腺苷对急性心肌梗死经皮冠状动脉介入治疗患者的心肌保护作用

Myocardial protective effect of adenosine during percutaneous coronary intervention in patients with acute myocardial infarction

目的评价急性心肌梗死（AMI）患者直接经皮冠状动脉介入治疗（PCI）中冠状动脉内应用腺苷的心肌保护作用。方法对42例AMI患者随机分为直接PCI过程中冠状动脉内腺苷注射组与生理盐水注射对照组各21例；先以球囊预扩张开通血管，腺苷组即刻予以腺苷300μg＋10m1生理盐水，对照组则予以生理盐水10ml，持续冠状动脉内注射1分钟，再予以支架治疗；术毕根据心肌梗死溶栓治疗试验（TIMI）血流分级对梗死相关动脉（IRA）进行再通后血流评价，测定术后4～24小时心肌生化标记物肌酸激酶（CK）及肌酸激酶同工酶（CK—MB）、肌钙蛋白Ⅰ（cTnⅠ）、术后1小时心电图ST段抬高总和回落（sum of ST—segment resolution，sumSTR）百分比、第3天和4周左室射血分数（LVEF）的变化。结果腺苷组患者术后CK、CK—MB、cTnⅠ峰值较对照组峰值明显降低[中位数（25％，75％百分住数）分别为CK1170（730，2169）U／L vs 1610（1056，3598）U／L；CKMB128（98，168）U／L vs178（125，345）U／L；cTnⅠ 17．5（12．9，20．6）μg／LVS25．9（17．5，58．9）μg／L]（均P〈0．05）；sumSTR腺苷组下降幅度较生理盐水组明显[中位数（25％，75％百分位数）72％（64％，82％）vs55％（25％，65％）]（P〈0．05）；PCI后4周无论腺苷组还是对照组患者LVEF均比3天时有明显改善，腺苷组（56．67±6．14）％VS（50．19±4．24）％，对照组（53．05±4．67）％vs（47．62±4．18）％（均P〈0．05）；3天时两组LVEF差异无统计学意义（50．19±4．24）％VS（47．62±4．18）％（P〉0．05），4周时腺苷组LVEF较对照组改善更显著（56．67±6．14）％VS（53．05±4．67）％（P〈0．05）。结论AMI直接PCI治疗中，冠状动脉内注射腺苷可以显著缓解AMI血管开通背景下发生的缺血-再灌注损伤，并有益于改善左心功能，冠状动脉内应用适宜剂量腺苷安全可行。

Objective To evaluate the myocardial protective effect of intraeoronary adenosine infusion in patients with acute myocardial infarction （AMI） after percutaneous coronary intervention （PCI）. Methods Forty-two AMI patients who received PCI successfully were randomly divided into two groups. After the balloon was inflated. adenosine（300μg） and saline（10 ml） were immediately injected by intracoronary injection in adenosine group and saline was injected in control group within one minute. Then the stenting was performed. Coronary flow of infarction related artery（IRA） was assessed by the method of thrombolysis in myocardial infarction trial（TIMI） grading. Serum levels of ereatine kinase（CK）, MB isoenzyme of creatine kinase（CK-MB）,cardiac troponin I（eTnI） were measured at 4 h,8 h. 12 h, 16 h, 20 h and 24 h after PCI. Sum of ST-segment resolution（sumSTR） was measured at 1 hour after PCI. The left ventricular ejection fraction（LVEF） by echocardiogram was evaluated at the third day and fourth week after PCI. Results Serum peak levels of CK, CK-MB and cTnI in adenosine group were significantly lower than those in saline group[median（25%,75%percentiles） CK 1 170 （730,2 169） U/L vs 1 610（1 056,3 598） U/L, CK-MB 128（98,168） U/Lvs 178（125,345） U/L, cTnⅠ 17.5（12.9,20.6） μg/Lvs 25.9（17.5,58.9）μg/L]（allP〈0.05）. Sum STR one hour after PCI of adenosine group was significantly higher than that of saline group[median（25 %, 75 % percentiles） 72 %（64 %, 82 % ） vs 55（25 %, 65 % ）] （ P 〈0.05）. LVEF in both adenosine and control group at the fourth week after PCI was significantly improved than that at the third day, adenosine group （56.67 ± 6.14） % vs （50.19 ± 4.24） %. control group （53.05±4.67） % vs （47.62±4.18） % （ P 〈0.05）. But LVEF at the third day between two groups after PCI showed no significant difference （50. 19 ±4.24）% vs （47.62± 4.18）% （ P 〉 0.05）. LVEF of the fourth week after PCI in adenosine group was significantly improved than that of saline group （56.67± 6.14） % vs （53.05± 4.67）% （P 〈0.05）. Conclusion Intraeoronary adenosine infusion during PCI significantly alleviated isehemia-reperfusion injury in AMI, ameliorated myocardial reperfusion and improved the left ventrieular function. Intraeoronary adenosine infusion in the patients with AMI during PCI was safe and feasible.