冠脉介入干预后血流及炎症因子的临床研究
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摘要
第一部分目的直接介入治疗是目前J急性ST段抬高心肌梗死的首选策略,然而,发现约40%的患者梗死相关动脉下游心肌血流灌注不足。本研究的目的是探讨急性心肌梗死患者的介入干预后慢血流/无复流现象与预后的关系。方法共有76例患者(61.9±8.9岁,男性40例)纳入本研究。评定术后相关动脉TIMl分级,以TIMI≤2级或TIMI3级且心肌显像分级≤2级判定的为慢血流或无复流,随访12个月,以是否发生主要不良心血管事件分组,主要不良心血管事件包括死亡、再发心肌梗死、不稳定型心绞痛/非ST段高心肌梗死、靶血管血运重建、中风和心力衰竭。结果随访期间,76例患者中共有21例(27.6%)发生不良心血管事件。心血管事件组与无心血管事件组比较糖尿病者多(P=0.0009)、发病-球囊时间长(P=0.0005)和术后慢血流或无复流发生率高(P=0.0017),差异有显著性；虽与无事件组比较,在事件发生组的梗死相关动脉靶病变略长,但未达到统计学意义水准(P=0.0847)。多元Cox回归分析显示再灌注血流(HR:2.915,95%CI:1.098-7.742, P=0.0317)、发病-球囊时间(HR:2.736,95%CI:1.050-7.126, P=0.0357)和糖尿病(HR:2.736,95%CI:1.028-2.221, P=0.0394)是不良事件发生的主要危险预测因素。结论除糖尿病外,再灌注慢血流或无复流、发病-球囊时间也是预测急性心肌梗死直接介入治疗后的主要不良心脏事件的危险因素。第二部分目的已知炎症反应参与动脉粥样硬化的进程,冠状动脉介入治疗也可引起血管壁损伤导致炎症反应,然而炎症因子与干预后相关动脉血流的关系尚不明确。探讨冠状动脉病变局部炎症反应标志物(基质金属蛋白酶-9和白介素-6)对其介入干预后血流的影响。方法分诊断性冠脉造影组(n=15,血样采集于造影前即刻和术后15分钟动脉取样)和PCI术组(n=39,血样采集于PCI术前, PCI术中冠脉病变局部及PCI术后15分钟),观测观测炎症因子变化及其与术后TIMI血流帧数的关系。结果：冠脉造影组和冠脉介入治疗两组之间的基质金属蛋白酶-9和白介素-6基础水平无统计学差异。造影组手术前后基质金属蛋白酶-9和白介素-6变化无差异。PCI组术后白细胞介素-6有显著意义的升高(P=0.025),而与外周动脉水平相比,冠脉病变局部更高(P<0.001),且局部水平与术后冠状动脉TIMI血流帧数呈密切正相关关系(r=0.57,P<0.001)；金属蛋白酶-9在3个不同部位和时间点处水平相比较虽无统计学差异,而此因子术后的变化以及去除基础影响的局部病变的实际水平均与白介素-6的变化存在一定的相关性(r=0.32,P=0.043;r=0.41,p=0.009),且局部的高出水平也与术后血流帧数较弱的相关(r=0.33,P=0.040)。结论：择期PCI治疗稳定型冠心病患者术后可见部分标志物升高,提示PCI操作可能诱发炎性反应；局部炎症因子IL-6高水平可能影响介入干预后相关动脉前向血流。第三部分目的既往研究证实冠状动脉血栓明显增加急性ST段抬高心肌梗死介入治疗术后心血管事件和支架血栓的风险,本研究探讨抽吸导管抽吸血栓是否增加有血栓负荷的急性心肌梗死患者置入支架后梗死相关动脉血流。方法所有入选急性心肌梗死拟介入治疗的患者血栓分级均2-3分,然后分为应用导管抽吸组(研究组)和未用导管抽吸(对照组)2组。测定术后相关动脉TIMI分级、心电图ST段回落以及术后5-7天射血分数,观察住院期间和1月主要不良心血管事件。结果两组患者术前基本情况无统计学差异(P>0.05),而两组累及血管支数、前降支病变比率、参考血管内径、梗死相关动脉病变长度、支架植入数量也无统计学差异(P>0.05)。研究组慢血流/无复流发生率低于对照组(13.3%vs.35.5%,P=0.0446),ST段回落百分比≥50%者多于未行血栓抽吸者(83.3%vs.58.1%,P=0.0305)。研究组术后5-7天的射血分数高于对照组,有显著性差异(0.579+0.08vs0.531±0.09,P=0.0358),住院期间主要心血管事件发生率抽栓的研究组呈现低于未抽栓的对照组趋势(6.7%vs.19.4%),但未达到统计学意义水准(P=0.1422)。结论血栓抽吸可减少存在血栓负荷患者慢血流或无复流的发生增加冠脉血流灌注,改善术后心脏功能,有望减少心脏事件发生。第四部分目的缺血预处理可减轻缺血再灌注损伤,然而由于急性心肌梗死的不可预测性而限制应用。最近发现再灌注开始时短暂阻塞冠状动脉血流同样对心脏具有保护作用,减轻心肌再灌损伤,后者称缺血后处理。观察缺血后处理对急性ST段抬高心肌梗死患者急诊经皮冠状动脉介入治疗后再灌注心肌的影响。方法62例急诊PCI患者入选,随机分为研究组(n=32)和对照组(n=30),前者应用缺血后处理技术,即开通梗死相关动脉lmin后,用球囊扩张30s阻塞血流,回抽30s开放血流,循环3次；对照组再灌注3分钟内不给予任何处理。测定术后相关动脉TIMl分级和心肌显影(MBG)分级、校正TIMI帧数、心电图ST段回落,监测手术前及术后和8小时肌酸激酶水平,以及术后半小时超敏C-反应蛋白活性。以术后冠状动脉达TIMl3级血流且MBG3级心肌显影为心肌得到完全再灌注(reflow)。结果两组年龄、发病球囊时间及冠心病危险因素等基本情况无统计学差异；病变血管支数、病变长度、抽吸导管应用两组比较也无显著性差异。研究组术后平均校正TIMI帧数低于对照组(28.5±9.1vs.37.4±12.4,P=0.0019)；研究组ST段回落百分比≥50%者高于对照组(93.8%vs.73.3%,P=0.0289),研究组术后血流再灌注者多于对照组(81.3%vs.56.7%,P=0.0359)、肌酸激酶低于对照组(2159.9+485.5vs.1452.4±201.6,P=0.0282),有统计学差异。另外显示研究组术后超敏C-反应蛋白低于对照组(8.2±2.8mg/L vs.10.9±3.1mg/L),差异有显著性(P=0.0005)。结论缺血后处理增加急性心肌梗死介入干预后心肌灌注,减轻炎性反应,有望改善患者预后。
Part1Objective Direct percutaneous coronary intervention is the generally accepted superior strategy in acute ST-segment election myocardial infarction(STEMI), Yet, in as many as40%of patients, myocardial perfusion in the infarct-related artery territory is insufficient. The aim of the present study was to assess the early clinical outcome and no-reflow phenomenon in patients with acute STEMI. Methods A total of76patients (61.9±8.9years,40men) with STEMI who received successful PCI were included in this study. The extent of coronary artery lesions was measured by quantitative coronary artery angiography (QCA).Low reflow and no reflow were diagnosed by thrombolysis in myocardial infarction (TIMI) flow grade≤2or TIMI flow3with a final myocardial blush grade≤2. Subjects were tracked for subsequent major adverse cardiovascular events (MACE):cardiac death, myocardial infarction, unstable angina/non-ST