合并慢性闭塞病变的急性心肌梗死患者临床特点和近期预后分析

doi:10.3969/j.issn.1006-7795.2015.06.024

摘要/Abstract

摘要： 目的分析合并非梗死冠状动脉慢性闭塞(chronic total occlusion,CTO)的急性ST段抬高心肌梗死(ST-segment elevation myocardial infarction,STEMI)的临床特点,探讨CTO病变对STEMI近期预后的影响。方法回顾性分析2011年1月至2012年12月首都医科大学附属潞河医院心脏监护病房(cardiac care unit,CCU)连续收治的STEMI并行急诊经皮冠状动脉介入(percutaneous coronary intervention,PCI) 治疗的391例患者,根据是否存在CTO病变,分为2组:CTO组(n=41例),非CTO组(n=350例)。主要观察指标为分析合并CTO的STEMI 的临床特点、术后30 d主要不良心脏事件(major adverse cardiac event,MACE)发生率和影响MACE的相关因素。结果 CTO组年龄、心功能不全、肾功能不全、三支病变、休克、恶性心律失常和主动脉球囊反搏(intra-aortic balloon pupm,IABP)使用率方面均明显高于非CTO组(P < 0.05),CTO组在术后心肌梗死溶栓(thrombolysis in myocardial infarction,TIMI)3级血流明显低于非CTO组(P < 0.05)。CTO组的肌酸磷酸激酶同工酶(creatine kinase MB,CK-MB)峰值和左室舒张末期内径(left ventricular end-diastolic diameter,LVEDD)均明显高于非CTO组〔( 307.19±149.04)U/L vs (208.08±129.56)U/L;(55.48±5.58)mm vs (52.33±4.41)mm,P < 0.05〕。CTO组左室射血分数(left ventricular ejection fraction,LVEF)明显低于非CTO组(51.86±9.61 vs 57.76±9.20,P < 0.05)。CTO组术后30 d病死率和MACE发生率明显高于非CTO组(22.0 vs 2.9,22.0 vs 3.7,P < 0.05)。多因素Logistic分析预测STEMI患者PCI术后30 d MACE的独立变量依次是:PCI术后TIMI血流 < 3级、肾功能不全、前壁心肌梗死、年龄 ≥ 65岁、恶性心律失常、CTO。结论合并CTO的STEMI患者病情危重,易合并心、肾功能不全、休克、恶性心律失常,冠脉病变弥漫,常合并三支病变,急诊PCI术后TIMI3级血流比例低,30 d病死率和MACE发生率高。CTO病变是STEMI近期预后不良的预测因素。

关键词: 心肌梗死, 急性, 介入治疗, 慢性闭塞病变

Abstract: Objective To investigate the clinical features and prognostic analysis on patients with ST-segment elevation myocardial infarction(STEMI) with chronic total occlusion(CTO) in a non-infarct-related artery. Methods In this study, a total of 391 patients with STEMI and receiving primary percutaneous coronary intervention(PCI) were enrolled from January 2011 to November 2012 in Beijing Lube Hospital. According to the existence of CTO, patients were divided into 2 groups;CTO group(41 cases ) and non-CTO group(350 cases). Both groups were given conventional secondary prevention treatment. The clinical feature of STEMI with CTO was analysed. The primary end point was 30-day incidence of MACE and influencing factors on MACE. Results The age, heart failure, renal insufficiency, 3 diseased vessels, shock, malignant arrhythmia, the usage of intra-aortic balloon pupm(IABP) of CTO group were higher than those of non-CTO group(P < 0.05). The rate of thrombolysis in myocardial infarction(TIMI) flow grade 3 after PCI of CTO group was significantly lower than that of non-CTO group(P < 0.05). The peak level of creatine kinase MB(CK-MB) and the left ventricular end-diastolic diameter(LVEDD) in CTO group was significantly higher than that of non-CTO group〔(307.19±149.04)U/L vs (208.08±129.56)U/L;(55.48±5.58)mm vs (52.33±4.41)mm, P < 0.05〕. The ejection fraction(EF) of CTO group was significantly lower than that of non-CTO group(51.86±9.61 vs 57.76±9.20, P < 0.05). The 30-days mortality and MACE of CTO group was significantly higher than that of non-CTO group(22.0 vs 2.9;22.0 vs 3.7, P < 0.05). A stepwise Logistic regression analysis further suggested the following independent predictors to 30-day incidence of major adverse cardiac event(MACE):TIMI flow grade < 3 after PCI, renal insufficiency, anterior wall infarction, age ≥ 65, malignant arrhythmia, CTO. Conclusion The incidence of heart failure, renal insufficiency, shock, malignant arrhythmia and 3 diseased vessels of CTO group was higher than that of non-CTO group. The rate of TIMI flow grade 3 after PCI of CTO group was lower than that of non-CTO group. The 30-days mortality and MACE of CTO group was significantly higher than that of non-CTO group. CTO was the predicting factor of 30-days poor prognosis of STEMI.

Key words: myocardial infarction, acute, percutaneous intervention, chronic total occlusion

中图分类号:

R542.2

许敏, 郭金成, 张海滨. 合并慢性闭塞病变的急性心肌梗死患者临床特点和近期预后分析[J]. 首都医科大学学报, 2015, 36(6): 969-973.

Xu Min, Guo Jincheng, Zhang Haibin. Clinical features and prognostic analysis on patients with ST-segment elevation myocardial infarction with chronic total occlusion[J]. Journal of Capital Medical University, 2015, 36(6): 969-973.

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