提前肝素化对ST段抬高型心肌梗死患者冠状动脉血流的影响及时间依赖性

Effect of advanced heparinization on coronary blood flow in patients with ST-segment elevation myocardial infarction and its time dependence

目的探讨提前肝素化对ST段抬高型心肌梗死(STEMI)患者急诊经皮冠状动脉介入(PCI)治疗前梗死相关血管(IRA)血流的影响及其时间依赖性。方法选取发病12 h内的接受急诊PCI的STEMI患者376例,随机分为试验组(n=181)和对照组(n=195)。试验组患者确诊后立即静脉推注普通肝素(UFH)60 U/kg,最大剂量5000U。对照组患者穿刺成功后动脉内应用UFH 2000U。两组患者PCI前均补充至(80~100)U/kg。比较两组患者PCI前IRA血流情况及PCI后慢血流、院内死亡、心力衰竭、出血的比例与住院时间。分析症状出现至UFH给药时间与UFH给药至冠脉造影时间对IRA再通的影响。结果试验组患者PCI前IRA再通比例高于对照组,血栓抽吸、住院时间低于对照组,差异有统计学意义(均P<0.05);PCI前冠脉内可见血栓、PCI后慢血流,院内心衰、出血及死亡的比例差异无统计学意义。提前肝素化与PCI前IRA再通呈正相关(OR=1.819,95%CI:1.166~2.837,P<0.01)。在试验组和对照组患者中,症状出现至UFH给药时间和IRA再通之间存在时间依赖性(<3 h:50.0%vs.29.2%,P<0.05;其余时段无统计学差异),与PCI前IRA再通负相关(OR=0.945,95%CI:0.816~0.986,P<0.05)。在试验组患者中,UFH给药至冠脉造影时间>30 min的患者PCI前IRA再通比例较高,差异有统计学意义(P<0.05),与PCI前IRA再通呈正相关(OR=2.610,95%CI:1.153~5.911,P<0.05)。结论提前肝素化能提高STEMI患者急诊PCI前IRA再通比例,改善患者预后,且不增加出血风险。症状出现后越早给予UFH,改善IRA再通的作用越强。确诊后立即应用UFH可作为无UFH禁忌症的STEMI患者PCI的辅助抗凝方案。

AIM To investigate the effect of advanced heparinization on infarct-related vessel(IRA)blood flow before emergency percutaneous coronary intervention(PCI)in patients with ST-segment elevation myocardial infarction(STEMI)and its time dependence.METHODS A total of 376 STEMI patients who received emergency PCI within 12 hours after onset were randomly divided into experimental group(n=181)and control group(n=195).The experimental group received intravenous injection of unfractionated heparin(UFH)60 U/kg immediately after diagnosis,with a maximum dose of 5000 U.In the control group,UFH2000 U was used in the artery after successful puncture.Both groups were supplemented to 80~100 U/kg before PCI.The blood flow of IRA before PCI,the proportion of slow blood flow,hospital death,heart failure,bleeding and hospital stay after PCI were compared between the two groups.The effect-s of symptom onset to UFH administration time and UFH administration to coronary angiography time on IRA recanalization were analyzed.RESULT The recanalization rate of IRA before PCI in the experiment-al group was higher than that in the control group,while the thrombus aspiration and hospital stay in t-he experimental group were significantly lower than those in the control group(P<0.05).The proportion of visible intracoronary thrombus before PCI,slow flow after PCI,inhospital heart failure,bleeding and death was lower in the experimental group than in the control group,and the difference was not statistically significant.Advanced heparinization was positively correlated with IRA recanalization before PCI(OR=1.819,95%CI 1.166~2.837,P<0.05).In the experimental group and the control group,there was a time dependence between symptoms onset to UFH administration time and IRA recanalization(<3 hours:50.0%vs.29.2%,P<0.05),symptoms onset to UFH administration time negatively correlated with IRA recanalization before PCI(OR=0.945,95%CI 0.816~0.986,P<0.05).In the experimental group,the proportion of IRA recanalization before PCI was higher in t-he patients whose time from UFH administration to coronary angiography was more than 30 minutes,and the difference was statistically significant(P<0.05),the time from UFH administration to coronary angiography more than 30 minutes was positively correlated with IRA recanalization before PCI(OR=2.610,95%CI 1.153~5.911,P<0.05).CONCLUSION Advanced heparinization increases the recanalization rate of IRA before emergency PCI in STEMI patients,improves the prognosis,and do not increases the risk of bleeding.The earlier UFH is given after the onset of symptoms,the stronger the effect of improving IRA recanalization is.The use of UFH immediately after diagnosis can be used as an auxiliary anticoagulant regimen for PCI in STEMI patients without UFH contraindications.