elevation myocardial infarction, heart failure, percutaneous coronary intervention, coronary artery bypass and stroke during12months following-up. The patients were divided into occurrence of MACE group (MACE group) and absence of MACE group (NMACE group). Results During12months follow-up,21of76(27.6%)study participants occurred main adverse cardiovascular events. There were more diagnosis of diabetes (P=0.0009), longer time from occurrence to balloon (P=0.0005) and higher rates of low reflow or no-reflow (P=0.0017) in the MACE group compared with NMACE group. Multivariate Cox analysis identified that reflow (HR:2.915,95%CI:1.098-7.742, P=0.0317), time from symptom to balloon (HR:2.736,95%CI:1.050-7.126, P=0.0357) and a diagnosis of diabetes (HR:2.736,95%CI:1.028-2.221, P=0.0394) as independent predictors of cardiovascular events after adjustment of all entered baseline variables. Conclusions Our study suggests that besides diabetes, low reflow or no reflow and time from symptom to balloon are prognostic factors for MACE in patients with acute ST elevation myocardial infarction following PCI. Part2Objective It has been found that inflammation play an important role in atherosclerosis, and the procedure of percutaneous coronary intervention (PCI) can lead to inflammation reaction.however the relationship of inflammation factors and the reflow has been less well defined in patients following PCI. The aim of this part is to study the effects of matrix metalloproteinase-9(MMP-9) and interleukin-6(IL-6) on the reflow after PCI. Methods We investigated the effects of both diagnostic coronary angiography (CA)[n=15; blood sampling immediately before CA and15min after CA] and PCI (n=39; blood sampling before PCI, local of PCI,15min after PCI) on levels of MMP-9and IL-6across comparable patient groups. Results There were no differences in baseline levels of MMP-9or IL-6between the two study groups (CA, PCI; all p=not significant). Following CA (before to15min after), there were no significant changes in MMP-9or IL-6(p=not significant). Following PCI, there were a significant increases of IL-6in femoral artery (P=0.025), even higher in the local lession in coronary artery. There were positive relation between local IL-6level and corrected thrombolysis in myocardial infarction frame count (cTFC, r=0.57, P＜0.001) after PCI, and there were also found that positive relation between the changes of MMP-9and IL-6following PCI (r=0.32,P=0.043), and found that a positive ralation between the changes of local MMP-9and local IL-6(r=0.41, p=0.009). The gental relation between changes of local MMP-9and cTFC was also expressed (r=0.33,P=0.040). Conclusions The increase of IL-6in patients following elective PCI may indicate that the procedure of PCI dereactly lead to inflammation reaction. The real level of regenal MMP-9as well as IL-6, remaining inflammation reaction in the lession of coronary artery, may affect on reflow after stenting. Part3Objective Thrombus overload had increased the risk of adverse cardiac events in patients with acute ST-elevation myocardial infarction (ASTEMI) following PCI. We sought to examine the effects of Diver DE aspiration on infarction related artery flow in thrombus over-load patients with ASTEMI undergoing primary PCI. Methods The patients were randomly assigned to aspiration group (study group, n=30) or no aspiration group (control group, n=31) by TIMI thrombus grade. TIMI, resolution of maximal ST-segment elevation were calculated before and after PCI; Left ventricular ejection fraction (LVEF) was detected by