替罗非班不同给药途径联合血栓抽吸对急性ST段抬高型心肌梗死病人预后的影响:一项随机、对照、开放研究

Effects of different administration routes of tirofiban combined with thrombus aspiration on prognosis of patients with acute ST⁃segment elevation myocardial infarction:a randomized,controlled and open⁃label study

目的研究替罗非班不同给药途径联合血栓抽吸对急性ST段抬高型心肌梗死(STEMI)病人预后的影响。方法将2014年3月至2017年3月三门峡市中心医院高血栓负荷的247例STEMI病人采用随机数字表法分为A(静脉注射)、B(梗阻冠脉开口处注射)、C(梗阻冠脉远端注射)三组采用替罗非班联合血栓抽吸辅助经皮冠状动脉介入治疗(PCI),比较三组PCI后心肌梗死溶栓试验(TIMI)血流分级水平、心肌灌注分级(TMPG)、校正的TIMI血流帧数计数(CTFC)、ST段回落率以及心功能状况,并随访三组PCI后1年内主要不良心血管事件(MACE)发生率。结果 PCI后三组TIMI血流分级水平差异有统计学意义(χ^2=10.592,P=0.005),C组Ⅲ级血流比例为47例(56.63%),高于A组27例(34.78%)和B组31例(33.82%),差异有统计学意义(P<0.05);三组TMPG分别为(2.19±0.38)级、(2.31±0.45)级和(2.53±0.47)级,CTFC分别为(26.34±3.72)帧、(27.08±3.84)帧和(28.45±3.91)帧,ST段回落率分别为(72.53±12.64)%、(76.29±13.42)%和(83.65±14.78)%,三组TMPG、CTFC和ST段回落率比较差异有统计学意义(F=12.918、6.444、14.136,P=0.000、0.002、0.000),且C组TMPG、CTFC和ST段回落率高于A、B两组,差异有统计学意义(P<0.05);治疗后30 d时三组左室射血分数(LVEF)明显升高,左室舒张末期内径(LVEDD)、左室收缩末期内径(LVESD)明显降低(P<0.05),三组治疗后各指标差异有统计学意义(P<0.05);且C组LVEF高于A、B两组,LVEDD和LVESD低于A、B两组,差异有统计学意义(P<0.05);PCI术中常见不良反应包括胸痛、心律失常、VRRs及充血性心力衰竭,三组比较均差异无统计学意义(P>0.05);随访1年时间显示,三组MACE发生率分别为21例(25.61%)、16例(19.51%)和5例(6.02%)差异有统计学意义(χ^2=11.759,P=0.003),且C组MACE发生率低于A、B两组,差异有统计学意义(P<0.05)。结论 PCI术中血栓抽吸后梗阻冠脉远端注射替罗非班治疗STEMI可有效改善病人TIMI血流分级水平,提高TMPG、CTFC和ST段回落率,促进病人心功能恢复,并降低治疗后MACE发生率,改善病人预后,疗效明显优于静脉注射和梗阻冠脉开口处给药。

Objective To study the effects of different administration routes of tirofiban combined with thrombus aspiration on the prognosis of patients with acute ST⁃elevation myocardial infarction(STEMI).Methods Two hundred and forty⁃seven cases of STEMI patients with high thrombotic load in Sanmenxia Central Hospital from March 2014 to March 2017 were divided into group A(in⁃travenous injection),group B(injection at the opening of obstructed coronary artery)and group C(injection at distal obstructed coronary artery)according to the random number table method,and the three groups were given tirofiban combined with thrombus aspiration assisted percutaneous coronary intervention(PCI).The thrombolysis in myocardial infarction(TIMI)test blood flow grade,TIMI myocardial perfusion grade(TMPG),corrected TIMI frame count(CTFC),ST⁃segment fall rate and cardiac function status were compared among the three groups after PCI,and the occurrence of major adverse cardiac events(MACE)within 1 year after PCI were followed up in the three groups.Results After PCI,there was a significant difference in TIMI blood flow grade level among the three groups(χ^2=10.592,P=0.005),and the proportion of grade III blood flow in group C was higher than that in group A and B[47 cases(56.63%)vs.27 cases(34.78%)vs.31 cases(33.82%)](P<0.05).The TMPG values in the three groups were(2.19±0.38),(2.31±0.45)and(2.53±0.47),and the CTFC values were(26.34±3.72)frames,(27.08±3.84)frames and(28.45±3.91)frames,respectively,and the ST⁃segment fall rates were(72.53±12.64)%,(76.29±13.42)%and(83.65±14.78)%,respectively,and there were statistically significant differences in the TMPG,CTFC and ST⁃segment fall rate among the three groups(F=12.918,6.444,14.136,P=0.000,0.002,0.000),and the TMPG,CTFC and ST⁃segment fall rate in group C were higher than those in group A and B(P<0.05).At 30d after treatment,left ventricular ejection fraction(LVEF)increased signifi⁃cantly while left ventricular end⁃diastolic diameter(LVEDD)and left ventricular end⁃systolic diameter(LVESD)decreased signifi⁃cantly in the three groups(P<0.05),and the difference in each index after treatment was significant(P<0.05).The LVEF in group C was higher than that in group A and B while the LVEDD and LVESD were lower than those in group A and B(P<0.05).Common adverse reactions during PCI included chest pain,arrhythmia,VRRs and congestive heart failure,and there were no signifi⁃cant differences among the three groups(P>0.05).One year of follow⁃up showed there was a significant difference in the inci⁃dence rate of MACE among the three groups[21 cases(25.61%)vs.16 cases(19.51%)vs.5 cases(6.02%)](χ^2=11.759,P=0.003),and the incidence rate of MACE in group C was lower than that in group A and B(P<0.05).Conclusions Tirofiban in⁃jection at distal obstructed coronary artery after thrombus aspiration during PCI for STEMI can effectively improve TIMI blood flow grade,increase the TMPG,CTFC and ST⁃segment fall rate,promote cardiac function recovery,reduce the incidence rate of MACE after treatment,and improve the prognosis of patients.And its efficacy is significantly better than that of intravenous injection and drug administration at the opening of obstructed coronary artery.