赵琳,耿巍,田祥,张旗,宋达,杨颖,桑大森,傅向华

• 1:承德医学院
• 2:保定市第一中心医院心内科
• 3:河北医科大学第二医院心内科

摘要(Abstract)：

目的研究缺血后适应对急性ST段抬高型心肌梗死(STEMI)患者心脏结构及功能的影响。方法全面检索Medline、Embase、the Cochrane Central Register of Controlled Trials、中国生物医学文献数据库、中国知网、万方数据库及维普期刊数据库,检索时间为从建库至2018年4月30日。主要结局指标为最终梗死面积、左心室射血分数,次要结局指标为心肌水肿程度、心肌挽救指数、微循环障碍发生率、左心室舒张末期容积。以上所有指标均通过心脏核磁共振成像评估及量化。结果共有12个研究纳入Meta分析。对于STEMI患者,冠状动脉内缺血后适应联合经皮冠状动脉介入治疗(PCI)与单纯PCI相比,可以显著减少最终心肌梗死面积(SMD–0.19,95%CI–0.38～0.00,P=0.048),可以显著增加左心室射血分数(WMD 1.62,95%CI0.39～2.85,P=0.010)及心肌挽救指数(WMD 3.69,95%CI0.25～7.13,P=0.035),有降低心肌水肿的趋势(SMD–0.18,95%CI–0.38～0.01,P=0.057),但未能显著降低微循环障碍发生率(RR 0.98,95%CI 0.84～1.14,P>0.05),未能减小左心室舒张末期容积(WMD–0.15,95%CI–3.05～2.74,P>0.05)。结论对于STEMI患者,缺血后适应联合PCI可以降低最终梗死面积、增加左心室射血分数及心肌挽救指数,并有降低心肌水肿的趋势,对心脏有显著保护作用,但未能降低微循环障碍发生率及左心室舒张末期容积。

关键词(KeyWords)： ST段抬高型心肌梗死;缺血后适应;心脏核磁共振成像;经皮冠状动脉介入治疗;缺血/再灌注损伤;Meta分析

Abstract:

Keywords:

基金项目(Foundation):

