前列地尔对ST段抬高型急性心肌梗死患者经皮冠状动脉介入治疗术中心肌微循环障碍的影响

Effect of alprostadil on myocardial microcirculation disturbance of patients with ST-segment elevation acute myocardial infarction treated by percutaneous coronary intervention

目的:探讨采用直接经皮冠状动脉介入治疗(PCI)的ST段抬高型急性心肌梗死(STEMI)患者应用前列地尔对心肌微循环障碍的影响。方法:选取自2015年6月—2018年2月在北京怀柔医院心血管内科住院治疗,诊断符合美国心脏协会/美国心脏病学会(AHA/ACC)的STEMI诊断标准且接受直接PCI术患者80例,将入选患者依据随机数字表法分为前列地尔组(40例)和对照组(40例)。前列地尔组在PCI治疗前及PCI后1～7 d静脉滴注前列地尔20μg,对照组以生理盐水代替前列地尔。两组其他治疗相同。比较两组患者心肌再灌注指标如校正的TIMI帧数(CTFC),心肌显影密度分级(MBG),PCI术后2 h ST段回落≥50%发生率,无复流发生率,入院时及PCI术后7 d血清中炎症指标如高敏C反应蛋白(hs-CRP)、肿瘤坏死因子-α(TNF-α)及白细胞介素-6(IL-6)含量;术后3 d及术后3个月超声心动图参数左室舒张末期内径(LVEDD)和左室射血分数(LVEF);随访术后3个月内发生的主要心脏不良事件(MACE)。结果:两组患者年龄、性别、冠心病危险因素、冠状动脉病变分布特点及PCI术基本资料差异均无统计学意义(P均> 0.05)。前列地尔组患者PCI术后TIMI3级、MBG3级比例及2 h ST段回落≥50%的发生率均高于对照组(P均<0.05),前列地尔组CTFC帧数低于对照组(P <0.001),差异均有统计学意义。前列地尔组无复流发生率低于对照组[5.0%(2/40例)比20.0%(8/40例),P=0.043],差异有统计学意义。两组患者入院时血清TNF-α、IL-6和hs-CRP差异均无统计学意义(P均> 0.05)。术后7 d前列地尔组患者TNF-α[(269.27±42.16)ng/L比(297.01±49.86)ng/L]、IL-6[(16.60±3.09)ng/L比(18.50±2.74)ng/L]和hs-CRP[(5.66±1.86)mg/L比(7.06±2.56)mg/L]低于对照组,差异有统计学意义(P均<0.01)。术后3个月前列地尔组LVEDD小于对照组[(46.15±2.34)mm比(47.90±2.80)mm],LVEF大于对照组(0.585 5±0.049 4比0.535 5±0.0784),差异有统计学意义(P均<0.05)。前列地尔组术后3个月内总的主要心脏不良事件发生率[7.5%(3/40例)比27.5%(11/40例),P=0.019]小于对照组,差异有统计学意义。结论:行直接PCI治疗的STEMI患者应用前列地尔能够有效减弱炎症反应、恢复心肌再灌注、减少心肌微循环障碍的的发生,同时可以改善患者心功能及预后。

Objective: To investigate the effect of alprostadil on myocardial microcirculation disturbance of patients with ST-segment elevation acute myocardial infarction (STEMI) treated by direct percutaneous coronary intervention (PCI). Methods: Eighty patients with STEMI, diagnosed by American Heart Association/American College of Cardiology (AHA/ACC) and undergoing direct PCI from Jun. 2015 to Feb. 2018, were enrolled in present study, and divided into alprostadil group and control group (40 each) with random number table.Before and 1-7 days after PCI, patients in alprostadil group received mainline of alprostadil 20 μg, while in the control group, normal saline was given instead of alprostadil. The indexes of myocardial reperfusion were compared between the two groups, such as corrected TIMI frame count (CTFC), myocardial development density grading (MBG) and ST segment drop (≥ 50%) at 2 hours after PCI, the number of cases of no reflux;the levels of serum inflammatory indexes at admission and 7 days after PCI, such as high sensitivity C-reactive protein (hs-CRP), contents of tumor necrosis factor (TNF-α) and interleukin-6 (IL- 6);and the echocardiographic parameters at 3 days and 3 months after PCI were counted, such as left ventricular enddiastolic diameter (LVEDD) and left ventricular ejection fraction (LVEF). The major adverse cardiac events (MACE) occurred within 3 months after PCI were followed-up. Results: There were no significant differences between the two groups in age, sex, risk factors of coronary heart disease, distribution characteristics of coronary artery lesions and basic data of PCI (P > 0.05). The incidence of TIMI grade 3, MBG grade 3 and ST segment fall (≥ 50%) after PCI was higher in alprostadil group than in control group (all P < 0.05), and the number of CTFC frames was lower in alprostadil group than in control group (P < 0.001). The incidence of no-reflux was lower in alprostadil group (5.0%, 2/40 cases) than in control group (20.0%, 8/40 cases) with statistical significance (P=0.043). There was no significant difference in serum TNF-α, IL-6 and hs-CRP between the two groups at admission (P>0.05). The levels were lower in alprostadil group than in control group 7 days after operation of TNF-α[(269.27+42.16)ng/L vs (297.01+49.86)ng/ L], IL-6 [(16.60+3.09)ng/L vs (18.50+2.74) ng/L] and hs-CRP [(5.66+1.86)mg/L vs (7.06+2.56)mg/L] with significant differences (P<0.01). Three months after operation, the LVEDD was smaller in alprostadil group than in control group [(46.15+2.34) mm vs.(47.90+2.80) mm], and LVEF was larger in alprostadil group than in control group [(0.585 5 ±0.049 4) vs.(0.535 5+0.078 4)] with significant difference (P<0.05). The overall incidence of MACE within 3 months after operation was lower in alprostadil group (7.5%, 3/40 cases) than in control group (27.5%, 11/40 cases) with significant difference (P=0.019). Conclusions: Alprostadil can effectively reduce inflammatory response, restore myocardial reperfusion, reduce the occurrence of myocardial microcirculation disorders in STEMI patients treated with direct PCI, and improve the cardiac function and prognosis.