STEMI患者直接PCI术后无复流的危险因素分析及风险预测评估研究

发布时间：2018-05-07 12:10

本文选题：ST段抬高性心肌梗死 + 无复流　；参考：《天津医科大学》2017年博士论文

【摘要】：目的:急性ST段抬高型心肌梗死(ST segment elevation myocardial infarction,STEMI)患者行直接经皮冠状动脉介入治疗(percutaneous coronary interventions,PCI)术后梗死相关动脉(infarction related artery,IRA)发生无复流现象,受损心肌的功能不但未得到恢复,反而损伤加重。虽然治疗策略不断改进,发生无复流仍然会导致患者预后不良。如何快速、准确地预测无复流的发生仍待进一步研究。通过分析无复流现象相关的临床治疗、造影特征、心电图及化验结果来识别高危人群,有助于降低无复流的发生率,但目前仍缺乏一个既及时高效又临床实用的评分系统。本研究旨在探讨发生无复流现象相关危险因素、建立简便实用的无复流风险评分系统,并对STEMI患者直接PCI无复流的发生进行危险分层,为临床提供防治直接PCI术后无复流的新措施,降低并发症发生,改善预后。方法:收集2010年1月至2016年5月在天津市胸科医院心内科成功行直接PCI治疗的临床资料完整的STEMI患者病例数据,按3:1比例随机分为模型组和验证组,根据PCI术中急性心肌梗死溶栓(thrombolysis in myocardial infarction,TIMI)血流分级和TIMI心肌灌注分级(TIMI myocardial perfusion grade,TMPG)结果将患者分为无复流组和正常血流组。冠状动脉前向血流TIMI≤2级或TIMI 3级而TMPG分级2级诊断为无复流。比较两组患者基本临床资料、冠脉造影特征及手术相关资料、实验室检查的差异,分析STEMI患者PCI术后发生无复流的危险因素。采用二项多变量Logistic回归研究的方法从模型组发生无复流的危险因素中筛选独立危险因素。按照Logistic模型的优势比(Odds ratio,OR)对危险因素进行风险赋值,建立无复流风险评分系统,筛选出无复流高风险的STEMI患者。采用受试者工作特征曲线(receiver operator characteristic curve,ROC)检验分别在模型组和验证组中评价该评分系统的真实性和可靠性。按同样方法,我们在老年亚组和女性亚组中单独做了分析。结果:PCI术后造影无复流的发生率为29.6%。模型组多变量Logistic回归分析显示年龄≥65岁、脉压50 mmHg、中性粒细胞和淋巴细胞比值7、LP(a)0.5mmol/L、ST抬高≥0.4、发病至开通时间6 h、侧支循环≤1级、血栓负荷≥4分为急性STEMI患者直接PCI治疗中发生无复流的独立危险因素。ROC曲线下面积0.675,准确性为中等。无复流现象危险因素评分:年龄≥65岁记为2分、脉压50 mmHg记为2分、中性粒细胞和淋巴细胞比值7记为2分、LP(a)0.5 mmol/L记为1分、ST抬高≥0.4记为2分、发病至球囊扩张病变时间6小时记为1分、侧支循环≤1级记为2分。无复流现象危险分层:总分值6分为低危,6-10分为中危,10分为高危。验证组二项Logistic回归分析的ROC曲线下面积0.660,准确性为良好。在老年亚组中,PCI术后造影无复流的发生率为36.6%。模型组多变量Logistic回归分析显示年龄≥80岁、无梗死前心绞痛、吸烟史、脉压50 mmHg、LP(a)0.5 mmol/L、ST段抬高的导联数≥4为急性STEMI患者直接PCI治疗中发生无复流的独立危险因素。ROC曲线下面积0.702,准确性为中等。无复流现象危险因素评分:年龄≥80岁记为2分、无梗死前心绞痛记为2分、吸烟史记为2分、脉压50 mmHg记为2分、LP(a)0.5 mmol/L记为2分、ST段抬高的导联数≥4记为3分。无复流现象危险分层:总分值5分为低危,5-8分为中危,8分为高危。验证组二项Logistic回归分析的ROC曲线下面积0.566。在女性亚组中,PCI术后造影无复流的发生率为28.8%。模型组多变量Logistic回归分析显示中性粒细胞百分比≥80、血糖8 mmol/L、左室射血分数50、β受体阻滞剂、后扩张、病变钙化≥中度为急性STEMI患者直接PCI治疗中发生无复流的独立危险因素。ROC曲线下面积0.747,准确性为中等。无复流现象危险因素评分:中性粒细胞百分比≥80记为3分、血糖8 mmol/L记为2分、左室射血分数50记为3分、β受体阻滞剂记为2分、后扩张记为2分、病变钙化≥中度记为3分。无复流现象危险分层:总分值5分为低危,5-8分为中危,8分为高危。验证组二项Logistic回归分析的ROC曲线下面积0.662。结论:1年龄≥65岁、脉压50 mmHg、中性粒细胞和淋巴细胞比值7、LP(a)0.5mmol/L、ST抬高≥0.4、发病至开通时间6 h、侧支循环≤1级、血栓负荷≥4分是STEMI患者直接PCI术中发生无复流现象的独立危险因素。年龄≥80岁、无心绞痛史、吸烟史、脉压50 mmHg、LP(a)0.5 mmol/L、ST段抬高的导联数≥4是老年STEMI患者直接PCI术中发生无复流现象的独立危险因素;中性粒细胞百分比≥80、血糖8 mmol/L、左室射血分数50、β受体阻滞剂、后扩张、病变钙化≥中度是女性STEMI患者直接PCI术中发生无复流现象的独立危险因素。2侧枝循环≤1级、ST段抬高的导联数≥4、左室射血分数50分别是判断基础人群、老年人群和女性人群STEMI直接PCI术中发生无复流现象的最强预测因子。3无复流风险评分系统有助于识别AMI介入术中发生无复流现象的高危患者。
[Abstract]:Objective: the patients with acute ST segment elevation myocardial infarction (ST segment elevation myocardial infarction, STEMI) have no reflow after percutaneous coronary intervention (percutaneous coronary interventions, PCI), and the function of the damaged myocardium is not recovered, but the function of the damaged myocardium is not recovered. It is worse. Although the treatment strategy is constantly improved, no reflow will still lead to poor prognosis. How to quickly and accurately predict the occurrence of no reflow is still to be further studied. The identification of high-risk groups by the analysis of the clinical treatment related to non reflux phenomenon, the characteristics of contrast, electrocardiogram and test results can help to reduce the non reflow. There is still a lack of a