急性心肌梗死直接经皮冠状动脉介入术心肌缺血再灌注损伤的发病因素分析

Analysis on correlative factors for occurrence of myocardial ischemia-reperfusion injury during primary percutaneous coronary intervention for acute myocardial infarction

目的探讨急性心肌梗死(AMI)直接经皮冠状动脉介入术(PCI)心肌缺血再灌注损伤(MIRI)发生的影响因素。方法回顾性分析2001年1月至2004年12月在我院接受直接PCI且成功开通梗死相关血管(IRA)的AMI患者228例。MIRI判断标准为AMI直接PCI开通IRA后数分钟内急性发生的严重心动过缓和低血压,或需电复律的严重室性心律失常,或IRA前向血流≤TIMI2级且除外因造影可见的血栓、栓塞、夹层或痉挛等所致急性闭塞。应用多因素logistic回归模型对18个临床和冠状动脉造影因素进行分析。结果logistic回归分析显示,AMI发病时间≤6h(P=0.014)、下壁梗死(P=0.006)和PCI前IRA前向血流≤TIMI1级(P=0.028)是MIRI发生的独立危险因子,多支血管病变(P=0.063)和肾功能不全(P=0.067)也是危险因子;而梗死前心绞痛是独立保护因子(P=0.005)。结论AMI发病时间短、下壁梗死、PCI前IRA前向血流≤TIMI1级、多支血管病变和肾功能不全增加直接PCI术MIRI发生的危险性,而梗死前心绞痛则可减少MIRI的发生。

Objective To explore the risk and protective factors for the occurrence of myocardial ischemia-reperfusion injury （MIRI） during primary percutaneous coronary intervention （PCI） for acute myocardial infarction （AMI）. Methods Clinical and angiographic data of 228 AMI patients in whom the infarct-related arteries （IRA） were successfully revascularized by primary PCI were analyzed retrospectively. MIRI was defined if the following conditions existed after PCI： severe bradycardia with hypotension, or lethal ventricular arrhythmias requiring electrical cardioversion, or IRA antegrade flow≤TIMI 2 grade flow without angiographic evidence of thrombus, emboli, dissection or spasm. Multivariate logistic regression was used to identify independent relative factors among 18 clinical and angiographic factors for occurrence of MIRI. Results Multivariate logistic regression analysis showed that independent risk factors for MIRI were the time intervals from AMI onset to IRA reflow ≤6 h （P =0. 014）, inferior infarction localization （P = 0. 006） , IRA antegrade flow prior to PCI ≤ TIMI 1 grade （ P = 0. 028 ） , multivessel lesions （ P = 0. 063 ） and renal inssuficiency （ P = 0. 067 ）. Pre-infarction angina was found to be an independent protective factor （P = 0. 005 ）. Conclusions Short time intervals from AMI onset to IRA revascularization, inferior wall infarction location, low IRA antegrade flow prior to PCI, multivessel lesions and renal insufficiency may promote the occurrence of MIRI during primary PCI, whereas pre-infarction angina may be a cardioprotective factor attenuating MIRI.