胡紅云　王岳松　邵旭武　王學(xué)忠　董學(xué)濱

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老年急性心肌梗死患者臨床特點(diǎn)和直接經(jīng)橈動(dòng)脈介入治療療效評(píng)價(jià)

胡紅云王岳松邵旭武王學(xué)忠董學(xué)濱

目的分析老年急性ST段抬高型心肌梗死(STEMI)患者臨床和冠脈病變特點(diǎn),評(píng)價(jià)經(jīng)橈動(dòng)脈直接介入治療的可行性和安全性。方法選取2011年1月至2015年5月因STEMI在我院行冠狀動(dòng)脈介入治療的患者,年齡≥65歲為老年組共105例,年齡<65歲為對(duì)照組,共102例。觀察2組臨床特征和冠脈病變特點(diǎn)以及直接經(jīng)橈動(dòng)脈介入治療效果。結(jié)果(1)臨床特征:老年組典型胸痛癥狀比例低于對(duì)照組(P<0.05),明確誘因比例高于對(duì)照組(P<0.05),發(fā)病至入院時(shí)間長于對(duì)照組(P<0.05),術(shù)中行臨時(shí)起搏和電復(fù)律的比例高于對(duì)照組(P<0.05);(2)冠脈病變特點(diǎn)和手術(shù)效果:老年組多支病變和球囊預(yù)擴(kuò)張比例高于對(duì)照組(P<0.05),單支病變、血栓抽吸和使用糖蛋白Ⅱb/Ⅲa受體抑制劑(GPI)的比例低于對(duì)照組(P<0.05);橈動(dòng)脈穿刺成功率、手術(shù)成功率和手術(shù)時(shí)間組間比較無統(tǒng)計(jì)學(xué)差異(P>0.05),門-球囊時(shí)間長于對(duì)照組(P<0.05),但2組間門-球囊時(shí)間<90 min的患者比例并無差異(P>0.05);(3)并發(fā)癥和心臟不良事件:2組出血和支架內(nèi)血栓發(fā)生率無統(tǒng)計(jì)學(xué)性差異(P>0.05),老年組心臟功能Killip≥Ⅲ級(jí)者多于對(duì)照組(P<0.05),術(shù)后24 h左室射血分?jǐn)?shù)(LVEF)低于對(duì)照組(P<0.05),但住院期間2組病死率差異無統(tǒng)計(jì)學(xué)意義 (P>0.05)。結(jié)論雖然老年STEMI患者臨床和冠脈病變特點(diǎn)與年輕患者相比有所不同,但經(jīng)橈動(dòng)脈直接冠狀動(dòng)脈介入治療與年輕患者一樣是安全有效的。

經(jīng)皮冠狀動(dòng)脈介入治療; 老年人; 臨床特點(diǎn); 橈動(dòng)脈; 療效

直接經(jīng)皮冠狀動(dòng)脈介入治療(PCI)是急性ST段抬高型心肌梗死(STEMI)最有效的治療方法,能早期持續(xù)有效地開通梗死相關(guān)動(dòng)脈,恢復(fù)心肌有效灌注[1]，經(jīng)橈動(dòng)脈直接冠脈內(nèi)介入治療由于具有創(chuàng)傷小、局部出血和血管并發(fā)癥少,尤其是術(shù)后拔除鞘管時(shí)不需中斷肝素等抗凝藥物治療等諸多優(yōu)點(diǎn),更適合于老年冠心病患者,尤其是STEMI患者[2]。但老年患者因橈動(dòng)脈和頭臂干動(dòng)脈扭曲發(fā)生率較高[3],而且在臨床和冠脈病變方面有些不同特點(diǎn)[4],選擇橈動(dòng)脈路徑是否延遲門-球囊時(shí)間而影響患者預(yù)后國內(nèi)相關(guān)報(bào)道文獻(xiàn)不多,本文通過對(duì)老年和年輕患者的臨床和冠脈病變特點(diǎn)以及手術(shù)效果的對(duì)比研究,評(píng)價(jià)老年STEMI患者經(jīng)橈動(dòng)脈直接冠脈內(nèi)介入治療的可行性和安全性。

1　資料與方法

1.1研究對(duì)象連續(xù)入選2011年1月至2015年5月因急性STEMI在我院行直接冠狀動(dòng)脈介入治療的患者207例,年齡≥65歲的分為老年組，共105例,年齡65～86歲,平均(73.9±4.9)歲,<65歲的為對(duì)照組，共102例,年齡35～64歲,平均(52.8±6.5)歲。入選標(biāo)準(zhǔn):llen’s試驗(yàn)陽性,符合急性STEMI診斷和直接PCI治療指征[6]。

