急诊PCI术中慢/无复流ST段抬高型急性心肌梗死患者术后口服尼可地尔观察

摘要

目的 观察急诊经皮冠状动脉介入(PCI)术中慢/无复流的急性ST段抬高型心肌梗死(STEMI)患者术后口服尼可地尔的效果.方法 将110例急诊PCI术中慢/无复流的STEMI患者随机分为观察组和对照组,各55例.两组患者术后均根据病情给予药物治疗,包括阿司匹林、氯吡格雷、血管紧张素转换酶抑制剂、血管紧张素受体拮抗剂、β受体阻滞剂、他汀类等.观察组在此基础上给予尼可地尔5 mg口服,3次/d,连用30 d.两组患者PCI后即刻和72 h、30 d行心电图检查,计算心梗相关导联指高ST段回落>50%峰值发生情况两组患者PCI后即刻和6、14、18、24、48 h抽外周血,用免疫荧光法检测血清肌酸激酶(CK)和肌酸激酶同工酶(CK-MB).两组患者发病后入院即刻和PCI术后24 h、72 h、7 d及30 d采用免疫放射分析法检测血浆脑钠肽(BNP)水平.两组患者发病后入院即刻、PCI术后7 d和PCI术后30 d行超声心动图检查,测量左室舒张末内径(LVEDD)、左室收缩末内径(LVESD)和左室射血分数(LVEF).记录两组患者PCI术后30 d内恶性心律失常、严重心力衰竭、急性心肌梗死机械并发症和死亡、新发心肌梗死、靶血管血运重建(TVR)发生情况.结果 PCI术后即刻、24 h、48 h、72 h、4d、5d、6 d、7 d及30 d,观察组分别有28例(50.91%)、38例(69.09%)、54例(98.18%)患者,对照组分别有24例(43.64%)、34例(61.82%)、49例(89.09%)心电图相关导联抬高ST段回落>50%峰值.观察组组PCI术后即刻、72 h及30 d心电图相关导联抬高ST段回落>50%峰值发生率均高于对照组(P均<0.05).观察组、对照组PCI术后24 h内血清CK峰值浓度分别为(1205±113)、(1520±221)IU/L,CK-MB峰值浓度分别为(192±23)、(238±25) μg/L,两组相比,P均<0.05.PCI术后30 d观察组血浆BNP水平及LVEDD、LVESD值均低于对照组(P均<0.05),LVEF高于对照组(P<0.05);PCI术后7 d两组上述指标相比(P均>0.05).观察组PCI术后30 d内发生恶性心律失12例(21.82%)、严重心力衰竭8例(14.55%)、急性心肌梗死机械并发症0例、死亡0例、新发心肌梗死5例(9.09%)、TVR 0例,对照组分别为4例(7.27%)、2例(3.64%)、0例、0例、4例(7.27%)、0例.观察组恶性心律失常、严重心力衰竭发生率高于对照组(P均<0.05).结论 急诊PCI术中慢/无复流的STEMI患者,术后口服尼可地尔可以减少心肌损伤,改善左心功能,降低术后30 d内恶性心律失常及严重心力衰竭发生率.%Objective To evaluate the effects of oral nicorandil after percutaneous coronary interventions (PCI) in reducing myocardial damage and improving left ventricular cardiac function as well as reducing adverse events in patients with slow/no-reflow phenomenon during PCI for acute ST-segment elevation myocardial infarction (STEMI).Methods Totally 110 patients with the slow/no-reflow phenomenon during PCI for STEMI were randomly classified into the observation group (n=55) and control group (n=55).Based on their conditions, patients in the two groups were given secondary coronary prevention drugs including aspirin, clopidogrel, angiotensin converting enzyme inhibitors, angiotensin receptor antagonists, β blockers, statins, ect.Moreover, patients in the observation group were administered oral nicorandil (5 mg, tid) for 30 days.The serum creatine kinase (CK) and creatine kinase isoenzyme (CK-MB) were detected by immunofluorescence at the admission of hospital, and 6, 14, 18, 24, and 48 h after PCI.The levels of plasma brain natriuretic peptide (BNP) were detected by immunoradiometric assay at the admission of hospital and 24 h, 72 h, 7 d and 30 d after PCI.Left ventricular end-diastolic diameter (LVEDD), left ventricular end-diastolic diameter (LVESD), and left ventricular ejection fraction (LVEF) were measured at the admission of hospital, and 7 d, 30 d after PCI.The incidence of malignant arrhythmia, severe heart failure, complications, death of acute myocardial infarction, new myocardial infarction, and target vessel revascularization (TVR) were recorded within 30 days after PCI.Results In the observation group, there were 28 patients (50.91%), 38 patients (69.09%), 54 patients (98.18%) with ECG-related lead elevation ST segment drop> 50% peak at immediate moment, 72 h, and 30 d after PCI, respectively, while in the control group, there were 24 patients (43.64%), 34 patients (61.82%), 49 cases (89.09%) with ECG-related lead elevation ST segment drop> 50% peak, respectively.The incidence of decrease in ECG related lead elevation ST segment drop> 50% peak at immediate moment, 72 h, 30 d after PCI was significantly higher in the observation group as compared with that of the control group (all P<0.05).The peak levels of CK and CK-MB after PCI within 24 h in the observation group and control group were statistically different between the two groups (1205 IU/L vs.1520 IU/L, 192 ug/L vs.238 ug/L, both P<0.05).BNP, LVEDD, and LVESD within 30 days after PCI were significantly lower in the observation group (P<0.05), whereas LVEF levels were higher than those of the control group (P<0.05).The above indicators within 7 days were not statistically different between the two groups (all P>0.05).Within 30 days after PCI, there were 12 (21.82%) of malignant arrhythmia, 8 (14.55%) of severe heart failure, 0 of complication for acute coronary syndrome, 0 of death, 5(9.09%) of new myocardial infarction, 0 of TVR in the control group, while there were 4 (7.27%) of malignant arrhythmia, 2 (3.64%) of severe heart failure, 0 of complication for acute coronary syndrome, 0 of death, 4(7.27%) of new myocardial infarction, 0 of TVR in the observation group.The incidence of malignant arrhythmia and serious heart failure within 30 days after PCI was significantly lower in the observation group than in the control group (both P<0.05).Conclusion For patients with slow/no-reflow phenomenon during PCI for STEMI, oral nicorandil may reduce myocardial damage, improve left ventricular cardiac function, and decrease the incidence of malignant arrhythmia and serious heart failure within 30 days after PCI.