作者(Author): 赵琳,耿巍,田祥,张旗,宋达,杨颖,桑大森,傅向华

参考文献(References)：

• [1]Ibanez B,James S,Agewall S,et al.2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation:the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology(ESC).Eur Heart J,2018,39(2):119-177.
• [2]Fox KA,Carruthers KF,Dunbar DR,et al.Underestimated and under-recognized:the late consequences of acute coronary syndrome(GRACE UK-Belgian Study).Eur Heart J,2010,31(22):2755-2764.
• [3]Yellon DM,Hausenloy DJ.Myocardial reperfusion injury.N Engl JMed,2007,357(11):1121-1135.
• [4]Murry CE,Jennings RB,Reimer KA.Preconditioning with ischemia:a delay of lethal cell injury in ischemic myocardium.Circulation,1986,74(5):1124-1136.
• [5]Zhao ZQ,Corvera JS,Halkos ME,et al.Inhibition of myocardial injury by ischemic postconditioning during reperfusion:comparison with ischemic preconditioning.Am J Physiol Heart Circ Physiol,2003,285(2):H579-H588.
• [6]Hahn JY,Song YB,Kim EK,et al.Ischemic postconditioning during primary percutaneous coronary intervention:the effects of postconditioning on myocardial reperfusion in patients with STsegment elevation myocardial infarction(POST)randomized trial.Circulation,2013,128(17):1889-1896.
• [7]Thibault H,Piot C,Staat P,et al.Long-term benefi t of postconditioning.Criculation,2008,117(8):1037-1044.
• [8]Staat P,Rioufol G,Piot C,et al.Postconditioning the human heart.Circulation,2005,112(14):2143-2148.
• [9]Bodi V,Ruiz-Nodar JM,Feliu E,et al.Eff ect of ischemic postconditioning on microvascular obstruction in reperf used myocardial infarction.Results of a randomized study in patients and of an experimental model in swine.Int J Cardiol,2014,175(1):138-146.
• [10]L?nborg J,Holmvang L,Kelb?k H,et al.ST-Segment resolution and clinical outcome with ischemic postconditoning and comparison to magnetic resonnance.Am Heart J,2010,160(6):1085-1091.
• [11]Tarantini G,Favaretto E,Marra MP,et al.Postconditioning during coronary angioplasty in acute myocardial infarction:the POST-AMI trial.Int J Cardiol,2012,162(1):33-38.
• [12]Holman ER,van Jonbergen HP,van Dijkman PR,et al.Comparison of magnetic resonance imaging studies with enzymatic indexes of myocardial necrosis for quantification of myocardial infarct size.Am J Cardiol,1993,71(12):1036-1040.
• [13]Thiele H,Kappl MJ,Conradi S,et al.Reproducibility of chronic and acute infarct size measurement by delayed enhancement-magnetic resonance imaging.J Am Coll Cardiol,2006,47(8):1641-1645.
• [14]Ibrahim T,Bulow HP,Hackl T,et al.Diagnostic value of contrastenhanced magnetic resonance imaging and single-photon emission computed tomography for detection of myocardial necrosis early after acute myocardial infarction.J Am Coll Cardiol,2007,49(2):208-216.
• [15]Cerqueira MD,Weissman NJ,Dilsizian V,et al.Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart.A statement for healthcare professionals from the cardiac imaging committee of the council on clinical cardiology of the American Heart Association.Circulation,2002,105(4):539-542.
• [16]Araszkiewicz A,Grygier M,Pyda M,et al.Ischaemic postconditioning reduces the extent of myocardial necrosis and microvascular obstruction zone in acute ST-elevation myocardial infarction.J Am Coll Cardio,2017,70(18):B288-B289.
• [17]王昆仑,张守彦,薛书峰,等.缺血后适应对65岁以下急性ST段抬高型心肌梗死患者的心脏保护作用.慢性病学杂志,2017,18(2):131-134.
• [18]Moher D,Liberati A,Tetzlaff J,et al.Preferred reporting items for systematic reviews and meta-analyses:the PRISMA statement.Int JSurg,2010,8(5):336-341.
• [19]Higgins JP,Altman DG,G?tzsche PC,et al.The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.BMJ,2011,343:d5928.
• [20]Larose E,Rodés-Cabau J,Pibarot P,et al.Predicting late myocardial recovery and outcomes in the early hours of ST-segment elevation myocardial infarction traditional measures compared with microvascular obstruction,salvaged myocardium,and necrosis characteristics by cardiovascular magnetic resonance.J Am Coll Cardiol,2010,55(22):2459-2469.
• [21]Giri S,Chung YC,Merchant A,et al.T2 quantification for improved detection of myocardial edema.J Cardiovasc Magn Reson,2009,11(1):56.
• [22]Mewton N,Thibault H,Roubille F,et al.Postconditioning attenuates no-refl ow in STEMI patients.Basic Res Cardiol,2013,108(6):383.
• [23]L?nborg J,Kelb?k H,Vejlstrup N,et al.Cardioprotective eff ects of ischemic Postconditioning in patients treated with primary percutaneous coronary intervention,evaluated by magnetic resonance.Circ Cardiovasc Interv,2010,3(1):34-41.
• [24]Dwyer NB,Mikami Y,Hilland D,et al.No cardioprotective benefi t of ischemic postconditioning in patients with ST-segment elevation myocardial infarction.J Interv Cardiol,2013,26(5):482-490.
• [25]S?rensson P,Rydén L,Saleh N,et al.Long-term impact of postconditioning on infarct size and left ventricular ejection fraction in patients with ST-elevation myocardial infarction.BMC Cardiovasc Disord,2013,13:22.
• [26]Thuny F,Lairez O,Roubille F,et al.Post-conditioning reduces infarct size and edema in patients with ST-segment elevation myocardial infarction.J Am Coll Cardiol,2012,59(24):2175-2181.
• [27]El?bieciak M,Wita K,Grabka M,et al.Eff ect of postconditioning on infarction size,adverse left ventricular remodeling,and improvement in left ventricular systolic function in patients with fi rst anterior ST segment elevation myocardial infarction.Pol Arch Med Wewn,2013,123(6):268-276.
• [28]Freixa X,Bellera N,Ortiz-Pérez JT,et al.Ischaemic postconditioning revisited:lack of effects on infarct size following primary percutaneous coronary intervention.Eur Heart J,2012,33(1):103-112.
• [29]Kim EK,Hahn JY,Song YB,et al.Effect of ischemic postconditioning on myocardial salvage in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction:cardiac magnetic resonance substudy of the POST randomized trial.Int J Cardiovasc Imaging,2015,31(3):629-637.
• [30]Limalanathan S,Andersen G?,Kl?w NE,et al.Effect of ischemic postconditioning on infarct size in patients with ST-elevation myocardial infarction treated by primary PCI results of the POSTEMI(Postconditioning in ST-elevation myocardial infarction)randomized trial.J Am Heart Assoc,2014,3(2):e000679.
• [31]Piper HM,Meuter K,Sch?fer C.Cellular mechanisms of ischemiareperfusion injury.Ann Thorac Surg,2003,75(2):S644-S648.
• [32]Wright J,Adriaenssens T,Dymarkowski S,et al.Quantifi cation of myocardial area at risk with T2-weighted CMR:comparison with contrast-enhanced CMR and coronary angiography.JACC Cardiovasc Imaging,2009,2(7):825-831.
• [33]Lou B,Cui Y,Gao H,et al.Meta-analysis of the eff ects of ischemic postconditioning on structural pathology in ST-segment elevation acute myocardial infarction.Oncotarget,2017,9(8):8089-8099.
• [34]Abdelnoor M,Sandven I,Limalanathan S,et al.Postconditioning in ST-elevation myocardial infarction:A systematic review,critical appraisal,and meta-analysis of randomized clinical trials.Vasc Health Risk Manag,2014,10:477-491.
• [35]Araszkiewicz A,Grygier M,Pyda M,et al.Postconditioning reduces enzymatic infarct size and improves microvascular reperfusion in patients with ST-segment elevation myocardial infarction.Cardiology,2014,129(4):250-257.
• [36]Khan AR,Binabdulhak AA,Alastal Y,et al.Cardioprotective role of ischemic postconditioning in acute myocardial infarction:a systematic review and meta-analysis.Am Heart J,2014,168(4):512-521.
• [37]S?rensson P,Saleh N,Bouvier F,et al.Eff ect of postconditioning on infarct size in patients with ST elevation myocardial infarction.Heart,2010,96(21):1710-1715.
• [38]Zhao M,Sonnenblick EH,Zhang H,et al.Increase in myofi lament separation in the"stunned"myocardium.J Mol Cell Cardiol,1992,24(3):269-276.
• [39]Heusch G.Cardioprotection:chances and challenges of its translation to the clinic.Lancet,2013,381(9861):166-175.
• [40]Minamino T.Cardioprotection from ischemia/reperfusion injury:basic and translational research.Circ J,2012,76(5):1074-1082.