急性期接受经皮冠状动脉介入治疗的心肌梗死患者运动耐量影响因素

Influencing factors of exercise tolerance in patients with myocardial infarction undergoing percutaneous coronary intervention revascularization in acute phase

目的探讨急性期接受经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗的心肌梗死(myocardial infarction,MI)患者运动耐量的影响因素.方法选取急性期入院并接受PCI治疗的首次MI患者112例,所有患者均于PCI治疗后完成心肺运动试验(cardiopulmonary exercise testing,CPET).依据峰值摄氧量(peak oxygen consumption,VO2 peak)占年龄预计值的百分比(VO2peak%)将患者分为两组,VO2 peak%≥84%者为运动耐量正常组(40例,占35.7%),VO2 peak%<84%者为运动耐量减低组(72例,占64.3%).比较两组患者性别、年龄、体重指数、吸烟史、高血压及糖尿病病史、入院前及接受PCI干预后药物治疗等一般情况;MI类型;肌钙蛋白I(TNI)峰值、MI部位、冠状动脉病变支数及病变类型、血运重建程度、支架数目的差异;进而针对既往存在糖尿病史MI患者的糖尿病发病情况及CPET检查时血糖控制情况进行亚组分析,探讨急性期接受PCI治疗的首次MI患者运动耐量的影响因素.对上述患者进行随访,观察PCI治疗后24个月内主要不良心血管事件(major adverse cardiovascular events,MACE):因胸痛入院、再次血运重建、再梗死以及全因死亡,比较不同运动耐量的PCI治疗后MI患者心脏事件的差异.结果运动耐量减低组患者糖尿病比例明显高于运动耐量正常组(37.5%比17.5%)、超声心动图左心室射血分数(LVEF)值低于运动耐量正常组[(60.6±10.0)%比(65.0±8.2)%],差异均有统计学意义(P值均<0.05).运动耐量减低组C型病变比例明显高于运动耐量正常组(69.4%比42.5%),P<0.05.糖尿病、C型病变是影响运动耐量减低的独立预测因素(糖尿病:OR=3.14,95%CI 1.167~8.362,P=0.023;C型病变:OR=3.32,95%CI 1.444~7.621,P<0.01).接受PCI治疗的MI合并糖尿病患者中,运动耐量减低组糖尿病患病时间明显长于运动耐量正常组[(7.7±3.6)年比(5.0±2.4)年]、空腹血糖达标以及糖化血红蛋白达标比例明显低于运动耐量正常组(40.7%比57.1%、55.6%比71.4%),组间差异均有统计学意义(P值均<0.05).糖化血红蛋白达标是影响急性期接受PCI治疗的MI合并糖尿病患者运动耐量的独立预测因素(OR=2.518,95%CI 1.395~7.022,P=0.021).随访运动耐量正常组患者因胸痛入院、再次血运重建及再梗死的发生率均低于运动耐量减低组,但差异均无统计学意义(P值均>0.05).结论糖尿病、C型病变是影响急性期接受PCI治疗的首次MI患者运动耐量减低的独立预测因素.糖化血红蛋白达标是改善接受PCI治疗的MI合并糖尿病患者运动耐量的独立预测因素.

Objective The aim of the study was to explore the influencing factors of exercise tolerance in patients with myocardial infarction (MI) after percutaneous coronary intervention (PCI) revascularization in acute state. Methods A total of 112 patients with first MI undergoing PCI revascularization in acute state and completing cardiopulmonary exercise testing (CPET) were enrolled. Exercise capacity was evaluated by peak oxygen consumption percentage (VO2 peak%) in CPET. Patients were divided into normal exercise capacity (NEC) group (n=40) and abnormal (AEC) group (n=72) according to VO2 peak% value. Clinical manifestations, histories of hypertension and diabetes, medications, coronary arterial angiography and echocardiography findings of patients were compared. The onsets of diabetes and blood glucose levels during the period of CPET were evaluated in the MI patients with diabetes. The patients were followed up for major adverse cardiovascular events (MACE)(admission due to chest pain, re?revascularization, re?infarction and all?cause death) within 24 months after PCI. Multivariate logistic regression analyses were conducted to examine influencing factors for exercise tolerance. Results The ratio of diabetes, type C lesions in the AEC group were higher than those in the NEC group (diabetes: 37.5% vs. 17.5%;type C lesions: 69.4% vs. 42.5%, respectively, all P<0.05). The left ventricular ejection fraction (LVEF) in patients in the AEC group was lower than that in the NEC group [(60.6±10.0)% vs.(65.0±8.2)%, P=0.019]. Multivariate logistic regression analyses showed that history of diabetes and history of type C lesions were the independent risk factors for the declined exercise capacity in the MI patients after PCI revascularization ( OR=3.14, 95%CI 1.167-8.362, P=0.023;OR=3.32, 95%CI 1.444-7.621, P<0.01). Among the MI patients with diabetes, the duration of diabetes in the AEC group was significantly longer than that in the NEC group[(7.7 ± 3.6)years vs.(5.0 ± 2.4)years] and the proportions of subjects reaching target levels of fasting plasma glucose (40.7% vs. 57.1%) and glycosylated hemoglobin A1c(HbA1c)(55.6% vs. 71.4%) in this group were significantly lower than those in the NEC group (all P<0.05). A multivariate logistic regression analysis showed that reaching HbA1c target was an independent predictor of improved exercise tolerance in MI patients with diabetes who received PCI ( OR=2.518, 95%CI 1.395-7.022, P=0.021). No significant differences were observed in incidence of admission due to chest pain, re?revascularization and re?infarction between the two groups within 24 months after PCI between the groups. Conclusions Diabetes and type C lesions are independent risk factors of declined exercise capacity in patients with first myocardial infarction who received revascularization in acute state. Reaching target HbA1c is independent factor of improved exercise capacity in patients with myocardial infarction and diabetes.