【摘要】：目的:本研究以本胸痛中心(Chest Pain Center,CPC)成立、改進(jìn)流程實(shí)施為節(jié)點(diǎn),評(píng)估CPC是否可以降低急性ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)的總?cè)毖獣r(shí)間、主要不良心血管事件(major adverse cardiovascular events,MACE),同時(shí)縮短住院平均天數(shù)和降低住院平均費(fèi)用,從而證實(shí)CPC在救治STEMI中的重要性以及社會(huì)效益。方法:本研究連續(xù)入選2015年10月1日-2016年11月30日就診于天津醫(yī)科大學(xué)第二醫(yī)院且發(fā)病時(shí)間在12小時(shí)內(nèi)的急性STEMI患者,納入標(biāo)準(zhǔn):發(fā)病12小時(shí)以內(nèi)的急性STEMI患者,同時(shí)滿足STEMI的診斷標(biāo)準(zhǔn):1.胸痛癥狀持續(xù)時(shí)間超過(guò)20min且不大于12小時(shí);2.兩個(gè)或者兩個(gè)以上的相鄰導(dǎo)聯(lián)出現(xiàn)ST段的抬高(胸導(dǎo)聯(lián)≥0.2mV,肢體導(dǎo)聯(lián)≥0.1mV)或者新發(fā)現(xiàn)的左束支傳導(dǎo)阻滯(Left bundle branch block,LBBB);3.心肌損傷標(biāo)志物(主要以肌鈣蛋白(Cardiac troponin,CTn)證實(shí)診斷;排除標(biāo)準(zhǔn):對(duì)抗血小板藥物以及抗凝藥物過(guò)敏者;活動(dòng)性出血者。以天津醫(yī)科大學(xué)第二醫(yī)院CPC成立、胸痛中心流程證實(shí)實(shí)施的時(shí)間——2016年6月1日為節(jié)點(diǎn),將STEMI患者分為CPC成立后組(簡(jiǎn)稱(chēng)成立后組)以及CPC成立前組(簡(jiǎn)稱(chēng)成立前組)。詳細(xì)記錄入選發(fā)病時(shí)間在12小時(shí)內(nèi)的急診STEMI患者的基本信息,包括就診時(shí)間、年齡、性別、發(fā)病時(shí)間、到達(dá)大門(mén)時(shí)間、來(lái)院途徑、既往病史等;以及住院后的時(shí)間節(jié)點(diǎn),包括就診-雙聯(lián)抗血小板藥物時(shí)間(Door-double dual antiplatelet therapy,DDAPT);門(mén)-肝素時(shí)間(Door-Heparin,D-H);門(mén)-球時(shí)間(Door-to-Balloon,Dto-B);癥狀發(fā)作到醫(yī)院大門(mén)時(shí)間(Symptom onset to Door,SO-Door)以及總?cè)毖獣r(shí)間。所有病人根據(jù)中國(guó)2015年急性STEMI診治和治療指南進(jìn)行診斷和治療,其中急診PCI是所有被入選的STEMI患者的最佳再灌注治療方案,作為再灌注治療的首選方案,同時(shí)預(yù)計(jì)D-to-B時(shí)間大于90min時(shí)實(shí)施溶栓治療。CPC的成立后實(shí)現(xiàn)了自行來(lái)醫(yī)院患者繞行CCU,網(wǎng)絡(luò)醫(yī)院和120系統(tǒng)來(lái)院患者繞行急診觀察室和CCU,從而減少D-to-B時(shí)間,為增加PCI術(shù)前血管再灌注率,在首次醫(yī)療接觸、明確診斷后立即給予負(fù)荷劑量的抗血小板藥物和抗凝藥物,盡早實(shí)施抗栓預(yù)處理。同時(shí)記錄造影結(jié)果,包括病變支數(shù)、病變節(jié)段數(shù)、罪犯病變、罪犯病變程度、是否有側(cè)枝循環(huán)、是否存在慢性閉塞病變(Chronic total occlusion,CTO)、術(shù)前TIMI血流分級(jí)、血栓分級(jí)、血栓染色,以及PCI結(jié)果,包括術(shù)后TIMI血流分級(jí)、支架個(gè)數(shù)、長(zhǎng)度等指標(biāo)。同時(shí)住院期間記錄患者心血管不良事件(Major adverse cardiovascular events,MACE)的發(fā)生情況,本文將MACE定義為一個(gè)臨床不良心血管事件的復(fù)合體,包括急性心力衰竭、致死性和非致死性卒中、惡性心律失常、心絞痛復(fù)發(fā)、心源性死亡等。此外,記錄出院前超聲心動(dòng)圖的指標(biāo),包括左房?jī)?nèi)徑大小、左室舒張末內(nèi)徑、左室收縮末內(nèi)徑以及左室的射血分?jǐn)?shù)(Left ventricular ejection fraction,LVEF)。出院時(shí)記錄平均住院天數(shù)以及平均住院費(fèi)用。結(jié)果:1.與成立前組相比,成立后組的白細(xì)胞的總數(shù)、單核細(xì)胞絕對(duì)值、中性粒細(xì)胞百分比、術(shù)后CK-MB以及超敏-C反應(yīng)蛋白的水平顯著降低,具有顯著性統(tǒng)計(jì)學(xué)意義(P0.05)。2.關(guān)于心功能分級(jí)方面,成立后組的KillipⅢ/Ⅳ級(jí)較成立前組比例顯著減低(10.4%vs.23.6%,P=0.006)。兩組間NT-proBNP的比較,成立前組高于成立后組(80.4(6.0,476.5)vs.18.3(5.0,128.4),P=0.012)。出院前超聲心動(dòng)圖檢查顯示,成立后組的LVEF顯著高于成立前組(55.38±7.79%VS.52.58±9.38%,P=0.029),具有顯著性統(tǒng)計(jì)學(xué)差異。3.本研究中有249例STEMI患者接受急診冠狀動(dòng)脈造影術(shù),其中成立前組120人,成立后組129人。與成立前組相比較,成立后組的PCI術(shù)前再灌注比例顯著增加(41.1%vs.25.8%,P=0.016),而PCI術(shù)后再灌注比例無(wú)顯著性統(tǒng)計(jì)學(xué)差異。此外,在PCI術(shù)前TIMI血栓分級(jí)比較中,成立后組在0、1級(jí)比例顯著高于成立前組(27.9%vs.16.7%,P=0.048;9.3%vs.1.7%,P=0.011),而在5級(jí)比例明顯低于成立前組(55.5%vs.69.2%,P=0.036)。4.在時(shí)間節(jié)點(diǎn)方面,成立后組的D-DAPT(15.53±14.15 vs.45.11±36.98,P0.001)、D-to-B(80.15±31.74 vs.154.52±50.68,P0.001)、D-H(29.50±27.04 vs.138.40±84.92,P0.001)、SO-Door(45(90.0,241.0)vs.210.0(122.25,309.75),P=0.004)以及總?cè)毖獣r(shí)間(266.21±224.31 vs.412.69±241.04,P0.001)均較短,存在顯著性統(tǒng)計(jì)學(xué)差異。5.在住院期間的MACE的比較中,成立前組的MACE發(fā)生率顯著高于成立后組(24.3%vs.12.7%,P=0.019)。其中,與成立后組相比,成立前組發(fā)生心源性死亡(10.0%vs.3.0%,P=0.026)、急性心力衰竭(19.3%vs.9.7%,P=0.027)均較高,均具有顯著性統(tǒng)計(jì)學(xué)的差異。6.以是否發(fā)生MACE(否=0,是=1)為因變量,依次進(jìn)行Logistic的回歸分析最終以年齡、射血分?jǐn)?shù)、D-to-B、SO-Door、總?cè)毖獣r(shí)間為自變量帶入Logistic回歸方程,通過(guò)應(yīng)用前向逐步回歸分析,并校正混雜因素,最終結(jié)果得出,D-to-B、SO-Door、總?cè)毖獣r(shí)間是MACE的獨(dú)立危險(xiǎn)因素。7.在預(yù)測(cè)住院期間MACE的ROC曲線分析中,D-to-B曲線下面積是0.631,95%可信區(qū)間是(0.540,0.722),SO-Door時(shí)間曲線下面積是0.661,95%可信區(qū)間是(0.575,0.747),總?cè)毖獣r(shí)間曲線下面積是0.674,95%可信區(qū)間是(0.588,0.760),其用于預(yù)測(cè)住院期間MACE有顯著性統(tǒng)計(jì)學(xué)差異。8.在住院天數(shù)以及費(fèi)用方面,成立后組的住院天數(shù)從7.60±4.50天縮短6.08±1.96,平均縮短了20%;而住院期間費(fèi)用從43517±23195元減少至35716±13465元,平均減少了17.9%,具有顯著性統(tǒng)計(jì)學(xué)差異。結(jié)論:1.以胸痛中心成立為節(jié)點(diǎn),胸痛中心成立后STEMI患者的D-DAPT、DH、D-to-B、SO-Door以及總?cè)毖獣r(shí)間顯著縮短,且PCI術(shù)前再灌注比例顯著增加,TIMI血栓負(fù)荷顯著降低。2.胸痛中心成立后時(shí)STEMI患者住院期間發(fā)生主要心血管不良事件顯著減低,其中以急性心力衰竭以及心源性死亡事件降低為著。此外,D-to-B、SODoor、總?cè)毖獣r(shí)間是STEMI患者住院期間發(fā)生MACE的獨(dú)立危險(xiǎn)因素。3.胸痛中心成立以后,STEMI患者顯著縮短了平均住院天數(shù),節(jié)約醫(yī)療資源,取得了更好的社會(huì)效益。