echocardiography5-7days after PCI. Major adverse cardiovascular events (MACE) were tracked during in-hospital and within one month following-up. Results There were no significantly found in clinical and lesion characteristics between two groups. The numbers of low reflow and no reflow in study group were less than those in control group (13.3%vs.35.5%, P=0.0446), and the ST segment resolution≥50%(83.3%vs.58.1%, P=0.0305) in aspiration group were higher than those in no aspiration group in thrombus grade two to three degree, and even the left ventricular ejection fractions in study group with aspiration were increased comparing with control without Diver CE (0.579±0.08vs.0.531±0.09, P=0.0358). There was a significant difference toward MACE in aspiration group compared to without aspiration (6.7%vs.19.4%), though it did not match the significant statistic level (P=0.1422). Conclusions Diver CE aspiration, increasing infarction related artery flow and improving left ventricular systolic function, would be better the prognosis of ASTEMI with thrombus over-load following Primary percutaneous coronary intervention. Part4Objective Ischaemic preconditioning limits the damage induced by subsequent ischaemia/reperfusion (I/R). However, preconditioning is of little practical use as the onset of an infarction is usually unpredictable. Recently, it has been shown that the heart can be protected against the extension of I/R injury if brief coronary occlusions are performed just at the beginning of the reperfusion. This procedure has been called postconditioning. We sought to examine the effects of postconditioning in patients with acute ST-elevation myocardial infarction (ASTEMI) undergoing primary PCI. Methods62patients with their first ASTEMI were randomly assigned to a study group (n=32) or control (n=30) within90minutes after adminssion. After predilatation, in the Control group, no intervention was applied in the first3minutes of reperfusion, while in the study group (Postconditioning group), three cycles of30-second angioplasty balloon deflation and30second inflation were repetitively applied. TIMI, corrected TIMI frame count, resolution of50%ST-segment elevation and creatine kinase were calculated before and after PCI. Results There were no significantly found in clinical and lesion characteristics between two groups. The numbers of reflow (81.3%vs.56.7%, P=0.0359) and ST segment resolution≥50%(93.8%vs.73.3.%, P=0.0289) in study group were much more that those in control, and the TIMI frame counts (28.5±9.1vs.37.4±12.4, P=0.0019) and creatine kinase (2159.9±485.5vs.1452.4±201.6, P=0.0282) were lower in the study group compared to control. Further, it was found that the hs-CRP levels in study group following PCI was significantly decreased comparing with those in control group following PCI(8.2±2.8mg/L vs.10.9±3.1mg/L, P=0.0005). Conclusions This study demonstrates that postconditioning in patients with acute ST-elevation myocardial infarction undergoing PCI, improving myocardial reperfusion and lessening inflammatory reaction, may benefit for the future.
