盐皮质激素受体拮抗剂治疗心力衰竭ST段抬高型心肌梗死患者的疗效和安全性研究

Efficacy and Safety of Mineralocorticoid Receptor Antagonists in Patients with ST-Elevation Myocardial Infarction in Heart Failure

急性ST段抬高型心肌梗死(STEMI)患者的死亡率一直居高不下,严重威胁人们的生命安全,因此需要一种可靠的治疗方法。盐皮质激素受体拮抗剂(MRA)治疗已显示可预防心力衰竭ST段抬高型心肌梗死(STEMI)患者的不良左心室(LV)重塑。但目前尚不了解在初次经皮冠状动脉介入治疗(PPCI)之前开始MRA治疗是否会带来减少心肌梗塞大小和防止不良LV重塑的额外益处。作者旨在调查在再灌注之前开始的MRA治疗是否能减少STEMI患者的心肌梗塞(MI)大小并防止不良的LV重塑。在2016年12月至2019年1月期间,从该院心内科筛查了连续性STEMI患者60例,同意STEMI患者在12 h内就诊且冠状动脉近端闭塞并伴有0级心肌梗塞溶栓,在立即接受达初级经皮冠状动脉介入治疗后,以1∶1的方式将患者随机分为MRA治疗组或安慰剂组,接受MRA治疗的患者在梗死相关动脉的血流恢复之前先接受200 mg(10 m L)的肾上腺素钾静脉推注,随后口服螺内酯25 mg,对照组患者则采用安慰剂治疗。主要终点是3个月时通过心血管磁共振得出的MI大小。MRI结果显示,经治疗3个月后,两组患者的最终MI大小无显著差异,无统计学意义(P>0.05)。此外,治疗结束时,患者的急性心肌梗死面积大小或心肌抢救次数也没有明显差异,无统计学意义(P>0.05)。在随访期间,所有患者的LVEF较治疗期间有改善的趋势,而且MRA组的LVEDV和LVESV下降幅度明显大于对照组,表明盐皮质激素受体拮抗剂治疗效果更佳。这项研究表明虽然在再灌注之前启动MRA治疗对降低STEMI患者的MI大小没有治疗效果,但是在治疗后3个月时,对患者的LV重塑具有明显的治疗效果。

The mortality of patients with acute ST segment elevation myocardial infarction(STEMI)is always high,which seriously threatens people’s life safety,so a reliable treatment is needed.Corticosteroid receptor antagonist(MRA)therapy has been shown to prevent adverse left ventricular(LV)remodeling in patients with congestive heart failure and ST segment elevation myocardial infarction(STEMI).It is unknown whether starting MRA prior to primary percutaneous coronary intervention(PPCI)will bring additional benefits in reducing myocardial infarction size and preventing poor LV remodeling.The authors aimed to investigate whether MRA therapy initiated prior to reperfusion can reduce the size of myocardial infarction(MI)and prevent poor LV remodeling in STEMI patients.From December 2016 to January 2019,60 consecutive STEMI patients were collected from Department of Cardiology of our hospital.They agreed that STEMI patients should be treated within 12 hours with proximal coronary artery occlusion and with grade 0 myocardial infarction thrombolysis.After primary percutaneous coronary intervention,the patients were randomly divided into MRA treatment group or placebo group in a 1∶1 manner Patients in the control group were treated with placebo after oral administration of spironolactone 25 mg(10 m L)of potassium adrenaline before the blood flow of the related artery was restored.The primary end point was the size of MI measured by cardiovascular magnetic resonance imaging at 3 months.MRI results showed that after 3 months of treatment,there was no significant difference in the final Mi size between the two groups(P>0.05).In addition,at the end of treatment,there was no significant difference in the size of acute myocardial infarction or the number of myocardial rescue(P>0.05).During the follow-up period,LVEF of all patients showed a trend of improvement compared with the treatment period,and the decrease of LVEDV and LVESV in MRA group was significantly greater than that in the control group,indicating that the therapeutic effect of corticosteroid receptor antagonist was better.This study shows that although MRA therapy before reperfusion has no therapeutic effect on reducing Mi size in STEMI patients,it has significant therapeutic effect on LV remodeling in patients with STEMI at 3 months after treatment.