血栓抽吸治疗在ST段抬高型心肌梗死患者中的临床疗效分析
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摘要
目的探讨ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)患者行经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗中应用血栓抽吸的临床疗效。方法回顾性分析2014年1月至2016年12月因STEMI于广州医科大学附属第三医院行PCI治疗的217例患者的一般临床资料。根据PCI治疗中有无行血栓抽吸术分为血栓抽吸+PCI治疗组(A组,n=76,35%)和单纯PCI治疗组(B组,n=141,65%)。收集两组患者的年龄、性别、糖尿病、原发性高血压(高血压)、胆固醇、低密度脂蛋白胆固醇、三酰甘油、有无吸烟及酗酒史等一般资料。记录患者梗死相关动脉(IRA),病变血管数量等手术相关资料,术后心肌再灌注情况及住院期间主要不良心血管事件发生情况。结果血栓抽吸组术后2 h心电图ST段回落大于70%的患者比例明显高于单纯PCI治疗组,差异有统计学意义[81.58%(62/76)vs. 68.09%(96/141),P=0.033]。术后1周血栓抽吸组患者左心室射血分数(left ventricular ejection fraction,LVEF)高于单纯PCI治疗组,差异有统计学意义[59.56%±7.16%vs. 57.26%±8.55%,P=0.013]。住院期间两组患者主要心血管不良事件发生率比较,差异无统计学意义[22.37%(17/76)vs. 23.40%(33/4141),P>0.05]。亚组分析:在年龄<65岁亚组比较,血栓抽吸组术后1周LVEF较单纯PCI组升高,差异有统计学意义[60.17%±5.89%vs. 58.39%±8.49%,P=0.003];而在年龄≥65岁亚组比较,两组患者术后主要不良心血管事件发生率比较,差异无统计学意义[30.77%(8/26)vs. 41.67%(20/48),P=0.356]。结论急诊PCI治疗时应用血栓抽吸治疗可改善STEMI患者术后微循环的再灌注情况,且有助于住院期间心功能的恢复,但对于近期主要不良心血管事件的发生率无明显改善;对于青中年的STEMI患者行PCI治疗时应用血栓抽吸治疗有助于改善患者近期的心脏功能。
Objectives To evaluate the clinical efficacy of thrombus aspiration in patients with ST-segment elevation myocardial infarction(STEMI)during percutaneous coronary intervention(PCI). Methods Clinical characteristics of 217 patients with STEMI undergoing PCI in the Third Affiliated Hospital of Guangzhou Medical University from January2014 to December 2016 were retrospectively analyzed. According to whether undergoing thrombus aspiration treatment during the course of PCI,patients were divided into thrombus aspiration group(n=76,35%)and PCI alone group(n=141,65%). We collected the general information such as age,sex,diabetes,hypertension,the surgical data such as infarct-related artery(IRA),number of diseased blood vessels,postoperative myocardial reperfusion and hospitalization events,incidence of major adverse cardiovascular events(MACE) during hospitalization. Results The patients percentage of ST-segment resolution(STR)≥70% in 2 hours after thrombectomy was significantly higher in thrombus aspiration group than that in PCI alone group[81.58%(62/76)vs. 68.09%(96/141),P=0.033]. Left ventricular ejection fraction(LVEF)in thrombus aspiration group was higher than that in PCI alone group one week after PCI[59.56%±7.16% vs. 57.26%±8.55%,P=0.013]. There was no significant difference in incidence of MACE between the two groups during hospitalization[22.37%(17/76)vs. 23.40%(33/4141),P>0.05]. In the subgroups of aged <65 years old,LVEF one week after thrombus aspiration was significantly higher in thrombus aspiration group than that in PCI alone group[60.17%±5.89% vs. 58.39%±8.49%,P=0.003]. While in the subgroup of patients aged ≥ 65 years,there was no significant difference in incidence of MACE between the two groups[30.77%(8/26)vs. 41.67%(20/48),P=0.356]. Conclusions The application of thrombus aspiration therapy in primary PCI can improve the microcirculatory reperfusion after STEMI and contribute to the recovery of heart function during hospitalization,but there is no significant improvement in the incidence of short-term MACE. And the use of thrombus aspiration for PCI in STEMI patients in young and middle-aged patients can improve the patients′ short-term cardiac function.
