關(guān)研究提出了急性心肌梗死患者血鉀應(yīng)維持在較高水平。隨著研究深入,人們發(fā)現(xiàn)正常范圍血鉀亦與心肌梗死后心血管不良事件發(fā)生相關(guān),并對(duì)于適宜血鉀范圍各自提出不同的的意見(jiàn),并且隨著?受體阻滯劑、再灌注治療和早期侵入性治療的廣泛應(yīng)用,梗死后心律失常發(fā)生率已明顯下降,亦有研究顯示低鉀血癥患者與正常血清鉀患者心律失常發(fā)生并無(wú)差異,因此,目前對(duì)心肌梗死患者的血鉀管理是一項(xiàng)富有爭(zhēng)議的工作,有必要進(jìn)一步探究不同水平血清鉀與預(yù)后的關(guān)系。本研究通過(guò)回顧性分析,根據(jù)不同血清鉀梯度分組,探討不同血鉀水平的患者院內(nèi)心血管不良事件發(fā)生有無(wú)差異,探究患者院內(nèi)不良事件發(fā)生的危險(xiǎn)因素。本研究分為以下兩部分:第一部分不同血鉀水平急性心肌梗死患者近期預(yù)后分析目的:探討不同血鉀水平的急性心肌梗死患者近期預(yù)后有無(wú)差異。方法:回顧性分析2013年5月至2016年5月連續(xù)入院急性心肌梗死病例,采集患者的基線資料(性別、年齡,吸煙史,既往病史)、入院即刻生命體征、血鉀、住院期間所有血鉀、血液生化指標(biāo)、再灌注治療情況,觀察住院期間不良事件(惡性心律失常、心源性休克、死亡)。根據(jù)入院血鉀將患者分為低血鉀組(血鉀3.50 mmol/L)和正常血鉀A組(3.50 mmol/L≤血鉀4.50 mmol/L)、正常血鉀B組(4.50 mmol/L≤血鉀5.50 mmol/L)。觀察入院低鉀血癥發(fā)生率、比較各組間惡性心律失常、心源性休克、死亡發(fā)生情況。結(jié)果:共收集病例232例,男性164例(70.70%),女性68例(29.30%),入院時(shí)測(cè)血鉀平均值3.95 mmol/L,低血鉀37例(15.90%),低血鉀組平均值3.23 mmol/L。低血鉀組與正常血鉀A組、正常血鉀B組比較性別、年齡、既往病史及經(jīng)皮冠狀動(dòng)脈介入治療(percutaneous coronary intervention,PCI)治療間無(wú)統(tǒng)計(jì)學(xué)差異。三組間白細(xì)胞、中性粒細(xì)胞、尿素氮、肌酐、GFR、肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)存在差異。三組間院內(nèi)心律失常發(fā)生比較:共15例發(fā)生室顫,發(fā)生率為6.47%,在低血鉀組、正常血鉀A組、正常血鉀B組之間發(fā)生存在統(tǒng)計(jì)學(xué)差異[16.70%(6)vs.3.90%(6)vs7.70%(3),P=0.019]。共13例記錄到非持續(xù)性室速,各組間發(fā)生率為[11.10%(4)vs.5.20%(8)vs2.60%(1),P=0.249]。三組間頻發(fā)室性早搏、心動(dòng)過(guò)緩、心房顫動(dòng)發(fā)生率比較未見(jiàn)統(tǒng)計(jì)學(xué)差異。在院期間共死亡23例,病死率9.91%,各組間病死率無(wú)統(tǒng)計(jì)學(xué)意義[13.90%(5)vs.8.40%(13)vs12.80%(5),P=0.497]。結(jié)論:AMI入院早期低鉀血癥患者院內(nèi)心室顫動(dòng)發(fā)生率較血鉀正常患者明顯升高,不同血鉀范圍內(nèi)室性早搏、心動(dòng)過(guò)緩、心房顫動(dòng)發(fā)生無(wú)明顯差異;入院血鉀在3.50~4.50 mmol/L范圍者室顫及院內(nèi)死亡率最低。第二部分不同水平血鉀對(duì)急性心肌梗死患者院內(nèi)心血管不良事件的預(yù)測(cè)作用目的:探討血鉀對(duì)急性心肌梗死患者院內(nèi)心血管不良事件的危險(xiǎn)因素的預(yù)測(cè)價(jià)值方法:回顧性分析2013年5月至2016年5月連續(xù)入院急性心肌梗死病例,采集患者的基線資料(性別、年齡,吸煙史,既往病史)、入院即刻生命體征、血鉀、住院期間所有血鉀、血液生化指標(biāo)、再灌注治療情況,觀察住院期間不良事件(惡性心律失常、心源性休克、死亡)。根據(jù)患者住院期間是否發(fā)生室性心律失常(室顫及室速)將患者分為心律失常組與無(wú)心律失常組,比較兩組患者間患病特征、入院時(shí)生命體征、血清學(xué)檢測(cè)、治療方式有無(wú)差異,采用Logistics回歸分析探求影響心律失常發(fā)生的危險(xiǎn)因素及不同水平血鉀在心律失常的預(yù)測(cè)價(jià)值。根據(jù)住院期間死亡發(fā)生情況將患者分為死亡組與存活組,分析患者院內(nèi)死亡的危險(xiǎn)因素及血鉀在院內(nèi)死亡的預(yù)測(cè)價(jià)值。結(jié)果:根據(jù)在院期間是否發(fā)生室性心律失常,將患者分為心律失常組與非心律失常組,兩組比較發(fā)現(xiàn):在性別、年齡、合并癥、治療方式間沒(méi)有統(tǒng)計(jì)學(xué)差異;心律失常組入院時(shí)收縮壓明顯低于非心律失常組,舒張壓及心率無(wú)統(tǒng)計(jì)學(xué)差異。心律失常組Killip評(píng)分高于非心律失常組。心律失常組白細(xì)胞水平高于非心律失常組,入院血鉀低于非心律失常組。兩組間血糖、血脂、CK、CK-MB無(wú)統(tǒng)計(jì)學(xué)差異。惡性心律失常多因素Logistic回歸顯示院內(nèi)室性心律失常發(fā)生的危險(xiǎn)因素為:鉀異常(3.50 mmol/L,≥4.50 mmol/L)(OR=0.154,95%CI=0.034~0.561,P=0.005),收縮壓100mmHg(OR=0.964,95%CI=0.938~0.991,P=0.009),Killip III-IV級(jí)(OR=0.217,95%CI=0.059~0.794,P=0.021)。根據(jù)在院期間是死亡,將患者分為死亡組與存活組,兩組比較發(fā)現(xiàn):總病死率為9.91%(23/232),女性病死率為17.60%(12/68),男性病死率為6.70%(11/164)。兩組間性別、年齡、Killip分級(jí)存在差異;兩組間合并癥無(wú)差異,死亡組再灌注治療比例低于存活組。兩組間比較入院即刻血鉀無(wú)統(tǒng)計(jì)學(xué)差異,兩組間紅細(xì)胞、血紅蛋白、肌酐、尿素氮存在統(tǒng)計(jì)學(xué)差異。梗死部位比較:廣泛前壁者病死率明顯升高,非ST抬高型心肌梗死病死率較低。兩組間心律失常發(fā)生及心源性休克發(fā)生情況比較:室顫及休克存在統(tǒng)計(jì)學(xué)差異,室速、房顫、心動(dòng)過(guò)緩比較無(wú)統(tǒng)計(jì)學(xué)差異。死亡直接原因?yàn)?心源性休克或心力衰竭17例(73.91%)、心臟室壁瘤破裂1例(4.34%)、心臟驟停3例(13.04%),其中心室顫動(dòng)1例、心室停頓2例,缺血性腦卒中2例(8.71%)。院內(nèi)死亡多因素分析示:室顫(OR=0.148,95%CI=0.029~0.76,P=0.023)、心源性休克(OR=0.096,95%CI=0.027~0.339,P0.001)、廣泛前壁心肌梗死(OR=0.171,95%CI=0.032~0.920,P=0.040)增加院內(nèi)死亡風(fēng)險(xiǎn),PCI(OR=4.899,95%CI=0.872~27.525,P=0.039)治療是保護(hù)性因素。結(jié)論:鉀異常(3.5mmol/L,≥4.5 mmol/L)增加急性心肌梗死患者院內(nèi)發(fā)生室性惡性心律失常風(fēng)險(xiǎn),心肌梗死發(fā)生后將患者血鉀維持在3.50 mmol/L~4.50mmol/L間;血鉀異常不直接影響患者院內(nèi)死亡,但可通過(guò)增加室顫發(fā)生率、增加死亡風(fēng)險(xiǎn)。
