血运重建治疗对合并心力衰竭的急性心肌梗死患者预后的影响

Effect of coronary revascularization on the prognosis of acute myocardial infarction patientscomplicated with heart failure

目的探讨合并心力衰竭的急性心肌梗死患者的临床特征和预后，并分析影响其预后的因素。方法前瞻性连续纳入349例行急诊经皮冠脉介入治疗（PCI）的急性sT段抬高心肌梗死（STEMI）同时合并急性心力衰竭患者，按左室射血分数是否正常（定义为LVEF〉150％）将患者分为左室射血分数正常组（LVEF≥50％，n=225）和左室射血分数降低组（LVEF〈50％，n=124），分别评价患者住院期间的临床、血管造影、超声心动图等相关资料并对患者进行长期随访。平均随访时间为367d，一级终点为全因病死率。结果左室射血分数正常组和左室射血分数降低组分别有4例（1．8％）和6例（4．8％）死亡，差异无统计学意义（P=0．314）。两组二级终点随访期间主要不良心脑血管事件差异具有统计学意义（P=0．022）。Cox回归分析发现，患者心功能Killip分级水平（HR=1．092，95％CI：1．040—1．149，P〈0．01）是影响患者死亡的独立预测因子。结论影响行经皮冠状动脉介入治疗的急性心肌梗死合并心力衰竭患者的预后因素为患者心功能分级水平；左室射血分数正常组和左室射血分数降低组长期病死率相似。

Objective To explore the clinical characteristics and prognosis of the patients of acute myocardial infarction complicated with heart failure by analyzing the prognostic factors of these patients. Methods This was a single-center prospective study of 349 patients with acute heart failure and ECG documented acute ST elevated myocardial infarction. All patients were treated with primary PCI. After PCI, clinical, angiographic and ECG characteristics, and prognosis of those with preserved （≥50% ） or reduced （ 〈 50% ） left ventrieular ejection fraction （LVEF） were assessed. Heart failure patients were divided into two groups： 124 with reduced EF （HFREF） and 225 with preserved EF （HFPEF）. After 367 days of average follow-up, the primary outcome and number of death were recorded. Results Of them, 4 （ 1.8% ） patients in the HFPEF group vs. 6 （4. 8% ） in the HFREF group died. The difference in rate of death between two groups was not significant （P = 0. 314）. There were significant difference in main adverse cardiac and cerebra vascular events （MACCE） occurred during follow-up period between the two groups （P =0. 022）. The Killip Classification of heart failure （HR = 1. 092, 95% CI 1. 040 ～ 1. 149, P 〈0. 01 ） was significantly related to the death rate during follow-up. Conclusions The independent factors affecting prognosis in patients with acute heart failure after coronary revascularization were closely consistent with the stratums of the Killip Classification. Patients with HFPEF had a similar prognosis as those with HFREF afterprimary stenting.