缺血后适应对急性心肌梗死患者急诊经皮冠状动脉介入术后早期心肌保护作用研究

Cardio-protective effect of ischemic post-conditioning in patients with acute myocardial infarction after emergency percutaneous coronary intervention

目的 评价缺血后适应（IPOC）对急性心肌梗死（AMI）患者急诊经皮冠状动脉介入术（PCI）后的早期心肌保护作用.方法 选取2010年10月至2013年2月于首都医科大学附属北京安贞医院行急诊PCI治疗的首发AMI患者216例,按照随机数字表法分为IPOC组（114例）和对照组（102例）.所有病例按照常规方法行PCI.对照组在支架置入后不予其他干预;IPOC组在支架置入再灌注的1 min内,在支架上方血流处用经皮腔内冠状动脉成形术球囊低压（4 kPa）扩张梗死相关动脉30 s,后球囊放气30 s,再扩张（6 kPa）30 s,重复3次.比较2组患者术后ST段回落情况,肌酸激酶、肌酸激酶同工酶（CK-MB）、心肌肌钙蛋白Ⅰ （c-TnⅠ）峰值,超声心动图指标[左心室舒张末期容积指数（LVEDVI）、左心室收缩末期容积指数（LVESVI）和左心室射血分数（LVEF）],再灌注心律失常发生率,心肌灌注状况和术后心肌梗死溶栓治疗（TIMI）血流分级.结果 对照组术后2hST段完全回落45例（44.1％）,术后4hST段完全回落54例（52.9％）,术后6hST段完全回落61例（59.8％）;IPOC组术后2h ST段完全回落55例（48.2％）,术后4hST段完全回落68例（59.6％）,术后6hST段完全回落73例（64.0％）.与对照组比较,IPOC组术后2、4、6 hST段回落情况明显改善,差异有统计学意义（P＜0.05）.与对照组比较,IPOC组术后肌酸激酶、CK-MB、c-TnⅠ峰值明显减低[（1 418 ±634）U/L比（2 324±862） U/L、（121±113） mmol/L比（188±147） mmol/L、（17±12） mmol/L比（21±10） mmol/L],差异有统计学意义（P＜0.05）.与对照组比较,IPOC组患者术中及术后再灌注心律失常发生率明显降低[22.8％ （26/114）比41.2％ （42/102）,5.3％（6/114）比21.6％（22/102）],差异有统计学意义（P＜0.05）.对照组心肌Blush分级0-1级6例,2级33例,3级63例;IPOC组心肌Blush分级0-1级5例,2级21例,3级88例.与对照组比较,IPOC组心肌Blush分级明显改善,差异有统计学意义（P＜0.05）.2组患者PCI术后24h、术后1周LVEDVI、LVESVI和LVEF,术后梗死血管TIMI血流比较,差异均无统计学意义（P＞0.05）.结论 IPOC用于AMI患者PCI术后能够缩小梗死面积,降低再灌注心律失常发生率,改善微循环,产生心肌保护作用.

Objective To evaluate the cardio-protective effect of ischemic post-conditioning （IPOC） in patients with acute myocardial infarction after emergency percutaneous coronary intervention （PCI）.Methods Two hundred and sixteen patients with acute myocardial infarction who received emergency PCI were randomly divided into IPOC group （114 cases） and the control group （102 cases）.Three times of balloon inflation （4 kPa,30 s） and deflation （30 s） of the stent were performed in the related artery within 1 min after stent implantation in IPOC group;no interventions were given after stent implantation in control group.The recovery of ST-segment,the peak levels of creatine kinase （CK）,creatine kinase-MB （CK-MB）,cardiac Troponin I （c-TNI）,the echocardiographic parameters including left ventricular end-diastolic volume index （LVEDVI）,left ventricular end-systolic volume index （LVESVI） and left ventricular ejection fraction （LVEF） after operation were measured and compared between the two groups.In addition,the incidences of reperfusion arrhythmias,the myocardial perfusion and thrombolysis in myocardial infarction （TIMI） flow grade were observed.Results There were 55,68,73 cases with complete recovery of ST-segment in IPOC group and 45,54,61 cases in control group at 2,4 and 6 h after operation （P 〈 0.05）.The peak levels of CK,CK-MB and c-TnⅠ in IPOC group were significantly lower than those in control group [（1 418 ±634） U/L vs （2 324 ± 862） U/L,（121 ± 113） mmol/L vs （188 ± 147） mmol/L,（17 ± 12） mmol/L vs （21 ± 10） mmol/L,respectively,P 〈 0.05].The incidences of reperfusion arrhythmias during and after operation in IPOC group were decreased obviously compared with those in control group [22.8%（26/114） vs41.2% （42/102）,5.3% （6/114）vs21.6% （22/102）,P〈0.05].In IPOC group,there were 5 cases of myocardial Blush grading 0-1,21 cases of Blush grading 2 and 88 cases of Blush grading 3,significantly different from those in control group [6 cases of Blush grading 0-1,33 cases of Blush grading 2 and 63 cases of Blush grading 3] （P 〈 0.05）.The LVESVI,LVEDSI,LVEF and TIMI flow grade 24 h and 1 week after operation showed no significant difference between two groups （P 〉 0.05）.Conclusion IPOC has cardioprotective effect in patients with acute myocardial infarction after PCI,which can reduce the infarct size,decrease the incidence of reperfusion arrhythmias and improve the microcirculation in myocardium.