急性ST段抬高型心肌梗死患者经皮冠状动脉介入治疗后冠状动脉微循环障碍的危险因素分析

Risk factors of coronary microvascular dysfunction after percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction

目的观察急性ST段抬高型心肌梗死(STEMI)患者经皮冠状动脉介入治疗(PCI)术后冠状动脉微循环障碍(CMD)发生情况,探讨CMD发生的危险因素。方法2019年5月—2022年5月新乡市中心医院诊治急性STEMI患者180例,均于PCI术后24h行超声心动图检查,记录心肌灌注评分,判定CMD发生情况。180例患者根据是否发生CMD分为CMD组102例和无CMD组78例,比较2组年龄、高血压史等临床资料、实验室指标、Killip分级、病变分支、症状至首次医疗接触(FMC)时间、FMC至肝素(FMC-H)时间、冠状动脉慢血流、血栓抽吸、球囊后扩张情况。采用多因素logistic回归分析急性STEMI患者PCI术后发生CMD的危险因素。2组分别于术后24h、6个月、12个月行超声心动图检查测量左室射血分数、左心室舒张末期内径。术后随访12个月,记录2组主要心血管不良事件(MACE)发生情况。结果CMD组年龄≥65岁、有高血压史、症状至FMC时间>4h、FMC-H时间>4h、冠状动脉慢血流比率(63.73%、60.78%、65.69%、69.61%、53.92%)均高于无CMD组(41.03%、32.05%、38.46%、41.03%、38.46%)(P<0.05)。年龄≥65岁(OR=3.190,95%CI:1.788~5.690,P<0.001)、高血压史(OR=4.382,95%CI:2.511~7.648,P<0.001)、症状至FMC时间>4h(OR=4.274,95%CI:2.196~8.320,P<0.001)、FMC-H时间>4h(OR=4.600,95%CI:2.749~7.699,P<0.001)、冠状动脉慢血流(OR=5.734,95%CI:3.571~9.206,P<0.001)是急性STEMI患者PCI术后发生CMD的危险因素。CMD组术后24h、6个月、12个月左室射血分数[(44.59±5.68)%、(49.60±5.33)%、(43.15±6.02)%]均低于无CMD组[(50.89±7.12)%、(54.26±5.49)%、(56.03±6.57)%](P<0.05),左心室舒张末期内径[(50.19±4.81)、(51.24±5.39)、(53.47±5.44)mm]均大于无CMD组[(47.52±4.03)、(48.02±3.57)、(49.83±3.51)mm](P<0.05)。术后12个月,CMD组MACE发生率(22.55%)高于无CMD组(6.41%)(χ^(2)=8.764,P=0.003)。结论年龄≥65岁、有高血压史、症状至FMC时间>4h、FMC-H时间>4h、冠状动脉慢血流的急性STEMI患者PCI术后易发生CMD,发生CMD的急性STEMI患者心功能恢复较差,发生MACE风险增高。

Objective To observe the occurrence of coronary microvascular dysfunction(CMD)in patients with acute ST-segment elevation myocardial infarction(STEMI)after percutaneous coronary intervention(PCI)and to explore the risk factors of CMD.Methods Totally 180 patients with acute STEMI were diagnosed and treated in Xinxiang Central Hospital from May 2019 to May 2022.and all of them were performed PCI.The myocardial perfusion score was recorded by echocardiography 24 h after operation to predict the occurrence of CMD.According to the occurrence of CMD,180patients were divided into CMD group(n=102)and no-CMD group(n=78).The clinical data such as age and hypertension history,laboratory indexes,Killip grade,diseased vessel,time of symptom onset to first medical contact(FMC),time of FMC to heparin administration(FMC-H),slow coronary blood flow,thrombus aspiration,and balloon post-dilatation were compared between two groups.Multivariate logistic regression was used to analyze the risk factors of CMD after PCI in acute STEMI patients.Echocardiography was performed in two groups in 24 h,6 months and 12months postoperatively to measure the left ventricular ejection fraction(LVEF)and left ventricular end-diastolic dimension(LVEDD).The patients were followed up for 12 months after operation to record the occurrence of major adverse cardiovascular event(MACE).Results The percentages of patients with age≥65 years,hypertension history,time of symptom onset to FMC>4h,time of FMC-H≤4 h and slow coronary flow were higher in CMD group(63.73%,60.78%,65.69%,69.61%,53.92%)than those in no-CMD group(41.03%,32.05%,38.46%,41.03%,38.46%)(P<0.05).Age≥65 years(OR=3.190,95%CI:1.788-5.690,P<0.001),hypertension history(OR=4.382,95%CI:2.511-7.648,P<0.001),time of symptom onset to FMC>4h(OR=4.274,95%CI:2.196-8.320,P<0.001),time of FMC-H>4 h(OR=4.600,95%CI:2.749-7.699,P<0.001),and slow coronary flow(OR=5.734,95%CI:3.571-9.206,P<0.001)were the risk factors of CMD after PCI in STEMI patients.In24 h,6 months and 12 months postoperatively,the LVEFs were lower in CMD group[(44.59±5.68)%,(49.60±5.33)%,(43.15±6.02)%]than those in no-CMD group[(50.89±7.12)%,(54.26±5.49)%,(56.03±6.57)%](P<0.05),and the LVEDDs were longer in CMD group[(50.19±4.81),(51.24±5.39),(53.47±5.44)mm]than those in no-CMD group[(47.52±4.03),(48.02±3.57),(49.83±3.51)mm](P<0.05).The incidence of MACE was higher in CMD group(22.55%)than that in no-CMD group(6.41%)12 months after operation(χ^(2)=8.764,P=0.003).Conclusion The acute STEMI patients with age≥65 years,history of hypertension,time of symptom onset to FMC>4 h,time of FMC-H>4 h and slow coronary blood flow are prone to develop CMD after PCI,and acute STEMI patients with CMD after PCI have poor recovery of cardiac function and high risk of MACE.