急性ST段抬高型心肌梗死患者早期左心室血栓形成的临床特征及转归分析

The clinical characteristics and outcome analysis of early left ventricular thrombosis in patients with acute ST-segment elevation myocardial infarction

[目的]探讨急性ST段抬高型心肌梗死(STEMI)患者早期左心室血栓形成(LVT)的临床特征、转归及相关影响因素。[方法]采用回顾性分析,于2019年1月—2021年12月在中国医学科学院阜外医院深圳医院心血管内科住院的急性前壁心肌梗死患者297例,其中,53例出现早期LVT的患者作为STEMI+LVT组,244例未出现LVT的患者作为STEMI组。收集并比较两组患者基本临床资料、发生栓塞事件、超声心动图和心脏磁共振成像资料、LVT的心室内形态学特点、冠状动脉造影及介入治疗和用药方案;采用多因素Logistic回归分析急性STEMI患者早期LVT的相关因素。[结果]两组患者在年龄、高血压、糖尿病、吸烟、多支病变、高敏C反应蛋白(hs-CRP)、血肌酐(SCr)、总胆固醇(TC)、甘油三酯(TG)、氨基末端脑钠肽前体(NT-proBNP)、抗血小板治疗比例差异均无统计学意义(P>0.05);STEMI+LVT组既往心肌梗死史、早期室壁瘤形成、合并休克(SCAI分类法)、主动脉内球囊反搏(IABP)或叶克膜(ECMO)支持率高于STEMI组(P<0.05)。STEMI+LVT组左心室舒张期末内径(LVEDD)、左心室收缩期末内径(LVESD)高于STEMI组,左心室射血分数(LVEF)显著低于STEMI组(P<0.05)。多因素Logistic回归分析显示,既往心肌梗死史(OR=3.376,95%CI:1.069~10.592,P=0.036)、早期室壁瘤形成(OR=3.020,95%CI:1.025~8.864,P=0.047)、合并休克(OR=3.321,95%CI:1.215~9.031,P=0.017)与急性STEMI患者早期LVT发生风险增加相关,而LVEF>40%(OR=0.193,95%CI:0.054~0.669,P=0.011)、急诊PCI(OR=0.254,95%CI:0.089~0.678,P=0.008)与急性STEMI患者早期LVT发生风险降低相关。[结论]急性STEMI患者早期LVT多见于左心室心尖部,合并休克、既往心肌梗死病史、早期室壁瘤、急诊PCI、基线LVEF>40%可能是STEMI患者早期LVT的独立影响因素。

Aim To investigate clinical characteristics,outcome analysis and related factors of early left ventricular thrombosis(LVT)in patients with acute ST-segment elevation myocardial infarction(STEMI).Methods With a retrospective study,from January 2019 to December 2021,297 patients with acute anterior wall myocardial infarction were enrolled in the Cardiovascular Department of Shenzhen Hospital,Fuwai Hospital,Chinese Academy of Medical Sciences.Among them,53 patients with early LVT were selected as the STEMI+LVT group,and 244 patients without LVT were selected as the STEMI group.Collect and compare basic clinical data,occurrence of embolic events,echocardiography and cardiac magnetic resonance imaging data,ventricular morphological characteristics of LVT,coronary angiography,interventional therapy,and medication plans between two groups of patients.Multivariate Logistic regression analysis was used to investigate the related factors of early LVT formation in acute STEMI patients.Results There was no significant difference between the two groups in age,hypertension,diabetes,smoking,multi vessel disease,high sensitivity C-reactive protein(hs-CRP),serum creatinine(SCr),total cholesterol(TC),triglyceride(TG),N-terminal pro-brain natriuretic peptide(NT-proBNP),and the proportion of patients receiving antiplatelet therapy(P>0.05).The STEMI+LVT group had a history of previous myocardial infarction,early ventricular aneurysm formation,concomitant shock(SCAI classification),and higher support rates for intra-aortic balloon pump(IABP)or extracorporeal membrane oxygenation(ECMO)compared to the STEMI group(P<0.05).Left ventricular end-diastolic diameter(LVEDD)and left ventricular end-systolic diameter(LVESD)in the STEMI+LVT group were higher than those in the STEMI group,LVEF in the STEMI+LVT group was obviously lower than that in the STEMI group(P<0.05).Multivariate Logistic regression analysis showed that a history of previous myocardial infarction(OR=3.376,95%CI:1.069~10.592,P=0.036),early ventricular aneurysm formation(OR=3.020,95%CI:1.025~8.864,P=0.047),and concomitant shock(OR=3.321,95%CI:1.215~9.031,P=0.017)were associated with an increased risk of early LVT formation in acute STEMI,while LVEF>40%(OR=0.193,95%CI:0.054~0.669,P=0.011)and emergency PCI(OR=0.254,95%CI:0.089~0.678,P=0.008)were associated with a reduced risk of early LVT formation in STEMI.Conclusion Early LVT formation in acute STEMI patients is more common in the left ventricular apex,the combination of shock,previous history of myocardial infarction,early ventricular aneurysm,emergency PCI and baseline LVEF>40%may be independent influencing factors for early LVT formation in acute STEMI patients.