远段溶栓联合经皮冠状动脉介入治疗急性ST段抬高型心肌梗死的疗效观察
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摘要
目的探讨经皮冠状动脉介入治疗(PCI)中远段溶栓与血栓抽吸对急性ST段抬高型心肌梗死(STEMI)患者心肌灌注及预后的影响。方法将96例STEMI患者(发病<6 h,血栓负荷重)分成远段溶栓组(46例)和血栓抽吸组(50例)。远段溶栓组采取治疗措施是经微导管将尿激酶原注射至闭塞段以远进行溶栓;血栓抽吸组采取措施是对闭塞血管行血栓抽吸后,再行球囊扩张或支架置入术。术后进行30 d随访。比较两组术后冠状动脉血流及心肌灌注情况,心源性死亡及严重心力衰竭发生率和左心室收缩功能变化。结果远段溶栓组TIMI血流≤Ⅱ级比例(2.2%比12.0%,P=0.008)显著低于血栓抽吸组;但TIMI血流Ⅲ级比例(97.8%比88.0%,P=0.017)、2 h心电图ST段回落>50%比例(65.2%比42.0%,P=0.019)显著高于血栓抽吸组,差异均有统计学意义。远段溶栓组左心室射血分数(LVEF)[(54.1±8.6)%比(52.8+7.3)%,P=0.047]显著高于血栓抽吸组,但左心室舒张末期内径(LVEDD)[(44.3±7.2)mm比(46.5±6.8)mm,P=0.038]、N末端B型脑钠肽前体(NT-pro BNP)水平[(117.8±71.8)μg/L比(161.2±72.3)μg/L,P=0.025]均显著低于血栓抽吸组,差异均有统计学意义。两组患者均未发生出血,且心源性死亡及严重心力衰竭发生率比较,差异均无统计学意义(均P>0.05)。结论 STEMI患者行PCI术中远段溶栓与血栓抽吸相比,可能降低慢血流/无复流发生率,改善30 d左心室收缩功能。
Objective To investigate the effects of distal thrombolysis versus thrombus aspiration on myocardial perfusion and prognosis in patients with acute ST segment elevation myocardial infarction(AMI)during emergency percutaneous coronary intervention(PCI).Methods 96 patients with acute ST segment elevation myocardial infarction(onset<6 hours)were randomly divided into thrombolysis group and distal thrombus aspiration group.Patients in the distal thrombolysis group(n =46)received transcatheter urokinase injection to the occlusive segment followed by balloon dilatation or stenting.Patients in the thrombus aspiration group(n =50)were given thrombus aspiration after balloon angioplasty or stenting.Patients were followed up for 30 days after operation.The coronary blood flow and myocardial perfusion were compared between the 2 groups.The incidence of major adverse cardiac events(MACE)and left ventricular systolic function after 30 days were compared.Results There was 1 case in the distal thrombolysis group(0.2%)and 6 case in the thrombus aspiration group(12%)presented with TIMI flow ≤ grade Ⅱ(P=0.008).A 65.2% of patients in the distal thrombolysis and 42.0% of patients in the thrombus aspiration group achieved > 50% of ST segment resolution in 2 hours(P=0.019).At 30-day follow up,the LVEF was found higher in the thrombolysis group compared with the aspiration group(54.1±8.6)% vs.(50.8±7.3)%,P =0.047 but the LVEDD(44.3±7.2)mm vs.(46.5±6.8)mm,P =0.038 and NTproBNP levels(117.8±71.8)μg/L vs.(161.2±72.3)μg/L,P =0.025 were found significantly lower in the thrombolysis group.Conclusions For the ST segment elevation myocardial infarction,distal thrombolysis,when compared with thrombus aspiration,may reduce the incidence of slow flow and no reflow,and may improve the left ventricular systolic function.
