急性ST段抬高心肌梗死急诊介入治疗后心肌再灌注不良对近、远期预后的影响

Association between post primary percutaneous coronary intervention myocardium reperfusion and prognosis in patients with acute ST-elevation myocardial infarction

目的 探讨急性心肌梗死急诊经皮冠状动脉介入治疗（PCI）后心肌再灌注状态不良的发生率及其对近、远期临床预后的影响.方法 回顾性收集964例急性ST段抬高心肌梗死（STEMI）行急诊PCI治疗患者的临床资料、冠状动脉造影资料与心电图,以ST段回落程度与心肌梗死溶栓试验心肌灌注（TMP）分级等指标评估心肌再灌注状态.患者分为4组：A组为ST段回落率≥50%并且术后TMP分级为Ⅲ级;B组为ST段回落率〈50%并且术后TMP分级为Ⅲ级;C组为ST段回落率≥50%并且术后TMP分级≤Ⅱ级;D组为ST段回落率〈50%并且术后TMP分级≤Ⅱ级.以A组代表心肌灌注状态良好者,D组代表心肌灌注状态不良者.分析心肌再灌注不良患者的发生率及其对近远期预后的影响.结果 STEMI急诊PCI术后梗死相关动脉前向血流达到TIMIⅢ级而TMP分级为Ⅱ级以下者占27.3%（237/964）,心电图ST段回落小于50%者占30.6%（266/964）.11.31%（109/964）的患者发生远端栓塞.A组占总例数的48.9%（425/964）,D组占总例数的10.5%（91/964）.与A组比较,D组患者在住院期间（RR=64.63,P〈0.01）以及随访期间（RR=11.69,P〈0.01）均有较高的主要不良心脏事件发生风险.结论 急性心肌梗死急诊PCI后不到50%的患者心肌再灌注良好,心肌再灌注状态与近、远期临床预后显著相关.

Objective To explore the prognostic impact of post primary percutaneous coronary intervention （PCI） reperfusion status on outcome in patients with acute ST-elevation myocardial infarction （STEMI）. Methods A retrospective analysis was performed in 964 patients undergoing primary PCI for STEMI. Electrocardiogram and TIMI myocardial perfusion grade （TMPG） were analyzed by reader blinded to the clinical course. Patients were divided to four groups according to ST segment resolution （STR） and TMPG： group A were patients with good STR and TMPG（425/964）, group B were patients with poor STR and good TMPG （239/964）, group C were patients with good STR and poor TMPG （113/964） and group D were patients with poor STR and TMPG （113/964）. Results Although TIMI grade Ⅲ flow was achieved after mechanical reperfusion, abnormal reperfusion was still present in about 1/3 patients as shown by poor STR or TMPG. Older age, cardiac dysfunction and diabetes, prolonged time of pain to balloon/emergency room are independent risk factors for abnormal reperfusion post PCI. Major aclverse cardiac events events in hospital （ RR = 64. 63, P 〈 0. 01 ） and during follow up（ RR = 11.69, P 〈 0. 01 ） were significantly higher in group D than in group A. Conclusion Poor post PCI reperfusion status is associated with higher in hospital and during follow up major aclverse cardiac events event in STEMI patients.