急性ST段抬高型心肌梗死直接经皮冠状动脉介入治疗术后不同左心室射血分数患者的临床特征及预后多中心比较研究

Clinical Features and Prognosis of STEMI Patients With Various Ejection Fraction After Primary PCI

目的:探讨急性ST段抬高型心肌梗死(STEMI)直接经皮冠状动脉介入治疗(PCI)术后不同左心室射血分数(LVEF)患者的临床特征及预后。方法:选择2015年10月1日至2016年10月30日在大连市6家医院确诊为急性STEMI并行直接PCI的患者734例。依据LVEF分为3组,LVEF降低组(rEF,LVEF<40%)50例、LVEF中间值组(mrEF,LVEF 40%~49%)141例及LVEF保留组(pEF,LVEF≥50%)543例。收集并记录3组患者的临床资料及直接PCI术后1年主要不良心脑血管事件(MACCE)发生情况。多因素Cox回归分析评估mrEF对急性STEMI直接PCI术后1年MACCE发生风险的影响。结果:mrEF组平均年龄显著大于pEF组[(65.1±12.5)岁vs(61.3±12.3)岁,P<0.05],而mrEF组与rEF组[(64.2±12.9)岁]比较差异无统计学意义。mrEF组和rEF组糖尿病、肾功能不全、既往脑卒中、Killip心功能分级≥2、左前降支病变的比例及心肌肌钙蛋白I(cTnI)水平均显著高于pEF组;rEF组既往心力衰竭、既往心肌梗死比例均显著高于mrEF组和pEF组,差异均有统计学意义(P均<0.05)。随访结束时MACCE共发生107例,其中rEF组23例、mrEF组27例、pEF组57例,rEF组和mrEF组MACCE发生率均显著高于pEF组(46.0%vs 19.1%vs 10.5%),差异有统计学意义(log-rank检验P<0.001)。多因素Cox回归分析显示,rEF和mrEF与急性STEMI患者直接PCI术后1年MACCE发生风险增加独立相关[(HR=3.224,95%CI:1.914~5.430,P<0.001)和(HR=1.679,95%CI:1.067~2.697,P=0.025)]。结论:急性STEMI直接PCI术后伴mrEF患者,与pEF患者比较年龄更大、合并症更多、预后更差;与rEF患者比较,尽管临床特征相似,但是预后更好。在临床实际工作中,应加强对急性STEMI后具有mrEF患者的二级预防管理,以改善急性STEMI患者的整体预后。

Objectives:To investigate the clinical features and prognosis of ST-segment elevation myocardial infarction(STEMI)patients with various left ventricular ejection fraction(LVEF)after primary percutaneous coronary intervention(PCI).Methods:A total of 743 consecutive patients who were diagnosed with acute STEMI and underwent primary PCI in 6 hospitals in Dalian from October 1st 2015 to October 30st 2016 were enrolled.According to pre-discharge LVEF,they were divided into 3 groups:rEF patients with LVEF<40%(n=50),mrEF=patients with 40%≤LVEF≤49%(n=141),pEF patients with LVEF≥50%(n=543).Clinical data,cardio-cerebral vascular major adverse events(MACCE)were collected and recorded in 3 groups.Multivariate Cox regression analysis was used to evaluate the effect of mrEF on the risk of MACCE in patients with acute STEMI after primary PCI.Results:Compared with the pEF group,patients in the mrEF group were older([65.1±12.5]years vs[61.3±12.3]years,P<0.05).The proportion of diabetes,renal insufficiency,previous stroke,Killip classification≥2,anterior descending lesion and cTNI level were significantly higher in rEF and mrEF groups than in pEF group(P<0.05).The proportion of previous myocardial infarction and previous heart failure was significantly higher in rEF group than in pEF and mrEF groups(P<0.05).The clinical follow-up duration was 1 year,MACCE occurred in 107 patients,including 23 patients in the rEF group,27 in the mrEF group,and 57 in the pEF group.The incidence of MACCE at 1 year after primary PCI in rEF group wag significantly higher in mrEF and pEF groups(46.0%vs 19.1%vs 10.5%,P<0.001).The difference in MACCE incidence was mainly caused by the difference in all-cause mortality.Multivariate Cox regression analysis showed that rEF(hazard ratio 3.224,95%CI:1.914-5.430,P<0.001)and mrEF(hazard ratio 1.679,95%CI:1.067-2.697,P=0.025)were independently associated with an increased risk of MACCE at 1 year after primary PCI compared with pEF.Conclusions:In STEMI patients after primary PCI,the clinical features and prognosis of mrEF group are different from pEF and rEF groups.Compared with those with pEF,patients with mrEF are older,have more comorbidities,and is associated with worse prognosis.Compared with those with rEF,although the clinical features are similar between mrEF and rEF,the prognosis of the mrEF patients is better than that of rEF patients.Compared with pEF,mrEF is independently associated with an increased risk of MACCE at 1 year after primary PCI in patients with acute STEMI.