经皮冠状动脉介入治疗患者发生无复流的预测因素及对预后的影响

Predictive factors and prognostic impact of no-reflow during percutaneous coronary intervention

目的探讨急性心肌梗死患者进行急诊经皮冠状动脉介入(PCI)治疗过程中发生无复流的危险因素,分析发生无复流对患者预后的影响。方法连续入选2015年1—12月于承德医学院附属医院及首都医科大学附属北京安贞医院因急性心肌梗死行急诊PCI治疗患者1010例。依据PCI过程中是否发生无复流分为发生无复流组(198例)和未发生无复流组(812例)。记录2组患者临床资料,出院前评价心脏功能及冠状动脉粥样硬化性心脏病(冠心病)二级预防药物使用情况,术后1、3、6、12、24、36个月进行电话及门诊随访,记录患者生存情况。结果发生无复流组罪犯血管为右冠状动脉者比例、预扩张次数、发生应激性高血糖与重度血栓负荷比例及空腹血糖水平均高于未发生无复流组[40.4%(80/198)比31.0%(252/812)、2.47(1.56,3.38)次比1.04(0.78,1.30)次、29.8%(59/198)比21.7%(176/812)、47.0%(93/198)比5.4%(44/812)、8.4(5.9,10.6)mmol/L比6.3(4.3,8.8)mmol/L](均P<0.05)。多因素Logistic回归分析结果显示,重度血栓负荷与预扩张次数是患者PCI治疗过程中发生无复流的独立危险因素(比值比=20.182、2.079,95%置信区间:3.961~102.827、1.292~3.345,均P<0.05)。2组患者出院前心功能指标比较差异均无统计学意义(均P>0.05)。未发生无复流组出院时β受体阻滞剂使用比例明显高于发生无复流组[55.3%(449/812)比44.4%(88/198)](P<0.05)。术后1~36个月随访2组患者累积生存率比较差异无统计学意义(P=0.243)。结论急性心肌梗死患者PCI治疗过程中多次进行预扩张及存在重度血栓负荷是发生无复流的独立危险因素,是否发生无复流对患者近期心功能改变及3年预后无明显影响。

Objective To explore the risk factors of no-reflow during emergency percutaneous coronary intervention(PCI)for acute myocardial infarction(AMI)patients,and to analyze the effect of coronary no-reflow on long-term outcomes.Methods Totally 1 010 AMI patients undergoing emergency PCI in Affiliated Hospital of Chengde Medical University and Beijing Anzhen Hospital,Capital Medical University from January to December 2015 were recruited.During PCI procedure,198 patients had coronary no-reflow(no-reflow)and 812 patients were included in control group.General clinical data,cardiac function indicators before discharge and drug use for coronary heart disease secondary prevention were recorded.Survival outcomes were observed through regular follow-up at 1,3,6,12,24,36 months after PCI.Results Percentage of right coronary artery as culprit vessel,times of pre-dilation,incidences of stress hyperglycemia and severe thrombus load,level of fasting blood sugar in no-reflow group were significantly higher than those in control group[40.4%(80/198)vs 31.0%(252/812),2.47(1.56,3.38)times vs 1.04(0.78,1.30)times,29.8%(59/198)vs 21.7%(176/812),47.0%(93/198)vs 5.4%(44/812),8.4(5.9,10.6)mmol/L vs 6.3(4.3,8.8)mmol/L](all P<0.05).Multivariate logistic regression analysis showed that severe thrombus load and pre-expansion times were independent risk factors of no-reflow during PCI(odds ratio=20.182,2.079;95%confidence interval:3.961-102.827,1.292-3.345;both P<0.05).There was no significant difference of cardiac function indicators between groups(P>0.05).Use rate ofβ-receptor blockers at discharge in control group was significantly higher than that in no-reflow group[55.3%(449/812)vs 44.4%(88/198)](P<0.05).There was no significant difference of cumulative survival rate between groups during 1-36 months follow-up(P=0.243).Conclusions Repeated pre-dilation and severe thrombosis load are independent risk factors of no-reflow during PCI.Coronary no-reflow has no obvious effect on postoperative cardiac function and 3-year outcomes.