Effect Observation Of Intracoronary Multi-target Combination Therapy On Primary Percutaneous Coronary Intervention Of Acute ST-segment Elevation Myocardial Infarction

Objective: This study was designed to investigate the effect of intracoronary combined injection of nitroprusside,tirofiban,and nicorandil on microcirculation and cardiac function in patients with acute ST-segment elevation myocardial infarction(STEMI)undergoing primary percutaneous coronary intervention(PPCI).Methods: 80 patients who was clearly identified as acute ST-segment elevation myocardial infarction(STEMI)for the first time,admitted to Department of Cardiology,The Third Hospital of Hebei Medical University during September 2016 and September 2017 was selected into this investigation.Patients with factors affecting the observed indicators such as cardiogenic shock,severe heart failure,severe liver and kidney function impairment,and history of previous hemorrhage were excluded.According to the randomized table method,the selected patients were randomly divided into experimental group(intracoronary application of sodium nitroprusside,tirofiban,nicorandil,n=39)and control group(intracoronary application of sodium nitroprusside,tirofiban,n=41).In the experimental group,after the guidewires through lesion or the balloon dilated showing forward blood flow,Sodium nitroprusside(200 μg),tirofiban(10 μg/kg),and nicorandil(2 mg)were given sequentially in the distal segment of the coronary target lesion using a puncture balloon,followed by tirofiban 0.10 μg/(kg·min)Intravenous pumping for 48 h after PCI,nicorandil 2 mg/h is continuously pumped to 24 h after surgery,followed by nicorandil 5 mg 3/day for long-term oral administration.The control group was given only sodium nitroprusside and tirofiban using the same method.Intravenous infusion of tirofiban just like the experimental group.The rest of the surgical procedure is performed routinely,and symptomatic treatment such as norepinephrine or dopamine should be given in the event of symptoms such as hypotension during the operation.Infarction related artery(IRA)was successfully established in both groups and the stent was successfully implanted.Observation indexes: Thrombolysis In Myocardial Infarction(TIMI)blood flow grading before and after PPCI,Corrected TIMI Frame Count(cTFC),TIMI Myocardial Perfusion Grading(TMPG),ST-segment resolution(STR)90 min after surgery,Creatine Kinase isoenzyme-MB(CK-MB)before surgery,Cardiac Troponic I(CTn I)level and postoperative peak,intraoperative reperfusion arrhythmia,severe hypotension,and perioperative hemorrhage.N-terminal pro-brain natriuretic peptide(NT-pro BNP)and left ventricular ejection fraction(LVEF)before and 7 days,3 months after the operation,Major cardiovascular adverse events within 3 months after surgery were also included in the indexes.Results:1.Baseline data: A total of 80 subjects were enrolled,39 in the experimental group and 41 in the control group,of which 47 were male(58.75%)and 33 were female(41.25%).Basic data such as Age,combined risk factors(hypertension,hyperlipidemia,diabetes,smoking history),BMI,the first medical contact time(FMC),number of diseased vessels,infarct-related artery,thrombus aspiration,the number of stents inserted,stent diameter and length during the operation was no statistical difference(all P>0.05).2.TIMI flow grading,TMPG,cTFC,postoperative 90 min STR comparison between the two groups: preoperative TIMI flow grading and TMPG blood flow grading were not significantly different between the two groups(P>0.05).At the end of surgery,the proportion of patients achieving TIMI flow grade 3 was 94.87% in the experimental group and 82.93% in the control group.The experimental group had a tendency to improve.However,there was no significant difference between the two groups(P>0.05).Compared with the control group,the proportion of TMPG grade 3 in the experimental group(92.31% vs 73.17%,P<0.05)and cTFC(22.12±7.03 vs 25.47±5.5,P<0.05)were improved to some extent.There are statistical differences.There was a difference in STR between the two groups at 90 min after surgery.Compared with the control group,the experimental group(84.62% vs63.41%,P<0.05)showed significant improvement.3.Comparison of CK-MB,cTnI,NT-pro BNP,and LVEF between the two groups: there was no significant difference in CK-MB and cTnI between the two groups before operation(P>0.05).Postoperative CK-MB and cTnI peak values had no significant difference between the two groups(P>0.05),but the experimental group has a tendency to improve.Preoperative NT-pro BNP and 1 day postoperative LVEF had no significant difference between the two groups(P>0.05).Compared with NT-pro BNP and LVEF at 7 days postoperatively,the experimental group showed a slight improvement trend,but the difference was no statistically significant(P>0.05).At 3 months after surgery,compared with the control group,NT-pro BNP(537.56±147.58 vs 616.78±182.86,P<0.05)and LVEF(52.67±3.3vs50.51±3.61,P=0.007<0.05)were significantly improved in the experimental group.The differences was statistical significant.4.The adverse events between the two groups were compared: the incidence of intraoperative reperfusion arrhythmia was less in the experimental group(12.82% vs 31.71%,P<0.05),which was statistically different from the control group.Severe hypotension and perioperative bleeding were not statistically significant between the two groups(P>0.05).One patient in the experimental group received hospitalization due to heart failure.One patient in the control group had heart failure during hospitalization and one patient was admitted to hospital because of heart failure.All patients were discharged after being actively treated.one patient in the experimental group and 2 patients in the control group developed postinfarction angina.All of them are given conservative treatment now.One patient in the control group had recurrent myocardial infarction during follow-up and was treated with emergency PCI(non-target blood vessel revascularization).The current condition was stable.The incidence of MACEs at 3 months after operation was not significantly different between the two groups(5.13% vs 12.2%,P>0.05).Conclusions:In the course of PPCI in STEMI patients,using multi-targets intervention with intracoronary injection of nitroprusside,tirofiban,and nicorandil can reduce the incidence of no-reflow,further improve myocardial microcirculation,increase horizontal perfusion of myocardial tissue and reduce the incidence of reperfusion arrhythmias.There was no significant difference in intraoperative severe hypotension and perioperative bleeding events compared with the control group.The follow-up time was up to 3 months after operation,compared with the control group,the cardiac function of the experimental group was significantly improved.However,the experimental group had no significant effect on the incidence of MACEs.