Objectives To evaluate the clinical efficacy of thrombus aspiration in patients with ST-segment elevation myocardial infarction(STEMI)during percutaneous coronary intervention(PCI). Methods Clinical characteristics of 217 patients with STEMI undergoing PCI in the Third Affiliated Hospital of Guangzhou Medical University from January2014 to December 2016 were retrospectively analyzed. According to whether undergoing thrombus aspiration treatment during the course of PCI,patients were divided into thrombus aspiration group(n=76,35%)and PCI alone group(n=141,65%). We collected the general information such as age,sex,diabetes,hypertension,the surgical data such as infarct-related artery(IRA),number of diseased blood vessels,postoperative myocardial reperfusion and hospitalization events,incidence of major adverse cardiovascular events(MACE) during hospitalization. Results The patients percentage of ST-segment resolution(STR)≥70% in 2 hours after thrombectomy was significantly higher in thrombus aspiration group than that in PCI alone group[81.58%(62/76)vs. 68.09%(96/141),P=0.033]. Left ventricular ejection fraction(LVEF)in thrombus aspiration group was higher than that in PCI alone group one week after PCI[59.56%±7.16% vs. 57.26%±8.55%,P=0.013]. There was no significant difference in incidence of MACE between the two groups during hospitalization[22.37%(17/76)vs. 23.40%(33/4141),P>0.05]. In the subgroups of aged <65 years old,LVEF one week after thrombus aspiration was significantly higher in thrombus aspiration group than that in PCI alone group[60.17%±5.89% vs. 58.39%±8.49%,P=0.003]. While in the subgroup of patients aged ≥ 65 years,there was no significant difference in incidence of MACE between the two groups[30.77%(8/26)vs. 41.67%(20/48),P=0.356]. Conclusions The application of thrombus aspiration therapy in primary PCI can improve the microcirculatory reperfusion after STEMI and contribute to the recovery of heart function during hospitalization,but there is no significant improvement in the incidence of short-term MACE. And the use of thrombus aspiration for PCI in STEMI patients in young and middle-aged patients can improve the patients′ short-term cardiac function.
引文
[1]葛均波,徐永健.内科学[M]. 8版.人民卫生出版社,2013.
[2] HENRIQUES J P S,ZIJLSTRA F,OTTERVANGER J P,et al. Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction[J].Eur Heart J,2002,23(14):1112.
[3]金玫.急性ST段抬高型心肌梗死诊断和治疗指南[J].中华心血管病杂志,2015,43(5):675-690.
[4] THIELE H,DESCH S,DE WAHA S.[Acute myocardial infarction in patients with ST-segment elevation myocardial infarction:ESC guidelines 2017][J]. Herz,2017,42(8):728-738.
[5]中华医学会心血管病学分会介入心脏病学组.中国经皮冠状动脉介入治疗指南(2016)[J].中华心血管病杂志,2016,44(5):382-400.
[6] MAGRO M,SPRINGELING T,VAN GEUNS R J,et al.Myocardial‘no-reflow’prevention[J]. Curr Vasc Pharmacol,2013,11(2):263-277.
[7] BURZOTTA F,TRANI C,ROMAGNOLI E,et al. Manual thrombus-aspiration improves myocardial reperfusion:the randomized evaluation of the effect of mechanical reduction of distal embolization by thrombus-aspiration in primary and rescue angioplasty(REMEDIA)trial[J]. J Am Coll Cardiol,2005,46(2):371-376.
[8] DE LUCA G,DUDEK D,SARDELLA G,et al. Adjunctive manual thrombectomy improves myocardial perfusion and mortality in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction:a metaanalysis of randomized trials[J]. Eur Heart J,2008,29(24):3002-3010.
[9] IKARI Y, SAKURADA M, KOZUMA K, et al. Upfront thrombus aspiration in primary coronary intervention for patients with ST-segment elevation acute myocardial infarction:report of the VAMPIRE(VAcuuM asPIration thrombus REmoval)trial[J]. JACC Cardiovasc Interv,2008,1(4):424-431.
[10] SVILAAS T,HORST I C C V D,ZIJLSTRA F. Thrombus aspiration during percutaneous coronary intervention in acute myocardial infarction study[J]. Neth Heart J,2008,151(3):409-413.
[11] SARDELLA G,MANCONE M,BUCCIARELLIDUCCI C,et al. The EXPIRA(thrombectomy with export catheter in infarctrelated artery during primary percutaneous coronary intervention)prospective,randomized trial[J]. J Am Coll Cardiol,2009,53(4):309-15.
[12] FROBERT O,LAGERQVIST B,OLIVECRONA G K,et al.Thrombus aspiration during ST-segment elevation myocardial infarction[J]. N Engl J Med,2013,369(17):1587-1597.
