急性ST段抬高心肌梗死合并肺动脉高压患者院内主要心脏不良事件分析

Major adverse cardiac events in patients of ST-segment elevation infarction with pulmonary hypertension

目的探讨急性ST段抬高心肌梗死（ST-segment element myocardial infarction,STEMI）合并肺动脉高压患者院内主要心脏不良事件（major adverse cardiac events,MACE）。方法回顾性分析近两年就诊于河北医科大学第二医院的STEMI连续病例。详细记录两组患者基本临床资料、住院期间药物治疗和再灌注治疗情况。对所有入选病例在入院后24小时内进行二维超声心动图检查,测量心脏各腔室大小,评价心室功能。记录患者住院期间MACE的发生情况。应用多因素logistic回归分析肺动脉高压与STEMI患者院内MACE发生的相关性。过去两年累计入选STEMI患者227例。根据超声心动图估测肺动脉压力,将入选患者分为肺动脉压力正常组（肺动脉压力〈40mmHg,1mmHg=0.133kPa,n=189例）和肺动脉高压组（肺动脉压力≥40mmHg,n=38例）。结果与肺动脉压力正常组比较,肺动脉高压组年龄较大（62.8±10.5）岁vs（68.4±11.9）岁（P〈0.01）,男性比例较少（85.7%vs 71.1%）（P〈0.05）,吸烟者较多（41.8%vs 60.5%）（P〈0.05）。两组在梗死部位、入院时Killip分级水平、GRACE评分和心肌型肌酸激酶同工酶（CK-MB）峰值水平方面均存在明显差异（P〈0.05）。在治疗方面,肺动脉高压组使用正性肌力药物的比例高于肺动脉压力正常组（32.3%vs 50.0%）（P〈0.05）。与肺动脉压力正常组比较,肺动脉高压组射血分数较低（57.5%±6.3%vs 52.1%±5.4%）（P〈0.01）,室壁运动积分指数较高（1.45±0.22vs1.83±0.34）（P〈0.01）,舒张期E/e’比例较高（11±1.3vs 16±2.4）（P〈0.01）,三尖瓣反流速度较快（1.4±0.28m/s vs 2.9±0.37 m/s）（P〈0.01）。肺动脉高压组住院期间MACE发生的比例较高（7.9%vs 21.1%）（P〈0.01）。多因素logistic回归结果提示,住院期间MACE发生的独立预测因素主要包括STEMI合并肺动脉高压（OR=66.64,95%CI=5.078-15.713,P〈0.01）、CK-MB峰值水平较高（OR=0.795,95%CI=-0.043-0.020,P〈0.01）以及脑钠素水平较高（OR=0.958,95%CI=0.106-0.177,P〈0.05）。结论合并肺动脉高压的STEMI患者院内MACE的发生率升高。

Objective To investigate the major adverse cardiac events（MACE）in patients of ST-segment elevation infarction（STEMI）with pulmonary hypertension.Methods All consecutive STEMI patients in recent two years from the Department of Cardiology of the Second Hospital of Hebei Medical University were enrolled.All eligible STEMI patients were divided into two groups according to pulmonary hypertension or not：normal pulmonary arterial pressure group（NP group）and pulmonary hypertension group（HP group）.The baseline clinical data and therapies were recorded.Echocardiography was performed within 24 hours after admission,and data of echocardiography were compared between the two groups.Multivariate logistic regression was used to analyze the association between clinical data and MACE incidence.A total of 227 cases were enrolled in the past two years,with 189 cases in NP group and 38 cases in HP group.Results Compared with patients in NP group,the age in HP group was older（62.8±10.5vs68.4±11.9）years old（P〈 0.01）,and male patients in HP group were less（85.7% vs 71.1%）（P〈 0.05）,but the smokers in HP group were more（41.8% vs 60.5%）（P〈 0.05）.The differences were also significant in infarction location,Killip classification on admission,GRACE score and peak CK-MB values between two groups（P〈 0.05）.Compared with patients in NP group,the left ventricle ejection fraction（LVEF）was lower（57.5% ±6.3%）vs（52.1%±5.4%）（P〈 0.01）.Ventricular wall montion score index（WMSI）,E/e＇in period of relaxation and counter flow velocity of tricuspid valve were higher in patients with HP group,（1.45±0.22 vs 1.83±0.34）,（11±1.3vs 16±2.4）,（1.4±0.28m/s vs 2.9±0.37m/s）,respectively（all P〈 0.01）.The MACE incidence during hospitalization in HP group was higher（7.9% vs 21.1%,P〈 0.01）.Multivariate logistic regression analysis found that the pulmonary hypertension,peak CK-MB value and BNP levels were independent predictors for MACE incidence.Conclusion Pulmonary hypertension is an independent predictor for MACE during hospitalization in STEMI patients.