尿激酶对直接经皮冠状动脉介入治疗术后无复流患者的疗效观察

Observations on effects of urokinase treatment in no-reflow phenomenon of primary coronary intervention for acute myocardial infarction

目的探讨尿激酶对直接经皮冠状动脉介入治疗(PCI)术后无复流(NF)的疗效。方法将71例急性心肌梗死(AMI)直接PCI术后NF患者随机分成尿激酶组(35例)和对照组(36例),尿激酶组PCI术后即刻予25万U尿激酶冠状动脉内注射,15 min后行冠状动脉造影,观察心肌梗死溶栓研究(TIMI)和Blush血流分级改变情况,术后第1天起再予尿激酶25万U静脉滴注,共3 d。两组术中均根据血压情况予必要的常规处理,比较两组一般临床特征、心功能及随访心血管事件的发生率。结果①尿激酶组TIMI及Blush血流较治疗前无明显改善,术后1 h ST段抬高下降幅度≥50％者占42．8％,与对照组(30．5％)的差异无显著性(P>0．05),术后72 h ST段抬高下降幅度≥50％者占77．1％,与对照组(52．8％)的差异有显著性(P<0．05)。②尿激酶组术后10 d梗死心肌节段心肌灌注积分为(3．00±1．25)分,显著低于对照组的(3．77±1．36)分(P<0．05)。③住院期间尿激酶组与对照组的左室舒张末期容积(LVEDV)、左室收缩末期容积(LVESV)、室壁运动积分(WMSI)和左室射血分数(LVEF)的差异均无显著性(P值均>0．05)。但尿激酶组随访期间的LVEDV、LVESV、WMSI较住院期间显著降低,LVEF则显著增加(P值均<0．05);对照组LVEDV、LVESV及WMSI较住院期间显著增加,LVEF则显著降低(P值均<0．05)。④尿激酶组在住院期间及随访期间恶性心律失常和心力衰竭的发生率较对照组显著下降(P值均<0．05);不稳定心绞痛、再次心肌梗死、再次血运重建及死亡发生率的差异无显著性(P值均>0．05)。结论应用小剂量尿激酶能改善心肌梗死后的左室重构,减少心脏事件的发生,对改善AMI直接PCI后NF的不良影响有一定作用。

Objective To appraise the effects of urokinase on no-reflow phenomenon after percutaneous coronary intervention（PCI） in patients with acute myocardial infarction（AMI）. Methods Seventy-one patients with no reflow phenomenon after PCI were enrolled, Patients were divided into urokinase group （n ： 35） and control group （n ： 36）. Two hundred fifty thousand units urokinase were injected into the coronary artery right after completion of PCI. Fifteen minutes later coronary angiography was performed again for comparison of TIMI flow and blush grading before and after PCI. The patients were given intravenous drip of 250 000 units urokinase in 100 mL normal saline or 5% glucose saline in half an hour every day for three days, after PCI. The clinical characteristics, cardiac function and cardiac events were analysed. Results ①In the urokinase group,comparison between pre and post-treatment： TIMI or blush grade did not show any significant difference. Neither TIMI nor blush showed any significant difference. The ST descent≥50% after 1 hour in both the urokinase and control groups was not significant while ST segment descent ≥50% in 72 hours in urokinase group was more than that in the control group.②10 days after the infarction, the myocardial segment perfusion score using SPECT in the urokinase group decreased significantly more than that in the control group. ③ Differences of LVEDV. LVESV. LVEF. WMSI between the 2 groups after 7 days were not significant, while LVEDV.LVESV.WMSI as well as LVEF in the urokinase group after 6 months decreased more than those in the control group. In the latter, LVEDV increased more significantly than that after 7 days while LVEF decreased more significantly than that after 7 days. ④Frequency of malignant arrhythmias,heart failure in the urokinase group decreased more notably than those in the control group. As regards to unstable angina, re-infarction, revascularization and mortality rate, the two groups were not significantly different during hospitalization and follow-up. Conclusions Low dose urokinase exhibits benefical effects on the harmful aftermath of no-reflow after PCI. It can improve left ventricle remodeling after AMI and reduce cardiac events. （Shanghai Med J, 2006, 29：711-714）