timely, efficient and clinically practical scoring system. This study aims to explore the risk factors associated with non reflow, establish a simple and practical non reflow risk scoring system, and carry out a dangerous layer of direct PCI without reflow in STEMI patients, and provide a clinical prevention and treatment for direct PCI without reflow. New measures to reduce the incidence of complications and improve the prognosis. Methods: a complete collection of STEMI patients' data from January 2010 to May 2016 in Department of Cardiology, Tianjin Thoracic Hospital, which were successfully treated with direct PCI treatment, were randomly divided into model group and verification group according to 3:1 ratio, according to the thrombolytic thrombolysis (thrombolysis in myocar) for acute myocardial infarction (thrombolysis in myocar). Dial infarction, TIMI) blood flow classification and TIMI myocardial perfusion classification (TIMI myocardial perfusion grade, TMPG), the patients were divided into no reflow group and normal blood flow group. The anterior coronary artery blood flow TIMI < < 2 or TIMI 3 grade, and TMPG classification 2 was no reflow. Compare the basic clinical data, coronary angiography features and surgical phase of the two groups. The risk factors for the non reflow of STEMI patients after PCI were analyzed by the difference of customs data and laboratory tests. Two multivariate Logistic regression methods were used to select independent risk factors from the risk factors of non reflow in the model group. The risk factors were set up according to the advantage ratio of the Logistic model (Odds ratio, OR) to risk factors. No reflow risk scoring system was used to screen STEMI patients without reflow and high risk. The authenticity and reliability of the scoring system were evaluated in the model group and the validation group by the receiver operator characteristic curve (ROC) test. The same method, we did the same method in the elderly subgroup and the female subgroup. Results: the incidence of non reflux after PCI was the multivariable Logistic regression analysis in 29.6%. model group, which showed that the age was 65 years old, the pulse pressure was 50 mmHg, the ratio of neutrophils and lymphocyte was 7, LP (a) 0.5mmol/L, ST elevation was more than 0.4, the onset time was 6 h, the collateral circulation was less than 1, and the thrombus load was more than 4 as the direct PCI treatment of the acute STEMI patients. The area under the independent risk factor.ROC curve was 0.675 and the accuracy was moderate. The risk factor of no reflow was 2, the pulse pressure was 50 mmHg, 2, the ratio of neutrophils and lymphocyte was 2, LP (a) 0.5 mmol/L was 1, ST elevation was more than 0.4 in 2, and the onset of balloon dilatation time 6 There were 1 points and 2 points in the collateral circulation less than grade 1. There was no risk stratification of the reflow phenomenon: the total score was 6 in low risk, 6-10 in middle risk and 10 in high risk. The area under the ROC curve of the two Logistic regression analysis was 0.660 and the accuracy was good. In the elderly subgroup, the incidence of no reflow after PCI was the multivariable Logist in the 36.6%. model group. IC regression analysis showed