急性心肌梗死急诊不同再灌注方案的临床分析

Study of different myocardial reperfusion therapy in acute myocardial infarction

目的探讨长沙地区急性心肌梗死不同院前心肌再灌注方案的实际执行状况和效果。方法本研究为非随机、前瞻性试验。入选的急性心肌梗死病例被分为尿激酶(UK)组、重组组织型纤溶酶原激活剂(r-tPA)组、经皮冠状动脉介入治疗(PCI)组和非再灌注组,非再灌注组的病例予以低分子肝素、阿司匹林治疗,观察不同方案的实际实施状况及近期疗效、并发症和费用-效果比。结果①106例AMI病人,87例施行了再灌注治疗(82%),急诊PCI组24例(23%),r-tPA组27例(25%),UK组36例(34%);非再灌注19例(18%)。②再通率为UK组61.3%,r-tPA组81.5%,PCI组95.8%;入院至开始再灌注时间为UK组(38.52±16.21)min,r-tPA组(46.23±17.13)min,PCI组(98.47±20.42)min;入院至再通时间为UK组(73.21±11.34)min,r-tPA组(122.12±23.46)min,PCI组(132.73±13.67)min。③住院期心绞痛发生率,再发心肌梗死率,心衰发生率,病死率在PCI组优于r-tPA组,r-tPA组优于UK组,三组均显著低于非再灌注组。④费用-再通率比为PCI组33893.16元,r-tPA组16717.53元,UK组3037.52元。结论在AMI的实际临床治疗中,大部分病人接受了急诊再灌注治疗。UK方案仍是采用最多的方案,可以在较短时间内实现IRA再通,且费用-效果比低,但再通率偏低,近期效果不满意。急诊PCI的再通率和近期临床效果最佳,但容易受多因素影响而耽误开始再灌注治疗的时间,且费用-效果比高。r-tPA的再通率、近期临床效果均明显高于UK,恢复IRA再通的时间与PCI接近,费用-效果比显著低于急诊PCI,是个比较理想可行的AMI急诊再灌注方案。

[Objective] To observe the actual application status and the result of different myocardial reperfusion therapy in acute myocardial infarction （AMI） patients in prehospital care in Changsha district. [Methods] Patients with AMI who met the criteria for intravenous thrombolysis therapy were unrandomly divided into urokinase （UK） group, reconstructive tissue plasminogen activator （r-tPA） group and percutaneous coronary invasion （PCI） group. Meanwhile, those who did not agree to receive repeffusion therapy were treated with low molecular weight heparin （LMWH） and aspirin. [Results] 106 patients were admitted in 3 years （2003.06.01-2006.05.31）. 87 patients （82%） underwent repeffusion therapy, 24 in PCI gpoup （23%）, 27 in r-tPA group （25%）, and 36 in UK group （34%）. Recanalizing rates were 95.8% in PCI group, 81.5% in r-tPA group, and 61.3% in UK group. The duration from door to recanalizing was （132.73±13.67） min in PCI group, （122.12±23.46） rain in r-tPA group, and （73.21±11.34） min in UK group. The rates of reinfarction, angina pectoris, heart failure and hospitalization death decreased significandy in PCI group and r-tPA group compared to those in UK group. Compared to the 19 patients who did not receive reperfusion therapy, the rates of reinfarction, angina pectoris, heart failure and hospitalization death in UK group decreased significantly too. The cost/effect rates were ￥33893.16 in PCI group, ￥16717.53 in r-tPA group, and ￥3037.52 in UK group. [Conclusion] Most part of AMI patients received repeffusion therapy. UK was used as thrombolyt/c the most commonly in Changsha district. The cost/effect rate of UK was the lowest in three reperfusion therapies, while the recanalizing rate was the lowest, too. The recanalizing rate of r-tPA was better than UK, and the cost/effect rate of r-tPA was lower than PCI. The t-tPA program is a desirable and feasible reperfusion therapy of A- MI in Changsha district.