醛固酮受体拮抗剂对心肌梗死后心脏重构影响

Aldosterone blockade improves cardiac remodeling after acute myocardial infarction

目的 探讨急性心肌梗死（AMI）患者早期应用醛固酮受体拮抗剂（AB）螺内酯对心脏重构的影响.方法 前瞻性研究,采用随机（随机数字法）、对照的方法,入选哈尔滨医科大学附属第一医院CCU病房2008年1月至2010年1月所有初次发病并且在24 h内住院的616例急性ST段抬高型心肌梗死（STEMI）患者.纳入标准：入选病例均为初发并且在24h内入院且符合急性STEMI诊断和治疗指南中的诊断标准.排除标准：排除非ST段抬高型心肌梗死,单纯右室梗死及陈旧性心肌梗死者；心功能分级（Killip）Ⅳ级或低血压状态者；肾功能不全者（血肌酐＞221 μmol/L）；血钾＞5.0 mmol/L者；发病距就诊时间超过24h及年龄＞75岁者.入选病例按照随机数字表归入对照组及治疗组,共528例受试者完成1年观察治疗,其中对照组266例,治疗组262例,两组患者在年龄、性别、既往病史,入院时情况、治疗情况等方面差异无统计学意义.治疗组（n=262）AMI患者在常规治疗的基础上加用螺内酯20 mg/d,对照组（n =266）行常规治疗.在发病后1个月和1年检测两组超声心动图、血钾、血肌酐,以评价螺内酯对心脏重构、左室功能和肾功能及血钾的影响.统计学方法应用PASW statistics 18.0软件进行统计处理.组间差异及组内差异应用t检验,如方差不齐时可用t检验.计数资料应用x2检验.结果 治疗组在、1年时超声指标LVESD、LVEDD、LVEF、LAD-ML、LAD-SI较对照组有显著改善（P＜0.05）,治疗组在1年时LVESD、LVEDD、LVPWT、LVEF、LAD-ML、LAD-SI均较1个月时明显改善（P＜0.05,其中LVEF P=0.007）,对照组LVEF在1年时较1个月时有明显改善（P=0.0277）.两组肌酐、血钾水平差异无统计学意义.结论 AMI患者在常规治疗的基础上早期联合应用小剂量（20 mg/d）螺内酯,可明显抑制AMI后的晚期重构,防止心力衰竭的发生.

Objective To investigate the effect of early application of aldosterone receptor blockade-spironolactone on cardiac remodeling in patients with acute myocardial infarction.Methods A total of 616 patients were enrolled in this prospective study,who were admitted to the CCU Division of the First Affiliated Hospital of Harbin Medical University from January 2008 to January 2010.Inclusive criteria were as follows：First-onset STEMI according to the diagnostic criteria in ST-segment elevation acutemyocardial infarction diagnosis and treatment guidelines and admitted within 24 hours from onset.Exclusive criteria were as follows：Non-STEMI,only right ventricular infarction and old myocardial infarction; cardiac function Killip Class Ⅳ or hypotensive state; renal dysfunction（serum creatinine 〉 221 μmol / L）; serum potassium 〉5.0 mmol / L; longer than 24 hours from onset and older than 75 years of age.All the patients were randomly divided into a control group of standard therapy and a treatment group of standard therapy combined with spironolactone 20 mg per day.Totally 528 patients were observed completely,including 266 patients in the control group and 262 patients in the treatment group.There was no statistical difference of clinical characteristics between the two groups,including age,gender,past medical history,admission situation,and treatment（P 〉 0.05）.The effect of spironolactone on cardiac remodeling、left ventricular function、renal function and blood levels of potassium were evaluated by detecting echocardiography,serum potassium and serum creatinine at one month and one year follow-up.Results Compared with the control group,the echocardiography indicators such as LVESD,LVEDD,LVEF,LAD-ML and LAD-SI were significantly improved in treatment group at one year（P 〈 0.05）.In treatment group,LVESD,LVEDD,LVPWT,LVEF,LAD-ML and LAD-SI were significantly improved at one year than one month（P 〈 0.05,and P =0.007 to LVEF）,and LVEF was significantly improved at one year than one month in control group（P =0.0277）.There were no statistical differences of serum potassium and serum creatinine between the two groups.Conclusions On the basis of conventional treatment,the early combination of low dose spironolactone（20 mg/d）could inhibit cardiac remodeling at late stage and prevent heart failure.