血栓抽吸治疗急性ST段抬高型心肌梗死前后神经内分泌因子水平的变化

Neuroendocrine changes in patients with ST segment elevation acute myocardial infarction receiving thrombus aspiration

目的探讨应用血栓抽吸装置GuardWire PlusTM行血栓抽吸治疗急性ST段抬高型心肌梗死(STEMI)对神经内分泌因子水平、外周血肌钙蛋白(cTnI)、TIMI血流变化的影响及其临床价值。方法将2004年9月至2006年9月在我院行急诊PCI的72例STEMI患者分为两组,抽吸组(TA组,38例)血栓抽吸后支架置入;非抽吸组(NTA组,34例)单纯PCI。于手术当天、术后第1、2、3、5天分别测定外周血中内皮素(ET)、血浆肾素活性(PRA)、醛固酮(ALD)、血管紧张素Ⅱ(AngⅡ)、去甲肾上腺素(NE)、肾上腺素(E)的水平。于术前、术后4h、8h、12h、16h、24h、2d、3d、5d分别测定外周血中cTnI的水平。支架置入后常规行冠状动脉造影,观察心肌血流灌注情况,测定支架置入后两组患者的TIMI血流。比较术后2h心电图ST段回落。术后1周及3个月应用彩色超声心动图测定左室射血分数(LVEF),评价心功能。结果两组病例均成功置入支架,术前两组患者的神经内分泌因子水平均显著升高,两组间差异无统计学意义。浓度-时间曲线显示术后神经内分泌因子水平均迅速下降,TA组较NTA组ET、PRA、AngⅡ、ALD、NE、E等神经内分泌因子水平于术后第1天或第2天下降明显[ET:术前152.37ng/L比153.63ng/L(P=0.858),术后第1天128.11ng/L比147.07ng/L(P=0.037),术后第2天122.22ng/L比139.64ng/L(P=0.040);PRA:术前2.87μL/(L.h)比2.87μL/(L.h)(P=0.998),术后第1天1.74μL/(L.h)比2.54μL/(L.h)(P=0.036),术后第2天1.70μL/(L.h)比2.29μL/(L.h)(P=0.032);ALD:术前200.14pmol/L比181.19pmol/L(P=0.508),术第1天156.06pmol/L比172.19pmol/L(P=0.001);AngⅡ:术前199.11ng/L比212.32ng/L(P=0.539),术后第1天149.26ng/L比188.37ng/L(P=0.040),术后第2天135.57ng/L比172.25ng/L(P=0.049);NE:术前3338.50pmol/L比2891.46pmol/L(P=0.310),术后第1天2440.62pmol/L比2803.29pmol/L(P=0.041);E术前622.27pmol/L比559.90pmol/L(P=0.368),术后第1天536.08pmol/L比586.89pmol/L(P=0.018)];术后第3天与第5天两组各神经内分泌因子水平已接近正常,组间差异无统计学意义。术前两组间cTnI水平差异无统计学意义,术后TA组的cTnI下降较NTA组快,酶峰TA组较NTA组提前,但是差异无统计学意义。神经内分泌因子水平与cTnI变化呈正相关。支架置入后常规冠状动脉造影显示两组患者的心肌灌注良好,TIMI血流均达到2级或3级,两组间差异无统计学意义。以术后2小时ST段回落幅度≥50%为标准,两组间差异无统计学意义。术后1周两组间左心功能差异无统计学意义;术后3个月两组的左心功能差别明显,TA组的LVEF明显高于NTA组(57.9%±2.3%比54.2%±3.0%,P=0.002)。结论血栓抽吸治疗急性STEMI较单纯PCI能够明显降低已升高的神经内分泌因子的浓度,使cTnI的酶峰提前、减轻对心肌的损害,心肌血流灌注改善,对心功能可能有潜在的保护作用。

Objective To study the changes in neuroendocrine, system and its respective effect in patients with ST segment elevation acute myocardial infarction （STEMI） using the thrombus aspiration system （GuardWire Plus^TM）. Methods Seventy two STEMI patients who received percntaneous coronary intervention （PCI） during September 2004 to September 2006 were enrolled in the study. All the patients were divided into 2 groups which were： the thrombus aspiration group （ TA group n = 38 ） and the nonthrombus aspiration group （ NTA group, n = 34） according to whether thrombus aspiration was applied or not before stenting. The plasma levels of endothelin （ET）, plasma renin activity （PRA）, aldosterone （ALD）, angiotensin Ⅱ （ Ang Ⅱ ）, norepinephrine （ NE ） and epinephrine （E） of all patients were measured on the day of operation and on 1, 2, 3 and 5 days after the operation. The cTNI levels were measured before the operation and at 4, 8, 12, 16 and 24 horus after the operation, as well as on 2, 3, and 5 days afterwards. The post-operational TIMI flow grades and ST-segment resolution were compared between the 2 groups. Left ventricular ejection fraction （LVEF） was measured by colour echocardiography at one week and three months after PCI. Results The plasma levels of all the neuroendocrine factors had no difference between the two groups before operation. The concentration-time curves of ET,PRA,Ang Ⅱ ,ALD,NE and E showed a rapid decline in their plasma levels in the TA group compared with the NTA group on 1 and 2 days after the operation （ P 〈 0. 05 ）. No difference was found in cTnI levels between the 2 groups before the operation （ P 〉 0.05 ）. The peak level of cTnI of the TA group showed up earlier compared with the NTA group but with no statistical significance （ P 〉 0. 05 ）. Post operational TIMI flow grades and ST segment resolution had no statistical differences between the 2 groups （ P 〉 0. 05 ）. In terms fo LVEF, no differences were found between the 2 groups at 1 week after the operation but patients in the TA group showed higher LVEF at 3 months after the operation compared with the NTA group （ P 〈 0. 05 ）. Conclusion Thrombus aspiration can ameliorate the neuroendocrine changes, minimize myocardial damage and enhance perfusion after myocardial infarction.