Effect of early heparin anticoagulation on blood flow and cardiac function in patients with acute ST segment elevation myocardial infarction treated by primary PCI
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摘要: 目的 探讨及早肝素抗凝对急性ST段抬高型心肌梗死(STEMI)患者行直接经皮冠状动脉介入(PPCI)治疗前TIMI血流及心功能的影响。方法 本研究回顾性分析了2017年12月—2023年5月就诊于成都市第五人民医院心血管内科行PPCI治疗的STEMI患者730例，根据肝素使用时机分为两组。早期组：确诊为STEMI后立即静脉注射普通肝素3 000 U，进入导管室穿刺成功后以100 U/kg补足普通肝素用量；延迟组：确诊为STEMI进入导管室后经鞘管注射普通肝素3 000 U，PCI前以100 U/kg补足普通肝素。经1∶1倾向性得分匹配后两组各167例患者，分析比较两组一般临床资料、心肌损伤标志物如初始肌钙蛋白、肌钙蛋白峰值及达峰时间。介入相关指标：术前TIMI血流分级、术后TIMI血流分级。术后指标：ST段回落率、左室射血分数、N末端脑钠肽前体、主要不良心血管事件、出血事件。结果 早期组术前TIMI 2~3级血流占比高于延迟组(P<0.05)；早期组在ST段回落率上优于延迟组(P<0.05)；早期组N末端脑钠肽前体峰值低于延迟组(P<0.05)；早期组院内心力衰竭及再发心绞痛发生率显著降低(P<0.05)；两组在心源性死亡、再发心肌梗死及出血事件发生率上无差异。Logistic回归分析提示及早肝素抗凝是术前TIMI 2~3级血流的独立预测因子。结论 STEMI患者发病后，及早肝素抗凝可提高梗死相关动脉的通畅性，改善患者心肌灌注；可减轻心肌损伤，改善心功能；降低院内主要不良心血管事件发生率且不增加出血风险。
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关键词:
- 急性ST段抬高型心肌梗死 /
- 直接经皮冠状动脉介入治疗 /
- 普通肝素 /
- 心肌灌注 /
- 心功能
Abstract: Objective To investigate the effect of early heparin anticoagulation on blood flow and cardiac function in patients with acute ST segment elevation myocardial infarction(STEMI) treated by PPCI.Methods This retrospective study analyzed 730 STEMI patients who underwent PPCI treatment at Chengdu Fifth People's Hospital from December 2017 to May 2023. Patients were divided into two groups based on the timing of heparin administration: patients were stratified into two groups based on the timing of heparin administration. The early group received 3000 U of heparin immediately upon STEMI diagnosis and 100 U/kg of heparin after successful puncture in the catheterization laboratory. In the delayed group, 3000 U of UFH was administered through the sheath catheter following the STEMI diagnosis, with 100 U/kg of UFH given prior to PCI. After 1: 1 propensity score matching, 167 patients in each group were compared in terms of clinical data, myocardial injury markers, interventional indexes, and postoperative outcomes.Results The early group had a higher preoperative blood flow ratio of TIMI grade 2-3, better ST segment regression rate, lower peak value of NT-proBNP, and decreased incidence of in-hospital heart failure and recurrent angina pectoris compared to the delayed group. Logistic regression analysis indicated that early heparin anticoagulation was an independent predictor of preoperative TIMI level 2-3 blood flow.Conclusion Early heparin anticoagulation can enhance IRA patency and myocardial perfusion post-STEMI, reduce myocardial injury, improve cardiac function, and lower the incidence of in-hospital MACE without increasing bleeding risk. -
