缺血后适应对急性心肌梗死直接经皮冠状动脉介入术后非罪犯血管病变进展的抑制作用

摘要

目的 探讨缺血后适应对急性ST段抬高型心肌梗死(STEMI)患者直接经皮冠状动脉介入(PCI)治疗后非罪犯血管病变进展的抑制作用.方法 连续入选2010年1月至2013年12月在首都医科大学附属北京安贞医院成功接受罪犯血管直接PCI治疗的急性STEMI患者200例,应用随机数字表分为2组,各100例,缺血后适应组在导丝通过闭塞病变到达血管远端后,送球囊至闭塞处以小压力扩张球囊,开通血管后迅速关闭30 s,随后扩张球囊再灌注30 s,反复通过球囊低气压充气/放气至少4个循环;对照组不进行缺血后适应.临床随访12个月,观察2组患者因非罪犯血管病变进展再次PCI情况,以及2组患者的临床特征.结果 200例患者均完成临床及造影随访.缺血后适应组术后12个月内因非罪犯血管病变进展行再次PCI率低于对照组[7.0％(7/100)比21.0％(21/100)],差异有统计学意义(P＜0.01).根据术后12个月随访情况将2组患者分为对照随访正常组(A组,79例)、对照随访因非罪犯血管病变进展行再次PCI组(B组,21例)、缺血后适应随访正常组(C组,93例)、缺血后适应随访因非罪犯血管病变进展行再次PCI组(D组,7例),血清肾上腺素、去甲肾上腺素水平B组高于A组,D组高于C组,差异均有统计学意义(均P＜0.001).A、B、C、D组患者非罪犯血管病变基线病变类型比较差异均无统计学意义(均P＞0.05).随访正常组(172例)血清肾上腺素、去甲肾上腺素和C反应蛋白水平均低于再次PCI组(28例)[(223±48) ng/L比(309±52) ng/L,(1 807±365) ng/L比(2 528±421) ng/L,(18±6) mg/L比(24±8)mg/L],差异均有统计学意义(均P＜0.001).结论 急性STEMI患者直接PCI术后的再次血管重建部分是非罪犯血管病变进展所致,缺血后适应可能会抑制非罪犯血管病变进展.%Objective To investigate the preventive effect of ischemic postconditioning on non-culprit lesion progression in patients with acute ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention(PCI).Methods A total of 200 STEMI patients undergoing primary PCI from January 2010 to December 2013 in Beijing Anzhen Hospital,Capital Medical University were randomly divided into ischemic postconditioning group and eontrol group,with 100 cases in each group.Postoperative recovery,non-culprit lesion progression and related clinical indicators were analyzed.Results Secondary PCI rate of non-culprit lesion in 12 months after operation in ischemic postconditioning group was significantly lower than that in control group [7.0％ (7/100) vs 21.0％ (21/100)] (P ＜0.01).Seventy-nine patients did not have reoperation(group A) and 21 patients had secondary PCI (group B) in control group;93 patients did not have reoperation (group C) and 7 patients had secondary PCI (group D) in ischemic postconditioning group.Serum levels of adrenaline and noradrenaline in group B were significantly higher than those in group A;levels of adrenaline and noradrenaline in group D were significantly higher than those in group C(P ＜0.001).Types of non-culprit lesion showed no significant difference among group A,B,C and D (P ＞ 0.05).Serum levels of adrenaline,noradrenaline and C-reactive protein in patients without reoperation(n =172) were significantly lower than those in patients with secondary PCI (n =28) [(223 ± 48) ng/L vs (309 ± 52) ng/L,(1 807 ± 365) ng/L vs (2 528 ± 421) ng/L,(18 ± 6) mg/L vs (24± 8)mg/L] (P ＜0.001).Conclusions Revascularization after primary PCI is related to non-culprit lesion progression in patients with STEMI.Ischemic postconditioning may prevent non-culprit artery lesion progression.