Effects of Bivalirudin on myocardial perfusion and infarct size in acute stage for elderly patients with thrombolytic failure and salvage PCI
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摘要: 目的：观察并探讨比伐卢定对溶栓失败后行挽救性经皮冠状动脉介入治疗（PCI）的老年患者心肌灌注、心肌梗死（心梗）面积及术后心功能的影响。方法：入选2015-01-2017-03因溶栓失败来我院行挽救性PCI的139例ST段抬高型心梗（STEMI）老年患者为研究对象，随机分为比伐卢定组（71例）和肝素组（68例）；比伐卢定组PCI围术期静脉应用比伐卢定行抗凝治疗，肝素组采用普通肝素行抗凝治疗。术后即刻记录梗死相关动脉（IRA）心梗溶栓实验（TIMI）3级的血流获得率、心肌灌注心肌染色分级（MBG）3级获得率，通过绘制心肌酶学曲线，估算2组入院72 h时的心梗面积，测定心肌损伤标志物并行超声心动图评价术后72 h心功能改善情况，记录住院期间并发症及主要不良心血管事件（MACE）的发生率。结果：比伐卢定组、肝素组分别有3例（4.2%）、2例（2.9%）改行冠状动脉旁路移植术（CABG）；比伐卢定组的术后即刻梗死相关动脉TIMI 3级血流获得率（92.6%：87.9%）、MBG 3级获得率（85.3%：81.8%）均高于肝素组，差异无统计学意义（均P>0.05）；2组术后72 h氨基末端B型脑钠肽前体（NT-proBNP）的自然对数ln （NT-proBNP）水平[（4.81±1.85） pg/ml：（4.60±1.78） pg/ml]、肌钙蛋白T （cTnT）[（8.3±4.3） ng/ml：（8.1±4.0） ng/ml]、左室射血分数（LVEF）[（45.7±5.8）%：（44.6±5.3）%]、二尖瓣血流舒张早期最大流速（E）与心房收缩期最大流速（A）的比值（E/A）（1.10±0.31：1.06±0.25）差异均无统计学意义（均P>0.05）；比伐卢定组入院72 h心肌酶学曲线下面积低于肝素组[（4 385.5±1 268.2） U·h·L-1：（4 724.8±1 435.7） U·h·L-1]，差异无统计学意义（P>0.05）。比伐卢定组患者术后出血（4.4%：12.1%）、血小板减少发生率（0：3.0%）、MACE发生率（4.4%：6.1%）均低于肝素组，差异均无统计学意义（均P>0.05）。结论：在溶栓失败后挽救性PCI时应用比伐卢定较普通肝素有可能在一定程度上改善急性期内心肌灌注，减少心梗面积及出血事件，但获益不显著。Abstract: Objective: To observe and explore the effects of Bivalirudin on myocardial perfusion, infarct size and postoperative cardiac function in elderly patients with thrombolysis failure and salvage PCI.Method: One hundred and thirty-nine elderly ST elevation myocardial infarction(STEMI) patients with failed thrombolysis and salvage PCI treatment from January 2015 to March 2017 were enrolled as study objects, which were divided into Bivalirudin group (71 cases) and heparin group (68 cases) according to random number with the former using Bivalirudin intravenously during PCI, and the latter using heparin during PCI. Grade 3 obtain rate of infarct related artery(IRA) in thrombolysis in myocardial infarction trial(TIMI) and myocardial blush grading(MBG) were recorded after PCI immediately. Area under the myocardial enzymes curve were introduced to estimate the 72 h infract size after admission. Myocardial injury markers and echocardiogram were examined to evaluate the improvement of 72 h postoperative cardiac function. PCI complications and major adverse cardiovascular events(MACE) during hospitalization were recorded.Result: There were 3 cases (4.2%) in the Bivalirudin group and 2 cases (2.9%) in the heparin group who received coronary artery bypass grafting.Both IRA grade TIMI3 obtain rate (92.6% vs 87.9%) and grade MBG3 obtain rate (85.3% vs 81.8%) were higher in the Bivalirudin group than in the heparin group but with no significant differences (all P>0.05). At the time point of 72 hours after PCI, there was no significant differences between the two group in ln(NT-proBNP)[(4.81±1.85)pg/ml vs (4.60±1.78) pg/ml], cTnT[(8.3±4.3)ng/ml vs (8.1±4.0) ng/ml], LVEF[(45.7±5.8)% vs(44.6±5.3)%] and E/A(1.10±0.31 vs 1.06±0.25)(all P>0.05). Myocardial enzyme AUC in the Bivalirudin group at 72 h were larger than that in the heparin group[(4 385.5±1 268.2)U·h·L-1:(4 724.8±1 435.7) U·h·L-1] with no significant difference(P>0.05).The postoperative bleeding rate (4.4% vs 12.1%), thrombocytopenia rate(0 vs 3.0%),incidences of MACE (4.4% vs 6.1%) in the Bivalirudin group were all lower than those in the heparin group, all with no significant differences(all P>0.05).Conclusion: For elderly patients with thrombolysis failure and salvage PCI, using Bivalirudin instead of heparin in acute stage may improve myocardial perfusion, alleviate infarct size and lower bleeding events to some degree, but the benefits is not significant.
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