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表 1 一般临床资料
Table 1. General clinical data
例(%), X±S, M(P25, P75) 项目 早期组(167例) 延迟组(167例) P 年龄/岁 71.29±7.44 71.28±7.39 0.994 男性 126(75.4) 123(73.7) 0.706 收缩压/mmHg 132.2±26.62 127.74±24.67 0.113 舒张压/mmHg 82.27±20.19 84.86±17.89 0.105 心率/(次/min) 79.38±17.29 77.88±19.34 0.455 吸烟 94(56.3) 100(59.9) 0.506 高血压病 85(50.9) 97(58.1) 0.187 糖尿病 64(38.3) 57(34.1) 0.426 高脂血症 17(10.2) 13(7.8) 0.444 脑梗死 11(6.6) 11(6.6) 1.000 冠心病 13(7.8) 14(8.4) 0.841 肥胖 5(3.0) 6(3.6) 0.759 高敏C反应蛋白/(mg/L) 5.63(1.10，8.50) 4.93(1.10，8.40) 0.777 红细胞/(×1012/L) 4.16±0.86 4.33±0.79 0.069 血红蛋白/(g/L) 111.71±14.86 110.71±13.70 0.751 白细胞/(×109/L) 7.01(3.62，8.36) 6.47(3.58，7.58) 0.444 血小板/(×109/L) 153.04±47.04 153.37±55.37 0.952 尿酸/(μmol/L) 418.23±191.46 418.14±172.66 0.996 血钾/(mmol/L) 4.04±0.84 4.00±0.71 0.608 总胆固醇/(mmol/L) 4.77±1.12 4.83±117 0.654 甘油三酯/(mmol/L) 1.41(0.69，1.63) 1.29(0.71，1.57) 0.432 高密度脂蛋白胆固醇/(mmol/L) 1.16±0.228 1.19±0.535 0.504 低密度脂蛋白胆固醇/(mmol/L) 2.82(2.26，2.79) 2.87(2.09，3.26) 0.120 肌酐/(μmol/L) 100.89(63.80，110.70) 97.33(62.90，104.00) 0.852 住院时间/d 7.12±1.58 716±1.61 0.810 发病至就诊时间/min 182.90(80.00，230.00) 172.69(80.00，230.00) 0.800 就诊至导丝通过时间/min 73.23±11.61 72.23±12.37 0.447 初始肌钙蛋白/(ng/mL) 6.93(0.10，15.08) 9.26(0.10，17.50) 0.087 注：1 mmHg＝0.133 kPa。 
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表 2 终点事件
Table 2. End events
例(%), X±S, M(P25, P75) 项目 早期组(167例) 延迟组(167例) P 术前TIMI 2~3级 50(29.9) 29(17.4) 0.001 术后TIMI 3级 164(98.2) 146(87.4) 0.010 STR良好 128(76.6) 92(55.1) ＜0.001 NT-proBNP/(ng/mL) 1 766.65(449.3，2 000.0) 2 137.83(599.4，2 080.0) 0.035 LVEF/% 57.08(47，65) 54.29(46，62) 0.073 肌钙蛋白峰值/(ng/mL) 25.62(8.10，50.00) 31.30(9.71，50.00) 0.045 肌钙蛋白达峰时间/h 15.11±2.49 17.29±2.69 ＜0.001 心源性死亡 3(1.8) 4(2.4) 0.702 再发心肌梗死 0 0 再发心绞痛 17(10.2) 34(20.4) 0.020 心力衰竭 18(10.8) 55(32.9) ＜0.001 出血事件 3(1.8) 2(1.2) 0.693
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表 3 影响TIMI 2~3级血流的多因素logistic回归分析
Table 3. Multivariate logistic regression analysis of influencing TIMI grade 2-3 blood flow
危险因素 OR 95%CI P 及早肝素抗凝 1.462 1.398~2.437 0.001 收缩压 1.009 0.990~1.030 0.353 舒张压 0.980 0.955~1.007 0.147 吸烟 0.997 0.058~1.956 0.993 高血压病 0.773 0.375~1.433 0.364 红细胞 1.155 0.778~1.716 0.475 初始肌钙蛋白 1.005 0.987~1.033 0.706
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