急诊经皮冠状动脉介入后无复流的临床及程序危险因素分析

Evaluation of clinical and procedural predictors of the no-reflow phenomenon in patients with acute myocardial infarction after primary percutaneous coronary intervention

目的探讨急性心肌梗死（acute myocardial infarction，AMI）患者急诊经皮冠状动脉介入（percutaneous coronaryintervention，PCI）术后出现无复流现象相关的危险因素。方法连续选取2008年1月至2010年12月于上海市东方医院心内科住院的AMI患者312例为研究对象。入选标准：发病12h内，或12h至24h内仍有持续缺血性胸痛，成功接受PCI手术治疗且资料完整者。排除标准：冠脉痉挛或罪犯病变直径狭窄程度≤50％、冠脉血流正常行保守治疗，严重左主干或三支血管病变需急诊冠脉搭桥术。根据PCI术后心肌梗死溶栓试验（TIMI）血流分级，患者分为正常血流组和无复流组。比较这两组患者基本临床资料、造影结果及手术相关资料的差异，采用单变量和多变量Logistic回归分析急性心肌梗死患者急诊PCI术后出现无复流现象的影响因素。结果20．3％的患者急诊PCI术后出现了无复流。单变量分析：年龄、再灌注时间（症状至PCI的时间）、入院时收缩压、心梗Killip分级、急诊PCI术前应用主动脉内气囊反搏（intra—aortic balloonpump，IABP）、PCI术前TIMI血流分级、闭塞病变类型、血栓负荷、靶病变长度、参考血管直径、再灌注方法与无复流现象相关（P〈0．05）。多变量Logistic回归模型分析发现，年龄〉65岁（OR=1．470，95％ CI 1．460～1．490，P=0．007）、再灌注时间〉6h（OR=1．270，95％ CI 1．160～1．400，P=0．001）、入院时低收缩压（〈100mmHg）（1mmHg=0．133kPa）（OR=1．910，95％ CI 1．018～3．896，P=0．004）、PCI术前应用IABP（OR=1．949，95％ CI 1．168～3．253，P=0．011）、PCI术前低（≤1）TIMI血流（OR=1．100，95％ CI 1．080～1．250，P〈0．01）、高血栓负荷（OR=1．600，95％ CI 1．470～2．760，P=0．030）、长靶病变（OR=1．948，95％ CI 1．908～1．990，P=0．019）是急诊PCI术后发生无复流现象的独立危险因素。结论可根据急性心肌梗死患者临床、造影及手术时的发现来预测急诊PCI术后是否发生无复流现象。

Objective To find out possible risk factors for no-reflow （NR） phenomenon in patients with acute myocardial infarction （AMI） after primary percutaneous coronary intervention （PCI） . Methods A total of 312 consecutive patients with acute myocardial infarction were enrolled from January 2008 to December 2010 at the Cardiology Departmemt of East Hospital, Tongji University School of Medicine in this study. Inclusion criteria were： （1） patients underwent successful primary PCI within 12 h of symptom onset; or （2） patients with ischemic chest pain continuing for more than 12 h underwent successful primary PCI within 24 h of symptom onset. Exeulsion criteria were ： （1） coronary atery spasm; （2） diameter stenosis of the culprit lesion was ≤50% and coronary blood flow was normal; （3） patients with severe left main coronary or multivessel disease, who had to require emergency surgical revascularization. According to thrombolysis in myocardial infarction （TIMI） flow grade, the patients were divided into reflow group and NR group. The clinical date, angiography findings and surgical date were compared between two groups. Univariate and multivariate logistic regression were used to determine the predictors for NR phenomenon. Results Sixty-one （20. 3% ） of the patients developed NR phenomenon after primary PCI. Univariate analysis showed that patients＇ age, time from onset to reperfusion, systolic blood pressure （SBP） on admission, Killip class of myocardial infarction, intra-aortic balloon pump （IABP） use before primaphy PCI, TIMI flow grade before primary PCI, type of occlusion, thrombus burden on baseline angiography, target lesion length, reference luminal diameter and method of repusion were correlated with NR phenomenon （P 〈 0. 05 for all）. Muhiple logistic regression analysis identified that age 〉 65 years （ OR = 1. 470, 95% CI 1. 460 - 1. 490, P = 0.007）, long time from onset to reperfusion 〉6 hours （OR = 1.270, 95% CI 1.160-1.400, P = 0.001）, low SBP on admission 〈100mmHg （1 mmHg=0.133 kPa） （OR=1.910, 95% CI 1.018-3. 896, P=0.004）, IABP use before PCI （OR = 1.949, 95% CI 1. 168-3.253, P=0.011）, low （ ≤ 1 ） TIMI flow grade before primary PCI （ OR = 1. 100, 95% CI 1. 080 - 1. 250, P 〈 0. 01 ） , high thrombus burden （ OR = 1. 600, 95% CI 1. 470 - 2.760, P = 0. 030） and long target lesion （ OR = 1. 948, 95% CI 1. 908 - 1. 990, P = 0. 019） on angiography as independent predictors of NR phenomenon. Conclusions The occurrence of NR phenomenon after primary PCI for acute myocardial infarction can be predicted using simple clinical, angiographic and procedural features.