Effects of pre-transport anticoagulation on coronary blood and cardiac function in patients with STEMI undergoing direct PCI
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摘要: 目的 探讨急性ST段抬高型心肌梗死(ST-segment elevation myocardial infarction，STEMI)患者在转运至行经皮冠状动脉介入治疗(percutaneous coronary intervention，PCI)之前用普通肝素预处理对接受直接PCI的冠脉血流、心功能和出血事件发生率的影响。 方法 采用回顾性队列研究方法，连续入选2020年6月1日-2022年6月30日于济宁市第一人民医院行直接PCI的STEMI患者138例，其中13例患者信息不完整，最终125例患者被纳入分析。根据肝素使用时间点，分为转运前抗凝组(确诊后于当地医院给药，共65例)和常规抗凝组(导管室内给药，共60例)。收集患者基线资料、胸痛中心时间节点、心肌损伤标记物等指标。主要观察指标为开通血管即刻的冠脉血流(TIMI血流分级)，次要观察指标为患者心功能(左室射血分数、N末端B型钠尿肽前体)、心肌损伤标志物(心肌肌钙蛋白I、肌红蛋白、肌酸激酶、肌酸激酶同工酶)、出血风险及不良心血管事件。 结果 两组患者基线资料、救治时间节点、病变血管差异无统计学意义(P>0.05)；常规抗凝组心肌损伤标志物肌酸激酶同工酶水平高于转运前抗凝组，差异有统计学意义(P＜0.05)；常规抗凝组肌红蛋白水平高于转运前抗凝组，差异有统计学意义(P＜0.05)；转运前抗凝组左室射血分数高于常规抗凝组，差异有统计学意义(P＜0.05)；转运前抗凝组梗死相关动脉(infarct-related artery，IRA)开通即刻TIMI血流分级0~1级35例(58.3%)，常规抗凝组49例(78.3%)，差异有统计学意义(P＜0.05)；进行多因素二元logistic回归分析，以校正混杂因素影响，转运前抗凝是IRA初始血流2~3级发生率的独立预测因素(OR=3.576，95%CI: 1.337~9.519，P=0.011)。两组不良事件及出血事件发生率差异无统计学意义(P>0.05)。 结论 转运前使用普通肝素预处理可改善STEMI患者IRA通畅性和心功能而不增加不良心血管事件及出血事件的发生率。
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关键词:
- 急性ST段抬高型心肌梗死 /
- 经皮冠状动脉介入治疗 /
- 普通肝素 /
- 冠脉血流 /
- 心功能
Abstract: Objective To investigate the effect of unfractionated heparin pretreatment on coronary blood flow, cardiac function and in-hospital bleeding events in patients with acute ST-segment elevation myocardial infarction(STEMI) undergoing primary percutaneous coronary intervention(PCI). Methods A retrospective cohort study was conducted on continuously selected 125 STEMI patients who underwent direct PCI in Jining First People's Hospital from June 1, 2020 to June 30, 2022. According to the time point of heparin use, they were divided into pre-transport anticoagulation group(65 cases, who were administered in local hospitals after diagnosis) and conventional anticoagulation group(60 cases, who were administered in catheter room). Baseline data, time node of chest pain center and biochemical indicators were collected. The main observation indexes were the coronary blood flow(TIMI blood flow grade) immediately after opening the blood vessel, and the secondary observation indexes were cardiac function(left ventricular ejection fraction, NT-proBNP), myocardial injury markers(cTnI, myoglobin, CK, creatine kinase isoenzyme[CK-MB]), bleeding risk and adverse cardiovascular events. Results There was no significant difference in baseline data, time node of treatment and diseased blood vessels between the two groups(P>0.05). The level of CK-MB in the conventional anticoagulation group was higher than that in the pre-transport anticoagulation group, and the difference was statistically significant(P < 0.05). The myoglobin level of the conventional anticoagulation group was higher than that of the pre-transport anticoagulation group, and the difference was statistically significant(P < 0.05). The left ventricular ejection fraction(LVEF) in the pre-transport anticoagulation group was higher than that in the conventional anticoagulation group, and the difference was statistically significant(P < 0.05). There were 35 cases(58.3 %) of TIMI blood flow grade 0-1 in the pre-transport anticoagulation group and 49 cases(78.3%) in the conventional anticoagulation group(P < 0.05). Multivariate binary logistic regression analysis was performed to adjust for confounding factors. Pre-transport anticoagulation was an independent predictor of the incidence of IRA initial blood flow grade 2-3(OR=3.576, 95%CI: 1.337-9.519, P=0.011). There was no significant difference in the incidence of major adverse cardiovascular events and bleeding events(P>0.05). Conclusion Pretreatment with unfractionated heparin before transport can improve IRA patency and cardiac function in STEMI patients without increasing the incidence of adverse cardiovascular events and bleeding events. -
