首次手术方式对短期内两次应用对比剂的冠心病患者临床预后的影响

Effect of the first operation on the clinical prognosis of coronary artery disease patients treated with contrast twice during a short period of time

目的回顾性分析首次手术方式对冠心病患者短期(1个月)内行两次经皮冠状动脉介入治疗(PCI)接触对比剂后,围术期对比剂诱导的急性肾损伤(CI-AKI)发生情况及远期预后的影响。方法回顾性分析2010年1月至2015年1月就诊于北部战区总医院心内科且30 d内两次应用对比剂的冠心病患者601例,按照首次接触对比剂的手术方式分为:A组(首次手术方式为急诊PCI,113例)和B组(首次手术方式为择期PCI,488例)。比较两组临床特点、围术期CI-AKI发生率及相关危险因素,随访1年患者主要不良心血管事件(MACE,包括心原性死亡、再发心肌梗死、支架内再狭窄、支架内血栓形成)。结果A组ST段抬高型心肌梗死患者、吸烟者比例和入院心率均高于B组;B组患者年龄、入院收缩压均高于A组,差异均有统计学意义(均P<0.05)。A组利尿药使用比例高于B组;钙通道阻滞药、血管紧张素转换酶抑制药/血管紧张素Ⅱ受体拮抗药应用比例较B组低,差异均有统计学意义(P<0.05);A组患者估算的肾小球滤过率(eGFR)水平显著高于B组,差异有统计学意义(P<0.001)。A组第1次术后CI-AKI发生率、第2次术后CI-AKI发生率均显著高于B组,差异有统计学意义(P<0.001)。logistic多因素回归分析显示:年龄(OR 1.058,95%CI 1.000~1.118,P=0.049)是首次手术方式为急诊PCI的患者第1次术后CI-AKI发生的独立危险因素;eGFR(OR 1.015,95%CI 1.000~1.030,P=0.048)是首次手术方式为急诊PCI的患者第2次术后CI-AKI的独立危险因素。随访1年,A组MACE发生率高于B组,但差异无统计学意义。A组支架内再狭窄事件发生率高于B组(P=0.037)。结论首次急诊PCI患者,短期内行两次PCI接触对比剂后围术期CI-AKI发生率均高于择期PCI患者。两种手术方式对于冠心病患者远期MACE事件发生率无明显影响。

Objective Retrospective analysis was conducted on the influence of the first operation on the perioperative contrast induced acute kidney injury(CI-AKI)incidence and long-term prognosis of patients with coronary heart disease after two interventional operations exposed to contrast agents within a short period of time(1 month).Methods A total of 601 patients with coronary heart disease treated in the Department of Cardiology of General Hospital of Northern Theater Command from January 2010 to January 2015 were analyzed retrospectively.According to the first contact with contrast medium,the patients were divided into two groups:group A(emergency operation,n=113)and group B(selective operation,n=488).The clinical characteristics,perioperative incidence of CI-AKI and related risk factors were compared between the two groups.MACE events(including cardiogenic death,recurrent myocardial infarction,in-stent restenosis and in-stent thrombosis)were obtained during a followed up time of 1 year.Results The proportion of STEMI patients,smokers and admission heart rate in group A were significantly higher than those in group B,and the age and systolic blood pressure in group B were significantly higher than those in group A(P<0.05).The proportion of diuretics in group A was higher than that in group B,the proportion of CCB and ACEI/ARB was lower than that in group B(P<0.05)the level of eGFR in group A was higher than that in group B(P<0.001).The incidence of CI-AKI after the first operation and after the second operation in group A were significantly higher than those in group B(P<0.001).The results of logistic regression analysis showed that age(OR 1.058,95%CI 1.000—1.118,P=0.049)was an independent risk factor for the occurrence of CI-AKI in patients who underwent emergency surgery for the first time.Meanwhile,eGFR(OR 1.015,95%CI 1.000—1.030,P=0.048)was an independent risk factor for CI-AKI in patients who underwent emergency surgery for the second time.Comparison of clinical end-point events:during 1 year follow up,the incidence of MACE events in group A was higher than that in group B,but there was no statistical significance.The incidence of in-stent restenosis in group A was higher than that in group B(P=0.037).Conclusions The incidence of CI-AKI during perioperative period was higher in patients undergoing emergency coronary interventional therapy after two interventional operations in a short period than in patients undergoing elective surgery.However,the two surgical methods had no significant effect on the incidence of long-term MACE events in patients with coronary heart disease.