182例急性ST段抬高型心肌梗死患者术后30 d冠脉慢血流/无复流危险因素分析

doi:10.6040/j.issn.1671-7554.0.2019.358

摘要/Abstract

摘要： 目的研究急性ST段抬高型心肌梗死(STEMI)患者急诊经皮冠状动脉介入治疗(PCI)术后冠状动脉慢血流/无复流(SCF/NCF)现象发生的危险因素,探讨术后30 d SCF/NCF对患者的影响。方法回顾性分析STEMI并行急诊PCI的患者334例,分为SCF/NCF组(n=182)及对照组(术后冠状动脉血流速度正常患者,n=152)。应用多因素二元Logistic回归分析研究STEMI患者急诊PCI术后与SCF/NCF现象发生有关联的危险因素,并于术后30 d内对所有患者进行随访,分析两组主要心脏不良事件(MACE)、再发心肌梗死、心源性死亡、全因死亡、支架内血栓的发生情况。结果 (1)两组患者间差异存在统计学意义的因素包括:血肌酐值升高(P=0.034,OR=1.009,95%CI:1.001~1.017),预扩后高TIMI帧数(P=0.025,OR=1.038,95%CI:1.005~1.072),高支架最大释放压(P=0.006,OR=1.525,95%CI:1.130~2.060),高血栓积分(P=0.030,OR=1.324,95%CI:1.028~1.705)是SCF/NCF发生的危险因素;靶血管为非RCA(P<0.001,OR=0.071,95%CI:0.025~0.200),高预扩囊最大扩张压(P=0.033,OR=0.864,95%CI:0.755~0.989),术中应用硝普钠(P=0.006,OR=0.126,95%CI:0.029~0.548)及IIb/IIIa受体拮抗剂(P=0.043,OR=0.438,95%CI:0.197~0.974)是SCF/NCF发生的保护性因素;其中靶血管为非RCA及术中应用硝普钠为减低SCF/NCF现象发生的主要保护性因素。(2)术后30 d内随访表明,两组患者MACE(14例 vs 8例, χ²=0.753,P=0.385)、心源性死亡(12例 vs 8例,χ²=0.243,P=0.622)、全因死亡(12例 vs 8例, χ²=0.243,P=0.622)、支架内血栓(2例 vs 0例, χ²=1.675,P=0.196)的发生情况无统计学意义;而SCF/NCF组再发心肌梗死的发生率高于对照组(6例 vs 0例, χ²=5.087,P=0.024)。(3)导致两组患者死亡的原因包括心源性休克、支架内血栓、心脏破裂、急性心力衰竭,其中心源性休克是导致STEMI患者死亡的首位原因(占比70%)。结论血肌酐值升高、预扩后高TIMI帧数、高支架最大释放压、高血栓积分与SCF/NCF的发生有统计学意义的正向关联,靶血管为非RCA、高预扩球囊最大扩张压、术中使用硝普钠以及IIb/IIIa受体拮抗剂与SCF/NCF的发生有统计学意义的负向关联。随访发现SCF/NCF组再发心肌梗死的发生率高于对照组。

关键词: 急性ST段抬高型心肌梗死, 急诊经皮冠状动脉介入治疗, 冠状动脉慢血流, 冠状动脉无复流, 危险因素, 随访

Abstract: Objective To study the risk factors of slow coronary flow/ no coronary flow(SCF/NCF)after the emergency percutaneous coronary intervention(PCI)in the patients with acute ST-segment elevation myocardial infarction 山东大学学报 (医学版)57卷11期 -张伟,等.182例急性ST段抬高型心肌梗死患者术后30 d冠脉慢血流/无复流危险因素分析 \=-(STEMI), and to explore the influences of SCF/NCF on the patients 30 days after the emergency PCI. Methods A total of 334 patients with STEMI and emergency PCI were analyzed retrospectively. They were divided into the SCF/NCF group(n=182)and control group(the patients with normal coronary flow after PCI,n=152). The multivariate Logistic regression analysis was used to study the risk factors correlated with SCF/NCF after emergency PCI. The follow-up was made to explore the incidence of major adverse cardiac events(MACE), myocardial re-infarction, cardiac death, all-cause death and instent thrombosis between the two groups 30 days after PCI. Results (1) The factors with statistical differences between the two groups showed that the elevation of serum creatinine(P=0.034, OR=1.009, 95%CI: 1.001-1.017), high TIMI frame counts after pre-dilation(P=0.025, OR=1.038, 95%CI: 1.005-1.072), the high maximum stent release pressure(P=0.006, OR=1.525, 95%CI: 1.130-2.060), the high thrombus score(P=0.030, OR=1.324, 95%CI: 1.028-1.705)were the risk factors of SCF/NCF phenomenon. Non-right coronary artery as the target vessel(P<0.001, OR=0.071, 95%CI: 0.025-0.200), the high maximum pre-dilation pressure(P=0.033, OR=0.864, 95%CI: 0.755-0.989), the usage of sodium nitroprusside(P=0.006, OR=0.126, 95%CI: 0.029-0.548)and IIb/IIIa receptor antagonist(P=0.043, OR=0.438, 95%CI: 0.197-0.974)during the procedure were the protection factors of the SCF/NCF phenomenon. Among these protection factors, non-right coronary artery as the target vessel and the usage of sodium nitroprusside were dominant. (2) After 30 days of the follow-up, there were no significant differences in the incidence of MACE(14 vs 8 cases, χ²=0.753, P=0.385), cardiac death(12 vs 8 cases, χ²=0.243, P=0.622), all-cause death(12 vs 8 cases, χ²=0.243,P=0.622)and in-stent thrombosis(2 vs 0 cases, χ²=1.675, P=0.196)between the two groups. Compared with the control group, the incidence of myocardial re-infarction in SCF/NCF group was higher(6 vs 0 cases, χ²=5.087, P=0.024). (3) The causes of death were cardiac shock, in-stent thrombosis, cardiac rupture and acute heart failure. Cardiac shock is the first cause of death which accounts for 70%. Conclusion The elevation of serum creatinine, high TIMI frame count after pre-dilation, the high maximum stent release pressure and the high thrombus score are positivly correlated to the SCF/NCF phenomenon. Non-right coronary artery as the target vessel, the high maximum pre-dilation pressure, the usage of sodium nitroprusside and IIb/IIIa receptor antagonist during the procedure are negativly correlated to the SCF/NCF phenomenon. The incidence of myocardial re-infarction in the SCF/NCF group was higher than that in the control group.

Key words: Acute ST-segment elevation myocardial infarction, Emergency percutaneous coronary intervention, Slow coronary flow, No coronary flow, Risk factors, Follow-up

中图分类号:

R543.3

张伟,赵红艳,杜凤立,苏国英. 182例急性ST段抬高型心肌梗死患者术后30 d冠脉慢血流/无复流危险因素分析[J]. 山东大学学报 (医学版), 2019, 57(11): 9-15.

ZHANG Wei, ZHAO Hongyan, DU Fengli, SU Guoying. Risk factors of slow or no coronary flow in 182 patients with acute ST-segment elevation myocardial infarction 30 days after operation[J]. Journal of Shandong University (Health Sciences), 2019, 57(11): 9-15.

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