院前肝素化联合一包药与急性ST段抬高型心肌梗死患者血管再通的相关性

doi:10.3969/j.issn.1004-583X.2023.03.006

摘要/Abstract

摘要：

目的探讨院前肝素化联合一包药(阿司匹林300 mg,氯吡格雷300 mg,阿托伐他汀40 mg)与直接经皮冠状动脉介入治疗(primary percutaneous coronary intervention, PPCI)对急性ST段抬高型心肌梗死(ST segment elevation myocardial infarction,STEMI)患者的血管再通价值。方法选取2021年6月至2022年8月就诊于我院行 PPCI的急性STEMI患者77例为研究对象,按照院前、院内肝素化联合一包药分为观察组( $n$ =21)和对照组( $n$ =56),其中观察组经胸痛中心联络微信群确诊为STEMI后立即静脉注射普通肝素5 000 U联合一包药;对照组是患者自行来院到我院急诊科确诊为STEMI后,院内给予普通肝素5 000 U联合一包药,立刻一键启动导管室行PPCI。对比分析两组的基线特征、即刻冠状动脉造影、血清学指标、术后主要心血管不良事件的发生情况、心肌梗死溶栓试验(the thrombolysis in myocardial infarction, TIMI)复流情况。结果两组性别、年龄、高血压、糖尿病、高血脂、症状发作时间等基线资料差异均无统计学意义( $P$ >0.05);两组前降支(left anterior descending artery,LAD)、回旋支(left circumflex artery,LCX)、右冠状动脉(right coronary artery,RCA)等心肌梗死相关动脉以及TIMI 2级比较,差异无统计学意义( $P$ >0.05),TIMI 0~1级、3级比较,差异有统计学意义( $P$ <0.05);两组术后的肌酸激酶同工酶(creatine kinase-MB,CK-MB)、血小板/淋巴细胞比值(platelet/lymphocyte ratio,PLR)、单核细胞/高密度脂蛋白胆固醇比值(monocyte /high-density lipoprotein cholesterol ratio, MHR)均较术前低,且观察组低于对照组( $P$ <0.05);两组术后发生心源性死亡、心力衰竭、卒中、再发性心绞痛和再次血运重建的概率差异无统计学意义( $P$ >0.05),而在出血发生概率上,观察组明显低于对照组( $P$ <0.05);对照组术后无复流率为19.6%,观察组没有无复流情况,对照组无复流率明显高于观察组( $P$ <0.05)。结论针对STEMI患者院前肝素化联合一包药的应用,不仅能有效提高梗死相关血管(infarction related artery,IRA)的再通率,改善心肌灌注和血清学指标水平,具有较高的安全性,显著降低术后无复流的发生率和术后心血管不良事件的发生率,改善预后,促进患者康复。

关键词: ST段抬高型心肌梗死, 经皮冠状动脉介入治疗, 肝素, 一包药, 急救医疗服务

Abstract:

Objective To explore the value of pre-hospital heparinization combined with one pack of drugs(Aspirin enteric-coated tablets 300 mg, Clopidogrel 300 mg, Atorvastatin tablets 40 mg) in patients with acute ST-segment elevation myocardial infarction (STEMI) underwent primary percutaneous coronary intervention (PPCI).Methods Totally 77 patients with acute STEMI who underwent PPCI in our hospital from June 2021 to August 2022 were enrolled as subjects. All subjects were allocated to observation group ( $n$ =21) and control group ( $n$ =56) according to the pre-hospital and in-hospital heparinization combined with one package of drugs. In the observation group, after being diagnosed as STEMI by the Chest Pain Center via contacting WeChat Group, the patient was intravenously injected with 5,000 U of ordinary heparin in combination with one pack of drugs immediately. In the control group, after the patient came to the emergency department of our hospital and diagnosed as STEMI, the patient was given 5,000 U of unfractionated heparin (UFH) combined with one pack of drugs, and immediately started PPCI in the catheter room. The baseline characteristics, immediate coronary angiography, serological indicators, major postoperative cardiovascular adverse events and reflow status in the thrombolysis in myocardial infarction (TIMI) test were compared between the two groups. Results There were no significant differences in gender, age, hypertension, diabetes, hyperlipidemia, symptom onset time and other baseline data between the two groups ( $P$ >0.05). There was no significant difference between the two groups in left descending artery (LAD), left circumflex artery(LCX), right coronary artery(RCA) and other infarction related artery (IRA) and TIMI2 grade ( $P$ >0.05),TIMI grades 0~1 and 3 were compared, and the difference was statistically significant ( $P$ <0.05). Postoperative values of creatine kinase MB (CK-MB), platelet / lymphocyte ratio(PLR) and monocyte / high-density lipoprotein cholesterol (HDL-C) ratio (MHR) in both groups were obviously lower than those before surgery, and the observation group was significantly lower than the control group ( $P$ <0.05). There were no significant differences in the probability of postoperative cardiac death, heart failure, stroke, recurrent angina, and revascularization between the two groups ( $P$ >0.05). However, the probability of bleeding in the observation group was significantly lower than that in the control group ( $P$ <0.05).The postoperative no-reflow rate in the control group was 19.6%, and there was no no-reflow in the observation group, indicating the no-reflow rate in the control group was significantly higher than the observation group ( $P$ <0.05).Conclusion The application of pre hospital heparin combined with one pack of drugs in patients with STEMI can not only effectively improve the revascularization rate of IRA, improve myocardial perfusion and serological indicators, but also significantly reduce the incidence of postoperative no-reflow and cardiovascular adverse events, improve prognosis and promote recovery.

