冠状动脉靶血管内注射尼可地尔对急性ST段抬高型心肌梗死患者急诊经皮冠状动脉介入治疗术中无复流现象的预防效果研究

Effect of Target Intracoronary Injection of Nicorandil for the Prevention of No-reflow Phenomenon during Emergency Percutaneous Coronary Intervention in Patients with Acute ST-segment Elevation Myocardial Infarction

目的观察无复流现象(NRP)发生前冠状动脉靶血管内注射尼可地尔对急性ST段抬高型心肌梗死(STEMI)患者急诊经皮冠状动脉介入治疗(PCI)术中NRP的预防效果。方法选择2015年1月—2016年9月河北医科大学第三医院收治的需行急诊PCI术的急性STEMI患者105例,采用随机数字表法分为尼可地尔组、硝普钠组和对照组,每组各35例。尼可地尔组采用球囊扩张及加压泵于靶血管向靶病变远端2 mm处预先注射尼可地尔2 mg、硝普钠组注射硝普钠200μg、对照组注射0.9%氯化钠溶液。观察PCI术前及结束时梗死相关血管心肌梗死溶栓试验(TIMI)血流分级、校正TIMI血流帧数(c TFC)、TIMI心肌灌注分级(TMPG)、术中NRP发生率及术后90 min ST段回落率(STR),PCI术前及术后1周时检测N末端脑钠肽前体(NT-pro BNP);PCI术前及术后每4 h检测肌酸激酶同工酶(CK-MB)及肌钙蛋白I(c Tn I),记录其峰值水平。PCI术前及术后1周时采用心脏彩超计算室壁运动积分指数(WMSI)及左心室射血分数(LVEF)。观察PCI术中低血压发生情况及术后预后情况。结果 3组患者术前TIMI血流分级、达到TMPG 3级的比例、NT-pro BNP、CK-MB、c Tn I、WMSI及LVEF比较,差异均无统计学意义(P>0.05)。硝普钠组和尼可地尔组患者术后c TFC及NRP发生率较对照组降低,术后达到TMPG 3级的比例及STR≥50%的比例较对照组升高(P<0.05);硝普钠组和尼可地尔组患者术后NT-pro BNP、CK-MB峰值、c Tn I峰值、WMSI较对照组降低,术后LVEF较对照组升高(P<0.05)。硝普钠组与尼可地尔组患者c TFC、术后达到TMPG 3级的比例、NRP发生率、STR≥50%的比例、术后NT-pro BNP、CK-MB峰值、c Tn I峰值、WMSI及LVEF比较,差异均无统计学意义(P>0.05)。对照组、硝普钠组及尼可地尔组术中分别有3例(9.1%)、8例(24.2%)及0例发生低血压,需多巴胺处理,3组低血压发生率比较,差异有统计学意义(χ2=10.236,P=0.006);其中硝普钠组低血压发生率较尼可地尔组升高(P<0.01)。3组PCI术后3个月主要心脏不良事件(MACEs)发生率分别为:15.2%(5/33)、6.1%(2/33)及5.9%(2/34),差异无统计学意义(χ2=2.276,P=0.320)。结论 NRP发生前冠状动脉靶血管内注射尼可地尔可安全、有效地预防急性STEMI患者急诊PCI术中NRP发生,并改善心肌灌注水平和心功能。

Objective To investigate the effect of target intracoronary injection of nicorandil for the prevention of no-reflow phenomenon（ NRP） during emergency percutaneous coronary intervention（ PCI） in patients with acute ST-segment elevation myocardial infarction（ STEMI）. Methods The enrolled 105 cases of acute STEMI receiving emergency PCI in the Third Hospital of Hebei Medical University from January 2015 to September 2016 were randomized them into nicorandil group,sodium nitroprusside group and control group with 35 cases in each, and treated with target intracoronary injection of 2 mg nicorandil diluted in 10 ml 0. 9% sodium chloride solution,200 μg sodium nitroprusside diluted in 10 ml 0. 9% sodium chloride solution,and 10 ml 0. 9% sodium chloride solution,respectively,into the place that was 2 mm distant from the target lesion via pre-dilated balloon and pressure pump. The TIMI flow grade of infarct-related artery,corrected TIMI frame count（ c TFC）,TIMI myocardial perfusion grade（ TMPG） before and at the end of PCI,the incidence of NRP during PCI,the ST-segment resolution（ STR） rate at 90 min after PCI were observed. N-terminal pro-brain natriuretic peptide（ NT-pro BNP） was measured before and at 1 week after PCI. CK-MB and c Tn I were measured before and at every 4 h after PCI,and their peak levels were recorded. Color Doppler echocardiography was used to calculate the wall motion score index（ WMSI） and left ventricular ejection fraction（ LVEF） before and at 1 week after PCI. The incidence of hypotension during PCI and postoperative prognosis were observed. Results Before PCI,the TIMI flow grade,the proportion of patients with TMPG grade 3,NT-pro BNP,values of CK-MB,c Tn I,WMSI and LVEF did not differ significantly among the three groups（ P 0. 05）. After PCI,compared with control group,the value of c TFC and the incidence of NRP in nicorandil group and sodium nitroprusside group were significantly decreased,but the proportion of patients with TMPG grade 3 and the proportion of STR ≥ 50% at 90 min after PCI were significantly increased（ P 0. 05）; compared with the control group,the level of NT-pro BNP,peak levels of CK-MB,c Tn I and WMSI in nicorandil group and sodium nitroprusside group were significantly decreased, but the LVEF was significantly increased（ P 0. 05）; there were no significant differences in the value of c TFC,the proportion of patients with TMPG grade 3,incidence of NRP,proportion of STR ≥50% at 90 min after PCI,level of NT-pro BNP,peak levels of CK-MB,c Tn I,WMSI and LVEF between the nicorandil group and sodium nitroprusside group（ P 0. 05）. The incidence of hypotension in the control group,sodium nitroprusside group and nicorandil group was 9. 1%（ 3/33）,24. 2%（ 8/33） and 0, respectively, which differed significantly among the groups（ χ2= 10. 236, P = 0. 006）; the sodium nitroprusside group had higher incidence of hypotension than the nicorandil group（ P 0. 01）; patients with hypotension in both the control group and the sodium nitroprusside group were treated by dopamine. The incidence of MACEs 3 months after PCI was 15. 2%（ 5/33）,6. 1%（ 2/33）and 5. 9%（ 2/34） in the control group, sodium nitroprusside group and nicorandil group respectively, which showed no significant differences among the three groups（ χ2= 2. 276,P = 0. 320）. Conclusion For patients with acute STEMI receiving emergency PCI,target intracoronary injection of nicorandil is safe,which can effectively prevent the incidence of NRP during PCI,as well as improve the myocardial perfusion and cardiac function.