远端缺血预处理预防急性冠状动脉综合征患者择期经皮冠状动脉介入术中无复流的临床研究

Clinical study of remote ischemic preconditioning in preventing no-reflow during elective percutaneous coronary intervention in patients with acute coronary syndrome

目的探讨远程缺血预处理(RIPC)预防急性冠状动脉综合征(ACS)患者择期经皮冠状动脉介入(PCI)术中无复流的临床价值。方法选取2019年5月至2021年5月温州市中医院收治的行择期PCI术的ACS患者160例,按照随机数字表法分为对照组和观察组各80例,分别给予现代医学常规治疗和现代医学常规治疗联合RIPC治疗。比较两组患者PCI术前及术后心肌梗死溶栓试验(TIMI)血流分级、TIMI心肌灌注分级(TMPG)、校正TIMI血流桢数(CTFC)及术中无复流、再灌注心律失常发生率,分析两组患者PCI术前及术后血清血管性血友病因子(vWF)、可溶性细胞间黏附分子-1(sICAM-1)、可溶性血管细胞黏附分子-1(sVCAM-1)、髓过氧化物酶(MPO)、超氧化物歧化酶(SOD)、左心室射血分数(LVEF)、左心室舒张末期容积(LVEDV)、左心室收缩末期容积(LVESV)变化及PCI术后出血事件和主要不良心血管事件(MACE)发生情况。结果观察组PCI术后TIMI血流分级和TMPG分级均优于对照组(χ^(2)=12.104、13.976,P<0.05)。观察组PCI术中无复流、再灌注心律失常发生率明显低于对照组(χ^(2)=5.331、6.632,P<0.05),PCI术后CTFC明显低于对照组(t=15.494,P<0.01)。两组PCI术后24 h血清vWF、sICAM-1、sVCAM-1、MPO较PCI术前明显升高(P<0.05),但对照组升高较观察组更为显著(t=3.231、4.330、2.566、4.333,P<0.05);两组PCI术后24 h血清SOD较PCI术前明显降低(P<0.05),但对照组降低较观察组更为显著(t=4.880,P<0.05)。两组PCI术后30 d LVEF较PCI术前明显升高(P<0.05),且观察组升高较对照组更为显著(t=2.587,P<0.05);两组PCI术后30 d LVEDV、LVESV较PCI术前明显降低(P<0.05),且观察组降低较对照组更为显著(t=7.294、4.049,P<0.05)。两组患者随访期间出血事件和MACE发生率无统计学差异(P>0.05)。结论ACS患者行择期PCI术前接受RIPC治疗可降低术中无复流发生率,改善心肌微血流灌注和心功能,减轻PCI术后氧化应激反应和血管内皮损伤,且并未增加短期出血事件和MACE发生率。

Objective To investigate the clinical value of remote ischemic preconditioning(RIPC)in preventing no-reflow during elective percutaneous coronary intervention(PCI)in patients with acute coronary syndrome(ACS).Methods A total of 160 ACS patients underwent elective PCI in Wenzhou Hospital of Traditional Chinese Medicine from May 2019 to May 2021 were selected.According to the random number table method,they were divided into control group and observation group(80 cases each),and given modern medical conventional treatment and modern medical conventional treatment combined with RIPC treatment,respectively.Thrombolysis in myocardial infarction(TIMI),TIMI myocardial perfusion grade(TMPG),corrected TIMI frame count(CTFC),incidence of no-reflow and reperfusion arrhythmia were compared between the two groups before and after PCI.Changes of serum levels of von Willebrand factor(vWF),soluble intercellular adhesion molecule-1(sICAM-1),soluble vascular cell adhesion molecule-1(sVCAM-1),myeloperoxidase(MPO),superoxide dismutase(SOD),left ventricular ejection fraction(LVEF),left ventricular end-diastole volume(LVEDV)and left ventricular end-systolic volume(LVESV)before and after PCI were analyzed.Bleeding events and major adverse cardiovascular events(MACE)after PCI were also analyzed.Results TIMI blood flow grading and TMPG of observation group after PCI were better than those in control group(χ^(2)=12.104,13.976;P<0.05).The incidences of no-reflow and reperfusion arrhythmia in observation group during PCI were significantly lower than those in control group(χ^(2)=5.331,6.632;P<0.05),and CTFC after PCI was significantly lower than that in control group(t=15.494,P<0.01).The serum levels of vWF,sICAM-1,sVCAM-1 and MPO in the two groups 24 h after PCI were significantly higher than those before PCI(P<0.05),but those in control group were more significantly increased than those in observation group(t=3.231,4.330,2.566,4.333;P<0.05).Serum SOD of two groups 24 h after PCI was significantly lower than those before PCI(P<0.05),but the decrease in control group was more significant than that in observation group(t=4.880,P<0.05).LVEF in both groups increased significantly 30 days after PCI(P<0.05),and the increase in observation group was more significant than that in control group(t=2.587,P<0.05).LVEDV and LVESV in both groups were significantly decreased 30 days after PCI(P<0.05),and those in observation group were more significantly decreaseed than those in control group(t=7.294,4.049;P<0.05).There was no significant difference in the incidences of bleeding events and MACE between the two groups during follow-up(P>0.05).Conclusion RIPC before elective PCI in patients with ACS can reduce the incidence of no-reflow during surgery,improve myocardial micro-perfusion and cardiac function,reduce oxidative stress response and vascular endothelial injury after PCI,and do not increase the incidences of short-term bleeding events and MACE.