替罗非班对心肌梗死急诊介入治疗后ST段回落及临床预后的作用

Early Impact of Tirofiban on ST-Segment Resolution and Clinical Outcomes After Primary PCI in Patients With Acute Myocardial Infarction

目的:前瞻性评价心肌梗死急诊直接经皮冠状动脉介入治疗(PCI)术中联合应用血小板Ⅱh／Ⅲa受体拮抗剂替罗非班对术后ST段回落及临床预后的影响。方法:141例接受急诊PCI治疗的初发急性ST段抬高型心肌梗死患者,随机分成替罗非班组(71例)和对照组(70例)。比较两组基础临床情况、介入治疗结果、急诊PCI术后1小时ST段抬高总和(∑ST)回落、术后90天左心室射血分数及主要心脏不良事件[再梗死、心力衰竭、再次血运重建(PCI／冠状动脉旁路移植术)、死亡]、胸痛复发的发生率。结果:两组基础临床情况、急诊PCI术前∑ST及梗死相关血管开通率均无显著性差异。替罗非班组与对照组相比, 2ST回落明显增加[(6．39±3．43)mm比(4．49±2．43)mm,P<0．01],术后90天主要心脏不良事件(死亡、再梗死、心力衰竭、再次血运重建)发生率(9．9％比25．7％,P<0．05)和胸痛复发率(7％比20％,P<0．05)均显著降低,左心室射血分数(0．59±0．06比0．52±0．06,P<0．01)显著增高。其中替罗非班组心力衰竭发生率(8．50%比22．9％,P<0．05)显著降低,但再梗死、再次血运重建及死亡发生率无显著性差异(P>0．05)。∑ST回落和替罗非班治疗(r=0．361,P< 0．01)及术后90天左心室射血分数(r=0．613,P<0．01)显著相关。多因素分析显示,替罗非班治疗是∑ST回落的唯一独立决定因素(P<0．01)。替罗非班组术后出血并发症发生率高于对照组,但无统计学意义(P>0．05)。结论:心肌梗死急诊直接PCI联合应用替罗非班安全有效,并显著加速ST段回落,显著改善术后90天临床预后和左心室功能。

Objective： To prospectively investigate the early impact of glycoproteinⅡ b/Ⅲ a inhibitor with tirofiban on ST-segment resolution and clinical outcomes after primary percutaneous coronary intervention （PCI） in patients with acute ST elevation myocardial infarction. Methods ： One hundred and forty-one consecutive patients with first acute ST-segment elevation myocardial infarction who un- derwent successful primary PCI were randomized to receive either tirofiban and primary PCI （n = 71 ） or primary PCI alone （n = 70）. Baseline characteristics, results of primary PCI and resolution of the sum of ST-segment elevation （ESTR） one hour after primary PCI, occurrence rates of MACE （ reinfarction, heart failure, revascalarization, death）, refractory angina and left ventricular ejection fraction at 90 days after procedure were compared between the two groups. Results ： Basic clinical characteristics, sum of ST-segment elevation before the procedure and angiographic features were similar between the two groups, but ESTR （6.39 ± 3.43 mm vs 4. 49 ± 2.43 mm, P 〈 0.01 ） and left ventricular ejection fraction （0. 59±0. 06 vs 0. 52 ±0. 06, P 〈0. 01 ） were significantly higher in tirofiban group. The occurrence rates of MACE （heart failure/death/reinfarction/revascularization） （9.9% vs 25.7% ,P 〈 0. 05）and refractory angina （7% vs 20%, P 〈 0. 05 ）at 90 days after procedure were significantly lower in tirofiban group. Except for heart failure（ 8.5% vs 22. 9% , P 〈 0. 05 ） , the incidence rates of reinfarction, revascularization and deaths（ P 〉 0. 05 ） did not significantly differ. ΣSTR was significantly correlated with tirofiban therapy（ r = 0. 361 ,P 〈 0. 01 ） and left ventricular ejection fraction （ r = 0. 613, P 〈 0. 01 ）. Multivariate linear regression analysis revealed that tirofiban was the only independent predictor of ESTR （ P 〈 0. 01 ）. The incidence of hemorrhayu complications was higher in tirofiban group than in control group, but did not reach statistical significance level. Conclusion： Adjuctive therapy with tirofiban is safe and effective for patients with acute ST-segment elevation myocardial infarction who undergo primary PCI. It provides a rapid ΣSTR and improves clinical outcomes and left ventricular function at 90 days after procedure.