急性ST段抬高型心肌梗死急诊冠状动脉介入治疗后早期左心室血栓的危险因素分析

Risk factors for early left ventricular thrombus in patients with acute ST-segment elevation myocardial infarction after primary percutaneous coronary intervention

目的探讨急诊冠状动脉介入治疗(primary percutaneous coronary intervention, pPCI)急性ST段抬高型心肌梗死(ST-segment elevation myocardial infarction, STEMI)后早期发生左心室血栓(left ventricular thrombus, LVT)的危险因素。方法急性STEMI并行pPCI治疗患者124例,其中早期发生LVT患者31例为LVT组,未发生LVT患者93例为无LVT组。比较2组患者临床资料、冠状动脉造影和超声心动图资料,采用多因素logistic回归分析急性STEMI患者行pPCI术后发生LVT的危险因素。结果 LVT组陈旧性心肌梗死(58.06%)、既往PCI史(32.26%)、Killip分级≥Ⅱ级(74.19%)、≥4个相邻导联ST段抬高(58.06%)、围手术期不良事件(54.84%),病理性Q波(61.29%)、术前TIMI血流0级(70.97%)、术后TIMI血流≤Ⅱ级(22.58%)和入院时左室射血分数≤40%(48.39%)比率以及入院时收缩压[142(135,152)mm Hg]、肌酸激酶同工酶峰值[58.00(19.00,141.00)u/L]和室壁瘤发生率(29.03%)高于无LVT组[15.05%、11.83%、36.56%、24.73%、33.33%、24.73%、32.26%、3.23%、8.60%、125(106,144)mm Hg、22.30(12.25,75.40)u/L、12.90%](P<0.05),总缺血时间[11.00(10.00,12.00)h]长于无LVT组[6.00(4.00,9.00)h](P<0.05);总缺血时间延长(OR=1.760,95%CI:1.092～2.836,P=0.020)、陈旧性心肌梗死(OR=22.371,95%CI:1.636～305.933,P=0.020)、pPCI术前TIMI血流0级(OR=19.767,95%CI:1.234～316.751,P=0.035)和入院时左室射血分数≤40%(OR=13.713,95%CI:1.137～165.373,P=0.039)为急性STEMI患者pPCI术后早期发生LVT的独立危险因素。结论急性STEMI患者pPCI后早期发生LVT的危险因素可能为术前TIMI血流0级、陈旧性心肌梗死、总缺血时间延长和入院时左室射血分数≤40%,应及时评估LVT的形成风险,以减少其发生。

Objective To investigate the risk factors for early left ventricular thrombus(LVT) in patients with acute ST-segment elevation myocardial infarction(STEMI) after primary percutaneous coronary intervention(pPCI). Methods Totally 124 patients with STEMI undergoing pPCI were divided into 31 patients with early LVT(LVT group) and 93 patients without LVT(non-LVT group). The clinical data, DSA and echocardiography findings were compared between two groups. Multivariate logistic regression was used to analyze the risk factors for LVT in STEMI patients after pPCI. Results The proportions of old myocardial infarction(58.06%), previous PCI history(32.26%), Killip grade≥Ⅱ(74.19%),≥4 adjacent leads ST-segment elevation(58.06%), perioperative adverse events(54.84%), pathological Q waves(61.29%), preoperative TIMI blood flow grade 0(70.97%), postoperative TIMI blood flow grade ≤Ⅱ(22.58%) and left ventricular ejection fraction ≤40% at admission(48.39%), as well as the systolic blood pressure(142(135, 152) mm Hg) at admission, creatine kinase MB peak level(58.00(19.00,141.00) u/L), and the incidence of ventricular aneurysm(29.03%) in LVT group were significantly higher than those in non-LVT group(15.05%, 11.83%, 36.56%, 24.73%, 33.33%, 24.73%, 32.26%, 3.23%, 8.60%, 125(106, 144) mm Hg, 22.30(12.25, 75.40) u/L, 12.90%)(P<0.05). The total ischemic time was significantly longer in LVT group(11.00(10.00, 12.00) h) than that in non-LVT group(6.00(4.00, 9.00) h)(P<0.01). The prolonged total ischemic time(OR=1.760, 95%CI: 1.092-2.836, P=0.020), old myocardial infarction(OR=22.371, 95%CI: 1.636-305.933, P=0.020),TIMI flow grade 0 before pPCI(OR=19.767,95%CI:1.234-316.751,P=0.035),and left ventricular ejection fraction≤40% at admission(OR=13.713,95%CI:1.137-165.373,P=0.039)were independent risk factors for LVT in STEMI patients after pPCI.Conclusion TIMI flow grade 0 before pPCI,old myocardial infarction,prolonged total ischemic time,and left ventricular ejection fraction ≤40% at admission are the risk factors for LVT in acute STEMI patients after pPCI,which should be evaluated in time in order to reduce the incidence of LVT.