估算肾小球滤过率与急性ST段抬高型心肌梗死患者心肌无复流的相关性研究

Relationship Between Estimated Glomerular Filtration Rate and Myocardial No-reflow in Patients With Acute ST-elevation Myocardial Infarction

目的:探讨估算肾小球滤过率(eGFR)与急性ST段抬高型心肌梗死(STEMI)患者心肌无复流(MNR)的相关性。方法:收集2013-01至2015-06期间烟台毓璜顶医院因STEMI接受急诊经皮冠状动脉介入治疗(PCI)的患者461例,其中男373例,女88例,平均年龄(61.46±12.29)岁。PCI成功开通心外膜血管后仍有部分患者存在心肌灌注不足的表现,即心肌无复流(MNR)。MNR定义为心肌梗死溶栓治疗临床试验(TIMI)血流分级<3级或TIMI 3级且心肌呈色分级(MBG)≤2。461例患者中98例发生MNR(无复流组),363例成功复流(复流组)。根据MDRD(Modification of Diet in Renal Disease)公式计算eGFR。比较两组球囊扩张时间、病变长度变化。结果:461例患者中共计98例(21.26%)患者发生MNR。410例(88.94%)患者PCI术后冠状动脉血流达TIMI 3级(复流组363例,无复流组47例);334例(72.45%)患者MBG3级(复流组334例,无复流组0例),两组比较差异均有统计学意义(P<0.001)。与复流组相比,无复流组发病至球囊扩张时间较长(P<0.001),syntax评分较增加(P<0.001),病变长度较延长(P=0.017),差异均有统计学意义。多因素Logistic回归分析表明收缩压[比值比(OR):0.984,95%可信区间(CI):0.970~0.984,P=0.023]、左心室射血分数(OR:0.957,95%CI:0.913~0.987,P=0.031)、eGFR(OR:0.964,95%CI:0.950~0.964,P<0.001)、发病至球囊扩张时间(OR:1.004,95%CI:1.002~1.004,P=0.001)是MNR发生的独立危险因素。受试者工作特征(ROC)曲线显示eGFR[曲线下面积:0.801,95%CI:0.743~0.859,P<0.001;理想阈值74.78 ml/(min·1.73m^2),敏感性为73.7%,特异性为77.3%]可以较好的预测MNR发生。结论:eGFR降低与STEMI患者行急诊PCI术后MNR的发生密切相关。

Objective： To explore the relationship between estimated glomerular filtration rate（eGFR） and myocardial no-reflow（MNR） in patients with ST-segment elevation myocardial infarction（STEMI） after primary percutaneous coronary intervention（PCI）.Methods： A total of 461 eligible STEMI patients treated by primary PCI in our hospital from 2013-01 to 2015-06 were enrolled including 373 male and 88 female with the mean age of（61.46±12.29） years. MNR was defined as TIMIgrade 3 or TIMI grade 3 with myocardial blush grades（MBG）≤2. The patients were divided into 2 groups： MNR group, n=98（21.26%） and Re-flow group, n=363. eGFR was calculated by MDRD（modification of diet in renal disease） equation. The balloon dilatation time and lesion length were compared between 2 groups.Results： There were 410（88.94%） patients reached post PCI TIMI grade 3 including 363 in Re-flow group and 47in MNR group; 334（72.45%） patients with MBG grade 3 including 334 in Re-flow group, 0 in MNR group, all P0.001. Compared with Re-flow group, MNR group had prolonged time form onset to balloon dilatation, P0.001, increased syntax score, P0.001 and extend length of lesion, P=0.017. Multi Logistic regression analysis showed that systolic blood pressure（OR=0.984, 95% CI 0.970-0.84, P =0.023）, left ventricular ejection fraction（OR=0.957, 95% CI 0.913-0.987, P =0.031）, eG FR（OR=0.964, 95% CI 0.950-0.964, P0.001）, the time from onset to balloon dilatation（OR=1.004, 95% CI 1.002-1.004, P=0.001） were the independent risk factors for MNR occurrence. The area of ROC_（eGFR）=0.801,（95% CI 0.743-0.859, P0.001） and the optimal threshold=74.78 ml/（min·1.73m^2） with the sensitivity of 73.7% and specificity of 77.3% may better predict the incidence of MNR.Conclusion： Decreased eGFR was closely related to MNR occurrence in STEMI patients after primary PCI.