胸前导联R波振幅总和/(S波+Q波)振幅总和比值在经PCI治疗的急性前壁ST段抬高性心肌梗死患者中的预测价值

Prognostic value of precordial total R wave amplitude/total(S wave+Q wave)amplitude ratio in patients with acute anterior ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention

目的在经皮冠状动脉介入(PCI)治疗的急性前壁ST段抬高心肌梗死(STEMI)患者中,探讨胸前导联R波振幅总和/(S波+Q波)振幅总和比值[R/(S+Q)]对患者预后的影响。方法共纳入273例PCI治疗的急性前壁STEMI患者。计算出院时患者心电图胸前导联R/(S+Q)。主要研究终点是2年临床随访期间主要不良心血管事件(MACE)发生情况,次要研究终点是任何支架血栓形成情况。结果与R/(S+Q)≥0.51组相比,R/(S+Q)<0.51组糖尿病患者明显升高(P<0.05),CK-MB数值升高(P<0.05),肌钙蛋白I数值升高(P<0.05)、LVEF明显降低(P<0.05),出院时胸前导联QRS时限更长(P<0.01),胸前导联出现病理性Q波的患者更多(P<0.01),胸前导联R波振幅总和明显减少(P<0.01),胸前导联(Q波+S波)振幅总和明显升高(P<0.01),胸前导联R/(S+Q)明显降低(P<0.01)。心电图胸前导联R/(S+Q)比值评估患者发生本研究定义的MACE发生风险的曲线下面积为0.711,对预测MACE发生的敏感度为81.8%,特异度为55.7%,最佳临界值为0.51。R/(S+Q)<0.51组患者中罪犯病变累及左前降支近段明显高于R/(S+Q)≥0.51组患者,以左前降支近段为主(P<0.01);R/(S+Q)<0.51组患者平均植入每枚支架直径明显高于R/(S+Q)≥0.51组患者(P<0.01);2年临床随访期间,R/(S+Q)<0.51组患者MACE发生率明显高于R/(S+Q)≥0.51组(P<0.01);心力衰竭发生率也明显高于R/(S+Q)≥0.51组患者(P<0.01)。R/(S+Q)<0.51组和R/(S+Q)≥0.51组术后2年无MACE累积生存率分别为68.9%和88.7%(Log-rank P<0.01),无心力衰竭累积生存率分别为75.0%和92.4%(Log-rank,P<0.01)。COX回归分析结果显示R/(S+Q)为2年临床随访期间MACE发生的独立预测因素(风险比:0.347,95%CI:0.143~0.844,P<0.05)。结论在PCI治疗的急性前壁STEMI患者中,2年临床随访期间,R/(S+Q)<0.51的患者MACE发生率明显高于R/(S+Q)≥0.51的患者,R/(S+Q)为预测本研究定义的MACE发生的危险因素。

AIM To demonstrate the prognostic value of precordial total R wave amplitude/total(S wave+Q wave)amplitude ratio[R/(S+Q)]in patients with acute anterior ST-segment elevation myocardial infarction(STEMI)undergoing percutaneous coronary intervention(PCI).METHODS In this retrospective study,we screened 273 patients with acute anterior STEMI who underwent PCI.Precordial R/(S+Q)was calculated at the time of hospital discharge.The primary endpoint was the major adverse cardiovascular event(MACE)and the secondary endpoint was any stent thrombosis at 2-year follow-up period.RESULTS Compared with the R/(S+Q)≥0.51 group,the R/(S+Q)<0.51 group had significantly higher diabetes patients(P<0.05),higher CK-MB values(P<0.05),higher troponin I values(P<0.05),lower LVEF(P<0.05),longer QRS duration of precordial leads at discharge(P<0.01),more patients with pathological Q waves in precordial leads(P<0.01),and significantly lower total R-wave amplitude in precordial leads(P<0.01),The total amplitude of precordial leads(Q wave+S wave)increased significantly(P<0.01),and the R/(S+Q)of precordial leads decreased significantly(P<0.01).The area under the curve of R/(S+Q)ratio of ECG precordial lead to evaluate the risk of mace defined in this study is 0.711,with a sensitivity of 81.8%,a specificity of 55.7%,and an optimal cutoff value of 0.51.In Group R/(S+Q)<0.51,the involvement of criminal lesions in the proximal part of the left anterior descending branch was significantly higher than that in Group R/(S+Q)≥0.51,and the proximal part of the left anterior descending branch was the main one(P<0.01);The average diameter of each stent implanted in Group R/(S+Q)<0.51 was significantly higher than that in Group R/(S+Q)≥0.51(P<0.01);During the 2-year clinical follow-up,the incidence of mace in the R/(S+Q)<0.51 group was significantly higher than that in the R/(S+Q)≥0.51 group(P<0.01);The incidence of heart failure was also significantly higher than that in the R/(S+Q)≥0.51 group(P<0.01).In the R/(S+Q)<0.51 group and the R/(S+Q)≥0.51 group,the 2-year cumulative survival rate without mace was 68.9%and 88.7%respectively(Log-rank P<0.01),and the cumulative survival rate without heart failure was 75.0%and 92.4%respectively(Log-rank,P<0.01).COX regression analysis showed that R/(S+Q)was an independent predictor of mace during the 2-year clinical follow-up(hazard ratio:0.347,95%CI:0.143~0.844,P<0.05).CONCLUSION During the 2-year clinical follow-up,the incidence of MACE in patients with R/(S+Q)<0.51 is significantly higher than that in patients with R/(S+Q)≥0.51 and R/(S+Q)is a risk factor in predicting poor outcomes in patients with acute anterior STEMI who underwent PCI.