[Abstract]:Objective: This study was established with Chest Pain Center (CPC) and improved the process as a node to assess whether CPC could reduce the total ischemic time of acute ST segment elevation myocardial infarction (ST-segment elevation myocardial infarction, STEMI). The average days of short hospitalization and the decrease in the average cost of hospitalization confirmed the importance and social benefits of CPC in the treatment of STEMI. Methods: This study was continuously selected for the acute STEMI patients who were diagnosed with the Second Hospital Affiliated to Tianjin Medical University in November 30th, October 1, 2015 and within 12 hours of the onset of the disease, which were included in the standard: within 12 hours of the onset of disease. Acute STEMI patients met the diagnostic criteria for STEMI: 1. chest pain symptoms lasted longer than 20min and not more than 12 hours; 2. two or more than two adjacent lead appeared ST segment elevation (chest lead > 0.2mV, limb lead > 0.1mV) or newly found left bundle branch block (Left bundle branch block, LBBB); 3. myocardial injury markers The object (mainly Cardiac troponin, CTn) confirmed diagnosis; exclusion criteria: anti thrombotic drugs and anticoagulant drug allergy; active bleeding. Established in Second Hospital Affiliated to Tianjin Medical University CPC, the heart pain center process confirmed the implementation time - June 1, 2016 as the node, the STEMI patients were divided into the group after the establishment of CPC (abbreviation) After the establishment of the group) and the pre founded group of CPC (pre establishment group), the basic information of the emergency STEMI patients was recorded in 12 hours, including the time of treatment, age, sex, time of onset, the time of arrival at the gate, the way to the hospital, the past history, and so on; and the time nodes after the hospitalization, including the medical double antiplatelet drugs. Time (Door-double dual antiplatelet therapy, DDAPT); the door - heparin time (Door-Heparin, D-H); door - ball time (Door-to-Balloon, Dto-B); symptoms onset to the hospital gate time (Symptom onset to) and total ischemia time. All patients were diagnosed and treated according to China's 2015 acute guidelines and treatment guidelines. Middle and emergency PCI is the best reperfusion therapy for all selected STEMI patients. As the first choice for reperfusion therapy, it is expected that D-to-B time is greater than 90min when the thrombolytic treatment of.CPC is set up, and the hospital patients bypass CCU, network hospital and 120 system patients bypass emergency observation room and CCU, thus reducing the rate of thrombolytic therapy. Less D-to-B time, in order to increase the rate of preoperative vascular revasculature for PCI, in the first medical contact, immediately after the diagnosis was given a dose of antiplatelet drugs and anticoagulants, early implementation of antithrombotic preconditioning. And record the results of the contrast, including the number of lesions, the number of segments of the lesion, the pathological changes of the offender, the degree of the offender's pathological changes, and whether there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether there was collateral circulation, or not. There were chronic occlusion (Chronic total occlusion, CTO), preoperative TIMI blood flow classification, thrombus classification, thrombus staining, and PCI results, including postoperative TIMI flow classification, number of stents, length and other indicators. Meanwhile, the occurrence of cardiovascular adverse events (Major adverse cardiovascular events, MACE) in patients was recorded during hospitalization. It was defined as a complex of adverse cardiovascular events, including acute heart failure, fatal and non lethal stroke, malignant arrhythmia, recrudescence of angina pectoris, cardiac death, etc.. In addition, the parameters of echocardiography before discharge, including the size of the left atrium, the left ventricular end diastolic diameter, the left ventricular end systolic diameter, and the left ventricular ejection, were also recorded. Blood fraction (Left ventricular ejection fraction, LVEF). Recorded average hospitalization days and average hospitalization expenses. Results: 1. compared