区域协同救治模式下转运距离对ST段抬高型心肌梗死患者溶栓治疗后或直接转运经皮冠状动脉介入治疗预后的影响

Eff ects of transport distance on prognosis of percutaneous coronary intervention after thrombolytic or primary percutaneous coronary intervention in ST-segment elevation myocardial infarction patients under the regional cooperative treatment model

目的探究区域协同救治模式下转运距离对ST段抬高型心肌梗死(STEMI)患者溶栓治疗后或直接转运经皮冠状动脉介入治疗(PCI)预后的影响。方法纳入2019年1月1日至2020年12月31日通过区域协同救治模式经网络医院溶栓治疗后或直接转运至中国人民解放军联勤保障部队第九二〇医院的STEMI患者477例,根据转运距离和再灌注方式分为A组(转运距离≥60 km溶栓治疗后转运PCI组)、B组(转运距离≥60 km直接转运PCI组)和C组(转运距离<60 km直接转运PCI组)。比较3组临床基线资料、时间节点、介入相关资料、院内用药资料,观察终点为术后1年主要不良心脑血管事件和心功能。结果477例患者平均年龄(60.6±12.4)岁,男性占77.1%。根据转运距离和再灌注方式分为3组:A组159例(33.3%),B组177例(37.1%),C组141例(29.6%)。A组较B组入门至出门(DIDO)时间[125(82,190)min比68(43,130)min,P<0.001]和首次医疗接触至球囊扩张(FMC2B)时间[288(210,371)min比196(149,315)min,P<0.001]延长,B组较C组发病至球囊扩张(S2B)时间[478(278,899)min比385(258,640)min,P=0.009]和FMC2B时间[196(149,315)min比189(135,247)min,P=0.048]延长,A组较C组发病至首次医疗接触时间[170(80,320)min比165(75,330)min,P=0.005]、DIDO时间[125(82,190)min比73(45,122)min,P<0.001]和FMC2B时间[288(210,371)min比189(135,247)min,P<0.001]延长,差异均有统计学意义。和A组相比较,B组术前心肌梗死溶栓治疗试验(TIMI)血流分级[0(0,3)级比3(0,3)级,P<0.001]和C组术前TIMI血流分级[0(0,3)级比3(0,3)级,P<0.001]均更优,差异均有统计学意义。A组较B组全因死亡率(8.2%比17.5%,P=0.011)和心原性死亡率(5.7%比15.8%,P=0.003)降低,术后1年左心室舒张末期内径(LVEDd)[(47.4±6.1)mm比(48.9±6.0)mm,P=0.021]减小、左心室射血分数(LVEF)[(50.0±8.4)%比(47.5±7.2)%,P=0.005]升高;B组较C组全因死亡率(17.5%比7.1%,P=0.006)和心原性死亡率(15.8%比5.7%,P=0.005)升高,术后1年LVEDd[(48.9±6.0)mm比(46.1±6.4)mm,P<0.001]增大、LVEF[(47.5±7.2)%比(49.4±8.0)%,P=0.038]降低,差异均有统计学意义。Logistic多因素回归分析显示,溶栓治疗(OR0.488,95%CI0.247~0.962,P=0.038)是转运距离≥60 km的STEMI患者溶栓治疗或直接转运PCI术后1年全因死亡的保护因素。结论转运距离是影响STEMI患者溶栓治疗后或直接转运PCI预后的重要因素,当转运距离≥60 km时应首选溶栓治疗后转运PCI,而转运距离<60 km可以直接转运PCI,从而使患者获得及时有效的早期再灌注治疗,降低远期临床不良事件及改善心功能。

Objective To investigate effects of transport distance on prognosis of STEMI patients who accepted thrombolysis combined with PCI or primary PCI under the regional cooperative treatment model.Methods In this retrospective study,477 STEMI patients who were transferred from non-PCI hospitals to the 920th Hospital of Joint Logistic Support Force through regional collaborative treatment mode between January 1,2019 and December 31,2020 were enrolled.According to transport distance and reperfusion strategy,they were divided into three groups,group A(transport distance≥60 km and thrombolysis combined with PCI),Group B(transport distance≥60 km and primary PCI)and group C(transport distance<60 km and primary PCI).The clinical baseline data,time nodes,intervention-related data and hospital medication data were compared between each group.The end points were major adverse cardiovascular events and cardiac function at 1-year followup.Results A total of 477 STEMI patients were enrolled[mean age was(60.6±12.4)years old],with 368 males(77.1%).According to transport distance and reperfusion strategy,the patients were divided into 3 groups:159(33.3%)in group A,177(37.1%)in group B,and 141(29.6%)in group C.Compared with group B,the time of Door-in and door-out(DIDO)[125(82,190)min vs.68(43,130)min,P<0.001]and the time of first medical contact to balloon(FMC2B)[288(210,371)min vs.196(149,315)min,P<0.001]in group A was significantly longer.Compared with group B,the time of Symptom onset to Balloon(S2B)[385(258,640)min vs.478(278,899)min,P=0.009]and FMC2B[189(135,247)min vs.196(149,315)min,P=0.048]in group C was signif icantly shorter,while the time of S2FMC[170(80,320)min vs.165(75,330)min,P=0.005]and DIDO[125(82,190)min vs.73(45,122)min,P<0.001]and FMC2B[288(210,371)min vs.189(135,247)min,P<0.001]in group A was significantly longer than the ones in group C.Compared with group A,the pre-operative TIMI blood flow in both group B[0(0,3)vs.3(0,3),P<0.001]and group C[0(0,3)vs.3(0,3),P<0.001]was significantly better.Compared with group B,the proportions of all-cause deaths(8.2%vs.17.5%,P=0.011)and cardiogenic deaths(5.7%vs.15.8%,P=0.003)were significantly less in group A,while LVEDd[(47.4±6.1)mm vs.(48.9±6.0)mm,P=0.021]was significantly smaller,LVEF[(50.0±8.4)%vs.(47.5±7.2)%,P=0.005]was significantly better at 1-year followup.Compared with group C,the proportions of all-cause deaths(17.5%vs.7.1%,P=0.006)and cardiogenic deaths(15.8%vs.5.7%,P=0.005)were significantly more in group B,while LVEDd[(48.9±6.0)mm vs.(46.1±6.4)mm,P<0.001]was signif icantly increased and LVEF[(47.5±7.2)%vs.(49.4±8.0)%,P=0.038]was significantly decreased at 1-year follow-up.Multivariate Logistic regression analysis showed that thrombolytic therapy(OR0.488,95%CI 0.247—0.962,P=0.038)was a protective factor for all-cause death at 1-year after PCI in STEMI patients whose transport distance was≥60 km.Conclusions Transport distance is an important f actor aff ecting the prognosis of STEMI patients who accepted thrombolysis combined with PCI or primary PCI.When the transport distance was more than 60km,it is the first choice of treatment strategy that was thrombolysis combined with PCI,while the transport distance was less than 60 km,it was primary PCI.Since early reperfusion therapy was timely and effective in STEMI patients.it could reduce long-term clinical adverse events and benefit cardiac function.