冠状动脉微循环阻力评估急性ST段抬高型心肌梗死PCI患者预后的临床研究

韩超; 张弘; 张慧; 安雯; 杨成昊; 张凌霄; 陈双宇; 郜俊清; 刘宗军

doi:10.13201/j.issn.1001-1439.2024.04.013

冠状动脉微循环阻力评估急性ST段抬高型心肌梗死PCI患者预后的临床研究

- 上海中医药大学附属普陀医院(上海，200062)
基金项目:
上海市“科技创新行动计划”医学创新研究专项(No：20Y11910100、21Y11909600、22Y11909600)；上海市普陀区卫生健康系统科技创新项目计划(No：ptkwws202320)；上海市普陀区卫生系统临床优势学科(No：2023ysxk01)；普陀区中心医院百人计划(No：2022-RCIC-01)；上海市第六人民医院医疗集团科学研究课题(No：21-ly-01)；成都中医药大学“杏林学者”学科人才科研提升计划(No：YYZX2022168)

详细信息

通讯作者: 刘宗军，E-mail：liuzongjun1548@shatcm.edu.cn

中图分类号: R541.4

收稿日期: 2023-10-19

刊出日期: 2024-04-13

Clinical study of coronary microcirculation resistance in predicting the prognosis of PCI patients with acute ST-segment elevation myocardial infarction

- Putuo District Central Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China

More Information

Corresponding author: LIU Zongjun, E-mail: liuzongjun1548@shatcm.edu.cn

Received Date: 19 October 2023

Publish Date: 13 April 2024

摘要

摘要: 目的探讨冠状动脉(冠脉)微循环阻力评估急性ST段抬高型心肌梗死(STEMI)患者预后的价值。方法本研究是一项前瞻性、观察性、单中心研究，纳入140例成功接受急诊经皮冠脉介入(PCI)治疗的STEMI患者，使用造影微循环阻力指数(CaIMR)分析罪犯血管和非罪犯血管的微循环阻力，其中诊断冠脉微血管功能障碍(CMD)61例(CMD组)，诊断非CMD 79例(非CMD组)。随访12个月，观察患者主要不良心血管事件(MACE，包括全因死亡、再次心肌梗死、因心衰住院及再次血运重建的复合结局)发生情况。采用Cox回归分析PCI术后1年MACE发生的预测因子。结果 CMD组MACE发生率显著高于非CMD组(10.13% vs 24.60%，P＜0.05)。多因素Cox回归分析显示，术后CaIMR(HR=5.887，95%CI：1.966~17.631，P＜0.002)、呋塞米使用(HR=4.38，95%CI：1.595~12.026，P=0.004)、肌钙蛋白(第7天)(HR=1.011，95%CI：1.003~1.018，P=0.004)以及Killip分级(HR=1.878，95%CI：1.28~2.756，P=0.001)是STEMI患者PCI术后1年内MACE发生的独立预测因子。罪犯血管CMD与心血管性死亡、心衰发作以及主要不良事件发生率相关，非罪犯血管与各主要不良事件发生率无显著相关性。结论 STEMI患者PCI术后的CaIMR对临床预后具有很好的预测作用。
- 冠脉微循环阻力指数 /
- 主要心血管不良事件 /
- 冠状动脉微循环功能障碍 /
- 急性ST段抬高型心肌梗死
Abstract: Objective To explore the value of coronary microcirculation resistance in evaluating the prognosis of patients with acute ST-segment elevation myocardial infarction(STEMI). Methods The study was a prospective, observational, single-center study involving 140 STEMI patients who successfully received emergency percutaneous coronary intervention(PCI) treatment. The contrast microcirculatory resistance index(CaIMR) was used to analyze the microcirculation resistance of culprit and non-culprit vessels, with 61 cases diagnosed with coronary microvascular dysfunction(CMD group) and 79 cases diagnosed with non-CMD(non-CMD group). Patients were followed up for 12 months to observe the occurrence of major adverse cardiovascular events(MACE, including all-cause mortality, myocardial infarction recurrence, hospitalization due to heart failure, and revascularization). The Cox regression model was used to analyze the predictors for MACE one year after PCI. Results The incidence of MACE was significantly higher in the CMD group than in the non-CMD group(10.13% vs 24.60%, P < 0.05). Multivariate Cox regression analysis showed that postoperative CaIMR(HR=5.887, 95%CI: 1.966-17.631, P < 0.002), furosemide usage(HR=4.38, 95%CI: 1.595-12.026, P=0.004), troponin(on the 7th day)(HR=1.011, 95%CI: 1.003-1.018, P=0.004), and Killip grade(HR=1.878, 95%CI: 1.28-2.756, P=0.001) were independent predictors of MACE occurrence in one year after PCI in STEMI patients. Criminal vascular disease CMD was associated with cardiovascular death, heart failure attacks, and the incidence of major adverse events, while non-criminal blood vessels CMD was not significantly correlated with the incidence of major adverse events. Conclusion CaIMR after PCI has a good predictive effect on the clinical prognosis in patients with acute STEMI.
- index of microcirculatory resistance /
- major adverse cardiovascular events /
- coronary microvascular dysfunction /
- ST-segment elevation myocardial infarction