[Abstract]:Acute myocardial infarction (Acute myocardial infarction, AMI) is one of the main causes of population death in China. In acute phase of myocardial infarction, the changes of various vital signs in patients with acute myocardial infarction are changed in varying degrees, and the changes of electrolyte are particularly obvious. Previous studies have shown that acute myocardial infarction will have different levels of potassium, sodium, calcium, and magnesium. The homeostasis of potassium homeostasis is significantly related to cardiovascular events and mortality. Potassium ions are widely distributed in intracellular fluid and only 2% in extracellular fluid. It is a key factor in the function of cardiac myocytes. Previous studies suggest that hypokalemia is associated with arrhythmia and sudden cardiac death. The related research suggests the blood of acute myocardial infarction. Potassium should be maintained at a high level. As the study goes deep, it is found that normal blood potassium is also associated with cardiovascular adverse events after myocardial infarction, and suggests different opinions on the appropriate range of blood potassium, and with the extensive use of receptor blockers, reperfusion therapy and early invasive treatment, arrhythmia after infarction There is no difference between the rate of birth and the occurrence of arrhythmia in patients with hypokalemia and normal serum potassium. Therefore, the management of blood potassium in patients with myocardial infarction is a controversial work. It is necessary to further explore the relationship between different levels of serum potassium and prognosis. This study was divided into two parts: the first part was the analysis of the short-term prognosis of patients with acute myocardial infarction with different blood potassium levels: To explore the acute levels of blood potassium. There is no difference in the short-term prognosis of patients with myocardial infarction. Methods: a retrospective analysis of the cases of acute myocardial infarction in hospital from May 2013 to May 2016 was reviewed. The baseline data (sex, age, smoking history, past medical history), the immediate physical signs of admission, blood potassium, all blood potassium, blood biochemical indexes and reperfusion treatment were observed. Adverse events (malignant arrhythmia, cardiogenic shock, death) were divided into low potassium group (potassium 3.50 mmol/L) and normal blood potassium A group (3.50 mmol/L < 4.50 mmol/L), and normal blood potassium B group (4.50 mmol/L < 5.50 mmol/L). The incidence of hypokalemia in admission was observed and the malignant arrhythmia was compared between the groups. Results: 232 cases were collected in a total of 232 cases, 164 men (70.70%) and 68 women (29.30%). The average value of blood potassium was 3.95 mmol/L, 37 cases of hypokalemia (15.90%), low potassium group was 3.23 mmol/L. low blood potassium group and normal blood potassium A group, and