“急诊PCI”模式下急性ST段抬高心肌梗死合并早期左心室血栓的危险因素分析

Risk factors analysis in patients with early left ventricular thrombus post acute ST-segment elevation myocardial infarction in primary PCI mode

目的探讨“急诊PCI”模式下急性ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)合并早期左心室血栓(left ventricular thrombus,LVT)的危险因素。方法连续收集2014年1月至2019年4月于河南省人民医院诊断为STEMI并行急诊冠脉介入治疗(primary percutaneous coronary intervention,pPCI)治疗的784例患者的临床资料,观察指标包括基线资料、冠状动脉造影资料、病程资料、实验室检查、辅助检查。排除严重器质性心脏病、既往左心室室壁瘤(left ventricular aneurysm,LVA)及LVT病史等患者。从中筛选出LVT患者(38例)为试验组,根据年龄(与实验组年龄差绝对值最小)、性别按l∶3个体匹配的原则选择匹配出同期住院的非LVT患者为对照组(114例)。采用Graphpad Prism5、SPSS 22.0、Medcalc软件进行统计分析,建立Logistic回归模型,以P<0.05为差异有统计学意义,对早期LVT形成的危险因素进行回顾性分析。结果线性趋势χ2检验提示,总缺血时间(total ischemic time,TIT)与LVT的发生呈线性关系(χ^2=304,P<0.01),且Spearman相关分析提示,TIT与LVT呈正相关性(ρ=0.626,P<0.01);多因素条件Logistic回归分析显示TIT延长、ST段抬高总幅度增加、pPCI术后TIMI血流≤2级、左心室射血分数(left ventricular ejection fraction,LVEF)下降、合并LVA为LVT发生的独立危险因素,其比值比(OR值)依次为1.996、13.689、16.996、0.868、9.195。构建模型1为LVA、ST段抬高总幅度,绘制其受试者工作特征曲线(receiver operating characteristic,ROC),并计算ROC曲线下的面积(area under curve,AUC)为0.889;向模型1中加入TIT、LVEF、术后TIMI血流≤2级得到模型2,其AUC为0.990,Delong法比较两者AUC值,差异有统计学意义(Z=3.294,P=0.001)。结论“急诊PCI”模式下STEMI合并早期LVT的危险预测因素或已发生改变,临床医生需对具有合并LVT高危因素的人群进行早期筛查,以降低其发生率,改善预后。积极开展术前急诊床旁超声心动图或有助于此。

Objective To investigate the risk factors of ST-segment elevation myocardial infarction(STEMI)with early left ventricular thrombus(LVT)under emergency percutaneous coronary intervention(PCI)mode.Methods The clinical data were collected from 784 patients with STEMI treated with emergency percutaneous coronary intervention(pPCI)in our hospital from January 2014 to April 2019.The observation indexes included baseline data,coronary angiography,disease course,laboratory examination and auxiliary examination.Patients with severe organic heart disease and having previous history of LVA and LVT were excluded.Totally 38 patients with LVT were selected as the experimental group and 114 patients with non-LVT selected as the control group according to the principle of age(the smallest absolute age difference between the experimental group and the control group)and sex.Data was analyzed by software Graphpad Prism5,SPSS 22.0 and Medcalc software were used for statistical analysis,and the Logistic regression model was established.A P<0.05 was considered statistically significant,and the risk factors of early LVT formation were retrospectively analyzed.Results There was a linear relationship between the prolongation of TIT and the occurrence of LVT(χ^2=304,P<0.01),and the Spearman relation was highly positive(ρ=0.626,P<0.01).Multivariate conditional logistic regression analysis showed that prolonged TIT(total ischemic time),increased total amplitude of ST elevation,TIMI blood flow≤grade 2 after pPCI,decreased LVEF and LVA were independent risk factors for LVT,and their odds ratios(OR)were 1.996,13.689,16.996,0.868 and 9.195,respectively.Model 1 was constructed as LVA and the total amplitude of elevation of ST segments,and the receiver operating characteristic(ROC)was drawn,and the area under the ROC curve(AUC)was calculated as 0.889.Model 2 was obtained by adding TIT,LVEF and postoperative TIMI blood flow≤2,and the AUC was 0.990.Delong method was used to compare the AUC values between the two groups,and there was a statistical difference(Z=3.294,P=0.001).Conclusions The risk factors of STEMI complicated with early LVT under"emergency PCI mode"may have changed.Clinicians should conduct early screening of high-risk people factors of LVT in order to reduce its incidence and improve the prognosis.It may be helpful to actively carry out emergency bedside echocardiography before operation.