with the pre establishment group, the total number of leukocytes, the absolute value of monocyte, the percentage of neutrophils, the level of CK-MB and the hypersensitive -C reaction protein were significantly lower than those in the pre establishment group. Study significance (P0.05).2. on the classification of cardiac function, the proportion of Killip III / IV in the group after establishment was significantly lower than that of the pre establishment group (10.4%vs.23.6%, P=0.006). The comparison between the two groups was higher than that of the group after the establishment (80.4 (6.0476.5) vs.18.3 (5.0128.4), P=0.012). There were significant statistical differences in the pre establishment group (55.38 + 7.79%VS.52.58 + 9.38%, P=0.029). In this study, 249 cases of STEMI patients received emergency coronary angiography, of which 120 were in the pre establishment group and 129 in the post establishment group. Compared with the pre establishment group, the proportion of PCI before the establishment of PCI was significantly increased (41.1%vs.25.8%, P=0.01). 6), and there was no significant difference in the proportion of reperfusion after PCI. In addition, in the TIMI thrombotic classification before PCI, the proportion of the group at the 0,1 level was significantly higher than that in the pre establishment group (27.9%vs.16.7%, P=0.048; 9.3%vs.1.7%, P=0.011), but the proportion in the grade 5 was significantly lower than that in the pre establishment group (55.5%vs.69.2%, P=0.036).4. in the time node, and the post group was established. D-DAPT (15.53 + 14.15 vs.45.11 + 36.98, P0.001), D-to-B (80.15 + 31.74 vs.154.52 + 50.68, P0.001), D-H (29.50 + 27.04 vs.138.40 + 84.92, P0.001), SO-Door (45 (45) vs.210.0 (45) vs.210.0) and total ischemia time (266.21 + 224.31) In the comparison of MACE during the hospital, the incidence of MACE in the pre establishment group was significantly higher than that of the post establishment group (24.3%vs.12.7%, P=0.019). Among them, cardiac death (10.0%vs.3.0%, P=0.026) and acute heart failure (19.3%vs.9.7%, P=0.027) in the pre establishment group were higher than those after the establishment, and all had significant statistical differences in.6. to be MACE (P=0.026). =0, is =1) for the dependent variable, the regression analysis of Logistic in turn eventually takes age, ejection fraction, D-to-B, SO-Door, and total ischemia time as the independent variable into the Logistic regression equation. Through the application forward regression analysis, and correcting the confounding factors, the final result is that D-to-B, SO-Door, total ischemia time is an independent risk factor.7. of MACE.7.. In the ROC curve analysis of MACE during the period of hospitalization, the area under the D-to-B curve is 0.631,95% confidence interval (0.540,0.722), the area under the SO-Door time curve is 0.661,95% confidence interval (0.575,0.747), the area under the total ischemia time curve is 0.674,95% confidence interval (0.588,0.760), and it is used to predict the MACE in the period of hospitalization. The number of hospitalization days and cost of.8. in hospital was shortened from 7.60 + 4.50 days to 6.08 + 1.96, and the average decreased by 20%. The cost of hospitalization decreased from 43517 + 23195 yuan to 35716 + 13465 yuan, and the average decreased by 17.9%, with significant statistical difference. Conclusion: 1. with the center of chest pain, the center of chest pain was established. The D-DAPT, DH, D-to-B, SO-Door, and total ischemia time in the patients with STEMI were significantly shortened, and the proportion of pre PCI reperfusion was significantly increased, and the TIMI thrombus load significantly decreased the major cardiovascular adverse events during the hospitalization of STEMI patients at the time of.2. chest pain, which was reduced in acute heart failure and cardiac death. In addition, D-to-B, SODoor, total ischemia time was the independent risk factor of MACE in patients with STEMI during the hospitalization of.3., after the establishment of.3. chest pain center, STEMI patients significantly shortened the average number of days of hospitalization, saved medical resources, and achieved better social benefits.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R542.22