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图 1 CaIMR与MACE的相关性分析

Figure 1. Correlation between CaIMR and MACE

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表 1 患者基线特征

Table 1. Baseline characteristics 例(%), M(P₂₅, P₇₅)

项目	总体(140例)	非CMD组(79例)	CMD组(61例)	P
年龄/岁	64.5(57.0，70.0)	65.0(57.5，71.5)	64.5(56.0，68.0)	0.624
男性	114(81.43)	64(81.00)	50(82.00)	0.885
绝经期女性	24(17.14)	13(16.46)	11(18.03)	0.806
高血压	69(49.29)	38(48.10)	31(50.80)	0.750
糖尿病	37(26.43)	21(26.60)	16(26.20)	0.963
高脂血症	6(4.29)	5(6.30)	1(1.60)	0.348
慢性肾病	2(1.43)	1(1.30)	1(1.60)	1.000
PCI史	9(6.43)	4(5.10)	5(8.20)	0.688
当前吸烟	70(50.00)	39(49.40)	31(50.80)	0.865
冠脉旁路移植术史	1(0.71)	1(1.30)	0	0.564
Killip分级
Ⅰ	128(91.43)	72(91.10)	56(91.80)	0.889
Ⅱ	3(2.14)	2(2.50)	1(1.60)	0.597
Ⅲ	2(1.43)	2(2.50)	0	0.317
Ⅳ	7(5.00)	3(3.80)	4(6.60)	0.359
临床用药
阿司匹林	140(100.00)	79(100.00)	61(100.00)	1.000
P₂Y₁₂抑制剂	140(100.00)	79(100.00)	61(100.00)	1.000
他汀类	140(100.00)	79(100.00)	61(100.00)	1.000
β受体阻滞剂	101(72.14)	56(70.90)	45(73.80)	0.706
ACEI/ARB/ARNI	86(61.43)	49(620)	37(60.70)	0.869
螺内酯	46(32.86)	27(34.20)	19(31.10)	0.705
呋塞米	46(32.86)	28(35.40)	18(29.50)	0.458
实验室检查
BNP(首次)/(pg/mL)	81.3(28.2，293.3)	71.0(29.5，178.5)	127.5(25.0，381.0)	0.598
cTn(首次)/(ng/mL)	29.98(4.27，97.37)	32.66(2.27，100.00)	49.64(8.08，83.74)	0.287
CK-MB(首次)/(ng/mL)	43.31(4.26，209.42)	47.01(15.75，100.00)	100.00(49.64，179.72)	0.020
BNP(峰值)/(pg/mL)	632.0(342.9，998.5)	556.0(346.8，994.5)	655.5(319.0，996.0)	0.646
cTn(峰值)/(ng/mL)	58.61(21.69，132.76)	24.70(3.19，161.18)	132.51(29.71，280.06)	0.030
CK-MB(峰值)/(ng/mL)	161.18(55.48，300.00)	131.41(55.16，290.11)	200.86(66.77，300.00)	0.072
BNP(第7天)/(pg/mL)	276.41(115.72，570.50)	229.37(127.26，490.00)	320.00(115.72，642.50)	0.124
cTn(第7天)/(ng/mL)	1.86(0.39，6.06)	1.84(0.48，5.05)	3.37(0.45，6.22)	0.761
CK-MB(第7天)/(ng/mL)	2.29(1.51，3.98)	2.19(1.62，3.72)	2.50(1.55，4.61)	0.517

