CRRT对急性心肌梗死后心功能不全低血压状态患者疗效分析

摘要

Objective The aim of this study was to evaluate the efficacy of continuous renal replacement therapy (CRRT) for patients with cardiac insufficiency and hypotension after acute myocardial infarction (AMI). Methods We recruited AMI patients in our hospital from June 2008 to December 2011. After primary percutaneous coronary intervention (PCI), 92 patients presented cardiac insufficiency, hypotension, and acute left heart failure. All heart failure patients received routine medications at first, and were then randomly divided into two groups, one in which patients were treated with routine medications and another in which patients were treated with CRRT in combination with routine medications. Results In the 46 patients who received routine internal medications, cardiac function improved gradually, but the improvement was slower as compared with that in the CRRT group. In the 46 patients who received CRRT, CRRT discontinued in 2 patients due to progressive decrease of platelets and in one patient due to systolic blood pressure lower than 90 mmHg, clinical manifestations of organ hypoperfusion, poor peripheral circulation, cool clammy skin and oliguria. In the rest of 43 patients in the CRRT group, vital signs were stable, heart failure symptoms and serum electrolytes improved significantly. After one week of CRRT, left ventricular ejection fraction (LVEF) also improved. The differences in mortality within one month, the mean period treated in intensive car unit, the mean hospitalized day, and the number of patients with recurrent heart failure were significant between the two groups. Conclusion CRRT is a relatively safe and effective strategy for patients with cardiac insufficiency and hypotension after AMI.%目的 探讨持续性肾脏替代治疗(continuous renal replacement therapy,CRRT)对急性心肌梗死后心功能不全伴低血压状态患者的疗效分析. 方法 收集2008年6月～2011年12月在北京安贞医院住院的急性心肌梗死患者,其中92例在急诊介入治疗、开通罪犯血管后出现急性心功能不全、低血压状态,并有急性左心衰竭发作.全部患者首先采用内科常规治疗,分为2组,1组继续标准药物治疗,另1组在静脉补液、血管活性药物支持下行CRRT治疗.探索CRRT对急性心肌梗死后心功能不全低血压状态患者的疗效. 结果 46例常规药物治疗患者,急性左心衰竭发作次数逐渐减少,电解质逐渐维持于正常水平,但改善情况均较CRRT组缓慢. 4例死于心源性猝死.随访至发病后1年,15.22％(7/46)患者间断有左心衰竭症状.46例行CRRT患者中,2例因血小板进行性减少而中止CRRT.1例因收缩压低于90 mmHg(lmmHg=0.133 kpa)且有脏器灌注不足临床表现终止CRRT.43例行CRRT患者生命体征平稳,心力衰竭症状明显减轻.CRRT治疗后血电解质较治疗前显著改善,B型脑利钠肽(BNP)、C反应蛋白明显降低(F=33.2;F=38.1,P＜0.05),1周后复测左室射血分数LVEF有所改善(F=4.1,P＜0.05),2例死于心源性猝死,其余41例,均在住院20～39天后出院,随访1年,无左心衰竭再次发作.2组患者1个月死亡率、平均重症监护时间、平均住院时间均有显著差异(x2=5.9,t=3.7,t=4.4; P＜0.05). 结论 急性心肌梗死后心功能不全并发低血压状态的患者行CRRT是一种相对安全而有效的治疗方法.不仅能在较短时间内稳定内环境,而且能干预心肌梗死后左心衰竭的发展和预后,使平均重症监护时间、平均住院时间显著降低.