發(fā)布時間：2018-05-07 12:10

  本文選題：ST段抬高性心肌梗死 + 無復流　； 參考：《天津醫(yī)科大學》2017年博士論文

【摘要】：目的:急性ST段抬高型心肌梗死(ST segment elevation myocardial infarction,STEMI)患者行直接經皮冠狀動脈介入治療(percutaneous coronary interventions,PCI)術后梗死相關動脈(infarction related artery,IRA)發(fā)生無復流現(xiàn)象,受損心肌的功能不但未得到恢復,反而損傷加重。雖然治療策略不斷改進,發(fā)生無復流仍然會導致患者預后不良。如何快速、準確地預測無復流的發(fā)生仍待進一步研究。通過分析無復流現(xiàn)象相關的臨床治療、造影特征、心電圖及化驗結果來識別高危人群,有助于降低無復流的發(fā)生率,但目前仍缺乏一個既及時高效又臨床實用的評分系統(tǒng)。本研究旨在探討發(fā)生無復流現(xiàn)象相關危險因素、建立簡便實用的無復流風險評分系統(tǒng),并對STEMI患者直接PCI無復流的發(fā)生進行危險分層,為臨床提供防治直接PCI術后無復流的新措施,降低并發(fā)癥發(fā)生,改善預后。方法:收集2010年1月至2016年5月在天津市胸科醫(yī)院心內科成功行直接PCI治療的臨床資料完整的STEMI患者病例數(shù)據(jù),按3:1比例隨機分為模型組和驗證組,根據(jù)PCI術中急性心肌梗死溶栓(thrombolysis in myocardial infarction,TIMI)血流分級和TIMI心肌灌注分級(TIMI myocardial perfusion grade,TMPG)結果將患者分為無復流組和正常血流組。冠狀動脈前向血流TIMI≤2級或TIMI 3級而TMPG分級2級診斷為無復流。比較兩組患者基本臨床資料、冠脈造影特征及手術相關資料、實驗室檢查的差異,分析STEMI患者PCI術后發(fā)生無復流的危險因素。采用二項多變量Logistic回歸研究的方法從模型組發(fā)生無復流的危險因素中篩選獨立危險因素。按照Logistic模型的優(yōu)勢比(Odds ratio,OR)對危險因素進行風險賦值,建立無復流風險評分系統(tǒng),篩選出無復流高風險的STEMI患者。采用受試者工作特征曲線(receiver operator characteristic curve,ROC)檢驗分別在模型組和驗證組中評價該評分系統(tǒng)的真實性和可靠性。按同樣方法,我們在老年亞組和女性亞組中單獨做了分析。結果:PCI術后造影無復流的發(fā)生率為29.6%。模型組多變量Logistic回歸分析顯示年齡≥65歲、脈壓50 mmHg、中性粒細胞和淋巴細胞比值7、LP(a)0.5mmol/L、ST抬高≥0.4、發(fā)病至開通時間6 h、側支循環(huán)≤1級、血栓負荷≥4分為急性STEMI患者直接PCI治療中發(fā)生無復流的獨立危險因素。ROC曲線下面積0.675,準確性為中等。無復流現(xiàn)象危險因素評分:年齡≥65歲記為2分、脈壓50 mmHg記為2分、中性粒細胞和淋巴細胞比值7記為2分、LP(a)0.5 mmol/L記為1分、ST抬高≥0.4記為2分、發(fā)病至球囊擴張病變時間6小時記為1分、側支循環(huán)≤1級記為2分。無復流現(xiàn)象危險分層:總分值6分為低危,6-10分為中危,10分為高危。驗證組二項Logistic回歸分析的ROC曲線下面積0.660,準確性為良好。在老年亞組中,PCI術后造影無復流的發(fā)生率為36.6%。模型組多變量Logistic回歸分析顯示年齡≥80歲、無梗死前心絞痛、吸煙史、脈壓50 mmHg、LP(a)0.5 mmol/L、ST段抬高的導聯(lián)數(shù)≥4為急性STEMI患者直接PCI治療中發(fā)生無復流的獨立危險因素。ROC曲線下面積0.702,準確性為中等。無復流現(xiàn)象危險因素評分:年齡≥80歲記為2分、無梗死前心絞痛記為2分、吸煙史記為2分、脈壓50 mmHg記為2分、LP(a)0.5 mmol/L記為2分、ST段抬高的導聯(lián)數(shù)≥4記為3分。無復流現(xiàn)象危險分層:總分值5分為低危,5-8分為中危,8分為高危。驗證組二項Logistic回歸分析的ROC曲線下面積0.566。在女性亞組中,PCI術后造影無復流的發(fā)生率為28.8%。模型組多變量Logistic回歸分析顯示中性粒細胞百分比≥80、血糖8 mmol/L、左室射血分數(shù)50、β受體阻滯劑、后擴張、病變鈣化≥中度為急性STEMI患者直接PCI治療中發(fā)生無復流的獨立危險因素。ROC曲線下面積0.747,準確性為中等。無復流現(xiàn)象危險因素評分:中性粒細胞百分比≥80記為3分、血糖8 mmol/L記為2分、左室射血分數(shù)50記為3分、β受體阻滯劑記為2分、后擴張記為2分、病變鈣化≥中度記為3分。無復流現(xiàn)象危險分層:總分值5分為低危,5-8分為中危,8分為高危。驗證組二項Logistic回歸分析的ROC曲線下面積0.662。結論:1年齡≥65歲、脈壓50 mmHg、中性粒細胞和淋巴細胞比值7、LP(a)0.5mmol/L、ST抬高≥0.4、發(fā)病至開通時間6 h、側支循環(huán)≤1級、血栓負荷≥4分是STEMI患者直接PCI術中發(fā)生無復流現(xiàn)象的獨立危險因素。年齡≥80歲、無心絞痛史、吸煙史、脈壓50 mmHg、LP(a)0.5 mmol/L、ST段抬高的導聯(lián)數(shù)≥4是老年STEMI患者直接PCI術中發(fā)生無復流現(xiàn)象的獨立危險因素;中性粒細胞百分比≥80、血糖8 mmol/L、左室射血分數(shù)50、β受體阻滯劑、后擴張、病變鈣化≥中度是女性STEMI患者直接PCI術中發(fā)生無復流現(xiàn)象的獨立危險因素。2側枝循環(huán)≤1級、ST段抬高的導聯(lián)數(shù)≥4、左室射血分數(shù)50分別是判斷基礎人群、老年人群和女性人群STEMI直接PCI術中發(fā)生無復流現(xiàn)象的最強預測因子。3無復流風險評分系統(tǒng)有助于識別AMI介入術中發(fā)生無復流現(xiàn)象的高�；颊�。
[Abstract]:Objective: the patients with acute ST segment elevation myocardial infarction (ST segment elevation myocardial infarction, STEMI) have no reflow after percutaneous coronary intervention (percutaneous coronary interventions, PCI), and the function of the damaged myocardium is not recovered, but the function of the damaged myocardium is not recovered. It is worse. Although the treatment strategy is constantly improved, no reflow will still lead to poor prognosis. How to quickly and accurately predict the occurrence of no reflow is still to be further studied. The identification of high-risk groups by the analysis of the clinical treatment related to non reflux phenomenon, the characteristics of contrast, electrocardiogram and test results can help to reduce the non reflow. There is still a lack of a timely, efficient and clinically practical scoring system. This study aims to explore the risk factors associated with non reflow, establish a simple and practical non reflow risk scoring system, and carry out a dangerous layer of direct PCI without reflow in STEMI patients, and provide a clinical prevention and treatment for direct PCI without reflow. New measures to reduce the incidence of complications and improve the prognosis. Methods: a complete collection of STEMI patients' data from January 2010 to May 2016 in Department of Cardiology, Tianjin Thoracic Hospital, which were successfully treated with direct PCI treatment, were randomly divided into model group and verification group according to 3:1 ratio, according to the thrombolytic thrombolysis (thrombolysis in myocar) for acute myocardial infarction (thrombolysis in myocar). Dial infarction, TIMI) blood flow classification and TIMI myocardial perfusion classification (TIMI myocardial perfusion grade, TMPG), the patients were divided into no reflow group and normal blood flow group. The anterior coronary artery blood flow TIMI < < 2 or TIMI 3 grade, and TMPG classification 2 was no reflow. Compare the basic clinical data, coronary angiography features and surgical phase of the two groups. The risk factors for the non reflow of STEMI patients after PCI were analyzed by the difference of customs data and laboratory tests. Two multivariate