胸痛中心模式下急性ST段抬高型心肌梗死救治现状研究
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摘要
目的:了解现有胸痛中心模式下急性ST段抬高型心肌梗死(STEMI)的救治情况和患者预后,为胸痛中心建设提供循证依据,进一步完善救治策略。方法:入选2016-09-2018-09来我院行急诊经皮冠状动脉介入治疗(PCI)的STEMI患者458例,根据入院时间将患者分为A、B、C、D组,比较各组发病-球囊扩张(S2B)时间、发病-首次医疗接触(S2FMC)时间、首次医疗接触-球囊扩张(FMC2B)时间、入门-球囊扩张(D2B)时间、心功能>Ⅱ级、院内病死率及院内不良心脑血管事件(MACCE)发生率。分析S2FMC时间、FMC2B时间与S2B时间的相关性。结果:所有入选患者中位S2B时间、S2FMC时间、D2B时间、FMC2B时间分别为206、87、54、93 min。通过胸痛中心认证后,中位D2B时间明显缩短(64 min∶51 min,P<0.01)。两年间中位S2B、S2FMC、FMC2B时间变化不显著(P>0.05)。心功能>Ⅱ级7.2%,院内病死率5.9%,院内MACCE发生率7.0%,两年间院内病死率及MACCE发生率均有下降趋势(P>0.05)。相关性分析显示,与FMC2B时间相比,S2FMC时间与S2B时间相关性更强(r:0.810∶0.477,P<0.001);进一步分析发现,自行来院、呼叫120及网络医院转运患者S2FMC时间与S2B时间均存在更强相关性(P<0.001)。结论:胸痛中心模式的运行缩短了D2B时间,但未明显减少患者S2B、S2FMC、FMC2B时间以及院内事件发生。因此缩短总缺血时间尤其是患者延误时间是改进的方向。
Objective:To investigate the treatment and prognosis status of patients with acute ST segment elevation myocardial infarction(STEMI) under chest pain center mode,providing a evidence-based basis for the chest pain center construction to improve treatment strategies.Method:From September 2016 to September 2018,458 patients with STEMI undergoing emergency PCI in our hospital were enrolled and divided into four groups according to the admission time.Symptom-to-balloon(S2 B) time,symptom-to-first medical contact(S2 FMC) time,first medical contact-to-balloon(FMC2 B) time,door-to-balloon(D2 B) time,cardiac function grade >Ⅱ,in-hospital mortality and major adverse cardiac-cerebral event(MACCE) were compared among four groups.The correlation between S2 FMC time,FMC2 B time and S2 B time were analyzed.Result:The median S2 B time,S2 FMC time,D2 B time and FMC2 B time were 206,87,54 and 93 min,respectively.The median D2 B time was significantly shortened after chest pain accreditation(64 min vs.51 min,P<0.01).There was no significant change in median S2 B,FMC2 B and S2 FMC time in two years(P>0.05).Cardiac function grade >Ⅱ was 7.2%,in-hospital mortality was 5.9% and MACCE was 7.0% in all patients.The mortality and MACCE decreased in two years(P>0.05).Correlation analysis showed that the correlation between S2 FMC time and S2 B time was stronger than that of FMC2 B time(r:0.810 vs.0.477,P<0.001).There was a stronger correlation between S2 FMC time and S2 B time even in different patients' referral(P<0.001).Conclusion:The chest pain center model could shorten D2 B time,but doesn't significantly reduce S2 B,S2 FMC,FMC2 B time and in-hospital events.Therefore,shortening the total ischemic time especially patient delay is the further work.
