急性前壁心肌梗死墓碑型心电图改变患者冠状动脉造影特点及急诊介入治疗

The characteristics of coronary angiography and primary percutaneous coronary intervention in patients with anterior wall acute myocardial infarction with "tombstoning" electrocardiographic pattern

目的：探讨前壁急性心肌梗死（AMI）墓碑型心电图改变患者临床、冠状动脉病变特点及急诊冠状动脉介入治疗（PCI）的效果。方法：接受急诊PCI的前壁AMI患者102例，根据心电图特点，分为墓碑组（31例）和非墓碑组（71例），对比分析其临床、冠状动脉病变特点、即刻手术成功率和住院期间主要心脏事件的发生情况。结果：墓碑组梗死前心绞痛比例明显低于非墓碑型组（P〈0．01）。墓碑组犯罪病变多位于左前降支（LAD）近端（64．5％：36．6％，P〈0．01），并发右冠状动脉和左回旋支病变的比例高（51．6％：21．1％，P〈0．0l；38、7％：17．0％，P〈0．01），术前TIMI血流分级0～1级比例明显高于非墓碑组（83．9％：59．1％，P〈0．05），墓碑组发病一球囊开通时间明显短于非墓碑组[（5．3±5．5）h：（7．4±6．8）h，P〈0．05]。2组术后TIMI血流分级、手术操作时间和手术成功率、术后2h心电图ST段的回落程度、肌酸激酶同工酶峰值、左室射血分数及主要不良心脏事件的发生情况均差异无统计学意义（P〉0．05）。结论：墓碑型前壁AMl患者犯罪病变多位于LAD近端且多为完全闭塞，常并发其他冠状动脉病变及缺乏良好的侧支循环保护，急诊PCI是安全、有效的，并能明显改善其预后。

Objective：To explore the characteristics of coronary angiography and the safety and efficacy of primary percutaneous coronary intervention in patients with anterior wall acute myocardial infarction with “tombstoning” electrocardiographic （ECG） pattern. Method：The data of 102 patients who were underwent primary percutaneous coronary intervention during April 2004 to April 2006 were analyzed retrospectively. They were divided into tombstoning ECGs group （n = 31） and non-tombstoning ECGs group （n = 71） according to ECG pattern. The clinical characteristics, coronary angiography findings and in-hospital results were analyzed in two groups. Result：The baseline characteristics two groups were similar except that preinfact angina were lower in tombstoning ECGs group. Compared with non-tombstoning ECGs group, The characteristics of coronary angiography was the significant differences in the tombstoning group, were as follows： ①LAD occlusions were mostly proximal （64.5 % ： 36.6 %, P〈0. 01） ; ②patients with tombstoning ECGs had a significantly greater incidence of RCA and LCX coronary lesion （51.6% ： 21. l%,P〈0. 01：38. 7% ： 17.0%,P〈0. 01）） ; ③patients with tombstoning ECGs had a significantly greater incidence of TIMI flow 0--1 grade before PCI （83.9% ： 59. 1% ,P〈0. 05） ;④patients with tombstoning ECGs were lack of good collateral circulation. There was no significant difference between the two groups on instant, clinical outcomes, time of procedure and procedural success rate, Time of symptom-balloon （hour） was shorter in tombstoning ECGs（5.3±5.5 ： 7. 4±6.8, P〈0. 05）. ST-segment resolution, peak of CK- MB, LVEF, and major adverse cardiac events were similar in two groups. Conclusion：The patients with tombstoning pattern on the admission ECG, who underwent angiography, were associated with occlusion of the proximal LAD artery and usually with involvement of more than one artery, and lack of good collateral circulation. Primary PCI was safe and effective, and could improve the prognosis of the patients with tombstoning pattern.