耿涛,宋志远,刘娟,徐泽升

• 1:沧州市中心医院心内二科

摘要(Abstract)：

目的探讨联合应用血栓抽吸和冠状动脉内注射溶栓药物重组人尿激酶原(rhproUK)对直接经皮冠状动脉介入治疗(PPCI)术中证实有重度血栓负荷的急性前壁心肌梗死患者PPCI效果及临床预后的影响。方法回顾性分析2015年1月至2019年6月于沧州市中心医院就诊的急性前壁心肌梗死患者368例的临床资料,将所有患者分为三组:A组(121例),PPCI术中单纯应用血栓抽吸;B组(130例),PPCI术中联合应用血栓抽吸及冠状动脉内注射替罗非班;C组(117例),PPCI术中联合应用血栓抽吸及冠状动脉内注射rh-proUK。收集患者住院期间心脏核磁共振成像结果及住院和随访期间超声心动图结果。观察终点为主要不良心血管事件,包括心肌梗死(含再发心肌梗死)、心血管死亡和靶血管再次行血运重建。结果三组患者心肌梗死溶栓治疗试验(TIMI)心肌灌注分级(TMP)<3级比例比较差异有统计学意义(P=0.006),其中B组和C组TMP<3级比例较A组明显减少(3.8%、3.4%比12.4%),差异均有统计学意义(均P<0.01)。三组患者在PPCI术后1周和1个月的左心室舒张末期内径(LVEDD)、左心室射血分数(LVEF)比较差异均无统计学意义(均P>0.05)。三组患者术后6个月LVEDD、LVEF比较,差异均有统计学意义(均P<0.05),其中,B组、C组LVEDD均低于A组[(49.3±7.4)mm、(48.8±8.6)mm比(51.6±5.5)mm],LVEF均高于A组[(49.6±6.9)%、(50.2±5.4)%比(47.7±8.3)%],差异均有统计学意义(均P<0.05),但B组和C组比较差异均无统计学意义(均P>0.05)。心脏磁共振成像结果显示,三组患者的心肌坏死面积差异有统计学意义(P=0.007),其中B组、C组心肌坏死面积均小于A组[(14.3±7.3)%、(14.0±6.9)%比(16.9±7.1)%],差异均有统计学意义(均P<0.05),但B组和C组间差异无统计学意义(P>0.05)。三组患者左心室心肌质量、LVEF比较,差异均无统计学意义(均P>0.05)。三组患者术后合并出血事件及主要不良心血管事件发生情况比较,差异均无统计学意义(均P>0.05)。结论 PPCI术中左前降支近中段有重度血栓负荷的患者,在应用血栓抽吸导管的同时于冠状动脉内注射rh-pro UK安全有效。

关键词(KeyWords)： 急性前壁心肌梗死;直接经皮冠状动脉介入治疗;冠状动脉内注射;重组人尿激酶原

Abstract:

Keywords:

基金项目(Foundation):

