丛占春,赵昕,荆全民

• 1:沈阳军区总医院心血管内科

摘要(Abstract)：

目的对靶血管存在非梗死相关(non-infarct related lesions,N-IRL)病变的急性ST段抬高型心肌梗死(ST-segment elevation myocardial inf arction,STEMI)患者的直接经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)策略及临床预后进行研究。方法回顾2015年1月至2015年6月在沈阳军区总医院接受直接PCI的STEMI患者418例,符合入选标准的患者共75例。根据N-IRL是否行PCI进行分组:研究组在处理梗死相关病变(infarct-related lesion,IRL)的同时干预N-IRL,共33例;对照组仅干预IRL,共42例。研究终点为主要不良心血管事件(major adverse cardiovascular events,MACE),包括心源性死亡、非致死性急性心肌梗死、靶血管血运重建(target vessel revascularization,TVR)、再住院(复发心绞痛和心力衰竭)。结果研究组患者左心室舒张末期内径(LVEDD)[43.16±6.88)mm比(46.24±3.48)mm,P=0.014]低于对照组,左心室射血分数(LVEF)[(62.47±5.31)%比(59.07±6.87)%,P=0.022)]高于对照组,差异均有统计学意义;两组患者其他基线资料比较,差异均无统计学意义(均P>0.05)。研究组N-IRL位于IRL近端比例(57.6%比33.3%,P=0.036)、平均置入支架数[(1.88±0.66)枚比(1.07±0.26)枚,P<0.001]、平均使用支架总长度[(51.41±19.15)mm比(25.45±9.48)mm,P<0.001]及平均对比剂用量[(140.61±45.41)ml比(119.05±35.32)ml,P=0.024]均高于对照组,差异均有统计学意义;而其他PCI相关临床资料比较,差异均无统计学意义(均P>0.05)。两组患者术后可疑的对比剂诱导的急性肾损伤(CIAKI)和卒中发生率比较,差异均无统计学意义(均P>0.05)。两组患者的MACE发生率比较,差异无统计学意义(P=0.446);其中心源性死亡、TVR及再住院的风险比比较,差异亦均无统计学意义(均P>0.05)。单因素Cox回归分析发现,年龄(HR 1.07,95%CI 1.01～1.12,P=0.019)、前壁心肌梗死(HR 4.10,95%CI 1.26～13.33,P=0.019)、N-IRL血管直径(HR 0.19,95%CI 0.06～0.60,P=0.004)、左主干(LM)或左前降支(LAD)近段病变(HR 3.01,95%CI 1.01～8.96,P=0.048)为MACE的预测因素。多因素Cox回归分析显示,年龄(HR 1.07,95%CI 1.01～1.13,P=0.015)、N-IRL血管直径(HR 0.25,95%CI 0.08～0.86,P=0.027)依然为M ACE的预测因素。以N-IR L位于IR L远端为亚组A,亚组A中研究组M ACE(H R 0.20,95%CI 0.05～0.80,P=0.022)和TVR(HR 0.10,95%CI 0.01～0.89,P=0.039)的风险高于对照组,差异均有统计学意义;亚组A中两组患者心源性死亡和再住院的风险比比较,差异均无统计学意义(均P>0.05)。以N-IRL位于IRL近端为亚组B,亚组B中两组患者MACE发生率比较,差异无统计学意义(P=0.198)。结论对于IRL远端的N-IRL,选择药物治疗是合理的;对于IRL近端的N-IRL,必要时行PCI可能是合理的。

关键词(KeyWords)： 急性ST段抬高型心肌梗死;靶血管;非梗死相关病变;经皮冠状动脉介入治疗

Abstract:

Keywords:

基金项目(Foundation): 国家重点研发计划项目(2016YFC1301300)

作者(Author): 丛占春,赵昕,荆全民

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