联合应用培哚普利和氯沙坦改善心肌梗死后左室重构和心功能的临床研究

Effects of combination treatment with perindopril and losartan on left ventricular remodeling and cardiac function in patients with myocardial infarction

目的:观察培哚普利和氯沙坦联合治疗对于急性前壁心肌梗死患者左室重构、心功能和血清Ⅲ型前胶原肽(PⅢNP)水平的影响。方法:急性前壁心肌梗死患者,随机分为培哚普利组、氯沙坦组和培哚普利+氯沙坦组。入院后行急诊冠脉造影和介入治疗,术后分别给予:培哚普利2-4mg/d;氯沙坦25-50mg/d;或二者联合。所有患者常规给予抗血小板、抗凝、他汀类调脂药等。3个月后超声心动图检测左室大小、左室容量和左室射血分数。酶免法和放免法测定血液脑钠肽(BNP)、C反应蛋白(CRP)和PⅢNP水平。结果:3组患者的基础临床特征无显著区别。与基础值相比,3个月后,所有患者均表现出血液中CRP水平下降、BNP和PⅢNP水平上升,且有不同程度的左室扩大和左心功能下降。与培哚普利组和氯沙坦组相比,联合用药组患者CRP、BNP和PⅢNP水平显著降低,且左室扩张和射血功能障碍程度均减轻。血清PⅢNP水平与CRP水平及左室舒张末期容积指数均呈显著正相关(r=0.597,r=0.543,均P<0.01),与左室射血分数呈显著负相关(r=-0.565,P<0.01)。结论:急性前壁心肌梗死患者,早期联合培哚普利和氯沙坦治疗可以进一步改善左室重构和心功能,其机制可能与抑制胶原合成、抑制心肌纤维化有关。

AIM： Inhibiting the renin-angiotensin-aldosterone system prevents left ventricular （ LV） remodeling after myocardial infarction （ MI） . This study was designed to assess the effects of a combination of perindopril and losartan on LV remodeling,cardiac function and serum procollagen type Ⅲ aminoterminal peptide （ PⅢNP） levels in patients with acute MI. METHODS： Patients with anterior MI were divided into 3 groups： MI ＋ perindopril,MI ＋ losartan, and MI ＋ perindopril ＋ losartan. After successful intervention therapy,perindopril 2-4 mg/d or losartan potassium 25-50 mg/d or combination of the both were administered. All patients took aspirin,clopidogrel and statins,while some of the patients were treated with beta-blockers,nitrate and a platelet glycoprotein IIb/Ⅲa receptor antagonist. Three months later, LV dimensions and LV ejection fraction （ LVEF） were measured by ultrasonography. Plasma brain natriuretic peptide （ BNP） ,serum C-reactive protein （ CRP） and PⅢNP levels were evaluated with ELISA or RIA. RESULTS： Baseline characteristics of the 3 groups were the same. All patients showed decreased CRP,increased BNP and PⅢNP levels,and LV dilation and dysfunction after treatment for three months. Compared with the 2 single therapy groups,patients in the combination group showed significantly lower CRP,BNP and PⅢNP levels,less LV dilation and higher LVEF. Serum PⅢ NP level was positively correlated with CRP level and LV end-diastolic volume index（ r = 0. 597 and r = 0. 543,respectively,both P 0. 01） ,and negatively correlated with LVEF（ r =-0. 565,P 0. 01） . CONCLUSION： For patients with AMI,combination of perindopril and losartan significantly inhibited LV remodeling and improved LV function. Inhibition of myocardial interstitial fibrosis might be part of the mechanism.