老年急性ST段抬高型心肌梗死合并高血栓负荷患者行直接支架术与延迟支架术的对比分析

A comparative analysis of direct stenting versus deferred stenting for the treatment of elderly patients with acute ST segment elevation myocardial infarction with a high thrombus load

目的比较直接支架术与延迟支架术治疗发病12 h内的60岁及以上老年急性ST段抬高型心肌梗死(STEMI)合并高血栓负荷患者中的安全性及有效性。方法选择2015年1月至2018年12月在北京安贞医院和北华大学附属医院实施经皮冠状动脉介入(PCI)治疗的年龄≥60岁的老年STEMI合并高血栓负荷(血栓评分≥4分)的患者252例,按照是否即刻植入支架分为直接支架组126例和延迟支架组126例;比较两组患者的基线信息、手术信息、临床结局以及随访1年时左室射血分数(LVEF)及主要心脏不良事件(MACE),采用Cox回归分析判定延迟支架植入是否为预后的影响因素。结果两组梗死相关动脉分布、发病至球囊扩张时间、血栓负荷评分及植入支架数量差异均无统计学意义(均P>0.05)。延迟支架组植入支架的直径和长度分别为(3.20±0.47)mm、(18.33±5.06)mm,直接支架组分别为(3.03±0.50)mm、(22.60±5.08)mm,差异有统计学意义(t=2.926、6.678,P=0.004、0.000)。延迟支架组梗死相关动脉支架术后慢血流发生率为2.38%(3/126)、远端栓塞率为3.17%(4/126)、低心肌灌注染色率为2.38%(3/126),低于直接支架组的15.87%(20/126)、24.60%(31/126)和20.63%(26/126)(χ^(2)=13.827、24.188、20.614,均P=0.000)。延迟支架组1年时LVEF为(0.60±0.05)%,显著高于直接支架组的(0.57±0.05)%(t=3.859、P=0.000)。两组患者在1年随访时MACE的发生率比较差异无统计学意义(P>0.05)。多因素Cox回归分析结果显示,延迟支架植入与MACE的发生无关,即延迟支架植入治疗并不是影响临床结局的因素(HR=0.827,95%CI:0.288~2.372,P=0.724)。结论延迟支架植入治疗与直接支架植入治疗对发病12 h以内的60岁及以上老年STEMI合并高血栓负荷患者同样安全有效,且延迟支架植入治疗能显著改善梗死相关动脉血流分级、降低远端栓塞率、提高心肌灌注染色3级率、增加植入支架的直径、减少植入支架的长度、提高LVEF。

Objective To compare the safety and effectiveness of direct stenting versus deferred stenting for the treatment of acute ST segment elevation myocardial infarction(STEMI)with a high thrombus load in patients aged 60 years and above.Methods In this study,we analyzed 252 elderly STEMI patients with a high thrombus load(thrombus score≥4 points)who received percutaneous coronary intervention(PCI)at Beijing Anzhen Hospital Affiliated or at the Affiliated Hospital of Beihua University from January 2015 to December 2018.They were divided into the direct stent group(n=126)and the deferred stent group(n=126)according to whether the stent was inserted immediately or not.Baseline information,surgical information,clinical outcomes and major adverse cardiac events were compared between the two groups at 1 year follow-up.Cox regression analysis was used to determine whether deferred stent implantation was a prognostic factor.Results There were no significant differences in the distribution of infarct-related arteries,time from onset to balloon dilatation,thrombus load scores and the number of stents between the two groups(all P>0.05).The diameter and length of the stent were(3.20±0.47)mm and(18.33±5.06)mm in the deferred stent group and(3.03±0.50)mm and(22.60±5.08)mm in the direct stent group,respectively,with a significant difference between the two groups(t=2.926,6.678,P=0.004,0.000).The incidences of slow blood flow,distal embolism and low myocardial perfusion staining in the deferred stent group were 2.38%(3/126),3.17%(4/126)and 2.38%(3/126),respectively,significantly lower than those in the direct stent group,which were 15.87%(20/126),24.60%(31/126)and 20.63%(26/126),respectively(χ^(2)=13.827,24.188,20.614,all P=0.000).The left ventricular ejection fraction(LVEF)at 1 year in the deferred stent group was(0.60±0.05)%,significantly higher than that in the direct stent group(0.57±0.05)%(t=3.859,P=0.000).There was no significant difference in major adverse cardiac events between the two groups at 1 year follow-up(P>0.05).Cox regression analysis results showed that deferred stent implantation was not a factor affecting the clinical outcome(HR=0.827,95%CI:0.288~2.372,P=0.724).Conclusions Deferred stent implantation and direct stent intervention are equally safe and effective for STEMI patients aged over 60 with a high thrombus load if admitted to the hospital within 12 hours after onset.Deferred stent implantation can significantly improve the infarct-related artery blood flow classification,reduce the distal embolism rate,increase the grade 3 rate of myocardial perfusion staining,increase the diameter of the stent,reduce the length of the stent and improve left ventricular ejection fraction.