1.2介入手術(shù)方法術(shù)前予腸溶阿司匹林300 mg、氯吡格雷300 mg(手術(shù)前未曾服用氯吡格雷者予600 mg)、阿托伐他汀80 mg頓服[6]。經(jīng)橈動(dòng)脈進(jìn)行選擇性冠狀動(dòng)脈造影和冠狀動(dòng)脈介入治療,見參考文獻(xiàn)[7]。術(shù)后2 h皮下注射低分子肝素,連續(xù)使用3 d;血栓抽吸和慢血流患者術(shù)中冠脈內(nèi)緩慢注射替羅非班10 μg/kg,在3 min內(nèi)推注完畢,術(shù)畢以0.15 μg/(kg·min)的速率維持滴注36 h。

1.3觀察指標(biāo)術(shù)中專人記錄2組橈動(dòng)脈穿刺成功率,橈動(dòng)脈介入手術(shù)成功率,橈動(dòng)脈穿刺時(shí)間(自穿刺部位麻醉至置入動(dòng)脈鞘管的時(shí)間),門-球囊時(shí)間(自進(jìn)入急診室至球囊開始擴(kuò)張或抽吸導(dǎo)管開始血栓抽吸的時(shí)間),手術(shù)時(shí)間(自進(jìn)入導(dǎo)管室至手術(shù)完成的時(shí)間);2組臨床和冠脈病變特點(diǎn),術(shù)后24 h超聲檢查結(jié)果,手術(shù)相關(guān)并發(fā)癥及住院期間不良事件等。

1.4統(tǒng)計(jì)學(xué)處理采用SPSS 17.0軟件包進(jìn)行統(tǒng)計(jì)分析,計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差表示,采用t檢驗(yàn)。計(jì)數(shù)資料以頻數(shù)和率表示,2組比較采用χ2檢驗(yàn)或Fisher精確概率法。P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

2　結(jié)果

2.12組臨床資料及冠脈病變特點(diǎn)2組患者合并高血壓、糖尿病和高脂血癥的比例差異無統(tǒng)計(jì)學(xué)意義(P>0.05),老年組在有明確誘因、發(fā)病至入院時(shí)間、多支病變以及需要臨時(shí)心臟起搏和緊急電復(fù)律等方面比例高于對(duì)照組(P<0.05)。2組罪犯血管分布、置入支架比例及個(gè)數(shù)比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05),但在置入支架前,老年組進(jìn)行球囊預(yù)擴(kuò)張的比例較高(P<0.05),而對(duì)照組進(jìn)行血栓抽吸以及冠脈內(nèi)使用糖蛋白Ⅱb/Ⅲa受體抑制劑(GPI)比例較高(P<0.05),見表1。

表1　2組臨床及冠狀動(dòng)脈病變特點(diǎn)

注:與老年組比較,*P<0.05

2.22組介入治療效果比較2組在橈動(dòng)脈穿刺成功率、穿刺時(shí)間、橈動(dòng)脈改為股動(dòng)脈以及手術(shù)成功率等方面差異無統(tǒng)計(jì)學(xué)意義(P>0.05);在手術(shù)時(shí)間、放射劑量、透視時(shí)間以及對(duì)比劑用量等方面老年組雖然有增高的趨勢,但2組差異無統(tǒng)計(jì)學(xué)意義(P>0.05);門-球囊時(shí)間老年組雖然長于對(duì)照組(P<0.05),但門-球囊時(shí)間<90 min患者的比例2組間差異無統(tǒng)計(jì)學(xué)意義(P>0.05),見表2。

表2　2組介入治療效果比較

注:與老年組比較,*P<0.05

2.3介入治療并發(fā)癥及心臟不良事件老年組和對(duì)照組分別有5例(4.8%)和4例(3.9%)發(fā)生出血并發(fā)癥(P>0.05),住院期間老年組心臟功能Killip≥Ⅲ級(jí)比例高于對(duì)照組(P<0.05),術(shù)后24 h心臟超聲檢查左室射血分?jǐn)?shù)(LVEF)低于對(duì)照組(P<0.05),支架內(nèi)急性血栓和住院期間病死率2組間差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，見表3。

表3　2組介入治療并發(fā)癥及心臟不良事件

注:與老年組比較,*P<0.05

3　討論

有研究表明,老年急性心肌梗死患者在危險(xiǎn)因素、臨床癥狀、誘發(fā)因素以及發(fā)病時(shí)間等方面與年輕人相比較存在較大差異[8]。本研究發(fā)現(xiàn),年輕患者,早發(fā)冠心病家族史比例較高,男性吸煙患者較多,胸痛癥狀明顯。而老年患者胸痛癥狀多不典型,發(fā)病至入院時(shí)間較長,大多有誘發(fā)因素。冠狀動(dòng)脈造影提示罪犯血管分布基本一致,好發(fā)部位最多見于左前降支,其次為右冠狀動(dòng)脈,回旋支少見。但在冠脈病變方面有些差異,老年患者多支病變較多[9],罪犯血管狹窄較重,血栓負(fù)荷較輕,因此,多數(shù)患者需要對(duì)罪犯血管進(jìn)行球囊預(yù)擴(kuò)張之后才能順利置入支架,且術(shù)中容易合并嚴(yán)重心律失常,需要臨時(shí)心臟起搏和電復(fù)律的患者較多;年輕患者單支病變較多,罪犯血管狹窄較輕,血栓負(fù)荷較重,部分患者只需對(duì)罪犯血管進(jìn)行血栓抽吸即可支架置入,少數(shù)患者,血栓抽吸之后,血管狹窄程度<50%,且TIMI血流達(dá)到3級(jí),不進(jìn)行支架置入也是安全的,國外已有這方面的研究[10]。

