罗新林,刘强,王丽丽,翁建新,左辉华,魏熠,曹茜

• 1:深圳市孙逸仙心血管医院心内科

摘要(Abstract)：

目的研究高血栓负荷的ST段抬高急性心肌梗死(STEMI)患者血栓抽吸后,延迟置入支架对患者预后的影响。方法选取129例血栓积分评分≥2分,经皮冠状动脉球囊扩张成形术(PTCA)和(或)血栓抽吸后血栓积分评分≤2分的STEMI患者纳入本研究,随机分为即时支架组(65例)和延期支架组(64例)。结果两组患者支架置入后TIMI积分、术后2 h ST段回落≥50%比较,差异均无统计学意义;而TIMI心肌灌注分级(TMP)积分即刻支架组显著低于延期支架组,差异有统计学意义(P<0.001)。延期支架组术后6个月较入院时左心室舒张末期容积(LVEDV)、左心室收缩末期容积(LVESV)降低,左心室射血分数(LVEF)升高,其中LVEDV降低差异有统计学意义(P<0.05);即时支架组6个月后较入院时LVEDV、LVESV升高,LVEF降低,其中LVESV升高(P<0.05)和LVEF降低(P<0.001)差异有统计学意义。术后30 d内两组间主要不良心血管事件(MACE)及主要出血事件比较,差异均无统计学意义。术后12个月时,两组心源性死亡、再发心肌梗死、靶血管血运重建比较,差异均无统计学意义(P<0.05),但即时支架组心力衰竭发生率较延期支架组显著增多(P<0.05),使得即时支架组MACE事件发生率较延期支架组显著升高(P<0.05)。两组间比较,延期支架组住院天数较即时支架组增多,差异有显著统计学意义(P<0.001),且住院费用显著增多,差异有显著统计学意义(P<0.001)。结论对于高血栓负荷的STEMI患者,经PTCA、血栓抽吸、强化抗栓处理后延迟行支架置入,可更好地改善患者的心肌灌注,减少心力衰竭的发生,从而使MACE事件发生率下降,但延期支架置入术患者的住院天数和住院费用会相应增加。

关键词(KeyWords)： 心肌梗死;血栓;心肌灌注;延迟行支架置入

Abstract:

Keywords:

基金项目(Foundation): 中国医师协会阳光心血管研究基金(SCRFCMDA201110)

作者(Author): 罗新林,刘强,王丽丽,翁建新,左辉华,魏熠,曹茜

参考文献(References)：

• [1]Steg PG,James SK,Atar D,et al.ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.Eur Heart J,2012,33:2569-2619.
• [2]O'Gara PT,Kushner FG,Ascheim DD,et al.2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction:executive summary:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Circulation,2013,127:529-555.
• [3]Vlaar PJ,Svilaas T,van der Horst IC,et al.Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary interventionin Acute myocardial infarction Study(TAPAS):a 1-year follow-up study.Lancet,2008,371:1915-1920.
• [4]Henriques JP,Zijlstra F,Ottervanger JP,et al.Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction.Eur Heart J,2002,23:1112-1117.
• [5]van't Hof AW,Liem A,Suryapranata H,et al.Angiographic assessment of myocardial reperfusion in patients treated with primary angioplasty for acute myocardial infarction:myocardial blush grade.Zwolle Myocardial Infarction Study Group.Circulation,1998,97:2302-2306.
• [6]Burzotta F,Trani C,Romagnoli E,et al.A pilot study with a new,rapid-exchange,thrombus-aspirating device in patients with thrombus-containing lesions:the Diver C.E.study.Catheter Cardiovasc Interv,2006,67:887-893.
• [7]Wiviott SD,Antman EM,Gibson CM,et al.Evaluation of prasugrel compared with clopidogrel in patients with acute coronary syndromes:design and rationale for the TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet Inhibitio N with prasugrel Thrombolysis In Myocardial Infarction38(TRITON-TIMI38).Am Heart J,2006,152:627-635.
• [8]Antman EM,Anbe DT,Armstrong PW,et al.ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction-executive summary.A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines(Writing Committee to revise the1999 guidelines for the management of patients with acute myocardial infarction).J Am Coll Cardiol,2004,44:671-719.
• [9]颜红兵,霍勇.急性冠状动脉综合征:认清本质指导实践.中国介入心脏病学杂志,2014,22:1-3.
• [10]Jaster M,Schwimmbeck P,Spensker S,et al.Randomized comparison of platelet-leukocyte aggregates and platelet activation in blood:heparin-coatedcoiled wire stent implantation versus balloon angioplasty in acute myocardial infarction.Thromb Res,2003,112:285-289.
• [11]Wilson SH,Berger PB,Mathew V,et al.Immediate and late outcomes after direct stent implantation without balloon predilatation.J Am Coll Cardiol,2000,35:937-943.
• [12]Warnholtz A,Ostad MA,Heitzer T,et al.Effect of tirofiban on percutaneous coronary intervention-induced endothelial dysfunction inpatients with stable coronary artery disease.Am J Cardiol,2005,95:20-23.
• [13]Antman EM,Anbe DT,Armstrong PW,et al.ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction-executive summary.A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines(Writing Committee to revise the1999 guidelines for the management of patients with acute myocardial infarction).J Am Coll Cardiol,2004,44:671-719.
• [14]Silber S,Albertsson P,Aviles FF,et al.Guidelines for percutaneous coronary interventions.The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology.Eur Heart J,2005,26:804-847.
• [15]Nagata Y,Usuda K,Uchiyama A,et al.Characteristics of the pathological images of coronary artery thrombi according to the infarct-related coronary artery in acute myocardial infarction.Circ J,2004,68:308-314.
• [16]Kang S,Yang Y.Coronary microvascular reperfusion injury and no-reflow in acute myocardial infarction.Clin Invest Med,2007,30:133-145.
• [17]胡立群,顾晔,曾昆,等.急诊经皮冠状动脉球囊扩张成形术延期支架置入对急性ST段抬高心肌梗死患者预后的影响.上海医学,2011,34:54-57.
• [18]胡信群,刘振江,方臻飞,等.延迟支架植入在高血栓负荷急性心肌梗死急诊介入治疗中的应用.中南大学学报(医学版),2010,35:483-486.
• [19]Tang L,Zhou SH,Hu XQ,et al.Effect of delayed vs immediate stent implantation on myocardial perfusion and cardiac function inpatients with ST-segment elevation myocardial infarction undergoing primary percutaneous intervention with thrombus aspiration.Can J Cardiol,2011,27:541-547.
• [20]Carrick D,Oldroyd KG,Mc Entegart M,et al.A randomized trial of deferred stenting versus immediate stenting to prevent no-or slow-reflow in acute ST-segment elevation myocardial infarction(DEFER-STEMI).J Am Coll Cardiol,2014,63:2088-2098.
• [21]Meneveau N,Séronde MF,Descotes-Genon V,et al.Immediate versus delayed angioplasty inacute myocardial infarction patients.Clin Res Cardiol,2009,98:257-264.