急性心肌梗死并发左心室游离壁破裂43例的临床特点

Clinical manifestations of 43 patients with acute myocardial infarction complicated by free wall rupture

目的探讨急性心肌梗死（AMI）患者出现左心室游离壁破裂并发症的危险因素及其冠状动脉造影特征，以早期识别高危患者并减少该并发症的发生。方法回顾性分析1995年1月至2010年1月收治的AMI患者共6192例的临床资料，其中并发左心室游离壁破裂者43例。采用logistic回归模型分析AMI患者并发左心室游离壁破裂的独立危险因素。结果左心室游离壁破裂距AMI发作的平均时间为（3．58±2．58）d。左心室游离壁破裂组年龄[（66．9±9．8）岁比（61．7±12．5）岁，P〈0．05]、女性比例[37．2％（16／43）比18．9％（34／180），P〈0．05]、就诊时间[7．00（4．00～20．00）h比5．00（3．00～8．00）h，P〈0．05]及入院时收缩压[（127．6±24．6）mmHg（1mmHg=0．133kPa）比（122．0±17．3）mmHg，P〈0．05]、血肌酐水平[（110．6±61．1）μmol／L比（82．1±30．9）mmol／L，P〈0．01]和血糖水平[（9．14±2．82）mmol／L比（6．49±2．30）mmol/L，P〈0．05]明显高于对照组。左心室游离壁破裂组急诊溶栓的比例高于对照组[13．95％（6／43）比2．78％（5／180），P〈0．05]。急诊冠状动脉造影的结果显示左心室游离壁破裂组的单支病变比例高于对照组[55．0％（11／20）比37．4％（34／91），P〈0．05]，应用logistic回归分析前进法确定AMI后左心室游离壁破裂的预测因素包括女性、高龄、就诊时间延迟、就诊时收缩压和血肌酐偏高（P均〈0．01）。左心室游离壁破裂组患者在心脏破裂前往往有提早下床活动、躁动、排便、剧烈咳嗽、呕吐等异常活动[41．9％（18／43）]，左心室游离壁破裂组的院内病死率达97．7％。结论女性、高龄、就诊时间延迟、就诊时的高血压及就诊时血肌酐升高是AMI后左心室游离壁破裂的独立危险因素。尽早、成功的再灌注治疗以及人院后积极控制血压及异常活动可减少AMI后左心室游离壁破裂的发生。

Objective To analyze the clinical characteristics of patients with acute myocardial infarction（AMI） complicated by free wall rupture （FWR） and to define the independent risk factors for FWR. Methods Clinical and angiographic data of 6192 AMI patients admitted to our department between January 1995 and January 2010 were retrospectively reviewed, FWR was confirmed in 43 patients by post- mortem examination. Multivariate logistic regression analysis was performed to identify risk factors for FWR. Results Rupture occurred at a median of 3.58 days after symptom onset. Risk factors associated with FWR were older age, female gender, delayed hospital admission, hypertension at admission and increased serum creatine level. Although patients with FWR had more single-vessel disease, their in-hospital mortality was very high （97.7%） . Undue physical efforts were documented in 41.9% patients with FWR. Conclusion Old age, female gender and prolonged time from the onset of symptoms to hospital, hypertension and high level of serum creatine at admission are independent factors of FWR.