汪雁博,谷新顺,范卫泽,郝国贞,姜云发,傅向华

• 1:河北医科大学第二医院心内科

摘要(Abstract)：

目的探讨ST段抬高心肌梗死(STEMI)患者经皮冠状动脉介入治疗(PCI)术前血流动力学状态与溶栓后早期PCI后心肌灌注水平的关系。方法回顾收集2010年1月至2013年6月于河北医科大学第二医院接受溶栓后早期PCI的STEMI患者的病历资料。根据患者PCI术后TIMI心肌灌注分级(TMPG)将患者分为心肌灌注不良组(TMPG≤2级)和心肌灌注正常组(TMPG=3级)。记录患者溶栓后PCI术前收缩压(SBP)、舒张压(DBP)和心率(HR)。比较两组患者PCI术前后TIMI血流分级、校正的TIMI帧数(CTFC)、TMPG以及血栓负荷积分。以Logistic回归方程计算出的每例STEMI患者溶栓早期PCI术后TMPG≤2级的发生概率值,构建以TMPG确定的心肌灌注水平为金标准的ROC曲线,分析ROC曲线下面积及最佳截点诊断STEMI患者溶栓早期PCI术后TMPG≤2级发生的特异性及敏感性。结果累计入选患者159例,其中灌注不良组31例(19.5%),灌注正常组128例(80.5%)。与灌注正常组患者相比,灌注不良组患者PCI术前SBP和DBP均低于灌注正常组(均P<0.001),HR有增加趋势(P=0.098);PCI术后7 d灌注正常组患者的心功能较好(P=0.005),梗死面积有降低趋势(P=0.054)。两组患者其他基线资料比较,差异无统计学意义(均P>0.05)。PCI术后灌注正常组TIMI血流分级Ⅲ级比例高于灌注不良组(P=0.039),CTFC水平低于灌注不良组[(24.6±1.4)帧比(28.0±3.6)帧,P<0.001]。与灌注正常组患者相比,灌注不良组患者应用替罗非班比例较高(P<0.001)。多因素Logistic回归分析发现,PCI术前DBP过低以及糖尿病史是PCI术后心肌灌注不良的独立预测因素。建立心肌灌注预报概率模型,血流动力学参数=1+exp[-(-4.091+0.085×DBP+0.016×SBP-0.037×HR)],求出各个样本TMPG水平的综合预报概率,绘制ROC曲线的检验变量。计算ROC曲线下面积为0.775(95%CI 0.683~0.868,P<0.001),截点值为0.789时,敏感性和特异性分别为78.1%和71.0%。结论低DBP水平是接受溶栓后早期PCI的STEMI患者心肌灌注不良的危险因素;以综合预测模型0.789为截点具有良好的敏感性和阴性预测价值。

关键词(KeyWords)： ST段抬高心肌梗死;经皮冠状动脉介入治疗;心肌灌注;血流动力学

Abstract:

Keywords:

基金项目(Foundation): 河北省2014年度医学科学研究重点课题计划(ZL20140074)

作者(Author): 汪雁博,谷新顺,范卫泽,郝国贞,姜云发,傅向华

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