不同球囊导管注射药物对经皮冠状动脉介入术中无复流现象的改善效果分析

Efficacy and safety of different drugs by balloon catheter injection for no-reflow following percutaneous coronary intervention

目的观察急性ST段抬高型心肌梗死(STEMI)患者行经皮冠状动脉介入术(PCI)中出现无复流时,经球囊导管输注不同药物的临床效果。方法2016年1月至2017年12月北京潞河医院心内科共收治1 280例STEMI患者,均经右侧桡动脉途径行PCI术,术中12.81%(164/1 280)患者出现无复流现象。将164例冠状动脉无复流患者按其就诊顺序1∶1∶1分别经球囊导管向冠状动脉内推注药物维拉帕米(维拉帕米组,55例),替罗非班(替罗非班组,55例)和硝酸甘油(硝酸甘油组,54例)。比较3组患者的冠状动脉血流恢复情况[心肌梗死溶栓治疗(TIMI)分级,心肌灌注(TMP)分级];监测药物不良反应(ADR)发生率;术后第7天、第30天复查心脏彩超评估左心功能[左心室射血分数(LVEF)和左心室舒张末期容积(LVEDV)];随访主要不良心血管事件(MACE)发生率。结果维拉帕米组、替罗非班组和硝酸甘油组达TIMI 3级的例数分别为49例(89.90%)、45例(91.82%)和33例(61.11%),3组比较差异有统计学意义(Hc=13.92,P<0.05);3组达TMP 3级比例分别为40例(72.73%)、36例(65.45%)和27例(50.0%),3组比较差异有统计学意义(Hc=6.23,P<0.05)。术后第30天,维拉帕米组LVEF和LVEDV的改善更为显著(P<0.05)。3组ADR发生率和MACE发生率比较,差异均无统计学意义(Hc=0.04、0.70,P>0.05)。结论STEMI患者PCI术中出现无复流时可采用经球囊导管推注维拉帕米以快速、有效、安全地恢复冠状动脉血流水平,改善左心功能。

Objective To evaluate the efficacy and safety of different drugs injected via balloon catheter for no-reflow after percutaneous coronary intervention (PCI) in patients with ST segment elevation myocardial infarction (STEMI). Methods From January 2016 to December 2017, 1 280 patients with STEMI were treated in Department of Cardiology, Beijing Luhe Hospital. All patients were underwent PCI and stent implantation in related infarct vessels (IRA). Among 1 280 patients no-reflow occurred in 164 cases (12.81%) during the procedure. No-reflow patients were divided into three study groups according to the order of consultation, who were given verapamil (verapamil group,55 cases),tirofiban (tirofiban group, 55 cases) or nitroglycerin (nitroglycerin group, 54 cases) by injection through balloon catheter. Coronary blood flow recovery (TIMI grading),myocardial perfusion level TMP grading (TMPG),average dose of drugs (mg) and adverse drug reactions (ADR) were compared among the three groups. Left ventricular ejection fraction (LVEF) and left ventricular end diastolic volume (LVEDV) were evaluated by echocardiography 7 and 30 d after operation. The incidence of major adverse cardiovascular events (MACE) was followed up. Results TIMI-3 ratio in verapamil, tirofiban and nitroglycerin groups was 89.90%(49/55), 91.82%(45/55) and 61.11%(33/54), respectively (Hc=13.920, P<0.05). TMP-3 ratio was 72.73%(40/55) in verapamil group, 65.45%(36/55) in tirofiban group and 50.0%(27/54) in nitroglycerin group,respectively (Hc=6.230,P<0.05). During the procedure, one case (1.82%) had slow heart rate and one case (1.82%) had hypotension in verapamil group;three cases 5.56%) had transient hypotension in nitroglycerin group, and there was no significant difference in the incidence of ADR among the three groups (Hc=0.040, P>0.05). There was no significant difference in LVEF and LVEDV among three groups on the d7 after operation (all P>0.05). The improvement of LVEF and LVEDV was more significant in verapamil group on d30 after operation (all P<0.05). One case (1.82%) of heart failure occurred in tirofiban group,three cases of heart failure and one case of recurrent myocardial infarction occurred in nitroglycerin group during six months of follow-up. There was no significant difference in the overall incidence of MACE among the three groups (Hc=0.070, P>0.05). Conclusion Verapamil can be injected throμgh balloon catheter to restore coronary blood flow rapidly, effectively and safely,and improve left ventricular function in STEMI patients with no-reflux during PCI.