围术期延时足量应用比伐芦定对接受直接经皮冠状动脉介入治疗急性心肌梗死患者影响

Effect of perioperative prolonged full dose infusion of Bivalirudin on patients undergoing primary percutaneous coronary intervention for acute myocardial infarction

目的探究围术期延时足量应用比伐芦定对接受直接经皮冠状动脉介入治疗(PPCI)的急性心肌梗死(AMI)患者的影响。方法将北部战区总医院自2016年3月至2019年3月收治的1795例接受PPCI的AMI患者纳入研究。根据围术期抗凝策略不同,将患者分入肝素组(n=1407)和比伐芦定组(n=388)。肝素组:冠状动脉造影前静脉注射5000 U肝素钠,PCI术前补充至100 U/kg;若术程>1 h,每小时追加1000 U;若活化凝血时间<225 s,给予肝素钠20 U/kg静脉推注。比伐芦定组:PCI术前静脉推注负荷剂量0.75 mg/kg,然后以1.75 mg/(kg·h)的速度持续泵注;若活化凝血时间<225 s,追加比伐芦定0.30 mg/kg静脉推注;比伐芦定最长应用时间为4 h[从1.75 mg/(kg·h)剂量开始计算时间]。采用倾向性匹配法校正组间差异。比较两组患者的一般资料,冠状动脉造影及PPCI相关资料,PPCI术后30 d终点事件发生情况。结果倾向性评分匹配前,比伐芦定组患者的年龄、既往脑卒中比例、CRUSADE评分均大于肝素组,差异有统计学意义(P<0.05);倾向性评分匹配后,两组患者一般资料比较,差异均无统计学意义(P>0.05)。倾向性评分匹配前,肝素组患者的闭塞病变比例、支架直径均大于比伐芦定组,差异有统计学意义(P<0.05);倾向性评分匹配后,两组患者冠状动脉造影及PPCI相关资料比较,差异均无统计学意义(P>0.05)。倾向性评分匹配前,两组患者PPCI术后30 d终点事件比较,差异均无统计学意义(P>0.05);倾向性评分匹配后,比伐芦定组复合终点事件发生率低于肝素组,差异有统计学意义(P<0.05)。结论与肝素比较,围术期延时足量应用比伐芦定可降低接受PPCI的AMI患者的复合终点事件发生风险,改善临床预后。

Objective To investigate the effect of prolonged full dose infusion of Bivalirudin in acute myocardial infarction(AMI)patients during primary percutaneous coronary intervention(PPCI).Methods A total of 1795 patients with AMI receiving PPCI were enrolled in this study from March 2016 to March 2019.Patients were divided into the heparin group(n=1407)and Bivalirudin group(n=388)according to different perioperative anticoagulation strategies.In heparin group,5000 U of heparin sodium was intravenously injected before coronary angiography and supplemented to 100 U/kg before PCI;if operation time was more than 1 hour,1000 U was added per hour.If the activated coagulation time was less than 225 s,heparin sodium was given 20 U/kg intravenously.In Bivalirudin group,the loading dose of intravenous injection before PCI was 0.75 mg/kg,and then continued pumping at a rate of 1.75 mg/(kg·h).If the activated coagulation time was less than 225 s,0.30 mg/kg of Bivalirudin was added intravenously.The maximum duration of Bivalirudin was 4 hours[time was calculated from dose of 1.75 mg/(kg·h)].The propensity matching method was used to correct the differences between the groups.The general information,coronary angiography and PPCI related data,and the incidence of endpoint events 30 days after PPCI were compared between the two groups.Results Before propensity score matching,the age,the proportion of previous stroke and CRUSADE score of Bivalirudin group were higher than those of heparin group,and the differences were statistically significant(P<0.05);after propensity score matching,there was no significant difference in the general information between the two groups(P>0.05).Before propensity score matching,the proportion of occlusive lesions and stent diameter in heparin group were larger than those in Bivalirudin group(P<0.05);after propensity score matching,there was no statistically significant difference in coronary angiography and PPCI related data between the two groups(P>0.05).Before the propensity score matching,there was no statistical significance in the comparison of endpoint events 30 days after PPCI between two groups(P>0.05);after propensity score matching,the incidence of compound end events in Bivalirudin group was lower than that in heparin group(P<0.05).Conclusion Compared with heparin,perioperative extended and adequate application of Bivalirudin can reduce the risk of compound endpoint events and improve clinical outcomes in AMI patients receiving PPCI.