Key words: ST-segment elevation myocardial infarction(STEMI), percutaneous coronary intervention(PCI), heparin, one pack of drugs, emergency medical service

中图分类号:

R542.22

闫海燕, 丁延魁, 郏红静, 王记远, 张学伟, 胡银杰, 楚骏杰, 胡红艳, 过高峰. 院前肝素化联合一包药与急性ST段抬高型心肌梗死患者血管再通的相关性[J]. 临床荟萃, 2023, 38(3): 232-236.

Yan Haiyan, Ding Yankui, JiaHongjing , WangJiyuan , Zhang Xuewei, Hu Yinjie, Chu Junjie, Hu Hongyan, Guo Gaofeng. Correlation of pre-hospital heparinization combined with one pack of drugs and revascularization in patients with acute ST-segment elevation myocardial infarction[J]. Clinical Focus, 2023, 38(3): 232-236.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2023.03.006

https://huicui.hebmu.edu.cn/CN/Y2023/V38/I3/232

图/表 5

表1 患者基线特征

Tab.1 Baseline characteristics of patients

组别	例数	性别[例(%)]		年龄 (岁)	高血压 [例(%)]	糖尿病 [例(%)]	高血脂 [例(%)]	症状发作时间 (h)
组别	例数	男	女	年龄 (岁)	高血压 [例(%)]	糖尿病 [例(%)]	高血脂 [例(%)]	症状发作时间 (h)
观察组	21	16(76.2)	5(23.8)	67.57±11.66	16(76.2)	4(19.0)	3(14.3)	2.40±2.07
对照组	56	46(82.1)	10(17.9)	62.75±12.08	36(64.3)	13(23.2)	18(32.1)	3.19±2.55
$t$ /χ²值		0.345		1.574	0.987	0.070	1.638	1.258
$P$ 值		0.557		0.120	0.320	0.933	0.201	0.212

表1 患者基线特征

Tab.1 Baseline characteristics of patients

组别	例数	性别[例(%)]		年龄 (岁)	高血压 [例(%)]	糖尿病 [例(%)]	高血脂 [例(%)]	症状发作时间 (h)
组别	例数	男	女	年龄 (岁)	高血压 [例(%)]	糖尿病 [例(%)]	高血脂 [例(%)]	症状发作时间 (h)
观察组	21	16(76.2)	5(23.8)	67.57±11.66	16(76.2)	4(19.0)	3(14.3)	2.40±2.07
对照组	56	46(82.1)	10(17.9)	62.75±12.08	36(64.3)	13(23.2)	18(32.1)	3.19±2.55
$t$ /χ²值		0.345		1.574	0.987	0.070	1.638	1.258
$P$ 值		0.557		0.120	0.320	0.933	0.201	0.212

表2 两组急诊冠状动脉造影结果比较[例(%)]

Tab.2 Comparison results of emergency coronary angiography[cases(%)]

组别	例数	IRA			TIMI分级
组别	例数	LAD	LCX	RCA	0~1级	2级	3级
观察组	21	12(57.1)	1(4.8)	8(38.1)	13(61.9)	2(9.5)	6(28.6)
对照组	56	25(44.6)	9(16.1)	22(39.3)	53(94.6)	2(3.6)	1(1.8)
χ²值		0.956	0.873	0.009	13.368	0.222	10.216
$P$ 值		0.328	0.350	0.924	<0.01	0.637	0.01