Objective To investigate the effects of distal thrombolysis versus thrombus aspiration on myocardial perfusion and prognosis in patients with acute ST segment elevation myocardial infarction(AMI)during emergency percutaneous coronary intervention(PCI).Methods 96 patients with acute ST segment elevation myocardial infarction(onset<6 hours)were randomly divided into thrombolysis group and distal thrombus aspiration group.Patients in the distal thrombolysis group(n =46)received transcatheter urokinase injection to the occlusive segment followed by balloon dilatation or stenting.Patients in the thrombus aspiration group(n =50)were given thrombus aspiration after balloon angioplasty or stenting.Patients were followed up for 30 days after operation.The coronary blood flow and myocardial perfusion were compared between the 2 groups.The incidence of major adverse cardiac events(MACE)and left ventricular systolic function after 30 days were compared.Results There was 1 case in the distal thrombolysis group(0.2%)and 6 case in the thrombus aspiration group(12%)presented with TIMI flow ≤ grade Ⅱ(P=0.008).A 65.2% of patients in the distal thrombolysis and 42.0% of patients in the thrombus aspiration group achieved > 50% of ST segment resolution in 2 hours(P=0.019).At 30-day follow up,the LVEF was found higher in the thrombolysis group compared with the aspiration group(54.1±8.6)% vs.(50.8±7.3)%,P =0.047 but the LVEDD(44.3±7.2)mm vs.(46.5±6.8)mm,P =0.038 and NTproBNP levels(117.8±71.8)μg/L vs.(161.2±72.3)μg/L,P =0.025 were found significantly lower in the thrombolysis group.Conclusions For the ST segment elevation myocardial infarction,distal thrombolysis,when compared with thrombus aspiration,may reduce the incidence of slow flow and no reflow,and may improve the left ventricular systolic function.
引文
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[2]O'Gara PT,Kushner FG,Ascheim DD,et al.2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol,2013,61(4):e78-140.
[3]Pu J,Ding S,Shan P,et al.Comparison of epicardial and myocardial perfusions after primary coronary angioplasty for STelevation myocardial infarction in patients under and over 75 years of age.Aging Clin Exp Res,2010,22(4):295-302.
[4]Roe MT,Ohman EM,Maas AC,et al.Shifting the open-artery hypothesis downstream:the quest for optimal reperfusion.J Am Coll Cardiol,2001,37(1):9-18.
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[7]Lagerqvist B,Fr?bert O,Olivecrona GK,et al.Outcomes 1 year after thrombus aspiration for myocardial infarction.N Engl J Med,2014,371(12):1111-1120.
[8]Jolly SS,Cairns JA,Yusuf S,et al.Randomized trial of primary PCI with or without routine manual thrombectomy.N Engl J Med,2015,372(15):1389-1398.
[9]田进文,彭利,刘谟焓,等.逆向精确溶栓联合支架植入术治疗急性冠状动脉闭塞病变1例.中华老年多器官疾病杂志,2013,12(8):633-635.
[10]杨跃进.冠状动脉无复流现象.内科急危重症杂志,2015,21(6):401-403.
[11]孙宇珺,周雯,丁嵩等.经靶向灌注导管在冠状动脉靶病变远段给予替罗非班对急性冠状动脉综合征患者心肌灌注的影响.中国介入心脏病学杂志,2015,23(1):5-10.
[12]Updated ESC Guidelines for managing patients with suspected nonST-elevation acute coronary syndromes.Eur Heart J,2011,32(23):2909-2910.
[13]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.急性ST段抬高型心肌梗死诊断和治疗指南.中华心血管病杂志,2015,43(5):675-690
[14]王江友,李浪.冠状动脉无复流现象防治的研究进展.中华老年心脑血管病杂志,2013,15(9):993-995.
[15]Schwartz RS,Burke A,Farb A,et al.Microemboli and microvascular obstruction in acute coronary thrombosis and sudden coronary death:relation to epicardial plaque histopathology.J Am Coll Cardiol,2009,54(23):2167-2173.
[16]Michaud K,Grabherr S,Faouzi M,et al.Pathomorphological and CT-angiographical characteristics of coronary atherosclerotic plaques in cases of sudden cardiac death.Int J Legal Med,2015,129(5):1067-1077.
[17]Ndrepepa G,Tiroch K,Fusaro M,et al.5-year prognostic value of no-reflow phenomenon after percutaneous coronary intervention in patients with acute myocardial infarction.J Am Coll Cardiol,2010,55(21):2383-2389.
[18]De Luca G,Verdoia M,Suryapranata H.Benefits from intracoronary as compared to intravenous abciximab administration for STEMI patients undergoing primary angioplasty:a meta-analysis of 8randomized trials.Atherosclerosis,2012,222(2):426-433.
[19]Choo EH,Kim PJ,Chang K,et al.The impact of no-reflow phenomena after primary percutaneous coronary intervention:a timedependent analysis of mortality.Coron Artery Dis,2014,25(5):392-398.
[20]O’Gara PT,Kushner FG,Ascheim DD,et al.2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Circulation,2013,127(4):e362–e425.
