Clinical study of intracoronary reverse application of recombinant human prourokinase thrombolysis combined with PCI on the prognosis of patients with acute ST-segment elevation myocardial infarction
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摘要: 目的 探讨冠状动脉(冠脉)内逆向应用重组人尿激酶原联合经皮冠脉介入治疗(PCI)对ST段抬高型心肌梗死(STEMI)患者预后的影响。方法 选择心内科行急诊PCI的STEMI患者120例，随机分为直接PCI组(A组)、血栓抽吸+PCI组(B组)、PCI+冠脉内正向溶栓组(C组)及冠脉内逆向溶栓+PCI组(D组)，每组各30例。比较4组基线资料、术后TIMI血流分级、校正TIMI帧数计数(CTFC)、2 h ST段回落率(STR)≥50%的比例、无复流/慢血流(NR/SF)发生率、左心室射血分数(LVEF)、肌钙蛋白I(cTnI)和B型利钠肽(BNP)峰值。记录随访3个月的LVEF、主要不良心血管事件(MACEs)及TIMI出血情况，对相关指标进行比较。结果 ① D组与A、B、C组比较，术后TIMI血流≤2级发生率、CTFC、NR/SF发生率、cTnI及BNP峰值显著降低，术后2 h STR≥50%的比例、LVEF显著升高(P< 0.05)；②随访3个月D组心力衰竭再住院发生率显著低于A、B、C组，且LVEF显著升高(P< 0.05)；③随访3个月，4组TIMI出血发生率差异无统计学意义(P>0.05)。结论 冠脉内逆向应用重组人尿激酶原联合PCI可有效地降低STEMI患者NR/SF发生率，改善心肌微循环灌注，减少心肌细胞坏死，改善患者左心室收缩功能及其预后，且不增加出血风险。
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关键词:
- 急性ST段抬高型心肌梗死 /
- 冠脉内逆向溶栓术 /
- 无复流/慢血流 /
- 重组人尿激酶原
Abstract: Objective To investigate the effect of intracoronary reverse application of recombinant human prourokinase combined with PCI on the prognosis of patients with ST-segment elevation myocardial infarction(STEMI).Methods One hundred and twenty patients with STEMI undergoing emergency PCI in the cardiology department were selected and randomly divided into PCI group(Group A), thrombus aspiration + PCI group(Group B), PCI + intracoronary forward thrombolysis group(Group C) and intracoronary arterial retrograde thrombolysis + PCI group(Group D), with 30 patients in each group. Baseline data, postoperative TIMI blood flow classification, corrected TIMI frame count(CTFC), the percentage of 2 h ST-segment resolution(STR) ≥50%, the incidence of no-reflow/slow flow(NR/SF), left ventricular ejection fraction(LVEF), peak cardiac troponin I(cTnI) and brain natriuretic peptide(BNP) were compared among the four groups. LVEF, major adverse cardiovascular events(MACEs), and TIMI bleeding were recorded at 3 months of follow-up, and the relevant indicators were compared.Results (1) In group D, the incidence of TIMI flow ≤ grade 2, CTFC, NR/SF incidence, cTnI and BNP peak were significantly lower, and the percentage of 2 h STR ≥50% and LVEF were significantly higher(allP< 0.05) than those in groups A, B, and C. (2) The incidence of rehospitalization for heart failure was significantly lower and LVEF was significantly higher in group D than those in groups A, B, and C at 3 months of follow-up(P< 0.05). (3) The difference in the incidence of TIMI bleeding among the four groups at 3 months of follow-up was not statistically significant(P>0.05).Conclusion Intracoronary reverse application of recombinant human prourokinase combined with PCI is effective in reducing the incidence of NR/SF, improving myocardial microcirculatory perfusion, reducing myocardial cell necrosis, and improving left ventricular systolic function and its prognosis in patients with STEMI without increasing the risk of bleeding. -
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表 1 4组患者临床基线资料
