心房颤动/心房扑动对急性心肌梗死后急诊经皮冠状动脉介入术患者近期预后的影响

Significance of atrial fibrillation/atrial flutter in prognosis in patients with primary percutaneous coronary intervention

目的评价急性心肌梗死后行急诊经皮冠状动脉介入治疗(PCI)的患者中心房颤动(房颤)/心房扑动(房扑)的发生率及其对患者预后的影响。方法本研究入选的患者为急性ST段抬高型心肌梗死,症状发作在24h内(大多数为12h内),并行急诊PCI,共计668例。将其分为房颤/房扑组(入院时或住院期间心电图检查存在房颤/房扑者)和无房颤/房扑组,除心电图外同时收集患者住院资料,包括年龄、性别、心肌梗死史、脑血管病史、高血压史、糖尿病史、冠心病家族史、急诊冠状动脉造影结果及急诊PCI术后TIMI血流分级、心功能killip分级等。结果入选的668例患者中,有房颤/房扑心电图记录者67例(约占10%),与无房颤/房扑组比较分析发现,存在房颤/房扑的患者具有以下几个临床特点:高龄;多数有既往心肌梗死或脑血管病史及糖尿病、高血压病史;冠状动脉造影显示多为多支血管病变;PCI术后梗死相关血管的TIMI血流分级低。年龄、心功能Killip分级为Ⅳ级、多支血管病变等是房颤/房扑发生的独立预示因子。房颤/房扑组住院死亡率明显高于无房颤/房扑组(9.0%vs3.1%,P<0.05),房颤/房扑组心源性休克、充血性心力衰竭、室性心律失常(特别是恶性室性心律失常)的发生率均明显高于无房颤/房扑组(P<0.05)。多因素Cox回归分析显示,房颤/房扑是住院死亡率的独立预示因子(RR值1.36,95%CI1.01～2.08)。结论房颤/房扑是急性心肌梗死急诊PCI患者群中常见的合并症与并发症,房颤/房扑的存在与住院死亡率密切相关,并受到包括年龄、性别、心功能状态(Killip分级)、血管病变支数、PCI术后TIMI血流分级等多种因素的影响,或许这些因素与房颤/房扑的发生之间存在相互影响,并将直接影响房颤/房扑患者的临床预后。

Objeelive Previous studies have reported that the incidence of atrial fibrillation （AF）/atrial fluttler in patients with AMI who were treated with thrombolysis is 7% - 10%. However, little is known concerning the incidence of AF/atrial flutfler and its effects on the prognosis of patients with AMI who are treated with PCI. Methods A total of 668 consecutive patients were studied in Beijing Chaoyang Hospital from Nov. 2000 to Jan. 2004. Patients were categorized into 2 groups according to the presence of AF/atrial flutter. Results The results showed that the incidence of AF/atrial fluttler was 10% and that the patients with AF/atrial fluttler were older, were in higher Killip classes, had higher rates of previous myocardial infarction and previous cerebrovascular diseases, multivessel discase, and had poorer reperfusion of the infarc-related artery than those without AF/atrial fluttler. Patients with AF/atrial fluttler had higher in-hospital （ 11.9% vs 5.3%, P 〈 0.05） mortality than those without AF/atrial fluttler. Multivariate Cox regrssion analysis revealed that AF/atrial fluttler was an independent predictor of in-hospital mortality （risk ratio 1.36, 95% confidence interval 1.01 - 2.08, P 〈 0.05）. Conclusion Current AF, and the development of new AF soon after AMI, is associated with increased risk of death.