本文選題：急性ST段抬高型心肌梗死　切入點(diǎn)：直接經(jīng)皮冠狀動(dòng)脈介入治療　出處：《河北醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的:探討急性ST段抬高型心肌梗死(ST segment elevation myocardial infarction,STEMI)直接經(jīng)皮冠狀動(dòng)脈介入治療(primary percutaneous coronary intervention,p PCI)術(shù)后心肌微循環(huán)灌注障礙的相關(guān)因素。方法:收集2015年2月至2016年12月于河北醫(yī)科大學(xué)第二醫(yī)院住院治療的STEMI行p PCI治療患者,根據(jù)TIMI心肌組織灌注分級(jí)(TIMI myocardial perfusion grade,TMPG)將患者分為兩組:心肌微循環(huán)灌注不良組即A組(TMPG 0~2級(jí)者)和心肌微循環(huán)灌注良好組即B組(TMPG3級(jí)者)。收集患者臨床基線資料,包括年齡、性別、是否吸煙、高脂血癥、糖尿病、高血壓、體重指數(shù)(body mass index,BMI)等。院前及術(shù)中資料,包括生化指標(biāo):血鉀、肌酐、血紅蛋白、血小板計(jì)數(shù)、低密度脂蛋白(Low Density Lipoprotein,LDL)、基線活化凝血時(shí)間(Activated Clotting Time,ACT)、肌酸激酶同工酶(Creatine Kinase-MB,CK-MB)、心肌肌鈣蛋白I(cardiac troponin I,c Tn I);心功能分級(jí)(Killip分級(jí))、入院時(shí)收縮壓、舒張壓及心率、癥狀至首次醫(yī)療接觸(first medical contact time,FMC)時(shí)間、FMC至肝素給予時(shí)間(FMC to heparin,FMC-H)、門球時(shí)間(door to balloon,D-B)、應(yīng)用抽吸導(dǎo)管、多支病變、術(shù)前及術(shù)后TIMI血流、梗死相關(guān)動(dòng)脈(Infarct Related Artery,IRA)、置入支架數(shù)量、支架長(zhǎng)度及直徑、預(yù)擴(kuò)、后擴(kuò)、支架釋放壓力、冠脈內(nèi)是否應(yīng)用替羅非班或山莨菪堿等。應(yīng)用多因素Logistic回歸分析探討STEMI患者p PCI術(shù)后心肌微循環(huán)灌注障礙的獨(dú)立危險(xiǎn)因素。以P0.05為有統(tǒng)計(jì)學(xué)差異。統(tǒng)計(jì)軟件采用SPSS16.0軟件包。結(jié)果:入選符合條件的患者共122例,其中A組18例(14.75%)和B組104例(85.25%)。兩組患者性別、年齡、BMI、吸煙、高脂血癥、高血壓、收縮壓、舒張壓、心率方面無(wú)統(tǒng)計(jì)學(xué)差異(P0.05),而糖尿病在A組比例明顯高于B組,有統(tǒng)計(jì)學(xué)差異(44.44%vs.21.15%,P=0.034)。兩組在血鉀、肌酐、血紅蛋白、血小板計(jì)數(shù)、LDL、基線ACT、CK-MB、c Tn I、Killip分級(jí)方面沒(méi)有統(tǒng)計(jì)學(xué)差異(P0.05)。兩組在IRA、支架直徑及長(zhǎng)度、釋放壓力、后擴(kuò)張壓力、術(shù)前TIMI血流(0級(jí)、1級(jí)、2級(jí)、3級(jí))、術(shù)后TIMI血流(2級(jí))方面無(wú)統(tǒng)計(jì)學(xué)差異(P0.05)。兩組在多支病變方面,A組明顯高于B組(77.8%vs.47.1%,P=0.016)。與B組相比,A組血栓抽吸應(yīng)用比例明顯增高(44.44%vs.1.92%,P0.001)。A組在替羅非班(50.00%vs.23.1%,P=0.018)、山莨菪堿(61.1%vs.17.3%,P0.001)方面應(yīng)用均高于B組。A組后擴(kuò)張比例高于B組(50%vs.20.19%,P=0.007),平均后擴(kuò)張壓力高于B組(0.89±1.02atm vs.0.28±0.60atm,P=0.024)。A組術(shù)后TIMI血流3級(jí)的比例明顯低于B組(44.4%vs.76.9%,P=0.011)。兩組在D-B方面無(wú)統(tǒng)計(jì)學(xué)差異(P0.05)。在癥狀-FMC方面,A組較B組更長(zhǎng)(6.60±2.61h vs.3.96±1.72h,P0.001);在FMC-H方面,B組肝素給予時(shí)間更早(2.74±1.36h vs.1.38±0.72h,P0.001)。多因素Logistic回歸分析顯示:癥狀-FMC(OR=1.914,95%CI=1.054~3.569,P=0.037),FMC-H(OR=4.796,95%CI=1.336~17.214,P=0.016)為STEMI患者行p PCI術(shù)后心肌微循環(huán)灌注障礙的獨(dú)立危險(xiǎn)因素。結(jié)論:對(duì)于STEMI患者的救治,應(yīng)最大限度地縮短心肌總?cè)毖獣r(shí)間,包括及時(shí)就診、盡早給予普通肝素阻斷凝血瀑布鏈等,有效地預(yù)防p PCI術(shù)后心肌微循環(huán)灌注障礙的發(fā)生,減輕心肌缺血-再灌注損傷,挽救高質(zhì)量的生命。
[Abstract]:Objective: To investigate the effect of acute ST elevation myocardial infarction (ST segment elevation myocardial infarction, STEMI) direct percutaneous coronary intervention (primary percutaneous coronary intervention, P PCI) related factors of postoperative myocardial microcirculation perfusion. Methods: from February 2015 to December 2016 in the second hospital of Hebei Medical University STEMI P PCI in the treatment of patients according to TIMI, myocardial perfusion grade (TIMI myocardial perfusion grade, TMPG) patients were divided into two groups: myocardial perfusion group (TMPG group, A bad 0~2 grade) and myocardial microcirculation perfusion group: B group (TMPG3 grade). The baseline clinical data were collected including age, gender, smoking, hyperlipidemia, diabetes, hypertension, body mass index (body mass, index, BMI). The data of before and during operation, including biochemical indexes: serum potassium, creatinine, hemoglobin, blood Platelet count, low density lipoprotein (Low Density, Lipoprotein, LDL), baseline activated clotting time (Activated Clotting, Time, ACT), creatine kinase isoenzyme (Creatine Kinase-MB, CK-MB), cardiac troponin I (cardiac troponin I C, Tn I); heart function classification (Killip classification), admission systolic blood pressure, diastolic pressure and heart rate, symptoms to the first medical contact (first medical contact time, FMC), FMC (FMC to to heparin given time heparin, FMC-H (door), to balloon, over time D-B), application of suction catheter, multivessel disease, preoperative and postoperative TIMI flow of infarct related artery (Infarct Related Artery, IRA), the number of stents, stent length and diameter, pre expansion, expansion, support the release of pressure, whether intracoronary tirofiban or anisodamine. Multivariate Logistic regression analysis of STEMI patients with P after PCI myocardial microcirculation perfusion 鐙珛鍗遍櫓鍥犵礌.浠0.05涓烘湁緇熻瀛﹀樊寮，

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