尼可地尔联合替罗非班对急性ST段抬高型心肌梗死患者PPCI无复流的疗效观察

Effect nicorandil combined with tirofiban on PPCI of no-reflow in the patients with acute ST-segment elevation myocardial infarction

目的观察冠状动脉靶血管内注射尼可地尔联合替罗非班对急性ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)患者直接经皮冠状动脉介入治疗(primary percutaneous coronary intervention,PPCI)术中无复流现象(no-reflow phenomenon,NRP)的治疗作用。方法选择急性STEMI患者120例,随机分为替罗非班组(T组)、尼可地尔组(N组)与联合用药组(T+N组),每组40例。于术中NRP发生即刻,T组、N组及T+N组经微导管冠状动脉靶血管内分别注射替罗非班25μg/kg、尼可地尔4mg及替罗非班25μg/kg+尼可地尔4mg,术后3组分别静脉泵注替罗非班0.15μg·kg^(-1)·min^(-1)、尼可地尔8mg/h、替罗非班0.15μg·kg^(-1)·min^(-1)+尼可地尔8mg/h至24h。观察PPCI术前及结束时梗死相关血管心肌梗死溶栓试验(thrombolysis in myocardial infarction,TIMI)血流分级、校正帧幅数(corrected TIMI frame count,cTFC)、TIMI心肌灌注分级(TIMI myocardial perfusion grade,TMPG)、术后90min ST段回落率(ST-segment resolution,STR),肌酸激酶同工酶(creatine kinase isoenzyme-MB,CK-MB)和肌钙蛋白I(cardiac troponin-I,cTnI)术前值及其术后峰值,术后1周N端脑钠肽前体(n-terminal pro-brain natriuretic peptide,NTproBNP)、室壁运动积分指数(wall motion score index,WMSI)及左心室射血分数(left ventricular ejection fractions,LVEF),术中恶性心律失常、低血压、出血情况及术后住院期间主要心脏不良事件(major adverse cardiacevents,MACEs)发生率。结果与N组和T组比,T+N组PPCI术后cTFC帧数、术后CK-MB和cTnI峰值及术后1周NTproBNP、WMSI均明显降低(P<0.05),而术后达到TIMI 3级和TMPG 3级的比例、术后90min完全STR及术后1周LVEF显著升高(P<0.05);N组与T组比较,上述指标差异无统计学意义(P>0.05)。N组及T+N组术中恶性心律失常发生率较T组低(P<0.05)。结论冠状动脉靶血管内注射尼可地尔联合替罗非班可安全、有效地治疗急性STEMI患者PPCI术中NRP,改善心肌灌注分级和心功能。

Objective To observe the treatment effects of the targeted coronary intravascular injection of nicorandil combined with tirofiban on no-reflow phenomenon（NRP） during primary percutaneous coronary intervention（PPCI）in patients with acute ST-elevation myocardial infarction（STEMI）.Methods One hundred and twenty patients with acute STEMI were randomly divided into tirofiban group（T group）, nicorandil group（N group） and combined medication group（T＋N group）, each group had 40 cases.When the NRP occurred,T group, N group and T＋N group were injected with tirofiban（25 μg/kg）, nicorandil（4 mg） and tirofiban（25 μg/kg） plus nicorandil（4 mg） respectively by the micro catheter coronary target vessels.After the operation, 3 groups were injected intravenously tirofiban（0.15 μg·kg-1·min-1）, nicorandil（8 mg/h）, tirofiban（0.15 μg·kg-1·min-1）plus nicorandil（8 mg/h） for 24 h, respectively.The thrombolysis in myocardial infarction（TIMI） blood flow grade of infarction related artery, corrected TIMI frame count（cTFC）, TIMI myocardial perfusion grade（TMPG） before and at the end of PPCI operations, the ST-segment resolution（STR） rate 90 min after operations, creatine kinase isoenzyme-MB（CK-MB） and cardiac troponin-I（cTnI） before operations and those peak volume after operations, n-terminal pro-brain natriuretic peptide（NTproBNP）, wall motion score index（WMSI）, left ventricular ejection fraction（LVEF）, the incidence of intraoperative malignant arrhythmia, hypotension, bleeding and major adverse cardiac events（MACEs） after operations were observed and recorded.Results Compared with N group and T group, the cTFC frames and the peak volume of CK-MB and cTnI after PPCI, and NTproBNP and WMSI 1 week after operations in T＋N group were significantly decreased（P〈0.05）, but the proportion of TIMI 3 grade and TMPG 3 grade after operations, the STR rate 90 min after operations and the LVEF 1 week after operations in T＋N group were significantly higher（P〈0.05）.There was no significant difference in the above indice between N group and T group（P〉0.05）.The incidence of malignant arrhythmia rate in N group or T＋N group was lower than that in T group（P〈0.05）.Conclusion Target coronary intravascular injection of nicorandil combined with tirofiban after NRP occurred can safely and effectively treat the occurrence of NRP during PPCI operation in acute STEMI patients, and improve the level of myocardial perfusion and heart function.