近年來,大量證據(jù)表明,與經(jīng)股動(dòng)脈路徑PCI相比,經(jīng)橈動(dòng)脈路徑的PCI能夠顯著降低出血風(fēng)險(xiǎn)和改善生存率[11]。本研究結(jié)果表明,急性STEMI患者直接經(jīng)橈動(dòng)脈介入治療,成功率為94.7%,出血并發(fā)癥為4.3%,路徑交叉率為5.3%。死亡3例,均為2支冠狀動(dòng)脈同時(shí)閉塞合并心源性休克患者,死亡率為1.4%，與國外研究結(jié)果基本一致。老年患者由于橈動(dòng)脈和頭臂干扭曲發(fā)生率較高[3],可能影響橈動(dòng)脈穿刺成功率、手術(shù)成功率以及門-球囊時(shí)間,從而影響到患者的預(yù)后。本研究發(fā)現(xiàn),與對(duì)照組相比,老年組橈動(dòng)脈穿刺成功率和手術(shù)成功率無顯著差異,門-球囊時(shí)間雖然長于對(duì)照組,但有99%的患者均能滿足指南要求的時(shí)間(門-球囊時(shí)間<90 min)[5],和對(duì)照組一樣,只有1例患者因術(shù)中發(fā)生“電風(fēng)暴”，門-球囊時(shí)間>90 min。

綜上所述,老年急性心肌梗死患者,雖然臨床和冠脈病變特點(diǎn)與年輕患者有所不同,門-球囊時(shí)間相對(duì)較長,但絕大部分患者均能夠在指南規(guī)定的時(shí)間內(nèi)完成再灌注治療,成功率高,并發(fā)癥少,與年輕患者同樣安全有效。

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Clinical characteristics and the therapeutic effect of coronary intervention by radial approach for elderly patients with acute myocardial infarction

HUHong-yun.

DepartmentofCardiovasology,MaanshanClinicalHospital,AnhuiMedicalUniversity,Maanshan243000,China;WANGYue-song,SHAOXu-wu,WANGYue-song,DONGXue-bin.DepartmentofCardiovasology,MaanshanPeople’sHospital,Maanshan243000,China

ObjectiveTo investigate clinical and coronary artery lesion characteristics in the elderly patients with ST-elevated myocardial infarction(STEMI), and to evaluate the feasibility and safety of interventional treatment by radial approach.MethodsPatients with STEMI who had received coronary artery intervention treatment from January 2011 to April 2015 in our hospital were selected, and according to the age they were divided into elderly group (aged ≥65 years old,n=105) and the control group (aged<65 years old,n=102). Clinical characteristics and coronary lesions were observed, and the efficacy of percutaneous coronary intervention was compared between the two groups.Results(1) Compared with control group, the ratio of typical chest pain was lower, the ratio of explicit incentive was higher, onset to admission time was longer, temporary pacemaker and cardioerter ratio was higher in the elderly group (P<0.05).(2) Compared with control group, multivessel lesion and balloon expansion ratio was higher, the proportion of single lesion, thrombus suction, and using GPⅡb/Ⅲa receptors inhibitors was lower in elderly group (P<0.05). There was no significant difference in success rate of radial artery puncture and operation, operation time between two groups (P>0.05). The door to balloon time was longer in elderly group than that in the control group (P<0.05), but there was no significant difference between the two groups (P>0.05) in the ratio of door to balloon time less than 90 min. (3) There was significant difference in bleeding and stent thrombosis between two groups (P<0.05),and ratio of heart function Killip ≥grade Ⅲ in elderly group was more than that in the control group (P<0.05). Postoperative 24 hours LVEF value was lower than that of the control group (P<0.05), but the mortality rate during hospitalization had no significant difference between the two groups (P>0.05).ConclusionsAlthough the aged patients with acute myocardial infarction have different clinical features and coronary lesions from the young patients, the interventional treatment by radial approach has the same safety and effectiveness.

percutaneous coronary intervention; aged; clinical characteristics; radial artery; efficacy

馬鞍山市科技計(jì)劃基金資助項(xiàng)目(2011-03-08)

243000安徽省馬鞍山市，安徽醫(yī)科大學(xué)馬鞍山臨床學(xué)院

心內(nèi)科(胡紅云)；243000安徽省馬鞍山市，馬鞍山市人民醫(yī)院心內(nèi)

王岳松，Email:wysl660l@126.com

R 542.22

Adoi:10.3969/j.issn.1003-9198.2016.03.015

2015-05-29)

科(王岳松，邵旭武，王學(xué)忠，董學(xué)濱)