normal blood potassium B group was compared with sex, age, past medical history and percutaneous coronary. There were no statistical differences between percutaneous coronary intervention (PCI) treatment. There were differences between three groups of leukocytes, neutrophils, urea nitrogen, creatinine, GFR, creatine kinase (CK), and creatine kinase isoenzyme (CK-MB). There were 15 cases of ventricular fibrillation in the three groups: 15 cases had ventricular fibrillation, the incidence was 6.47%, and in the hypokalemia group, positive There was a statistical difference between the normal blood potassium A group and the normal blood potassium B group [16.70% (6) vs.3.90% (6) vs7.70% (3), 13 cases of P=0.019]. were recorded to non persistent ventricular tachycardia, the incidence of each group was [11.10% (4) vs.5.20% (8) vs2.60% (1), P=0.249]. three was frequent ventricular premature beat, bradycardia, and the incidence of atrial fibrillation was not statistically different. In hospital, there was no statistical difference. During the period, 23 cases were killed and the mortality rate was 9.91%. The mortality rate between each group was not statistically significant [13.90% (5) vs.8.40% (13) vs12.80% (5). P=0.497]. conclusion: the incidence of ventricular fibrillation in patients with early hypokalemia was significantly higher than that of the normal blood potassium patients. There was no significant difference in the occurrence of ventricular premature beat, bradycardia and atrial fibrillation in different blood potassium models. The hospitalized blood potassium was the lowest in the 3.50~4.50 mmol/L range of ventricular fibrillation and hospital mortality. Second the predictive value of different levels of blood potassium on hospital cardiovascular adverse events in patients with acute myocardial infarction: To explore the predictive value of the risk factors of blood potassium on hospital inward adverse events in patients with acute myocardial infarction: a retrospective analysis of 2013 From May to May 2016, patients with acute myocardial infarction were hospitalized continuously. Baseline data (sex, age, smoking history, past medical history), immediate physical signs, potassium, all blood potassium, blood biochemical indexes, reperfusion treatment during hospitalization were collected, and the adverse events (malignant arrhythmia, cardiogenic shock, death) were observed. According to the patients' ventricular arrhythmia (ventricular fibrillation and ventricular tachycardia) during the period of hospitalization, the patients were divided into arrhythmia group and non cardio arrhythmia group. The characteristics of the two groups were compared, the vital signs, the serological examination, and the treatment methods were different, and the Logistics regression analysis was used to explore the risk factors and different factors affecting the occurrence of arrhythmia. The predictive value of horizontal blood potassium in arrhythmia. According to the incidence of death during hospitalization, the patients were divided into the death group and the survival group. The risk factors of hospital death and the predictive value of blood potassium in hospital death were analyzed. Group two groups found that