【參考文獻(xiàn)】

相關(guān)期刊論文 前4條

1 Geng QIAN;Chen WU;Yun-dai CHEN;Chen-chen TU;Jin-wen WANG;Yong-an QIAN;;急性ST段抬高型心肌梗死繼發(fā)心臟破裂的預(yù)測(cè)因素分析(英文)[J];Journal of Zhejiang University-Science B(Biomedicine & Biotechnology);2014年12期

2 Rodrigo Estévez-Loureiro;ángela López-Sainz;Armo Pérez de Prado;Carlos Cuellas;Ramón Calvio Santos;Norberto Alonso-Orcajo;Jorge Salgado Fernández;Jose Manuel Vázquez-Rodríguez;Maria López-Benito;Felipe Fernández-Vázquez;;Timely reperfusion for ST-segment elevation myocardial infarction:Effect of direct transfer to primary angioplasty on time delays and clinical outcomes[J];World Journal of Cardiology;2014年06期

3 Sabine Vecchio;Elisabetta Varani;Tania Chechi;Marco Balducelli;Giuseppe Vecchi;Matteo Aquilina;Giulia Ricci Lucchi;Alessro Dal Monte;Massimo Margheri;;Coronary thrombus in patients undergoing primary PCI for STEMI:Prognostic significance and management[J];World Journal of Cardiology;2014年06期

4 Geng QIAN;Hong-bin LIU;Jin-wen WANG;Chen WU;Yun-dai CHEN;;Risk of cardiac rupture after acute myocardial infarction is related to a risk of hemorrhage[J];Journal of Zhejiang University-Science B(Biomedicine & Biotechnology);2013年08期

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本文編號(hào)：2160442