182例急性ST段抬高型心肌梗死患者术后30 d冠脉慢血流/无复流危险因素分析

Risk factors of slow or no coronary flow in 182 patients with acute ST-segment elevation myocardial infarction 30 days after operation

目的研究急性ST段抬高型心肌梗死(STEMI)患者急诊经皮冠状动脉介入治疗(PCI)术后冠状动脉慢血流/无复流(SCF/NCF)现象发生的危险因素,探讨术后30 d SCF/NCF对患者的影响。方法回顾性分析STEMI并行急诊PCI的患者334例,分为SCF/NCF组(n=182)及对照组(术后冠状动脉血流速度正常患者,n=152)。应用多因素二元Logistic回归分析研究STEMI患者急诊PCI术后与SCF/NCF现象发生有关联的危险因素,并于术后30 d内对所有患者进行随访,分析两组主要心脏不良事件(MACE)、再发心肌梗死、心源性死亡、全因死亡、支架内血栓的发生情况。结果①两组患者间差异存在统计学意义的因素包括:血肌酐值升高(P=0.034,OR=1.009,95%CI:1.001~1.017),预扩后高TIMI帧数(P=0.025,OR=1.038,95%CI:1.005~1.072),高支架最大释放压(P=0.006,OR=1.525,95%CI:1.130~2.060),高血栓积分(P=0.030,OR=1.324,95%CI:1.028~1.705)是SCF/NCF发生的危险因素;靶血管为非RCA(P<0.001,OR=0.071,95%CI:0.025~0.200),高预扩囊最大扩张压(P=0.033,OR=0.864,95%CI:0.755~0.989),术中应用硝普钠(P=0.006,OR=0.126,95%CI:0.029~0.548)及IIb/IIIa受体拮抗剂(P=0.043,OR=0.438,95%CI:0.197~0.974)是SCF/NCF发生的保护性因素;其中靶血管为非RCA及术中应用硝普钠为减低SCF/NCF现象发生的主要保护性因素。②术后30 d内随访表明,两组患者MACE(14例vs 8例,χ^2=0.753,P=0.385)、心源性死亡(12例vs 8例,χ^2=0.243,P=0.622)、全因死亡(12例vs 8例,χ^2=0.243,P=0.622)、支架内血栓(2例vs 0例,χ^2=1.675,P=0.196)的发生情况无统计学意义;而SCF/NCF组再发心肌梗死的发生率高于对照组(6例vs 0例,χ^2=5.087,P=0.024)。③导致两组患者死亡的原因包括心源性休克、支架内血栓、心脏破裂、急性心力衰竭,其中心源性休克是导致STEMI患者死亡的首位原因(占比70%)。结论血肌酐值升高、预扩后高TIMI帧数、高支架最大释放压、高血栓积分与SCF/NCF的发生有统计学意义的正向关联,靶血管为非RCA、高预扩球囊最大扩张压、术中使用硝普钠以及IIb/IIIa受体拮抗剂与SCF/NCF的发生有统计学意义的负向关联。随访发现SCF/NCF组再发心肌梗死的发生率高于对照组。

Objective To study the risk factors of slow coronary flow/no coronary flow(SCF/NCF) after the emergency percutaneous coronary intervention(PCI) in the patients with acute ST-segment elevation myocardial infarction(STEMI), and to explore the influences of SCF/NCF on the patients 30 days after the emergency PCI. Methods A total of 334 patients with STEMI and emergency PCI were analyzed retrospectively. They were divided into the SCF/NCF group(n=182)and control group(the patients with normal coronary flow after PCI,n=152). The multivariate Logistic regression analysis was used to study the risk factors correlated with SCF/NCF after emergency PCI. The follow-up was made to explore the incidence of major adverse cardiac events(MACE), myocardial re-infarction, cardiac death, all-cause death and instent thrombosis between the two groups 30 days after PCI. Results ① The factors with statistical differences between the two groups showed that the elevation of serum creatinine(P=0.034, OR=1.009, 95%CI: 1.001-1.017), high TIMI frame counts after pre-dilation(P=0.025, OR=1.038, 95%CI: 1.005-1.072), the high maximum stent release pressure(P=0.006, OR=1.525, 95%CI: 1.130-2.060), the high thrombus score(P=0.030, OR=1.324, 95%CI: 1.028-1.705) were the risk factors of SCF/NCF phenomenon. Non-right coronary artery as the target vessel(P<0.001, OR=0.071, 95%CI: 0.025-0.200), the high maximum pre-dilation pressure(P=0.033, OR=0.864, 95%CI: 0.755-0.989), the usage of sodium nitroprusside(P=0.006, OR=0.126, 95%CI: 0.029-0.548) and IIb/IIIa receptor antagonist(P=0.043, OR=0.438, 95%CI: 0.197-0.974) during the procedure were the protection factors of the SCF/NCF phenomenon. Among these protection factors, non-right coronary artery as the target vessel and the usage of sodium nitroprusside were dominant. ② After 30 days of the follow-up, there were no significant differences in the incidence of MACE(14 vs 8 cases, χ^2=0.753, P=0.385), cardiac death(12 vs 8 cases, χ^2=0.243, P=0.622), all-cause death(12 vs 8 cases, χ^2=0.243,P=0.622) and in-stent thrombosis(2 vs 0 cases, χ^2=1.675, P=0.196) between the two groups. Compared with the control group, the incidence of myocardial re-infarction in SCF/NCF group was higher(6 vs 0 cases, χ^2=5.087, P=0.024). ③ The causes of death were cardiac shock, in-stent thrombosis, cardiac rupture and acute heart failure. Cardiac shock is the first cause of death which accounts for 70%. Conclusion The elevation of serum creatinine, high TIMI frame count after pre-dilation, the high maximum stent release pressure and the high thrombus score are positivly correlated to the SCF/NCF phenomenon. Non-right coronary artery as the target vessel, the high maximum pre-dilation pressure, the usage of sodium nitroprusside and IIb/IIIa receptor antagonist during the procedure are negativly correlated to the SCF/NCF phenomenon. The incidence of myocardial re-infarction in the SCF/NCF group was higher than that in the control group.