[21]Jones DA,Rathod KS,Gallagher S,et al.Manual Thrombus Aspiration Is Not Associated With Reduced Mortality in Patients Treated With Primary Percutaneous Coronary Intervention:An Observational Study of 10,929 Patients With ST-Segment Elevation Myocardial Infarction From the London Heart Attack Group.JACC Cardiovasc Interv,2015,8(4):575-584.
[2]O'Gara PT,Kushner FG,Ascheim DD,et al.2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol,2013,61(4):e78-140.
[3]Pu J,Ding S,Shan P,et al.Comparison of epicardial and myocardial perfusions after primary coronary angioplasty for STelevation myocardial infarction in patients under and over 75 years of age.Aging Clin Exp Res,2010,22(4):295-302.
[4]Roe MT,Ohman EM,Maas AC,et al.Shifting the open-artery hypothesis downstream:the quest for optimal reperfusion.J Am Coll Cardiol,2001,37(1):9-18.
[5]Ding S,Pu J,Qiao ZQ,et al.TIMI myocardial perfusion frame count:a new method to assess myocardial perfusion and its predictive value for short-term prognosis.Catheter Cardiovasc Interv,2010,75(5):722-732.
[6]Pu J,Ding S,He B.Rebuttal:TIMI myocardial perfusion frame count:an angiographic method to assess flow in the myocardium but not in the epicardial artery.Catheter Cardiovasc Interv,2010,76(7):1073-1075.
[7]Lagerqvist B,Fr?bert O,Olivecrona GK,et al.Outcomes 1 year after thrombus aspiration for myocardial infarction.N Engl J Med,2014,371(12):1111-1120.
[8]Jolly SS,Cairns JA,Yusuf S,et al.Randomized trial of primary PCI with or without routine manual thrombectomy.N Engl J Med,2015,372(15):1389-1398.
[9]田进文,彭利,刘谟焓,等.逆向精确溶栓联合支架植入术治疗急性冠状动脉闭塞病变1例.中华老年多器官疾病杂志,2013,12(8):633-635.
[10]杨跃进.冠状动脉无复流现象.内科急危重症杂志,2015,21(6):401-403.
[11]孙宇珺,周雯,丁嵩等.经靶向灌注导管在冠状动脉靶病变远段给予替罗非班对急性冠状动脉综合征患者心肌灌注的影响.中国介入心脏病学杂志,2015,23(1):5-10.
[12]Updated ESC Guidelines for managing patients with suspected nonST-elevation acute coronary syndromes.Eur Heart J,2011,32(23):2909-2910.
[13]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.急性ST段抬高型心肌梗死诊断和治疗指南.中华心血管病杂志,2015,43(5):675-690
[14]王江友,李浪.冠状动脉无复流现象防治的研究进展.中华老年心脑血管病杂志,2013,15(9):993-995.
[15]Schwartz RS,Burke A,Farb A,et al.Microemboli and microvascular obstruction in acute coronary thrombosis and sudden coronary death:relation to epicardial plaque histopathology.J Am Coll Cardiol,2009,54(23):2167-2173.
[16]Michaud K,Grabherr S,Faouzi M,et al.Pathomorphological and CT-angiographical characteristics of coronary atherosclerotic plaques in cases of sudden cardiac death.Int J Legal Med,2015,129(5):1067-1077.
[17]Ndrepepa G,Tiroch K,Fusaro M,et al.5-year prognostic value of no-reflow phenomenon after percutaneous coronary intervention in patients with acute myocardial infarction.J Am Coll Cardiol,2010,55(21):2383-2389.
[18]De Luca G,Verdoia M,Suryapranata H.Benefits from intracoronary as compared to intravenous abciximab administration for STEMI patients undergoing primary angioplasty:a meta-analysis of 8randomized trials.Atherosclerosis,2012,222(2):426-433.
[19]Choo EH,Kim PJ,Chang K,et al.The impact of no-reflow phenomena after primary percutaneous coronary intervention:a timedependent analysis of mortality.Coron Artery Dis,2014,25(5):392-398.
[20]O’Gara PT,Kushner FG,Ascheim DD,et al.2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Circulation,2013,127(4):e362–e425.
[21]Jones DA,Rathod KS,Gallagher S,et al.Manual Thrombus Aspiration Is Not Associated With Reduced Mortality in Patients Treated With Primary Percutaneous Coronary Intervention:An Observational Study of 10,929 Patients With ST-Segment Elevation Myocardial Infarction From the London Heart Attack Group.JACC Cardiovasc Interv,2015,8(4):575-584.