摘要：目的 探讨急性下壁心肌梗死患者行急诊经皮冠状动脉(冠脉)介入治疗(PCI)术中出现心室纤颤(VF)的可能因素.方法 纳入沧州市人民医院2016年5月至2018年5月发病24 h内行急诊PCI的急性下壁心肌梗死患者572例,按照PCI术中是否发生VF分为VF组(52例)和非VF(NVF)组(520例).比较两组临床资料、冠脉病变特点及冠脉评分(Gensini评分)的差异,采用多因素Logistic回归分析急诊PCI术中VF发生的相关危险因素;绘制受试者工作特征曲线(ROC),评价各危险因素的检验效能.结果 两组性别、年龄、饮酒史、吸烟史、高血压史、糖尿病史、既往应用β受体阻滞剂和阿司匹林、入院时收缩压、心率和肌酸激酶同工酶(CK-MB)、心肌肌钙蛋白I(cTnI)峰值等一般资料比较差异均无统计学意义(均P＞0.05).VF组再通前心肌梗死溶栓(TIMI)血流0级、高血栓负荷、罪犯血管为右冠脉(RCA)和闭塞部位为RCA近段患者比例以及Gensini评分均显著高于NVF组〔TIMI血流0级:80.8%(42/52)比58.1%(302/520),高血栓负荷:71.2%(37/52)比58.1%(302/520),罪犯血管为RCA :84.6%(44/52)比73.7%(383/520),梗死相关动脉(IRA)闭塞部位为RCA近段:61.5%(32/52)比41.2%(214/520),Gensini评分(分):93.84±16.48比61.37±20.01,均P＜0.05〕.多因素Logistic回归分析显示,罪犯血管为RCA〔优势比(OR)＝1.967,95%可信区间(95%CI)＝1.696～3.015, P＝0.032〕、再通前TIMI血流0级(OR＝3.032,95%CI＝1.248～3.675,P＝0.043)、IRA闭塞部位为RCA近段(OR＝2.288,95%CI＝1.458～3.895,P＝0.024)、Gensini评分(OR＝6.558,95%CI＝2.168～13.359,P＝0.001)及高血栓负荷(OR＝1.781,95%CI＝1.016～3.017,P＝0.033)均为急性下壁心肌梗死行急诊PCI患者术中发生VF的危险因素(均P＜0.05).ROC曲线分析显示,再通前TIMI血流0级、Gensini评分以及高血栓负荷均对急诊行PCI治疗急性下壁心肌梗死患者术中发生VF有一定的预测价值,ROC曲线下面积(AUC)分别为0.613、0.869、0.605,95%CI分别为0.540～0.687、0.787～0.969、0.521～0.675,P值分别为0.007、0.000、0.012,提示Gensini评分对术中发生VF有中等预测价值,而再通前TIMI血流0级和高血栓负荷的预测价值偏低.当Gensini评分最佳截断值为96.50时,其敏感度为85.50%,特异度为81.20%.结论 罪犯血管为RCA、再通前TIMI血流0级、IRA闭塞部位为RCA近段、Gensini评分、高血栓负荷为急性下壁心肌梗死急诊PCI术中发生VF的危险因素,再通前TIMI血流0级、Gensini评分及高血栓负荷均对急诊行PCI急性下壁心肌梗死患者术中发生VF有一定的预测价值.%Objective To explore the possible causative factors of appearance of ventricular fibrillation (VF) during emergency percutaneous coronary intervention (PCI) in patients with acute inferior myocardial infarction. Methods Five hundred and seventy two patients with acute inferior myocardial infarction who underwent emergency PCI 24 hours after onset from May 2016 to May 2018 in Cangzhou People's Hospital were enrolled, they were divided into a VF group (52 cases) and a non-VF group (NVF, 520 cases) according to whether VF occurred or not during PCI. The differences in clinical data, characteristics of coronary artery disease and coronary artery score (Gensini score) between the two groups were compared; multivariate Logistic regression analysis was used to analyze the risk factors related to the occurrence of VF during emergency PCI; the receiver operating characteristic curve (ROC) was drawn to evaluate the efficacy of each risk factor. Results There were no statistical significant differences in sex, age, past histories of drinking alcohol, smoking, hypertension, diabetes, previous use of β blockers, aspirin, the peak values at admission of systolic blood pressure, heart rate, creatine kinase isoenzyme (CK-MB) and cardiac troponin I (cTnI), etc between the two groups (all P > 0.05). The proportions of patients with grade 0 blood flow in myocardial infarction thrombolysis (TIMI) before recanalization, with high thrombus load, criminal vessels being right coronary artery (RCA) and proximal segment of RCA, Gensini score in VF group were significantly higher than those in NVF group [TIMI 0: 80.8% (42/52) vs. 58.1% (302/520), high thrombus load: 71.2% (37/52) vs. 58.1% (302/520), criminals being RCA: 84.6% (44/52) vs. 73.7% (383/520), the occlusion site of infarction-related artery (IRA) being the proximal segment of RCA: 61.5% (32/52) vs. 41.2% (214/520), Gensini scores: 93.84±16.48 vs. 61.37±20.01, all P < 0.05]. The multiple logistic regression analysis showed that the risk factors for VF occurrence during emergency PCI for patients with acute inferior myocardial infarction included the criminals being RCA [odds ratio (OR) = 1.967, 95% confidence interval (95% CI) = 1.696-3.015, P =0.032], TIMI blood flow grade 0 before re-canalization (OR = 3.032, 95%CI = 1.248-3.675, P = 0.043), the occlusion site of infarction-related artery (IRA) being the proximal segment of RCA (OR = 2.288, 95%CI = 1.458-3.895, P =0.024), Gensini score (OR = 6.558, 95%CI = 2.168-13.359, P = 0.001] and high thrombus load (OR = 1.781, 95%CI =1.016-3.017, P = 0.033); they all were risk factors of occurrence of ventricular fibrillation during emergency PCI in patients with acute inferior myocardial infarction (all P < 0.05). ROC curve analysis showed that TIMI blood flow grade 0 before re-canalization, Gensini score and higher thrombus load had certain predictive value for VF occurrence during emergency PCI for acute inferior wall myocardial infarction; the area under ROC curve (AUC) was 0.613, 0.869 and 0.605, and 95% CI was 0.540-0.687, 0.787-0.969 and 0.521-0.675, the P value was 0.007, 0.000 and 0.012, respectively, suggesting that Gensini score had moderate predictive value for intra-operative VF, while the predictive values of TIMI blood flow grade 0 before re-canalization and higher thrombus load were relatively low. When the Gensini score had an optimal cutoff value of 96.50, the sensitivity was 85.50% and the specificity was 81.20%. Conclusion The risk factors of VF occurrence in emergency PCI for patients with acute inferior myocardial infarction are criminal vessel RCA, TIMI blood flow grade 0 before re-canalization, IRA occlusion site being proximal segment of RCA, Gensini score and high thrombus load; pre-recanalization TIMI blood flow grade 0, Gensini score and higher thrombus load all have certain predictive value for the occurrence of VF in emergency PCI for acute inferior myocardial infarction.