Part1Objective Direct percutaneous coronary intervention is the generally accepted superior strategy in acute ST-segment election myocardial infarction(STEMI), Yet, in as many as40%of patients, myocardial perfusion in the infarct-related artery territory is insufficient. The aim of the present study was to assess the early clinical outcome and no-reflow phenomenon in patients with acute STEMI. Methods A total of76patients (61.9±8.9years,40men) with STEMI who received successful PCI were included in this study. The extent of coronary artery lesions was measured by quantitative coronary artery angiography (QCA).Low reflow and no reflow were diagnosed by thrombolysis in myocardial infarction (TIMI) flow grade≤2or TIMI flow3with a final myocardial blush grade≤2. Subjects were tracked for subsequent major adverse cardiovascular events (MACE):cardiac death, myocardial infarction, unstable angina/non-ST elevation myocardial infarction, heart failure, percutaneous coronary intervention, coronary artery bypass and stroke during12months following-up. The patients were divided into occurrence of MACE group (MACE group) and absence of MACE group (NMACE group). Results During12months follow-up,21of76(27.6%)study participants occurred main adverse cardiovascular events. There were more diagnosis of diabetes (P=0.0009), longer time from occurrence to balloon (P=0.0005) and higher rates of low reflow or no-reflow (P=0.0017) in the MACE group compared with NMACE group. Multivariate Cox analysis identified that reflow (HR:2.915,95%CI:1.098-7.742, P=0.0317), time from symptom to balloon (HR:2.736,95%CI:1.050-7.126, P=0.0357) and a diagnosis of diabetes (HR:2.736,95%CI:1.028-2.221, P=0.0394) as independent predictors of cardiovascular events after adjustment of all entered baseline variables. Conclusions Our study suggests that besides diabetes, low reflow or no reflow and time from symptom to balloon are prognostic factors for MACE in patients with acute ST elevation myocardial infarction following PCI. Part2Objective It has been found that inflammation play an important role in atherosclerosis, and the procedure of percutaneous coronary intervention (PCI) can lead to inflammation reaction.however the relationship of inflammation factors and the reflow has been less well defined in patients following PCI. The aim of this part is to study the effects of matrix metalloproteinase-9(MMP-9) and interleukin-6(IL-6) on the reflow after PCI. Methods We investigated the effects of both diagnostic coronary angiography (CA)[n=15; blood sampling immediately before CA and15min after CA] and PCI (n=39; blood sampling before PCI, local of PCI,15min after PCI) on levels of MMP-9and IL-6across comparable patient groups. Results There were no differences in baseline levels of MMP-9or IL-6between the two study groups (CA, PCI; all p=not significant). Following CA (before to15min after), there were no significant changes in MMP-9or IL-6(p=not significant). Following PCI, there were a significant increases of IL-6in femoral artery (P=0.025), even higher in the local lession in coronary artery. There were positive relation between local IL-6level and corrected thrombolysis in myocardial infarction frame count (cTFC, r=0.57, P＜0.001) after PCI, and there were also found that positive relation between the changes of MMP-9and IL-6following PCI (r=0.32,P=0.043), and found that a positive ralation between the changes of local MMP-9and local IL-6(r=0.41, p=0.009). The gental relation between changes of local MMP-9and cTFC was also expressed (r=0.33,P=0.040). Conclusions The increase of IL-6in patients following elective PCI may indicate that the procedure of PCI dereactly lead to inflammation reaction. The real level of regenal MMP-9as well as IL-6, remaining inflammation reaction in the lession of coronary artery, may affect on reflow after stenting. Part3Objective Thrombus overload had increased the risk of adverse cardiac events in patients with acute ST-elevation myocardial infarction (ASTEMI) following PCI. We sought to examine the