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表 2 患者血管造影和PCI特征

Table 2. Angiography and PCI data 例(%), M(P₂₅, P₇₅)

项目	总体(140例)	非CMD组(79例)	CMD组(61例)	P
罪犯血管
左前降支	84(60.00)	50(63.30)	34(55.70)	0.366
左回旋支	14(10.00)	7(8.90)	7(11.50)	0.609
右冠脉	42(30.00)	22(27.80)	20(32.80)	0.527
多支病变	102(75.00)	61(79.20)	41(69.50)	0.194
症状发作至再通时间/h	3.32(2.20，6.43)	3.50(2.31，6.33)	3.88(2.47，7.37)	0.820
入院至血管开通时间/min	74(63，87)	79(65，88)	70.5(63，87)	0.215
糖蛋白Ⅱb/Ⅲa抑制剂使用	94(67.14)	54(68.40)	40(65.60)	0.728
血栓抽吸	48(34.29)	24(30.40)	24(39.30)	0.268
平均植入支架/枚	1	1	1	0.177
支架直径/mm	3.00(2.69，3.11)	3.00(2.75，3.00)	3.00(2.68，3.38)	0.718
支架总长度/mm	30(22，43)	30(23，46)	26(22，34)	0.067
PCI后TIMI分级
2	1(0.71)	0	1(1.6)	0.436
3	139(99.29)	79(100)	61(100)	1.000

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表 3 单因素Cox回归分析结果

Table 3. Univariate Cox regression analysis results

变量	HR(95%CI)	P
术后IMR	3.351(1.287~8.724)	0.013
cTn(第7天)	1.012(1.006~1.019)	＜0.001
呋塞米	5.205(1.999~13.551)	＜0.001
螺内酯	4.031(1.608~10.107)	0.003
CRP	1.010(1.001~1.018)	0.022
心率	1.025(1.001~1.049)	0.04
LVEF	0.958(0.919~0.999)	0.043
糖尿病史	2.445(1.013~5.902)	0.047
BNP(峰值)	1.000(1.000~1.001)	0.048
Killip分级	2.255(1.600~3.179)	＜0.001

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表 4 多因素Cox回归分析

Table 4. Multivariate Cox regression analysis results

变量	HR(95%CI)	P
cTn(第7天)	1.011(1.003~1.018)	0.004
呋塞米	4.380(1.595~12.026)	0.004
killips分级	1.878(1.280~2.756)	＜0.001
术后IMR	5.887(1.966~17.631)	0.002

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表 5 随访期间MACE发生情况

Table 5. MACE during follow-up 例(%)

项目	总体(140例)	非CMD组(79例)	CMD组(61例)
全因死亡	8(5.71)	3(3.8)	5(8.2)
再次心肌梗死	1(1.3)	1(1.3)	0
心衰住院	15(10.71)	5(6.3)	10(16.4)
再次血运重建	2(1.43)	1(1.3)	1(1.64)
总MACE	23(16.43)	8(10.13)	15(24.60)

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