Logistic regression methods were used to select independent risk factors from the risk factors of non reflow in the model group. The risk factors were set up according to the advantage ratio of the Logistic model (Odds ratio, OR) to risk factors. No reflow risk scoring system was used to screen STEMI patients without reflow and high risk. The authenticity and reliability of the scoring system were evaluated in the model group and the validation group by the receiver operator characteristic curve (ROC) test. The same method, we did the same method in the elderly subgroup and the female subgroup. Results: the incidence of non reflux after PCI was the multivariable Logistic regression analysis in 29.6%. model group, which showed that the age was 65 years old, the pulse pressure was 50 mmHg, the ratio of neutrophils and lymphocyte was 7, LP (a) 0.5mmol/L, ST elevation was more than 0.4, the onset time was 6 h, the collateral circulation was less than 1, and the thrombus load was more than 4 as the direct PCI treatment of the acute STEMI patients. The area under the independent risk factor.ROC curve was 0.675 and the accuracy was moderate. The risk factor of no reflow was 2, the pulse pressure was 50 mmHg, 2, the ratio of neutrophils and lymphocyte was 2, LP (a) 0.5 mmol/L was 1, ST elevation was more than 0.4 in 2, and the onset of balloon dilatation time 6 There were 1 points and 2 points in the collateral circulation less than grade 1. There was no risk stratification of the reflow phenomenon: the total score was 6 in low risk, 6-10 in middle risk and 10 in high risk. The area under the ROC curve of the two Logistic regression analysis was 0.660 and the accuracy was good. In the elderly subgroup, the incidence of no reflow after PCI was the multivariable Logist in the 36.6%. model group. IC regression analysis showed that age more than 80 years old, no pre infarction angina, smoking history, pulse pressure of 50 mmHg, LP (a) 0.5 mmol/L, ST segment elevation guide number more than 4 is an independent risk factor of no reflow in acute STEMI patients with independent risk factors under the.ROC curve area under.ROC curve 0.702, accuracy is moderate. The risk factor of no reflow phenomenon score: age > 80 years, 2, 2 Scores, no pre infarction angina were recorded as 2 points, smoking records were 2 points, pulse pressure 50 mmHg were recorded as 2, LP (a) 0.5 mmol/L was recorded as 2 points, and ST segment elevation guide number was 3. No reflow phenomenon risk stratification: total score 5 was low risk, 5-8 was in middle risk, 8 was at high risk. The area 0.566. under ROC curve under the ROC curve of two item Logistic regression analysis in female sub In the group, the incidence of no reflow after PCI was a multivariable Logistic regression analysis in the 28.8%. model group, which showed that the percentage of neutrophils was more than 80, blood glucose 8 mmol/L, left ventricular ejection fraction 50, beta blocker, postdilation, and calcification more than moderate as an independent risk factor of non reflow in direct PCI treatment of acute STEMI patients under the.ROC curve. The area was 0.747 and the accuracy was moderate. The risk factors of no reflow were scored: the percentage of neutrophils was more than 80 in 3, the blood sugar 8 mmol/L was recorded as 2, the left ventricular ejection fraction was 3, the beta blocker was 2, the dilatation was 2, the lesion calcification was more than moderate as 3. The total score was 5 in low risk, 5-8 points. For the middle risk, 8 was at high risk. The area under the ROC curve of two Logistic regression analysis in the test group showed that the 1 age was more than 65 years old, the pulse pressure was 50 mmHg, the ratio of neutrophils and lymphocyte was 7, LP (a) 0.5mmol/L, ST elevation was more than 0.4, the onset time was 6 h, the collateral circulation was less than 1, and the thrombus load of more than 4 was no reflow in PCI PCI operation of STEMI patients. Independent risk factors of the phenomenon. The age of 80 years old, no angina history, smoking history, pulse pressure 50 mmHg, LP (a) 0.5 mmol/L, ST segment elevation lead number more than 4 are independent risk factors for non reflow phenomenon of direct PCI operation in elderly STEMI patients; neutrophils percentage is more than 80, blood sugar 8 mmol/L, left ventricular ejection fraction 50, beta receptor blocker, post dilatation, Calcification more than moderate is an independent risk factor for non reflow phenomenon in direct PCI operation in female STEMI patients,.2 collateral circulation is less than grade 1, the number of lead in ST segment elevation is more than 4, left ventricular ejection fraction 50 is the basic population, and the strongest predictor of non reflow phenomenon in the STEMI direct PCI operation of the elderly and the female population,.3 without reflux wind,.3 The risk scoring system can help identify high-risk patients who have no reflow during AMI intervention.

