马玉良,王伟民,刘健,卢明瑜,王龙,李琪,刘传芬

• 1:北京大学人民医院心脏中心

摘要(Abstract)：

目的比较血栓抽吸导管及血小板膜糖蛋白(GP)Ⅱb/Ⅲa受体拮抗剂在急性ST段抬高心肌梗死(STEMI)患者直接经皮冠状动脉介入治疗(PPCI)过程中的不同应用,探讨减轻血栓负荷,改善心肌灌注的最佳策略。方法回顾性分析2007年1月至2009年6月因STEMI于我院就诊,且急诊行PPCI的患者179例的临床资料。根据PPCI手术过程中对血栓处理方法的不同分为单纯介入对照组(n=74)、血栓抽吸组或GPⅡb/Ⅲa受体拮抗剂组(n=59)、血栓抽吸+GPⅡb/Ⅲa受体拮抗剂组(n=46)。比较各组术后慢血流或无复流、术后1hST段70%回落、术后肌酸激酶同工酶(CK-MB)及肌钙蛋白(Tn)I从发病到达峰值时间、术后1周超声左室射血分数(LVEF)及左室舒张末内径(LVDd)、术后大出血情况、住院期间死亡率等指标。结果血栓抽吸+GPⅡb/Ⅲa受体拮抗剂组与对照组相比,慢血流或无复流的发生率显著降低(6.5%比20.3%,P<0.05),最高导联ST段70%回落发生率显著升高(54.3%比23.0%,P<0.05);血栓抽吸或GPⅡb/Ⅲa受体拮抗剂组与对照组相比,慢血流或无复流的发生率有降低趋势(10.2%比20.3%),最高导联ST段70%回落发生率有升高趋势(37.3%比23.0%),但未达到统计学差异(P均>0.05)。术后CK-MB/TnI从发病到达峰值时间、术后1周超声提示LVEF/LVDd以及住院期间死亡率各组间差异无统计学意义(P>0.05)。术后大出血发生率各组间差异无统计学意义(P>0.05)。结论STEMI患者在PPCI术中联用血栓抽吸与GPⅡb/Ⅲa受体拮抗剂可有效减轻冠状动脉内血栓负荷,预防无复流现象,改善心肌组织微循环灌注。

关键词(KeyWords)： 心肌梗死;血管成形术,经腔,经皮冠状动脉;冠状动脉血栓形成;血小板膜糖蛋白Ⅱb/Ⅲa受体拮抗剂;血栓抽吸

Abstract:

Keywords:

基金项目(Foundation):

作者(Author): 马玉良,王伟民,刘健,卢明瑜,王龙,李琪,刘传芬

参考文献(References)：

• [1]Antman EM,Anbe DT,Armstron GPW,et al.ACC/AHA guide-lines for the management of patients with ST-elevation myocardial infarction.JACC,2004,44:671-719.
• [2]Silber S,Albertsson P,Aviles FF,et al.Guidelines for percutane-ous coronary interventions.The task force for percutaneous coro-nary interventions of the european society of cardiology.Eur Heart J,2005,26:804-847.
• [3]Keeley EC,Boura JA,Grines Cl.Primary angioplasty versus intra-venous thrombolytic therapy for acute myocardial infarction:a quantitative reviewof23randomised trials.Lancet,2003,361:13-20.
• [4]Rezkalla SH,Kloner RA.Coronary no-reflow phenomenon:from the experimental laboratory to the cardiac catheterization laborato-ry.Catheter Cardiovasc Interv,2008;72:950-957.
• [5]Eeckhout E,Kern MJ.The coronary no-reflow phenomenon:a re-view of mechanisms and therapies.Eur Heart J,2001,22:729-739.
• [6]Ugo Limbruno,Raffaele De Caterina.EMERALD,AIMI,and PROMISE:is there still a potential for embolic protection in pri-mary PCI-European Heart Journal,2006,27:1139-1145.
• [7]Burzotta F,Trani C,Romagnoli E,et al.Manual thrombusaspira-tion improves myocardial reperfusion:the randomized evaluation of the effect of mechanical reduction of distal embolization by thrombus-aspiration in primary and rescue angioplasty(REME-DIA)trial.JACC,2005,46:371-376.
• [8]Vlaar PJ,Svilaas T,vander Horst IC,et al.Cardiac death and re-infarction after1year in the Thrombus Aspiration during Percuta-neous coronary intervention in Acute myocardial infarction Study(TAPAS):a1-year follow-up study.Lancet,2008,371:1915-1920.
• [9]Petronio AS,De Carlo M,Ciabatti N,et al.Left ventricular re-modeling after primary coronary angioplasty in patients treated with abciximab or intracoronary adenosine.Am Heart J,2005,150:1015.
• [10]Montalescot G,Antoniucci D,Kastrati A,et al.Abciximab in pri-mary coronary stenting of ST-elevation myocardial infarction:a European meta-analysis on individual patients′data with long-term follow-up.Eur Heart J,2007,28:443-449.
• [11]Danzi GB,Sesana M,Capuano C,et al.Comparison in patients having primary coronary angioplasty of abciximab versus tirofiban on recovery of left ventricular function.Am J Cardiol,2004,94:35-39.
• [12]刘振江,周胜华,沈向前.替罗非班对急性ST段抬高型心肌梗死患者介入治疗术后心肌组织灌注水平的影响.临床心血管病杂志,2007,23,417-420.
• [13]谢晓春,刘胜林,杨军珂,等.替罗非班对急性心肌梗死急诊介入治疗后微血管功能不全和早期左心室重构的影响.中国循环杂志,2007,22,267-270.
• [14]沈杰,张奇,张瑞岩,等.急诊冠状动脉支架术联合国产替罗非班治疗急性ST段抬高性心肌梗死的临床疗效和安全性.中华心血管病杂志,2007,35,1005-1009.
• [15]Niccoli G,Burzotta F,Galiuto L,et al.No-Reflow in Humans.JACC,2009,54,281-292.