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表 1 转运前抗凝组与常规抗凝组基线资料比较
基线资料 转运前抗凝组(65例) 常规抗凝组(60例) P 性别/例(%) 0.10 男 40(61.5) 45(75.0) 女 25(38.5) 15(25.0) 年龄/岁 67.42±12.53 63.20±12.29 0.06 吸烟史/例(%) 28(48.1) 26(51.9) 0.45 高血压病史/例(%) 0.42 1级 11(16.9) 6(10.0) 2级 4(6.2) 3(5.0) 3级 15(23.1) 21(35.0) 糖尿病病史/例(%) 13(20.0) 7(11.7) 0.23 脑卒中病史/例(%) 8(12.3) 8(13.3) 0.86 冠心病病史/例(%) 7(10.8) 9(15.0) 0.33 住院天数/d 8.14±3.40 7.87±3.31 0.67 
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表 2 转运前抗凝组与常规抗凝组实验室检查结果比较
检查指标 转运前抗凝组(65例) 常规抗凝组(60例) P 肌钙蛋白/(ng/mL) 17.97(4.05，40.75) 27(5.44，68.00) 0.43 肌红蛋白/(ng/mL) 200.00(97.00，881.00) 492.00(172.25，900.00) 0.03 肌酸激酶/(ng/mL) 964.00(413.00，2 611.00) 1681.00(413.00，3 005.00) 0.46 肌酸激酶同工酶/(ng/mL) 107.00(29.35，191.48) 126.50(39.89，243.87) 0.03 乳酸脱氢酶/(U/L) 485.50(301.75，793.75) 709(375.50，948.10) 0.05 凝血酶原时间/s 13.10(11.63，39.33) 11.70(11.10，22.55) 0.03 纤维蛋白原/(g/L) 2.69(2.36，3.44) 2.42(2.05，2.98) 0.23 INR 1.11(1.01，1.22) 1.01(0.97，1.09) 0.00 D-二聚体/(mg/L) 0.43(0.28，0.57) 0.32(0.18，0.76) 0.10 部分活化凝血酶时间/s 35.40(27.57，120.52) 32.6(28.65，46.05) 0.06 凝血酶时间/s 22.90(17.05，80.00) 16.6(14.20，34.74) 0.01 中性粒细胞百分数/% 82.25(73.13，87.82) 81.95(72.4，86.75) 0.21 降钙素原/(ng/mL) 0.07(0.03，0.14) 0.06(0.03，0.25) 0.64 C反应蛋白/(mg/L) 2.73(1.06，5.04) 3.80(1.72，6.03) 0.11 红细胞/(×109/L) 4.28±0.63 4.38±0.59 0.32 红细胞压积/(L/L) 40.37±11.29 40.30±5.15 0.97 血红蛋白/(g/L) 129.00±20.60 136.47±18.61 0.39 白细胞/(×1012/L) 10.39±3.95 10.33±3.22 0.92 血小板/(×109/L) 225.83±59.80 223.27±53.85 0.81
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表 3 转运前抗凝组与常规抗凝组时间节点资料比较
时间节点 转运前抗凝组(65例) 常规抗凝组(60例) P S-F时间/min 150(93.50，252.50) 138(60.25，50) 0.09 S-W时间/min 300(241，448) 260(193，399) 0.09 D-W时间/min 73(55，87) 72(58，85) 0.93
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表 4 转运前抗凝组与常规抗凝组心功能比较
心功能 转运前抗凝组(65例) 常规抗凝组(60例) P LVEF/% 59(55，62) 57(50，60) 0.04 LVDD/mm 47(44，50) 48(46，51) 0.77 NT-ProBNP/(pg/mL) 371(139，1 540) 291(107，748) 0.19
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表 5 转运前抗凝组与常规抗凝组冠脉造影结果比较
项目 转运前抗凝组(65例) 常规抗凝组(60例) P 罪犯血管/例(%) 0.26 LM 0 0 LAD 33(50.8) 32(53.3) LCX 1(1.5) 4(6.7) RCA 31(47.7) 24(40.0) 置入支架数目/个 1 1 1 手术时长/min 43.97±30.13 45.14±19.89 0.80
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表 6 转运前抗凝组与常规抗凝组TIMI血流比较
例(%) 分组 转运前抗凝组(65例) 常规抗凝组(60例) P TIMI 0~1级 TIMI 2级 TIMI 0~1级 TIMI 2级 即刻血流 38(58.5) 27(41.5) 46(76.7) 14(23.3) 0.03 术后血流 2(3.1) 63(96.9) 1(1.7) 59(98.3) 0.68
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表 7 转运前抗凝组与常规抗凝组出血事件及MACE发生率比较
项目 转运前抗凝组(65例) 常规抗凝组(60例) P MACE/例(%) 9(13.8) 5(8.3) 0.40 出血风险/例(%) 2(3.1) 2(3.3) 0.94
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表 8 TIMI血流的logistic分析
项目 单因素 多因素 OR 95%CI P OR 95%CI P 年龄 1.010 0.980~1.041 0.531 1.003 0.965~1.042 0.892 性别 0.828 0.368~1.863 0.684 0.486 0.169~1.392 0.179 吸烟史 0.827 0.390~1.754 0.621 1.206 0.482~3.018 0.688 冠心病病史 0.750 0.198~1.904 0.389 2.296 0.534~9.873 0.264 高血压病史 1.481 0.696~3.184 0.380 0.669 0.284~1.578 0.358 糖尿病病史 1.167 0.431~3.297 0.771 0.881 0.263~2.956 0.838 脑卒中病史 0.986 0.341~3.100 0.260 0.981 0.408~6.345 0.497 转运前抗凝 2.335 1.075~5.070 0.032 3.576 1.337~9.519 0.011 Killip分级>1 1.250 0.367~4.255 0.721 0.990 0.229~4.272 0.989 肌钙蛋白 1.000 1.000~1.000 1.000 1.000 1.000~1.000 0.857 肌红蛋白 1.000 1.000~1.000 1.000 1.000 0.999~1.001 0.941 肌酸激酶同工酶 0.999 0.997~1.001 1.000 1.000 1.000~1.000 0.130 D-二聚体 0.864 0.607~1.200 0.393 0.875 0.999~1.001 0.543 肌酸激酶 1.000 1.000~1.000 1.000 1.000 1.000~1.000 0.361
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