Objective:To investigate the treatment and prognosis status of patients with acute ST segment elevation myocardial infarction(STEMI) under chest pain center mode,providing a evidence-based basis for the chest pain center construction to improve treatment strategies.Method:From September 2016 to September 2018,458 patients with STEMI undergoing emergency PCI in our hospital were enrolled and divided into four groups according to the admission time.Symptom-to-balloon(S2 B) time,symptom-to-first medical contact(S2 FMC) time,first medical contact-to-balloon(FMC2 B) time,door-to-balloon(D2 B) time,cardiac function grade >Ⅱ,in-hospital mortality and major adverse cardiac-cerebral event(MACCE) were compared among four groups.The correlation between S2 FMC time,FMC2 B time and S2 B time were analyzed.Result:The median S2 B time,S2 FMC time,D2 B time and FMC2 B time were 206,87,54 and 93 min,respectively.The median D2 B time was significantly shortened after chest pain accreditation(64 min vs.51 min,P<0.01).There was no significant change in median S2 B,FMC2 B and S2 FMC time in two years(P>0.05).Cardiac function grade >Ⅱ was 7.2%,in-hospital mortality was 5.9% and MACCE was 7.0% in all patients.The mortality and MACCE decreased in two years(P>0.05).Correlation analysis showed that the correlation between S2 FMC time and S2 B time was stronger than that of FMC2 B time(r:0.810 vs.0.477,P<0.001).There was a stronger correlation between S2 FMC time and S2 B time even in different patients' referral(P<0.001).Conclusion:The chest pain center model could shorten D2 B time,but doesn't significantly reduce S2 B,S2 FMC,FMC2 B time and in-hospital events.Therefore,shortening the total ischemic time especially patient delay is the further work.
引文
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[8] Solhpour A,Chang KW,Arain SA,et al.Ischemic time is a better predictor than door-to-balloon time for mortality and infarct size in ST-elevation myocardial infarction[J].Catheter Cardiovasc Interv,2016,87(7):1194-1200.
[9] 宋毓青,王楠,王昭,等.胸痛中心持续改进对急性ST段抬高型心肌梗死患者诊疗效果的影响及存在问题分析[J].中国介入心脏病学杂志,2018,26(7):372-376.
[10] Margolis G,Letourneau-Shesaf S,Khoury S,et al.Trends and predictors of prehospital delay in patients undergoing primary coronary intervention[J].Coron Artery Dis,2018,29(5):373-377.
[11] Song F,Yu M,Yang J,er al.Symptom-onset-to-balloon time,ST-segment resolution and in-hospital mortality in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention in china:from china acute myocardial infarction registry[J].Am J Cardiol,2016,118(9):1334-1339.
[2] Ndrepepa G.Improving myocardial injury,infarct size,and myocardial salvage in the era of primary PCI for STEMI[J].Coron Artery Dis,2015,26(4):341-355.
[3] 向定成,秦伟毅,周民伟.胸痛中心建设规范与实践[M].北京:人民军医出版社.2013:
[4] 陈伟伟,高润霖,刘力生,等.《中国心血管病报告2017》概要[J].中国循环杂志,2018,33(1):1-8.
[5] Menees DS,Peterson ED,Wang Y,et al.Door-to-balloon time and mortality among patients undergoing primary PCI[J].N Engl J Med,2013,369(10):901-909.
[6] Sung PH.Minimizing door-to-balloon time is not the most critical factor in improving clinical outcome of ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention[J].Crit Care Med,2014,42(8):1788-1796.
[7] Nallamothu BK,Normand SL,Wang Y,et al.Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time:a retrospective study[J].Lancet,2015,385(9973):1114-1122.
[8] Solhpour A,Chang KW,Arain SA,et al.Ischemic time is a better predictor than door-to-balloon time for mortality and infarct size in ST-elevation myocardial infarction[J].Catheter Cardiovasc Interv,2016,87(7):1194-1200.
[9] 宋毓青,王楠,王昭,等.胸痛中心持续改进对急性ST段抬高型心肌梗死患者诊疗效果的影响及存在问题分析[J].中国介入心脏病学杂志,2018,26(7):372-376.
[10] Margolis G,Letourneau-Shesaf S,Khoury S,et al.Trends and predictors of prehospital delay in patients undergoing primary coronary intervention[J].Coron Artery Dis,2018,29(5):373-377.
[11] Song F,Yu M,Yang J,er al.Symptom-onset-to-balloon time,ST-segment resolution and in-hospital mortality in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention in china:from china acute myocardial infarction registry[J].Am J Cardiol,2016,118(9):1334-1339.