【學位授予單位】：天津醫(yī)科大學
【學位級別】：博士
【學位授予年份】：2017
【分類號】：R542.22

【相似文獻】

相關期刊論文 前10條

1 王嵐峰,吳雙,李為民;無復流現(xiàn)象的治療進展[J];中國介入心臟病學雜志;2005年02期

2 夏菁;冠脈無復流現(xiàn)象治療的研究進展[J];現(xiàn)代診斷與治療;2005年05期

3 程璐;;急診經皮冠狀動脈介入術無復流與左心功能恢復的關系[J];遼寧醫(yī)學雜志;2006年06期

4 陳桂英;周立君;黃永麟;李為民;;冠脈無復流現(xiàn)象的臨床意義及處理[J];中國實用內科雜志;2007年02期

5 荀平;高航;;冠脈無復流現(xiàn)象的診治進展[J];心臟雜志;2007年06期

6 楊秀秀;陳韻岱;;無復流現(xiàn)象的預防與治療[J];心肺血管病雜志;2008年01期

7 張春震;趙郁;;冠狀動脈無復流現(xiàn)象的防治進展[J];中國現(xiàn)代醫(yī)生;2008年10期

8 郭任維;任艷琴;邢愛華;王全義;呂曉春;郝愛萍;;經皮冠狀動脈介入術中無復流現(xiàn)象臨床分析[J];中國介入心臟病學雜志;2009年05期

9 劉玉鵬;王曉麗;;經皮冠狀動脈介入治療術中無復流現(xiàn)象的研究進展[J];新醫(yī)學;2010年02期

10 施佳;歐少君;金惠根;;藥物防治無復流研究進展[J];心血管病學進展;2010年02期

相關會議論文 前10條

1 黃東;馬劍英;王翔飛;張峰;錢菊英;葛雷;葛均波;;經微導管使用不同血管擴張劑對急診經皮冠狀動脈介入治療術中無復流現(xiàn)象的療效比較[A];中華醫(yī)學會第11次心血管病學術會議論文摘要集[C];2009年

2 朱升四;劉俊;周旭晨;朱皓;鄭曉群;曲新凱;黃榕，

本文編號：1856864