表2 两组急诊冠状动脉造影结果比较[例(%)]

Tab.2 Comparison results of emergency coronary angiography[cases(%)]

组别	例数	IRA			TIMI分级
组别	例数	LAD	LCX	RCA	0~1级	2级	3级
观察组	21	12(57.1)	1(4.8)	8(38.1)	13(61.9)	2(9.5)	6(28.6)
对照组	56	25(44.6)	9(16.1)	22(39.3)	53(94.6)	2(3.6)	1(1.8)
χ²值		0.956	0.873	0.009	13.368	0.222	10.216
$P$ 值		0.328	0.350	0.924	<0.01	0.637	0.01

表3 两组血清学指标比较( x -±s)

Tab.3 Comparison of Serological indexes ( x -±s)

组别	例数	CK-MB(μg/L)		PLR		MHR
组别	例数	术前	术后	术前	术后	术前	术后
观察组	21	78.21±5.77	35.12±4.27^*	153.28±12.01	100.24±8.77^*	22.42±4.31	9.54±3.11^*
对照组	56	77.67±5.69	49.13±4.85	152.16±11.34	126.13±9.86	22.13±4.18	15.16±3.89
$t$ 值		0.369	11.643	0.380	10.560	0.269	5.939
$P$ 值		0.713	<0.01	0.705	<0.01	0.789	<0.01

表3 两组血清学指标比较( x -±s)

Tab.3 Comparison of Serological indexes ( x -±s)

组别	例数	CK-MB(μg/L)		PLR		MHR
组别	例数	术前	术后	术前	术后	术前	术后
观察组	21	78.21±5.77	35.12±4.27^*	153.28±12.01	100.24±8.77^*	22.42±4.31	9.54±3.11^*
对照组	56	77.67±5.69	49.13±4.85	152.16±11.34	126.13±9.86	22.13±4.18	15.16±3.89
$t$ 值		0.369	11.643	0.380	10.560	0.269	5.939
$P$ 值		0.713	<0.01	0.705	<0.01	0.789	<0.01

表4 两组主要心血管不良事件发生情况比较[例(%)]

Tab.4 Comparison of Major cardiovascular adverse events[cases(%)]

组别	例数	心源性死亡	心力衰竭	卒中	再发性心绞痛	再次血运重建	出血
观察组	21	0(0)	1(4.8)	1(4.8)	2(9.5)	1(4.8)	0(0)
对照组	56	1(1.8)	3(5.4)	2(3.6)	4(7.1)	3(5.4)	10(17.9)
χ²值		0.380	0.011	0.058	0.121	0.011	4.226
$P$ 值		0.538	0.917	0.810	0.728	0.917	0.040

表4 两组主要心血管不良事件发生情况比较[例(%)]

Tab.4 Comparison of Major cardiovascular adverse events[cases(%)]

组别	例数	心源性死亡	心力衰竭	卒中	再发性心绞痛	再次血运重建	出血
观察组	21	0(0)	1(4.8)	1(4.8)	2(9.5)	1(4.8)	0(0)
对照组	56	1(1.8)	3(5.4)	2(3.6)	4(7.1)	3(5.4)	10(17.9)
χ²值		0.380	0.011	0.058	0.121	0.011	4.226
$P$ 值		0.538	0.917	0.810	0.728	0.917	0.040

表5 两组术后TIMI复流情况比较[例(%)]

Tab.5 Comparison of TIMI reflow after operation[cases(%)]

组别	例数	0级	1级	2级	3级	无复流率
观察组	21	0(0)	0(0)	0(0)	21(100.0)	0
对照组	56	0(0)	0(0)	11(19.6)	45(80.4)	11(19.6)
χ²值		-	-	-	-	4.813
$P$ 值		-	-	-	-	0.028

表5 两组术后TIMI复流情况比较[例(%)]

Tab.5 Comparison of TIMI reflow after operation[cases(%)]

组别	例数	0级	1级	2级	3级	无复流率
观察组	21	0(0)	0(0)	0(0)	21(100.0)	0
对照组	56	0(0)	0(0)	11(19.6)	45(80.4)	11(19.6)
χ²值		-	-	-	-	4.813
$P$ 值		-	-	-	-	0.028

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