| 第一部分 Clinical significance of no-reflow in different stages of primary percutaneous coronary intervention among patients with acute myocardial infarctionsBackground: Primary percutaneous coronary intervention(PCI) is the most efficient strategy to restore antegrade blood flow of patients with acute myocardial infarction.The coronary no reflow(NR) phenomenon, which is associated with poor clinical outcomes, is usually referred to as a post-percutaneous coronary intervention(PCI) state. However NR can occur in different stages of the PCI procedure, not only including the post-stenting stage, but from balloon pre-dilation to pre-stenting. The clinical significance of NR in the different stages of the PCI procedure is unclear. The purpose of the current study was to analyze the clinical and angiographic characteristics, the prognosis for NR patients in the aforementioned two stages, and to determine the predictors of NR in the early stage.Methords: Between January 2009 and December 2013, a total of 420 consecutive patients with ST-Segment Elevation Myocardial Infarction(STEMI) underwent primary PCI.Sixty-three patients(15%) with NR constituted the study population. The patients were divided into an early NR group and a subsequent NR group. The clinical and angiographic findings were compared between the two groups. Multivariate logistic regression was used to determine the predictors for early NR. The long-term clinical outcomes after PCI were analyzed.Results: Regarding the baseline characteristics, we identified that the early NR group had statistically significant effects on the higher percentage of diabetes mellitus(42.9% vs. 20%), lower admission SBP(102.2±8.3 mm Hg vs. 110.5±7.6 mm Hg), a higher percentage of Killip classification III(71.4% vs. 45.7%,) and the longer reperfusion time(7.1±2.3 h vs. 5.88±2.2 h) compared to the subsequent NR group.There were significant differences between the two groups with respect to the percentage of initial thrombolysis in myocardial infarction(TIMI) flow 0/1(64.3% vs. 37.1%), target lesion length(31.4±13.6 mm vs. 20.5±17.3 mm), and thrombus score ≥ 4(67.9% vs. 42.9%; P<0.05 for all). Multiple stepwise logistic regression analysis indicated that an admission SBP<100 mm Hg(OR=4.580; 95% CI=1.385–15.150; P=0.0130), reperfusion time ≥ 6 h(OR=4.978; 95% CI=1.468–16.882; P=0.010), and a thrombus score ≥ 4(OR=2.708; 95% CI=0.833–8.799; P=0.008) were the independent determinants of the early NR. During a 1-year follow-up, the all-cause mortality and overall MACE in the early NR group occurred significantly more often than the subsequent NR group(28.6% vs. 5.7% and 35.7% vs. 14.3%, respectively, P<0.05). The early NR group had a lower LVEF(42.5±4.7mm vs. 47.8±3.5mm, P<0.001) and a larger LVEDD(56.0±4.0mm vs. 51.5 ±4.7mm, P=0.001) at the end of the follow-up.Conclusion: Early NR patients during primary PCI have more severe baseline clinical and angiographic characteristics, as well as a poorer long-term prognosis.第二部分 The clinical observation of preoperative strengthening atorvastatin therapy for patients underwent the direct PCIObjective:Whether or not strengthening statin therapy could improve no reflow phenomenon during the primary PCI, there are a lot of controversy in current clinic.To explore whether preoperative strengthening atorvastatin therapy for patients underwent the direct PCI can improve myocardial no reflow and effect intraoperative usage of vasodilator to deal with no reflow.Methods: 130 cases of patients underwent the direct PCI were randomly divided into loading dose treatment group and control group. Loading dose treatment group(60 cases), given 80 mg loading dose atorvastatin chewing before PCI and 20 mg/d dose by oral after PCI; Control group 70 cases, given 20 mg/d standard doses of atorvastatin by oral. Records of the patient’s baseline clinical data, LVEF and LVEDD and intraoperative usage of therapeutic drugs for no reflow(including diltiazem hydrochloride 、 nitroprusside 、 adenosine 、 tirofiban). Intraoperative thrombolysis using myocardial infarction(TIMI) flow grade classification and corrected TIMI frame count(CTFC) blood flow to evaluate myocardial microcirculation perfusion, coronary angiography and PCI image informations were collected. Major adverse cardiac events(MACE) were recored during the periord of a month follow-up;LVEF and LVEDD were measured after one month.Results: the loading dose treatment group which occur no reflow were 13 cases(21.7%), the control group were 18 cases(25.7%).By comparison between the two groups, there was no statistically significant difference(P=0.589). The former group had 2 no reflow cases(3.3%) before the end of PCI precudure, the latter had 4 cases(5.7%)(P = 0.976). Repetition utilization rate of diltiazem hydrochloride、repetition utilization rate of nitroprusside、repetition utilization rate of adenosinewere were lower than control group respectively(8.3%vs21.4%,5% vs 18.6%, 5%vs 17.1%,respectively, P all < 0.05).Regarding utilization rate of tirofiban between two groups, the differences were not statistically significant(3.3%vs11.4%,P =0.084). In terms of MACE,the former was lower than the latter(8.3%vs22.9%, P = 0.023). LVEF of loading dose treatment group was slightly higher than that of the control group, LVEDD of loading dose treatment group was slightly lower than that of the control group, but there was no statistically significant difference(P all > 0.05). Loading dose treatment group had a lower serum hs-CRP level in comparsion with control group[7.8(6.2-18.3) vs 10.3(8.6-20.6),P <0.05].In comparsion with the baseline,The level of hs-CRP in loading dose treatment group lower than the baseline[7.8(6.2-18.3)vs16.5(13.4-25.4),P<0.05],as well as in control group [10.3(8.6-20.6) vs15.9(12.5-24.3),P <0.05] at the end of the follow-up.Conclusion: although the preoperative strengthening atorvastatin treatment fail to show improvement for the occurrence of no reflow during direct PCI, it can reduce the intraoperatie usage of vasodilator for no reflow, and improve recent clinical prognosis. |
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