冠状动脉内应用山莨菪碱对急性心肌梗死介入治疗后无再流及心室功能和收缩同步性的影响

Influence of intracoronary administration of anisodamineon on no-reflow,ventricular function and systolic synchrony in acute myocardial infarction patients undergoing percutaneous coronary intervention

目的探讨冠状动脉内应用山莨菪碱对急性心肌梗死介入治疗(AMI-PCI)后无再流患者的逆转作用并评价其对患者局部、整体心室功能和收缩同步性的影响。方法自2003年1月至2006年2月首发急性前壁心肌梗死并于12 h 内行急诊 PCI 的患者136例,根据心肌灌注分级方法(myocardial blush grade,MBG)确认无再流患者(MBG 0～1级)47例(男36例,女11例),平均年龄(63.23±11.24)岁,随机分为两组:A 组(山莨菪碱组,24例)和 B 组(对照组23例),A 组于 PCI 后即刻由指引导管冠状动脉内注射山莨菪碱1000μg/次,余治疗同 B 组。于 PCI 后即行左心室造影,测定心室容积、压力参数和室壁运动积分(wall motion score,WMS);AMI 后1周时行平衡法核素心室造影,测定左室整体和局部收缩功能、舒张功能和收缩同步性参数;AMI 后6个月随访时重复行心室造影和核素心室造影检查测定上述参数,同时随访并记录术后6个月内主要不良心脏事件(MACE)的发生率。结果 (1)A 组患者在冠状动脉内应用山莨菪碱1000μg/次,平均(2.53±0.34)次后 MBG由(0.74±0.32)级增加到用药后的(2.33±0.28)级。(2)AMI-PCI 后6个月随访时,A 组左室收缩末容积指数、左心室舒张末期容积指数、WMS 和左室舒张末期压均较 B 组明显降低[(40.53±8.12)ml/m^2比(50.32±8.26)ml/m^2,(80.13±9.74)ml/m^2比(87.17±10.25)ml/m^2,(8.24±1.31)比(10.23±1.82),(13.36±4.21)mm Hg(1 mm Hg=0.133 kPa)比(16.38±3.21)mm Hg,P 均<0.05];核素心室造影参数比较,A 组左室射血分数、峰射血率和峰充盈率等参数均较 B 组明显增加[(44.02±5.86)%比(38.52±5.18)%,(1.86±0.09)EDV/s 比(1.61±0.09)EDV/s,(2.19±0.32)EDV/s 比(1.78±0.17)EDV/s,P 均<0.05]。(3)A 组 AMI-PCI 后6个月左室局部射血分数(LrEF)_2-LrEF_8均分别较 B 组增加13.96%、25.02%、30.36%、22.86%、27.67%、22.07%和18.71%(P 均<0.05)。(4)相位分析示 A 组左室收缩同步性参数相角程、半高宽和峰相位标准差亦均低于 B 组[(46.04±8.93)°比(53.19±16.62)°,P<0.05;(23.02±6.27)°比(25.02±5.31)°,P>0.05;(7.92±4.12)°比(11.76±4.11)°,P<0.05]。(5)在6个月随访期内,A 组 MACE 发生率明显低于 B 组。结论冠状动脉内注射山莨菪碱可明显逆转 AMI-PCI 后无再流现象,改善无再流患者的心室功能和收缩同步性,降低 MACE 发生率。

Objective To evaluate the influence of intracoronary administration of anisodamine on myocardial blush grade （MBG） and left ventricular regional and global systolic function and synchrony in the acute myocardial infarction （AMI） patients with no-reflow phenomenon post percutaneous coronary intervention （PCI）. Methods Forty-seven AMI patients who underwent PCI within 12 hours of onset and MBG was 0-1 were randomized to receive standard therapy [group B, n =23, 18 males, mean age（ 62. 72 ± 11.48）years ] or standard therapy plus intracoronary administration of anisodamine [ 200μg/ml, group A, n =24, 18 males, mean age （64. 23 ± 12. 27 ）years]. The left ventriculography （LVG） was performed immediately and 6 months after PCI to measure the ventricular volume, LVEDP and wall motion score （WMS）. Equilibrium radionuclide angiography （ERNA） was performed 1 week and 6 months after PCI to determine the parameters of left ventricular regional, global systolic function and systolic synchrony. Incidence of major adverse cardiac events （MACE） during the follow-up was analyzed. Results Anisodamine [ （2530 ± 340） μg/person） ] was well tolerated by patients. The MBG remained unchanged in group B and significantly increased from grade 0. 74 ± 0. 32 to grade 2. 33 ± 0. 28 10 min after anisodamine injection in group B. Six months post PCI, LVESVI [ （40. 53 ± 8. 12 ） ml/m^2 vs. （50. 32 ± 8.26） ml/m^2 ], LVEDVI[ （ 80.13 ± 9. 74） ml/m^2vs. （87. 17± 10.25 ）ml/m^2], WMS [（8.24 ±1.31） vs. （10.23 ± 1.82）] and LVEDP [（13.36±4.21） vs. （16.38 ±3.21） mm Hg, 1 mm Hg = 0.133 kPa]were significantly lower in group A compared with that in group B （ all P 〈 0. 05 ） while LVEF [ （ 44. 02 ± 5.86）% vs. （38.52 ±5.18）%], PER [（1.86 ±0.09） EDV/s vs. （1.61 ±0.09）EDV/s] and PFR [ （2. 19 ±0. 32） EDV/s vs. （1.78 ± 0. 17 ） EDV/s ] measured by ERNA were significantly increased in group A compared with that in group B （ all P 〈 0. 05 ）. （ 2 ） LrEF2-LrEFs in group A were higher by 13.96% ,25.02% ,30. 36% ,22. 86% ,27.67% ,22. 07% and 18. 71% respectively compared with that in group B. （3） Phase analysis showed that the left ventricular systolic synchrony parameters PS [ （46. 04 ± 8. 93）° vs. （ 53. 19 ± 162）°], FWHM [ （23.02 ±6. 27）° vs. （25. 02 ±5.31 ）°] and PSD [ （7.92 ± 4. 12）° vs. （11.76 ±4. 11）°] were also significantly lower in group A than that in group B （all P 〈 0. 05）. （4） During the 6 months of follow-up, the incidence of MACE in group A was significantly lower than that in group B （ P 〈 0. 05）. Conclusion Intracoronary administration of anisodamine is safe and could partly attenuate the no-reflow phenomenon, improve the left ventricular systolic function and synchrony and reduce the incidence of MACE in patients with no-reflow phenomenon post AMI-PCI.