早期应用肝素对急性ST段抬高型心肌梗死直接经皮冠状动脉介入治疗患者冠状动脉血流的影响

Effect of early application of heparin on coronary blood flow in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

目的探讨急性ST段抬高型心肌梗死(STEMI)患者直接经皮冠状动脉介入(pPCI)治疗前,在急救车或急诊室上游给予普通肝素抗凝对冠状动脉血流的影响。方法连续纳入2017年1月至2018年8月就诊于首都医科大学附属北京安贞医院急诊,诊断为STEMI并行急诊冠状动脉造影的患者,按照入导管室前是否给予普通肝素抗凝治疗,分为早期肝素抗凝组(163例)和术中肝素抗凝组(476例)。分析入选患者基线资料,梗死相关动脉基本情况,介入操作特点。主要终点指标为介入治疗前心肌梗死溶栓试验(TIMI)2~3级血流。次要终点指标为首次医疗接触-导丝通过时间、术后TIMI 3级血流、急性支架内血栓。安全性终点指标为院内出血发生率。结果2组患者除收缩压外其他基线资料差异均无统计学意义(均P>0.05)。2组之间梗死相关动脉位置差异无统计学意义(P>0.05),所有患者均接受了冠状动脉造影,术中肝素抗凝组457例(96.0%)行pPCI,早期肝素抗凝组160例(98.2%)行pPCI治疗。主要终点事件:早期肝素抗凝组pPCI术前TIMI 2~3级血流比例高于术中肝素抗凝组[27.6%(45/163)比18.1%(86/476)],差异有统计学意义(χ^(2)=6.781,P=0.009)。次要终点事件:早期肝素抗凝组与术中肝素抗凝组初次医疗接触-导丝通过时间、术后TIMI 3级血流比例、急性支架内血栓比例差异均无统计学意义(均P>0.05)。早期肝素抗凝组与术中肝素抗凝组出血学术研究会2~5级院内出血发生率差异无统计学意义[1.8%(3/163)比1.1%(5/476)](χ^(2)=0.613,P=0.434)。结论急性STEMI患者早期给予普通肝素抗凝可以改善pPCI前的冠状动脉通畅率,早期使用固定剂量的普通肝素是安全的,不会增加大出血并发症发生率。

Objective To investigate the effect of application heparin in ambulances or emergency rooms on coronary blood flow in patients with acute ST-segment elevation myocardial infarction(STEMI)undergoing primary percutaneous coronary intervention(pPCI).Methods From January 2017 to August 2018,patients with STEMI admitted to Department of Emergency,Beijing Anzhen Hospital,Capital Medical University were consecutively selected.Patients were divided into early heparin anticoagulation group(163 cases)and intraoperative heparin anticoagulation group(476 cases)according to whether heparin was given before entering the catheter room.The baseline data of patients,basic information of infarct-related arteries,and characteristics of interventional procedures were analyzed.The primary endpoint was thrombolysis in myocardial infarction(TIMI)grade 2-3 blood flow before interventional therapy.Secondary endpoints were the time from first medical contact to wire,postoperative TIMI grade 3 blood flow,and acute stent thrombosis.The safety endpoint was hospital bleeding.Results There were no significant differences in baseline data between the two groups except systolic blood pressure(all P>0.05).There was no significant difference in the location of infarct-related arteries between the two groups(P>0.05).All patients underwent coronary angiography.Among them,457 patients(96.0%)received pPCI in the intraoperative heparin anticoagulation group,and 160 patients(98.2%)received pPCI in the early heparin anticoagulation group.Primary endpoint:the proportion of TIMI grade 2-3 blood flow in the early heparin anticoagulation group was higher than that in the intraoperative heparin anticoagulation group[27.6%(45/163)vs 18.1%(86/476)](χ^(2)=6.781,P=0.009).Secondary endpoints:there were no significant differences between the early heparin anticoagulation group and the intraoperative heparin anticoagulation group in the time from first medical contact to wire,the proportions of TIMI grade 3 blood flow and acute stent thrombosis after surgery(all P>0.05).There was no significant difference in the incidence of Bleeding Academic Research Consortium grade 2-5 between the early heparin anticoagulation group and the intraoperative heparin anticoagulation group[1.8%(3/163)vs 1.1%(5/476)](χ^(2)=0.613,P=0.434).Conclusions Early application of heparin can improve the coronary patency rate in acute STEMI patients before pPCI.Early application of a dose of heparin is safe and does not increase bleeding complications.