早期应用肝素对老年急性ST段抬高型心肌梗死患者冠状动脉无复流的影响

Effects of early application of heparin on coronary no-reflow in elderly patients with acute ST-segment elevation myocardial infarction

目的探讨老年急性ST段抬高型心肌梗死(STEMI)直接PCI时,在急救车或急诊室上游给予普通肝素抗凝是否能改善术中无复流发生。方法连续纳入2017年1月~2018年8月首都医科大学附属北京安贞医院行急诊冠状动脉造影且术中采用肝素抗凝治疗的老年STEMI患者257例,按照入导管室前是否给予普通肝素抗凝治疗(5000 U)分为早期抗凝组69例,术中抗凝组188例。分析入选患者基线资料、梗死相关动脉基本情况以及PCI操作特点。主要终点:术中无复流发生。次要终点:术前TIMI 2~3级血流、首次医疗-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:院内出血分级。结果术中抗凝组术中无复流比例明显高于早期抗凝组,差异有统计学意义(34.6%vs 20.3%,P=0.028)。术中抗凝组术前TIMI 2~3级血流比例明显低于早期抗凝组,差异有统计学意义(17.0%vs 29.0%,P=0.034)。2组初次医疗-导丝通过时间、术后TIMI 3级血流、急性支架内血栓、院内出血学术研究会分级2~5型及各型出血比例比较,差异无统计学意义(P>0.05)。结论老年STEMI患者早期上游给予普通肝素可以降低直接PCI术中冠状动脉无复流发生率,增加直接PCI术前冠状动脉通畅率,并且不增加出血并发症。

Objective To investigate whether it is beneficial of early application of heparin in an ambulance or before entering emergency room on coronary no-reflow in elderly patients with acute ST-segment elevation myocardial infarction(STEMI) undergoing primary percutaneous coronary intervention(PCI).Methods A total of 257 elderly STEMI patients who received emergency coronary angiography and anticoagulant treatment by heparin during primary PCI in our hospital from January 2017 to August 2018 were consecutively enrolled to this study.According to whether receiving 5000 U heparin before entering the catheterization laboratory, they were divided into early heparin treatment group(n=69) and intraoperative heparin treatment group(n=188).The baseline data, basic conditions of infarct-related arteries, and characteristics of interventional procedures were analyzed.Primary endpoint: no-reflow during interventional therapy.Secondary endpoints: TIMI grade 2-3 flow before interventional therapy, time from first medical contact to wire crossing(FMC-to-W),postoperative TIMI grade 3 flow, and acute stent thrombosis.Safety endpoint: class of hospital bleeding by Bleeding Academic Research Consortium(BARC).Results The ratio of coronary no-reflow was signifincatly higher(34.6% vs 20.3%,P=0.028),and that of TIMI grade 2-3 flow was obviously lower(17.0% vs 29.0%,P=0.034) in the intraoperative heparin treatment group than the early heparin treatment group.There were no statistical differences in the FMC-to-W,postoperative TIMI grade 3 flow, acute stent thrombosis, BARC 2-5 grades of hospital bleeding and proportion of each type of bleeding between the 2 groups(P>0.05).Conclusion Early application of heparin in elderly STEMI patients can reduce the incidence of coronary no-reflow during primary PCI,increase the coronary patency rate before primary PCI,and didn’t increase bleeding complications.