急性心肌梗死患者心电图缺血分级与靶血管狭窄程度的临床研究

Clinical study of ECG ischemic grading and target vessel stenosis degree in patients with acute myocardial infarction

目的 研究心电图缺血分级与急性心肌梗死（acute myocardial infarction，AMI）靶血管定位及狭窄程度的关系。方法 选择我院2016年1月至2017年6月收治的AMI患者80例，发病时间〈12 h，根据Birnbaum心电图缺血分级分为二级缺血组50例和三级缺血组30例，采用冠状动脉造影直径目视法比较靶血管定位及狭窄程度，检测肌酸激酶同工酶（CK-MB）、肌钙蛋白（cTnI）和N端脑钠肽前体（pro-BNP）水平，左心室舒张末内径（LVEDd）和左心室射血分数（LVEF）；术后7 d采用99mTe-MIBI心肌灌注断层显像（SPECT）测量放射性缺损面积即心肌梗死面积；随访6个月，比较主要心脏不良事件（MACE）的发生率。结果 三级缺血组CK-MB、cTnI和pro-BNP的基线水平及升高幅度（干预后－基线值）均高于二级缺血组，差异有统计学意义[CK-MB：基线值：（56.7±12.3） U/L比（26.8±8.7）U/L，t＝12.326，P〈0.001；升高幅度：（66.7±13.5） U/L比（35.6±6.9）U/L，t＝32.545，P〈0.001。cTnI：基线值：（8.6±2.2） μg/L比（4.5±1.3） μg/L，t＝6.598，P＝0.003；升高幅度：（15.2±5.7） μg/L比（6.3±2.5） μg/L，t＝9.524，P〈0.001。pro-BNP：基线值：（356.7±65.8） μmol/L比（254.5±56.7） μmol/L，t＝10.326，P〈0.001；升高幅度：（658.4±135.2） μmol/L比（356.2±95.4） μmol/L，t＝25.254，P〈0.001]。组间LVEDd和LVEF值比较差异无统计学意义[LVEDd：（55.2±2.6） mm比（54.8±2.3）mm，t＝0.263，P＝0.785；LVEF：（42.5±4.8）%比（43.3±4.5）%，t＝0.426，P＝0.659]。三级缺血组左前降支、左主干和左主干分叉病变发生率较高（50.0%比10.0%，χ2＝16.000，P〈0.001；16.7%比4.0%，χ2＝2.348，P＝0.125；10.0%比4.0%，χ2＝0.356，P＝0.551），二级缺血组以回旋支和右冠及分支病变为主（10.0%比30.0%，χ2＝4.301，P＝0.038；10.0%比40.0%，χ2＝8.238，P＝0.004；3.3%比12.0%，χ2＝0.845，P＝0.358）；三级缺血组靶病变数目〉1和100%管腔狭窄的比例均高于二级缺血组[靶病变数目〉1：36.7%（11/30）与14.0%（7/50），P值为0.019；100%管腔狭窄：40.0%（12/30）与12.0%（6/50），P值为0.004]，差异均有统计学意义。三级缺血组心肌梗死面积明显增加，MACE发生率上升，差异有统计学意义[（16.7±3.5）%比（10.5±3.6）%，t＝5.754，P＝0.019；23.3%比6.0%，χ2＝5.150，P＝0.023]。结论 心电图缺血分级可评估AMI靶血管定位及狭窄程度，有重要的临床应用价值。

Objective To study the relationship between ECG ischemic grading and target vessel stenosis degree in patients with acute myocardial infarction（AMI）.Methods A total of eighty patients with AMI treated in Beijing Friendship Hospital, Capital Medical University from January 2016 to June 2017 were enrolled in the study, with the onset time〈12 h, According to the Birnbaum ECG grading, the patients were divided into the grade two ischemic group（50 cases） and grade three ischemic group（30 cases）. CAG diameter visual method was used to compare the target vessels localization and stenosis degrees, the levels of CK-MB, cTnI and pro-BNP, left ventricular end diastolic diameter （LVEDd） and ejection fraction （LVEF） were detected, myocardial infarction area （MIS） was measured by 99mTe-MIBI myocardial perfusion imaging （SPECT） at 7 d after operation, the incidence of major cardiac adverse events （MACE） was followed up for 6 months. area of myocardial defect, that is myocardial infarction size（MIS）with SPECT 7d after operation, during the 6 months follow-up, the incidence of major adverse cardiac events （MACE）.Results The baseline lines of CK-MB, cTnI and pro-BNP and increased ranges （post intervention-baseline value） in the grade three ischemic group were higher than those of grade two ischemia group, there were statistically significant differences in baseline values： （CK-MB： （56.7±12.3） U/L vs.（26.8±8.7） U/L, t=12.326, P〈0.001; increase： （66.7±13.5） U/L vs.（35.6）±6.9） U/L, t=32.545, P〈0.001; cTnI： baseline value： （8.6±2.2） g/L vs.（4.5±1.3） g/L, t=6.598, P=0.003; increase： （15.2±5.7） g/L vs.（6.3±2.5） g/L, t=9.524, P〈0.001; pro-BNP： baseline value： （356.7±65.8） mol/L vs.（254.5±56.7） mol/L, t=10.326, P〈0.001; increase： （658.4±135.2） mol/L vs.（356.2±95.4） mol/L, t=25.254, P〈0.001）. There was no significant difference in LVEDd and LVEF between groups.（LVEDd： （55.2±2.6） mm vs.（54.8±2.3） mm, t=0.263, P=0.785; LVEF： （42.5±4.8）% vs.（43.3±4.5）%, t=0.426, P=0.659）. The occurrence rates of left anterior descending, left main lesions and left main bifurcation lesions in the grade three ischemic group were higher （50.0% vs.10.0%, χ2=16.000, P〈0.001; 16.7% vs.4.0%, χ2=2.348, P=0.125; 10.0% vs.4.0%, χ2=0.356, P=0.551）, and the circumflex and right coronal and branch lesions proportions took the most part in the grade two ischemic group（10.0% vs.30.0%, χ2=4.301, P=0.038; 10.0% vs.40.0%, χ2=8.238, P=0.004; 3.3% vs.12.0%, χ2=0.845, P=0.358）; the proportions of target lesion number〉1 and 100% stenosis in the grade three ischemic group were significantly than those in the in the grade two ischemic group （target lesion number〉1： 36.7% （11/30） vs.14% （7/50）, P=0.019; 100% stenosis： 40% （12/30） vs.12% （6/50）, P=0.004）, the difference is statistically significant.The MIS value increased significantly in the grade three ischemia group, and the incidence of MACE increased.The difference was statistically significant （ （16.7±3.5）% vs.（10.5±3.6）%, t=5.754, P=0.019, 23.3% vs.6%, χ2=5.150, P=0.023）.Conclusion ECG ischemic grading can evaluate the location of AMI target vessel and the degree of stenosis, and it has important clinical value.