effects of Diver DE aspiration on infarction related artery flow in thrombus over-load patients with ASTEMI undergoing primary PCI. Methods The patients were randomly assigned to aspiration group (study group, n=30) or no aspiration group (control group, n=31) by TIMI thrombus grade. TIMI, resolution of maximal ST-segment elevation were calculated before and after PCI; Left ventricular ejection fraction (LVEF) was detected by echocardiography5-7days after PCI. Major adverse cardiovascular events (MACE) were tracked during in-hospital and within one month following-up. Results There were no significantly found in clinical and lesion characteristics between two groups. The numbers of low reflow and no reflow in study group were less than those in control group (13.3%vs.35.5%, P=0.0446), and the ST segment resolution≥50%(83.3%vs.58.1%, P=0.0305) in aspiration group were higher than those in no aspiration group in thrombus grade two to three degree, and even the left ventricular ejection fractions in study group with aspiration were increased comparing with control without Diver CE (0.579±0.08vs.0.531±0.09, P=0.0358). There was a significant difference toward MACE in aspiration group compared to without aspiration (6.7%vs.19.4%), though it did not match the significant statistic level (P=0.1422). Conclusions Diver CE aspiration, increasing infarction related artery flow and improving left ventricular systolic function, would be better the prognosis of ASTEMI with thrombus over-load following Primary percutaneous coronary intervention. Part4Objective Ischaemic preconditioning limits the damage induced by subsequent ischaemia/reperfusion (I/R). However, preconditioning is of little practical use as the onset of an infarction is usually unpredictable. Recently, it has been shown that the heart can be protected against the extension of I/R injury if brief coronary occlusions are performed just at the beginning of the reperfusion. This procedure has been called postconditioning. We sought to examine the effects of postconditioning in patients with acute ST-elevation myocardial infarction (ASTEMI) undergoing primary PCI. Methods62patients with their first ASTEMI were randomly assigned to a study group (n=32) or control (n=30) within90minutes after adminssion. After predilatation, in the Control group, no intervention was applied in the first3minutes of reperfusion, while in the study group (Postconditioning group), three cycles of30-second angioplasty balloon deflation and30second inflation were repetitively applied. TIMI, corrected TIMI frame count, resolution of50%ST-segment elevation and creatine kinase were calculated before and after PCI. Results There were no significantly found in clinical and lesion characteristics between two groups. The numbers of reflow (81.3%vs.56.7%, P=0.0359) and ST segment resolution≥50%(93.8%vs.73.3.%, P=0.0289) in study group were much more that those in control, and the TIMI frame counts (28.5±9.1vs.37.4±12.4, P=0.0019) and creatine kinase (2159.9±485.5vs.1452.4±201.6, P=0.0282) were lower in the study group compared to control. Further, it was found that the hs-CRP levels in study group following PCI was significantly decreased comparing with those in control group following PCI(8.2±2.8mg/L vs.10.9±3.1mg/L, P=0.0005). Conclusions This study demonstrates that postconditioning in patients with acute ST-elevation myocardial infarction undergoing PCI, improving myocardial reperfusion and lessening inflammatory reaction, may benefit for the future.
引文
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