Table 1. Clinical baseline information of the four groups of patients
例(%), X±S 项目 A组(30例) B组(30例) C组(30例) D组(30例) P 年龄/岁 54.33±9.33 58.13±11.22 55.53±11.74 57.60±9.83 0.471 男性 22(73.3) 18(60.0) 22(73.3) 21(70.0) 0.641 吸烟 20(66.7) 16(53.3) 19(63.3) 18(60.0) 0.747 高血压 21(70.0) 17(56.7) 24(80.0) 22(73.3) 0.248 糖尿病 6(20.0) 8(26.7) 7(23.3) 11(36.7) 0.496 既往PCI史 1(3.3) 1(3.3) 1(3.3) 2(6.7) 1.000 TC/(mmoL·L-1) 4.60±0.94 4.75±0.91 4.94±0.67 5.06±1.19 0.259 TG/(mmoL·L-1) 1.86±0.72 1.85±0.73 1.86±1.00 1.94±0.74 0.975 LDL-C/(mmoL·L-1) 3.04±0.70 3.14±0.74 3.24±0.74 3.32±0.85 0.526 HDL-C/(mmoL·L-1) 1.06±0.26 1.09±0.25 1.12±0.15 1.17±0.27 0.285 WBC/(×109·L-1) 11.15±3.01 11.19±2.54 9.67±2.77 9.97±3.17 0.085 发病时间 < 6 h 22(73.3) 21(70.0) 22(73.3) 25(83.3) 0.659 6~12 h 8(26.7) 9(30.0) 8(26.7) 5(16.7) 0.659 
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表 2 4组患者术中参数情况
Table 2. Intraoperative parameters in the four groups of patients
例(%), X±S 项目 A组(30例) B组(30例) C组(30例) D组(30例) P 冠脉特点 单支病变 6(20.0) 9(30.0) 10(33.3) 9(30.0) 0.687 两支病变 5(16.7) 8(26.7) 8(26.7) 9(30.0) 0.659 三支病变 19(63.3) 13(43.3) 12(40.0) 12(40.0) 0.208 罪犯血管 前降支 14(46.7) 12(40.0) 18(60.0) 11(36.7) 0.277 回旋支 5(16.7) 1(3.3) 2(6.7) 2(6.7) 0.392 右冠脉 11(36.7) 17(56.7) 10(33.3) 17(56.7) 0.125 置入支架数 1个支架 21(70.0) 25(83.3) 27(90.0) 26(86.7) 0.188 2个支架 8(26.7) 3(10.0) 3(10.0) 4(13.3) 0.285 3个支架 1(3.3) 2(6.7) 0(0) 0(0) 0.615 术前TIMI血流分级 0级 21(70.0) 26(86.7) 27(90.0) 22(73.3) 0.144 1级 5(16.7) 3(10.0) 2(6.7) 6(20.0) 0.477 2级 4(13.3) 1(3.3) 1(3.3) 2(6.7) 0.522 3级 0(0) 0(0) 0(0) 0(0) 术后TIMI血流分级 ≤2级 12(40.0)1) 9(30.0)1) 10(33.3)1) 2(6.7) 0.023 3级 18(60.0)1) 21(70.0)1) 20(66.7)1) 28(93.3) 0.023 D-to-B/min 94.90±19.99 101.08±28.89 101.84±30.19 104.66±27.55 0.555 再灌注心律失常 10(33.3) 6(20.0) 8(26.7) 3(10.0) 0.164 与D组比较，1)P < 0.05。
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表 3 心肌组织灌注水平
Table 3. Myocardial tissue perfusion levels
例(%), X±S 项目 A组(30例) B组(30例) C组(30例) D组(30例) P CTFC/帧 28.30±4.761) 27.07±3.421) 27.30±4.331) 24.13±3.29 0.001 NR/SF 12(40.0)1) 9(30.0)1) 10(33.3)1) 2(6.7) 0.023 STR≥50% 7(23.3)1) 11(36.7)1) 10(33.3)1) 20(66.7) 0.005 与D组比较，1)P < 0.05。
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表 4 术后观察指标情况
Table 4. Postoperative observation indexes
M(P25, P75), X±S 项目 A组(30例) B组(30例) C组(30例) D组(30例) P cTnI峰值/(ng·mL-1) 37.59±9.641) 36.47±8.101) 38.63±9.781) 30.96±10.46 0.011 BNP峰值/(pg·mL-1) 393.15
(214.33，747.63)1)361.44
(239.09，750.38)1)530.30
(278.45，849.93)1)219.70
(140.45，307.24)0.001 LVEF/% 59.93±6.591) 61.17±7.111) 58.63±5.221) 64.50±4.64 0.002 与D组比较，1)P < 0.05。
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表 5 随访期间MACEs及心功能情况
Table 5. MACEs and cardiac function during follow-up
例(%), X±S 项目 A组(30例) B组(30例) C组(30例) D组(30例) P MACEs发生情况 心源性死亡 0(0) 2(6.7) 1(3.3) 0(0) 0.615 再发心肌梗死 0(0) 0(0) 0(0) 0(0) 心力衰竭再住院 10(33.3)1) 8(26.7)1) 8(26.7)1) 1(3.3) 0.030 靶血管再次血运重建 0(0) 0(0) 0(0) 0(0) LVEF/% 62.50±5.671) 63.93±6.621) 61.63±5.521) 67.43±4.70 0.001 与D组比较，1)P < 0.05。
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