急性ST段抬高型心肌梗死患者不同再灌注治疗策略的疗效研究

A comparative study on the effect of different reperfusion strategies among patients with ST-segment elevated myocardial infarction

目的探讨不同再灌注治疗策略在急性ST段抬高型心肌梗死(STEMI)患者救治过程中的疗效和安全性。方法纳入2017年4月至2018年2月就诊于河北医科大学第二医院胸痛中心且行急诊冠状动脉造影(CAG)的STEMI患者共118例,按照患者再灌注治疗策略将患者分为直接经皮冠状动脉介入治疗(PPCI)组74例,静脉溶栓后转诊行早期PCI(EPCI)组32例,冠状动脉内溶栓联合PCI(CPCI)组12例。收集所有患者基线资料,比较三组患者手术相关指标、住院期间心功能相关指标以及主要不良心脑血管事件(MACCE)发生率。结果三组患者症状发作至首次再通时间比较,差异有统计学意义(P<0.001)。EPCI组症状发作至首次再通时间少于PPCI组[(3.94±1.39)h比(6.18±1.80)h,P<0.016]和CPCI组[(3.94±1.39)h比(9.08±1.24)h,P<0.016],而PPCI组少于CPCI组[(6.18±1.80)h比(9.08±1.24)h,P<0.016],差异均有统计学意义。PPCI组与EPCI组、PPCI组与CPCI组患者术前心肌梗死溶栓治疗试验(TIMI)血流分级,PPCI组与CPCI组术后TIMI血流分级比较,差异均有统计学意义(均P<0.016)。三组患者急诊支架置入率比较,差异有统计学意义(P<0.001)。PPCI组患者急诊支架置入率高于EPCI组(90.5%比56.2%,P<0.016)和CPCI组(90.5%比50.0%,P<0.016),差异均有统计学意义。EPCI组患者术后校正的TIMI帧数低于PPCI组[(28.22±6.46)帧比(34.28±9.18)帧,P<0.016],差异有统计学意义。三组患者肌酸激酶(CK)峰值比较,差异有统计学意义(P=0.012)。CPCI组患者CK峰值高于PPCI组[(3695.92±894.52)U/L比(2261.95±1698.74)U/L,P<0.016]和EPCI组[(3695.92±894.52)U/L比(1830.75±1438.76)U/L,P<0.016],差异均有统计学意义。三组患者肌酸激酶同工酶(CKMB)峰值比较,差异有统计学意义(P=0.014)。CPCI组患者CK-MB峰值高于PPCI组[(392.42±348.36)U/L比(226.74±156.10)U/L,P<0.016]和EPCI组[(392.42±348.36)U/L比(219.84±151.30)U/L,P<0.016],差异均有统计学意义。三组患者血清肌钙蛋白I(c Tn I)峰值比较,差异有统计学意义(P=0.008)。EPCI组患者cTnI峰值低于PPCI组[(55.44±19.32)ng/ml比(72.54±32.10)ng/ml,P<0.016]和CPCI组[(55.44±19.32)ng/ml比(79.76±26.77)ng/ml,P<0.016],差异均有统计学意义。三组患者住院期间再发心肌梗死、脑出血及其他出血事件发生率比较,差异均无统计学意义(均P>0.05)。结论 EPCI和CPCI均可在一定程度上改善STEMI患者术后血流情况,且未发现出血风险增加。

Objective To investigate the efficacy and safety of different reperfusion strategies in the treatment of acute ST-segment elevation myocardial infarction(STEMI). Methods A total of 118 STEMI patients who were admitted to Chest Pain Center of the Second Hospital of Hebei Medical University from April 2017 to February 2018 and underwent emergency coronary angiography(CAG) were divided into direct percutaneous coronary intervention(PPCI) group of 74 patients, early PCI(EPCI) group of 32 patients after intravenous thrombolysis, and intracoronary thrombolysis combined with PCI(CPCI) group of 12 cases. The baseline data of all patients were collected, and the operationrelated indicators, cardiac function-related indicators during hospitalization and the incidence of major adverse cardiac and cerebrovascular events(MACCE) were compared among the three groups. Results There was a significant difference in the time from onset to first recanalization between the three groups(P<0.05). The time from symptom onset to first recanalization in EPCI group was shorter than that in PPCI group [(3.94±1.39) h vs.(6.18±1.80) h, P<0.016] and CPCI group [(3.94±1.39) h vs.(9.08±1.24) h,P<0.016];the time from symptom onset to first recanalization in PPCI group was shorter than that in CPCI group [(6.18±1.80)h vs.(9.08±1.24) h,P<0.016], the difference was statistically significant. There were differences in the distribution of TIMI blood flow grading between PPCI group and EPCI group,PPCI group and CPCI group before operation(all P<0.016). There were differences in the distribution of TIMI blood flow grading between PPCI group and CPCI group after operation(P<0.016).There was significant difference in emergency stent implantation rate among the three groups(P<0.001). The emergency stent implantation rate in PPCI group was higher than that in EPCI group(90.5% vs. 56.2%, P<0.016) and CPCI group(90.5% vs. 50.0%, P<0.016).Postoperative corrected TIMI frames in EPCI group were lower than those in PPCI group [(28.22±6.46) frame vs.(34.28±9.18) frame,P<0.016].There was significant difference in the peak value of creatine kinase(CK) among the three groups(P=0.012). The peak value of CK in CPCI group was higher than that in PPCI group [(3695.92±894.52) U/L vs.(2261.95±1698.74) U/L,P<0.016] and EPCI group [(3695.92±894.52) U/L vs.(1830.75±1438.76)U/L, P<0.016]. The peak value of creatine kinase isoenzyme(CK-MB) in the three groups was significantly different(P=0.014). The peak value of CK-MB in CPCI group was higher than that in PPCI group [(392.42±348.36) U/L vs.(226.74±156.10) U/L, P<0.016] and EPCI group [(392.42±348.36) U/L vs.(219.84±151.30) U/L,P<0.016]. There was significant difference in the peak value of serum cardiac troponin I(cTnI) among the three groups(P=0.008). The peak value of cTnI in EPCI group was lower than that in PPCI group [(55.44±19.32) ng/ml vs.(72.54±32.10) ng/ml, P<0.016] and CPCI group [(55.44±19.32) ng/ml vs.(79.76±26.77) ng/ml, P<0.016]. There was no significant difference in the incidence of recurrent myocardial infarction, cerebral hemorrhage and other bleeding events among the three groups during hospitalization(all P>0.05). Conclusions EPCI and CPCI could improve the blood flow of STEMI patients to a certain extent, and do not significantly increase the risk of bleeding.