[13] JOLLY S S,CAIRNS J A,YUSUF S,et al. Randomized trial of primary PCI with or without routine manual thrombectomy[J]. N Engl J Med,2015,372(15):1389-1398.
[14] ZHANGY,PENGL,FANYY,etal.Additionalmanualthrombus aspiration for ST-segment elevation myocardial infarction during percutaneous coronary intervention:an updated meta-analysis[J]. J Geriatr Cardiol,2016,13(4):344-354.
[15] ELGENDY A Y,ELGENDY I Y,MAHMOUD A N,et al.Long-term outcomes with aspiration thrombectomy for patients undergoing primary percutaneous coronary intervention:A meta-analysis of randomized trials[J]. Clin Cardiol,2017,40(8):534-541.
[16] GE J,SCHAFER A,ERTL G,et al. Thrombus aspiration for ST-segment-elevation myocardial infarction in modern era:still an issue of debate?[J]. Circ Cardiovasc Interv,2017,10(10). pii:e005739.
[2] HENRIQUES J P S,ZIJLSTRA F,OTTERVANGER J P,et al. Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction[J].Eur Heart J,2002,23(14):1112.
[3]金玫.急性ST段抬高型心肌梗死诊断和治疗指南[J].中华心血管病杂志,2015,43(5):675-690.
[4] THIELE H,DESCH S,DE WAHA S.[Acute myocardial infarction in patients with ST-segment elevation myocardial infarction:ESC guidelines 2017][J]. Herz,2017,42(8):728-738.
[5]中华医学会心血管病学分会介入心脏病学组.中国经皮冠状动脉介入治疗指南(2016)[J].中华心血管病杂志,2016,44(5):382-400.
[6] MAGRO M,SPRINGELING T,VAN GEUNS R J,et al.Myocardial‘no-reflow’prevention[J]. Curr Vasc Pharmacol,2013,11(2):263-277.
[7] BURZOTTA F,TRANI C,ROMAGNOLI E,et al. Manual thrombus-aspiration improves myocardial reperfusion:the randomized evaluation of the effect of mechanical reduction of distal embolization by thrombus-aspiration in primary and rescue angioplasty(REMEDIA)trial[J]. J Am Coll Cardiol,2005,46(2):371-376.
[8] DE LUCA G,DUDEK D,SARDELLA G,et al. Adjunctive manual thrombectomy improves myocardial perfusion and mortality in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction:a metaanalysis of randomized trials[J]. Eur Heart J,2008,29(24):3002-3010.
[9] IKARI Y, SAKURADA M, KOZUMA K, et al. Upfront thrombus aspiration in primary coronary intervention for patients with ST-segment elevation acute myocardial infarction:report of the VAMPIRE(VAcuuM asPIration thrombus REmoval)trial[J]. JACC Cardiovasc Interv,2008,1(4):424-431.
[10] SVILAAS T,HORST I C C V D,ZIJLSTRA F. Thrombus aspiration during percutaneous coronary intervention in acute myocardial infarction study[J]. Neth Heart J,2008,151(3):409-413.
[11] SARDELLA G,MANCONE M,BUCCIARELLIDUCCI C,et al. The EXPIRA(thrombectomy with export catheter in infarctrelated artery during primary percutaneous coronary intervention)prospective,randomized trial[J]. J Am Coll Cardiol,2009,53(4):309-15.
[12] FROBERT O,LAGERQVIST B,OLIVECRONA G K,et al.Thrombus aspiration during ST-segment elevation myocardial infarction[J]. N Engl J Med,2013,369(17):1587-1597.
[13] JOLLY S S,CAIRNS J A,YUSUF S,et al. Randomized trial of primary PCI with or without routine manual thrombectomy[J]. N Engl J Med,2015,372(15):1389-1398.
[14] ZHANGY,PENGL,FANYY,etal.Additionalmanualthrombus aspiration for ST-segment elevation myocardial infarction during percutaneous coronary intervention:an updated meta-analysis[J]. J Geriatr Cardiol,2016,13(4):344-354.
[15] ELGENDY A Y,ELGENDY I Y,MAHMOUD A N,et al.Long-term outcomes with aspiration thrombectomy for patients undergoing primary percutaneous coronary intervention:A meta-analysis of randomized trials[J]. Clin Cardiol,2017,40(8):534-541.
[16] GE J,SCHAFER A,ERTL G,et al. Thrombus aspiration for ST-segment-elevation myocardial infarction in modern era:still an issue of debate?[J]. Circ Cardiovasc Interv,2017,10(10). pii:e005739.