急性心肌梗死合并新发右束支阻滞的临床特征及其在急诊再灌注决策中的价值

Clinical characteristics of acute myocardial infarction patients with new onset right bundle branch block and its value on decisions of emergency reperfusion therapy

目的摇探讨急性心肌梗死（AMI）合并新发右束支阻滞（RBBB）临床特征及其在急诊再灌注治疗决策中的价值。方法摇回顾性收集538例接受急诊介入诊疗AMI患者的临床资料,分为新发RBBB组、无束支阻滞（BBB）组和新发左束支阻滞（LBBB）组;比较3组临床基线资料、急诊冠状动脉造影及院内主要不良心脏事件（MACE）发生率;筛选AMI患者出现新发RBBB及住院期间发生MACE事件的独立预测因素。结果摇 AMI患者合并新发RBBB的发生率为6. 32%,多见于左前降支（LAD）（52. 94%）近段（42. 98%）完全闭塞,其次为右冠状动脉（RCA）（38. 24%）近段（28. 96%）。与无BBB组相比,新发RBBB组患者心功能分级域级以上比率（Killip）、CKMB峰值更高;梗死相关血管（IRA）前向TIMI血流0/1级比率、IRA近段闭塞比率、急诊接受经皮冠状动脉介入治疗（PCI）比率（91. 18% vs 69. 04%）[OR=4. 634（95% CI 1. 395-15. 399）,P= 0. 012]以及住院期间MACE事件发生率（61.76% vs 17. 36%,P〈0. 001）更高;与新发LBBB组相比,新发RBBB组CKMB峰值较低,IRA前向TIMI血流0/1级比率和接受急诊PCI比率（91. 18% vs 57. 69%）[OR=7. 578（95% CI 1. 836 -31. 277）,P=0. 005]更高,超急期二者的检出率、IRA近段闭塞比率及院内MACE事件发生率（61. 76% vs 46. 15%,P=0. 660）无明显差异。 Logistic回归逐步法分析显示患者的IRA前向TIMI血流0/1级及IRA近段闭塞与是否出现新发RBBB呈正相关。 COX回归比例风险模型逐步分析显示新发RBBB（RR=3. 33,P〈0. 001）、新发LBBB（RR=2. 97,P〈0. 001）均为院内MACE事件的独立预测因素。结论摇新发RBBB多为LAD或RCA近段完全闭塞所致,临床症状重、住院期间MACE事件发生率高,且可出现在AMI超急期,同新发LBBB一样同为住院期间发生MACE事件的独立因素,故其应作为急诊再灌注治疗的指证。

Objective To analyze the clinical characteristics and the value of decision making in early reperfusion therapy of new onset right bundle branch block（ RBBB） patients with acute myocardial infarction（ AMI）. Methods A cohort of 538 patients with AMI who received primary coronary angiographic in our hospital was analyzed retrospectively. The patients were divided into three groups： new RBBB,none bundle branch block（ NBBB）,new left bundle branch block（LBBB）,The difference of baseline clinical characteristics,coronary angiographic,and in hospital major cardiovascular events（ MACE） between RBBB group and the other two groups were analyzed respectively. Independent predictors of new onset RBBB in AMI patients were screened by Logistic regression stepwise method. Independent predictors of MACE during hospitalization were analyzed by COX regression proportional hazard model. Results ①New onset RBBB was present in 6. 32% of AMI patients. The infarct-related artery（ IRA） was mostly left anterior descending branch,the next was right coronary artery（ RCA）. ②Compared with the NBBB group,the ratio of Killip ≥ Ⅱ,the peak of CK-MB were higher,the ratio of TIMI flow 0 /1 in the proximal occlusion of IRA and received primary percutaneous coronary intervention（ PCI）（ 91. 18% vs 69. 04%） [OR = 4. 634（ 95% CI 1. 395-15. 399）,P 0. 012]of the RBBB group were significantly higher. The RBBB group had a higher in-hospital MACE ratio than NBBB group（ 61. 76% vs 17. 36%,P 0. 001）. The distribution of IRA between the two groups had a significant difference（ P 0. 001）. 52. 94% was LAD and 38. 24% was RCX in RBBB group. Compared with LBBB group,the peak of CK-MB of RBBB group was lower,The ratio of TIMI flow 0 /1 of the IRA and received（ PCI）（ 91. 18% vs 57. 69%） [OR = 7. 578（ 95% CI 1. 836-31. 277）,P = 0. 005] were higher. The ratio of detection in hyperacute phase in AMI,proximal occlusion of IRA,IRA distribution and in-hospital MACE（ 61. 76% vs 46. 15%,P = 0. 660） between RBBB and LBBB group had no statistical difference. Logistic regression showed that proximal occlusion and TIMI flow 0 /1 of IRA were predictive factors of new onset of RBBB. Cox regression showed new onset of RBBB（ RR = 3. 33,P 0. 001） and LBBB（ RR = 2. 97,P 0. 001） were both independent predictors of in-hospital MACE. Conclusions New onset RBBB is usually induced by proximal complete occlusion of LAD or RCX. The clinical symptom of these patients is severe,the ratio of in-hospital MACE is high. Furthermore it＇s also an inde- pendent predictor of in-hospital MACE as new onset LBBB. RBBB should be strongly considered as a standard indication for reperfusion therapy as new onset LBBB.