there was no statistical difference between sex, age, complication and treatment, and the systolic pressure of arrhythmia group was lower than that of non arrhythmia group at admission, and the diastolic pressure and heart rate had no statistical difference. The Killip score of arrhythmia group was higher than that of non arrhythmia group. The level of leukocyte in arrhythmia group was higher than that of non arrhythmia group. The blood potassium of hospital was lower than that of non arrhythmia group. There was no significant difference in blood sugar, blood lipid, CK, CK-MB between the two groups. Multiple factors Logistic regression of malignant arrhythmia showed that the risk factors for the occurrence of ventricular arrhythmia were potassium abnormal (3.50 mmol/L, 4.50 mmol/L) (OR=0.154,95%CI=0.034~ 0.561, P=0.005), systolic pressure 100mmHg (OR=0.964,95%CI=0.938~0.991, P). =0.009), Killip III-IV (OR=0.217,95%CI=0.059~0.794, P=0.021). According to the death in the hospital, the patients were divided into the death group and the survival group. The two groups were found to have a total fatality rate of 9.91% (23/232), a female mortality rate of 17.60% (12/68), and a male mortality rate of 6.70% (11/164). There were differences in sex, age, and Killip classification among the two groups; the two groups were interconnected. There was no difference in complications. The proportion of reperfusion treatment in the death group was lower than that in the survival group. There was no statistical difference between the two groups. There was a statistical difference between the two groups of red blood cells, hemoglobin, creatinine and urea nitrogen. The infarct sites were compared: the mortality rate of the extensive anterior wall patients was significantly higher, the mortality rate of non ST elevation myocardial infarction was lower. The two groups of cardiac arrhythmias were lower. There were statistical differences in ventricular fibrillation and shock. There were no statistical differences in ventricular tachycardia, atrial fibrillation and bradycardia. The direct causes of death were cardiogenic shock or heart failure in 17 cases (73.91%), ventricular aneurysm rupture in 1 cases (4.34%), cardiac arrest in 3 cases (13.04%), ventricular fibrillation in 1 cases, ventricular pause 2. For example, 2 cases of ischemic stroke (8.71%). Multifactor analysis of hospital death: OR=0.148,95%CI=0.029~0.76 (P=0.023), OR=0.096,95%CI=0.027~0.339 (P0.001), extensive anterior wall myocardial infarction (OR=0.171,95%CI=0.032~0.920, P=0.040) increase the risk of hospital death, PCI (OR=4.899,95%CI=0.872~27.525, P=0.039) treatment is protection Conclusions: potassium abnormalities (3.5mmol/L, > 4.5 mmol/L) increase the risk of ventricular arrhythmia in patients with acute myocardial infarction. After the onset of myocardial infarction, the patient's blood potassium is maintained between 3.50 mmol/L~4.50mmol/L, and the blood potassium abnormality does not directly affect the patient's hospital death, but it can increase the risk of death by increasing the incidence of ventricular fibrillation.
【學(xué)位授予單位】：蚌埠醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R542.22

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