老年急性ST段抬高心肌梗死急诊介入治疗后心肌组织水平再灌注不良的发生率及其对临床预后的影响

摘要

Objective To explore the incidence and the prognostic impact of poor reperfusion state on myocardial level in elderly acute ST-elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention ( PCI) . Methods A formal analysis was performed in 398 patients undergoing primary PCI for STEMI. The analysis of ECGs and TIMI Myocardial Perfusion grade was done retrospectively with the reader blinded to the clinical course. All the patients were divided into 4 groups. Group A: the patients whose ST segment dropped >50% and got TMP grade Ⅲ perfusion after PCI; Group B: the patients whose ST segment dropped <50% and got TMP grade IB perfusion after PCI; Croup C: the patients whose ST segment dropped >50% and got poor perfusion TMP graded II after PCI; Croup D: the patients whose ST segment dropped <50% and the perfusion TMP graded II after PCI. The clinical characteristics and the prognosis were compared among different groups. Results Although TIMI grade H flow was achieved after mechanical reperfusion, about 1/3 patients got an abnormal reperfusion state on tnyocardial level detected by STR and TIMI Myocardial Perfusion grade, and about 14.3% patients got a poor reperfusion state on myocardial level. These patients were older, had higher comorbidities of cardiac dysfunction and diabetes, had longer time of Pain to Balloon/emergency room, et aL Compared with the patients with better reperfusion, they were associated with a longer hospital admission time, lower LVEF, high ratio of postinfarction angina and distal embolism, higher IABP utility rates. Compared with group D, a higher ratio of in hospital MACE event and during follow up were found as the incidence of MACE is 43% in group C (P = 0. 11) , 24% in group B (P < 0.01 ) and 2.7% in group A (P < 0. 01 ). Conclusions In the elderly patients of acute STEMI after primary PCI, only 40% patients got good reperfusion state on myocardial level, and more than half of the patients got an abnormal reperfusion state and 14. 3% patients got a poor reperfusion state. These patients were associated with a higher rates of in hospital MACE event and during follow up.%目的 探讨老年急性心肌梗死(acute myocardial infarction,AMI) -急诊经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗后心肌组织水平再灌注状态不良的发生率及其对近、远期临床预后的影响.方法 回顾性收集398例老年急性ST段抬高心肌梗死(ST-elevation myocardial infarction,STEMI)行急诊PCI治疗患者的临床资料、冠状动脉造影资料与心电图,以ST段回落程度与TIMI心肌灌注(TIMI Myocardial Perfusion,TMP)分级等指标评估心肌组织水平再灌注状态,患者分为4组,A组为ST段回落率＞50%并且术后TMP分级为Ⅲ级；B组为ST段回落率＜50%而术后TMP分级=Ⅲ级；C组为术后TMP分级≤Ⅱ级而ST段回落率＞50%；D组为ST段回落率＜50%并且术后TMP分级≤Ⅱ级.分析心肌组织水平再灌注不良患者的发生率及其对近远期预后的影响.结果 STEMI急诊PCI术后梗死相关血管(infarction related artery,IRA)前向血流达到TIMIⅢ级而TMP分级为Ⅱ级以下者占37.2%,心电图ST段回落小于50%者占37.2%,均接近1/3.12.5%的患者具有远端栓塞.术后ST段回落率＞50%并且TMP分级为Ⅲ级者占总人数的39.8%,ST段回落率＜50%,并且术后TMP分级≤Ⅱ级占总人数的14.3%.心肌组织灌注状态不良者与心肌组织灌注状态良好者相比平均住院日更长,左室EF值更低,梗死后心绞痛发生率更高,远端栓塞发生率更高,IABP辅助应用比率更大,心功能恶化、心脏性死亡更高.与D组相比,随访期间MACE的发生风险在C组为43% (P =0.11),在B组为24% (P＜0.01),在A组为2.7%(P＜0.01).结论 老年急性心肌梗死行急诊PCI治疗后IRA再通者仅有不到40%的患者其心肌组织水平得到了良好的再灌注,其近、远期预后较好,而剩余约60%的患者其心肌组织水平存在不同程度的再灌注障碍,其中有大概约超过10%的患者其心肌组织水平存在较差的再灌注状态,这些患者在住院期间以及远期随访期间有着极高的MACE发生风险.