急性心肌梗死患者直接经皮冠状动脉介入治疗疗效与预后的影响因素

Factors influencing outcomes of patients with acute myocardial infarction receiving primary percutaneous coronary intervention

目的研究接受直接PCI治疗的ST段抬高AMI患者中,PCI术后即刻TIMI血流分级、心电图ST段的回落、心肌酶峰值、LVEF以及随访期间不良事件发生情况的影响因素,特别是评价症状发作至球囊打开时间(symptom-onset-to-balloon time,SOTB)以及接诊至球囊打开时间(door-to-bal-loon time,DTB)与上述指标的关系。方法入选2001年1月至2006年4月因ST段抬高AMI收入北京大学第一医院、接受了直接PCI,且已随访半年以上的患者120例,随访时间5.0～65.4个月,中位随访时间20.1个月,收集包括疾病史、吸烟史、体重指数、入院时Killip分级等基线资料,记录SOTB时间,DTB时间、冠状动脉病变情况、合并用药情况、术后TIMI血流分级、心电图ST段的回落、术后心肌酶峰值、LVEF,记录随访期间不良事件。采用多因素Logistic回归分析,评价上述指标对疗效及预后的影响。结果(1)SOTB是影响PCI术后即刻TIMI血流分级的独立的危险因素:与SOTB大于360min的患者相比,SOTB小于360min的患者发生无血流/慢血流的危险明显降低(OR=0.2,95%CI:0.0～1.0,P=0.045);(2)肥胖是影响术后心肌酶峰值的独立的危险因素(β=117.3,95%CI:12.1～222.6,P=0.029);(3)高龄、肥胖、术前Killip分级是影响术后LVEF的独立危险因素,其中高龄(β=-6,95%CI:-9.7～-2.2,P=0.002)、肥胖(β=-3.8,95%CI:-7.6～-0.1,P=0.044)与低的LVEF显著相关,而术前Killip分级Ⅰ级与高的LVEF显著相关(β=4.9,95%CI:0.4～9.4,P=0.033);(4)术前Killip分级与多支血管病变是随访期间不良事件发生的独立的预测因素:与KillipⅡ级以上患者相比,KillipⅠ级患者随访期间不良事件发生风险明显降低(OR=0.1,95%CI:0.0～0.7,P=0.022);而与单支病变患者相比,多支血管病变随访期间不良事件发生明显增加(OR=10.5,95%CI:1.1～99.4,P=0.041)。结论多种因素可以影响接受直接PCI的AMI患者临床疗效及预后,包括高龄、肥胖、多支血管病变、术前心功能,而SOTB和AMI患者PCI术后TIMI血流分级显著相关。

Objective To identify the factors which could influence the clinical outcomes including postprocedural TIMI flow, ST-segment recovery, peak concentration of CK-MB, left ventricular ejection fraction （LVEF） by echocardiography and the incidence of major adverse cardiac event in patients with AMI receiving primary PCI. Time issues including the symptom-onset-to-balloon time （SOTB） and the door-to- balloon time （DTB） were also studied. Methods One hundred and twenty patients hospitalized in Peking University First Hospital with acute ST-segment elevation myocardial infarction between Jan. 2001 to Apr. 2006 were enrolled in this study. The median duration of the follow up was 20. 1 months （ ranged from 5 to 65.4 months after the procedure）. The preprocedural Killip classification, history of underlying diseases, BMI, history of smoking, SOTB, DTB, lesions angiographic characteristics the treatment protocol and the clinical outcomes of all patients were documented. The influential factors for respective clinical outcomes were identified using multivariate logistic regression test. Results （1） SOTB was identified as an independent risk factor for pestproeedural TIMI flow. Compared with that of patients with SOTB 〉 360 min, the risk of no-reflow phenomenon was decreased in patients with SOTB ≤ 360 rain （OR = 0. 2,95 % CI：0.0- 1.0,P =0. 045）. （2） Obesity was identified as an independent risk factor for peak concentration of CK- MB （β= 117.3,95% CI：12.1 -222.6,P =0.029）. （3） Age （above 60 years old）, obesity, and preprocedural Killip classification were identified as independent risk factors for postprocedural LVEF. Old age （β = - 6,95 % CI： - 9.7 - - 2. 2, P = 0. 002） and obesity （ β = - 3.8,95 % CI： - 7.6 - - O. 1, P = 0. 044） were associated with low LVEF but preprocedural cardiac function of Killip Class I was associated with high LVEF （ β = 4. 9,95% CI： 0. 4 - 9. 4, P = 0. 033 ）. （4） Preprocedural Killip classification and multivessel disease were independent predictors for major adverse cardiac event in the follow-up period. The risk of major adverse cardiac event during follow-up decreased in patients with preprocedural Killip class I compared with patients with Killip class Ⅱ～Ⅳ （OR =0. 1,95% CI：0. 0 -0. 7, P =0. 022）, but the risk increased in patients with multivessel disease compared with those who had single vessel disease （OR = 10. 5, 95% CI： 1.1 - 99.4, P = 0. 041 ）. Conclusion The clinical outcomes and prognosis of patients with AMI treated with primary PCI were associated with a variety of risk factors including age, obesity, multivessel disease, and preprocedural cardiac function. In addition, SOTB was related to postprocedural TIMI flow in patients with AMI undergoing primary PCI.