CHA2DS2-VASc评分系统对急性ST段抬高型心肌梗死患者行直接经皮冠状动脉介入治疗中无复流发生的预测价值

Value of CHA2DS2-VASc score in predicting“No-reflow”in patients treated with primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

目的初步探讨CHA2DS2-VASc评分系统对急性ST段抬高型心肌梗死(STEMI)患者行直接经皮冠状动脉介入(PPCI)治疗中发生无复流的预测价值。方法选择2012年1月—2015年10月间因发生STEMI于复旦大学附属中山医院行PPCI治疗的956例患者,男754例、女202例;根据术中心肌梗死溶栓治疗(TIMI)血流分级将患者分为血流正常组(靶血管TIMI血流为3级,804例)和无复流组(靶血管TIMI血流≤2级,152例),所有纳入研究患者均利用CHA2DS2-VASc评分系统进行评分,收集两组患者的临床基线资料、实验室检查结果、PPCI手术相关信息,以及靶血管再次血运重建和院内死亡患者构成比、住院时间、术后肌酸激酶同工酶(CK-MB)峰值。采用logistic单因素和多因素回归分析PPCI术后无复流发生的独立危险因素,根据ROC曲线分析CHA2DS2-VASc评分系统预测STEMI患者PPCI术中无复流的特异度和灵敏度。结果血流正常组的术前收缩压显著高于无复流组(P<0.05),术前心率显著快于无复流组(P<0.05),女性、吸烟患者构成比和CHA2DS2-VASc评分系统显著低于无复流组(P值均<0.05)。血流正常组SYNTAX积分、术后CK-MB峰值,以及高血栓负荷、术中行高血栓抽吸、术中于冠状动脉内予替罗非班、院内死亡的患者构成比均显著低于无复流组(P值均<0.01);行支架植入术的患者构成比显著高于无复流组(P<0.05),支架总长度、住院时间均显著短于无复流组(P值均<0.01)。logistics单因素和多因素回归分析结果均显示,CHA2DS2-VASc评分、吸烟史、支架长度、高血栓负荷、SYNTAX积分是PPCI术中发生无复流的危险因素(P值分别<0.01、0.05)。针对CHA2DS2-VASc评分系统中各项因素的单因素和多因素logistic分析结果显示,充血性心力衰竭、高血压病史、年龄≥75岁和女性这4个因素对PPCI术中无复流发生具有独立的预测价值(P值分别<0.05、0.01)。CHA2DS2-VASc≥3分为PPCI术中无复流发生的预测最佳值,其预测灵敏度为0.76,特异度为0.63。结论 CHA2DS2-VASc≥3分对STEMI患者PPCI术中无复流发生具有独立预测意义,可用于初步评估无复流的发生风险,根据CHA2DS2-VASc评分对拟行PPCI的患者进行危险分层并采取相应的抗栓方案可能降低术中无复流发生的风险。

Objective To investigate whether the CHA2DS2-VASc score could be used to predict noreflow phenomenon in the primary percutaneous intervention(PPCI)for acute ST-segment elevation myocardial infarction(STEMI).Methods CHA2DS2-VASc score was applied to 956 consecutive patients presenting with acute STEMI treated by PPCI from January 2012 to October 2015 in Zhongshan Hospital.There were 754 males and 202 females.They were divided into normal reflow group(n=804)and no-reflow group(n=152)according to blood flow during thrombolysis and thrombin inhibition in myocardial infarction(TIMI).Clinical baseline information,laboratory examination,PPCI related information,target vessel revascularization again,constituent ratio of hospital deaths,hospital stay and peak creatine kinase-myocardial enzyme(CK-MB)after PPCI were collected and analyzed.Independent risk factors of no-reflow after PPCI were measured by univariate and multivariate regression analyses.Specificity and sensitivity of CHA2DS2-VASc score for prediction of no-reflow after PPCI were evaluated by receiver operating characteristic(ROC)curve analysis.Results Preoperative systolic pressure was significantly higher in the normal reflow group than that in the no-reflow group,as well as the constituent ratio of patients undergoing stent implantation and heart rate(all P<0.05).CHA2DS2-VASc score and constituent ratios of female and smoking patients in the normal reflow group were significantly lower than those in the no-reflow group,as well as synergy between percutaneous coronary intervention with taxus and cardiac surgery(SYNTAX)score,peak CK-MB after PPCI,constituent ratios of patients with high thrombosis burden,use of thrombus aspiration,tirofiban intro-coronary treatment and hospital deaths(all P<0.01).The total length of stents implanted and hospital stay in the normal reflow group were significantly shorter than those in the no-reflow group(both P<0.01).After univariate and multivariate regression analyses,risk factors associated with noreflow included CHA2DS2-VASc score(age≥75years,female,congestive heart failure,hypertension),smoking,long stent length,high thrombosis burden,and high SYNTAX score(P<0.05,0.01).The receiver operator characteristic(ROC)curve revealed that the cut-off value of CHA2DS2-VASc score was≥3,with a sensitivity of0.76 and a specificity of 0.63.Conclusion CHA2DS2-VASc score can be used to identify STEMI patients at risk for developing no-reflow in the PPCI.