作者(Author): 耿涛,宋志远,刘娟,徐泽升

参考文献(References)：

• [1] Romano M, Buf foli F, Lettieri C, et al. No refl ow in patients undergoing primary angioplasty for acute myocardial infarction at high risk:incidence and predictive factors. Minerva Cardioangiol,2005, 53(1):7-14.
• [2] Ibánez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Rev Esp Cardiol(Engl Ed), 2017, 70(12):1082.
• [3] Spaulding C, Henry P, Teiger E, et al. Sirolimus-eluting versus uncoated stents in acute myocardial infarction. N Engl J Med, 2006,355(11):1093-1104.
• [4] Brener SJ, Cristea E, Mehran R, et al. Relationship between angiographic dynamic and densitometric assessment of myocardial reperfusion and survival in patients with acute myocardial infarction treated with primary percutaneous coronary intervention:the harmonizing outcomes with revascularization and stents in AMI(HORIZONS-AMI)trial. Am Heart J, 2011, 162(6):1044-1051.
• [5] Hiroshi I. Etiology and clinical implications of microvascular dysfunction in patients with acute myocardial infarction. Int Heart J,2014, 55(3):185-189.
• [6] Bell WR. Present-day thrombolytic therapy:therapeutic agentspharmacokinetics and pharmacodynamics. Rev Cardiovasc Med,2002, 3(Suppl 2):S34-S44.
• [7] Yao Z, Li W, Cheng L, et al. Comparison of the ef fect of recombinant human pro-urokinase and tirofi ban on myocardial blood fl ow perfusion in ST elevation myocardial infarction patients receiving primary percutaneous coronary intervention:A one-center retrospective observational study. Medicine, 2019, 98(27):e16143.
• [8] Thygesen K, Alpert JS, Jaf fe AS, et al. Fourth universal defi nition of myocardial infarction(2018). Eur Heart J, 2019, 40(3):237-269.
• [9]中华医学会心血管病学分会，中华心血管病杂志编辑委员.急性ST段抬高型心肌梗死诊断和治疗指南（2019）.中华心血管病杂志，2019, 47(10):766-783.
• [10] Yip HK, Chen MC, Chang HW, et al. Angiographic morphologic features of infarct-related arteries and timely reperfusion in acute myocardial infarction:predictors of slow-flow and no-reflow phenomenon. Chest, 2002, 122(4):1322-1332.
• [11] Hara M, Saikawa T, Tsunematsu Y, et al. Predicting no-refl ow based on angiographic features of lesions in patients with acute myocardial infarction. J Atheroscler Thromb, 2005, 12(6):315-321.
• [12] Burzotta F, Trani C, Romagnoli E, et al. A pilot study with a new, rapid-exchange, hrombus-aspirating device in patients with thrombus-containing lesions:the Diver C.E. study. Catheter Cardiovasc Interv, 2006, 67(6):887-893.
• [13] Geng T, Zhang JG, Song ZY, et al. Aspiration thrombectomy and intracoronary tirofi ban in ST-segment elevation myocardial infarction:Combination treatment for patients undergoing primary percutaneous coronary intervention. Herz, 2016, 41(8):1-8.
• [14] Fu Y, Gu XS, Hao GZ, et al. Comparison of myocardial microcirculatory perfusion after catheter-administered intracoronary thrombolysis with anisodamine versus standard thrombus aspiration in patients with ST-elevation myocardial infarction. Catheter Cardiovasc Interv, 2019, 93(S1):839-845.
• [15] Mehran R, Rao SV, Bhatt DL, et al. Standardized bleeding defi nitions for cardiovascular clinical trials:a consensus report from the Bleeding Academic Research Consortium. Circulation, 2011,123(23):2736-2747.
• [16] Romagnoli E, Burzotta F, Trani C, et al. Rationale for intracoronary administration of abciximab. J Thromb Thrombolysis, 2007, 23(1):57-63.
• [17] Auf fret V, Oger E, Leurent G, et al. E ffi cacy of pre-hospital use of glycoprotein IIb/IIIa inhibitors in ST-segment elevation myocardial infarction before mechanical reperfusion in a rapid-transfer network(from the Acute Myocardial Infarction Registry of Brittany). Am J Cardiol, 2014, 114(2):214-223.
• [18]耿涛，宋志远，王炳勋，等.联合应用血栓抽吸及冠状动脉内注射替罗非班的安全性和有效性.重庆医学，2018, 47(2):211-213.
• [19] de Vita M, Coluccia V, Burzotta F, et al. Intracoronary use of GP IIb/IIIa inhibitors in percutaneous coronary interventions. Curr Vasc Pharmacol, 2012, 10(4):448-453.
• [20] Gu YL, Kampinga MA, Wieringa WG, et al. Intracoronary versus intravenous administration of abciximab in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention with thrombus aspiration:the comparison of intracoronary versus intravenous abciximab administration during emergency reperfusion of ST-segment elevation myocardial infarction(CICERO)trial. Circulation, 2010, 122(25):2709-2717.
• [21] Iversen A, Abildgaard U, Galloe A, et al. Intracoronary compared to intravenous bolus abciximab during primary percutaneous coronary intervention in ST-segment elevation myocardial infarction(STEMI)patients reduces 30-day mortality and target vessel revascularization:a randomized trial. J Interv Cardiol, 2011, 24(2):105-111.
• [22] Kelly RV, Crouch E, Krumnacher H, et al. Safety of adjunctive intracoronary thrombolytic therapy during complex percutaneous coronary intervention:initial experience with intracoronary tenecteplase.Catheter Cardiovasc Interv, 2005, 66(3):327-332.
• [23] Kim JS, Kim JH, Jang HH, et al. Successful revascularization of coronary artery occluded by massive intracoronary thrombi with alteplase and percutaneous coronary intervention. J theroscler Thromb, 2010, 17(7):768-770.
• [24] Kumar A, Sharif f M, Doshi R. Index of microvascular resistance and outcomes following intra-coronary thrombolysis with percutaneous intervention in STEMI:a meta-analysis of randomized control trials.J Thromb Thrombolysis, 2020, 49(3):487-491.
• [25]农京国，白静，彭亮，等.冠状动脉内逆向溶栓在急性ST段抬高型心肌梗死患者直接介入治疗术后1年随访.中华老年心脑血管病杂志，2016, 18(9):905-908.
• [26]陈存芳，贾博，徐绍辉，等.经血栓抽吸导管注射重组人尿激酶原对高血栓负荷ST段抬高型心肌梗死患者急诊介入治疗效果的影响.临床心血管病杂志，2019, 35(1):75-78.