that age more than 80 years old, no pre infarction angina, smoking history, pulse pressure of 50 mmHg, LP (a) 0.5 mmol/L, ST segment elevation guide number more than 4 is an independent risk factor of no reflow in acute STEMI patients with independent risk factors under the.ROC curve area under.ROC curve 0.702, accuracy is moderate. The risk factor of no reflow phenomenon score: age > 80 years, 2, 2 Scores, no pre infarction angina were recorded as 2 points, smoking records were 2 points, pulse pressure 50 mmHg were recorded as 2, LP (a) 0.5 mmol/L was recorded as 2 points, and ST segment elevation guide number was 3. No reflow phenomenon risk stratification: total score 5 was low risk, 5-8 was in middle risk, 8 was at high risk. The area 0.566. under ROC curve under the ROC curve of two item Logistic regression analysis in female sub In the group, the incidence of no reflow after PCI was a multivariable Logistic regression analysis in the 28.8%. model group, which showed that the percentage of neutrophils was more than 80, blood glucose 8 mmol/L, left ventricular ejection fraction 50, beta blocker, postdilation, and calcification more than moderate as an independent risk factor of non reflow in direct PCI treatment of acute STEMI patients under the.ROC curve. The area was 0.747 and the accuracy was moderate. The risk factors of no reflow were scored: the percentage of neutrophils was more than 80 in 3, the blood sugar 8 mmol/L was recorded as 2, the left ventricular ejection fraction was 3, the beta blocker was 2, the dilatation was 2, the lesion calcification was more than moderate as 3. The total score was 5 in low risk, 5-8 points. For the middle risk, 8 was at high risk. The area under the ROC curve of two Logistic regression analysis in the test group showed that the 1 age was more than 65 years old, the pulse pressure was 50 mmHg, the ratio of neutrophils and lymphocyte was 7, LP (a) 0.5mmol/L, ST elevation was more than 0.4, the onset time was 6 h, the collateral circulation was less than 1, and the thrombus load of more than 4 was no reflow in PCI PCI operation of STEMI patients. Independent risk factors of the phenomenon. The age of 80 years old, no angina history, smoking history, pulse pressure 50 mmHg, LP (a) 0.5 mmol/L, ST segment elevation lead number more than 4 are independent risk factors for non reflow phenomenon of direct PCI operation in elderly STEMI patients; neutrophils percentage is more than 80, blood sugar 8 mmol/L, left ventricular ejection fraction 50, beta receptor blocker, post dilatation, Calcification more than moderate is an independent risk factor for non reflow phenomenon in direct PCI operation in female STEMI patients,.2 collateral circulation is less than grade 1, the number of lead in ST segment elevation is more than 4, left ventricular ejection fraction 50 is the basic population, and the strongest predictor of non reflow phenomenon in the STEMI direct PCI operation of the elderly and the female population,.3 without reflux wind,.3 The risk scoring system can help identify high-risk patients who have no reflow during AMI intervention.

【学位授予单位】：天津医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R542.22

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