| Coronary atherosclerotic heart disease is one of the major diseases threatening human health at present.The revascularization therapy is an important method for the treatment of coronary heart disease.ST-segment elevation myocardial infarction(STEMI)is the the most serious classfication of coronary heart disease,with high morbidity and mortality.Early myocardial reperfusion is the main method to decrease the mortality and improve long-term prognosis of STEMI.More and more evidence proves that,due to the unique advantages of drug reperfusion,the comprehensive effect of thrombolysis combined with early PCI is not inferior to that of direct PCI.In addition,some studies have shown that thrombolysis combined with PCI is more beneficial to protect myocardial microcirculation and improve the myocardial perfusion level of STEMI.Multivessel disease is present in approximately 40% to 65% of patients with acute myocardial infarction undergoing percutaneous coronary intervention.A number of clinical studies and meta-analyses have shown that complete revascularization,especially staged complete revascularization,can reduce the incidence of angina pectoris and ischemia-driven revascularization.However,in patients with STEMI and multivessel disease and renal insufficiency,the efficacy of staged complete revascularization as compared with revascularization of the infarct-related vessel alone remains to be explored.Acute kidney injury(AKI)is a common complication in hospitalized patients with acute myocardial infarction(AMI),especially in the coronary care unit(CCU).AMI patients have a high risk of AKI during hospitalization,with an incidence rate of 12.1% to 55.6%.According to research,AKI negatively impacts the short-and long-term prognosis of patients with AMI.The early detection of patients at risk and timely preventive measures are effective ways to reduce the occurrence of AKI and its sequelae.As a result,the early detection of patients at high risk for AKI is critical in clinical practice.Over the past decade,several predictive models for AKI have been developed for patients with coronary heart disease.However,most of these models were used to predict the occurrence of contrast-induced nephropathy during interventional surgery.A growing body of evidence implies that AKI has complex and multifaceted pathophysiology in this clinical context that extends beyond the delivery of contrast material during catheterization.Clinically,however,there is a lack of predictive tools to evaluate AKI in patients with AMI,including patients with non-operative treatment.Therefore,the establishment of clinical models using common indicators to predict AKI in AMI patients(including AMI patients without interventional therapy)has important temporary practical value.Because patients with renal insufficiency are often excluded from randomized reperfusion therapy trials,evidence-based evidence for the diagnosis and treatment of patients with acute myocardial infarction and renal dysfunction is sparse.Therefore,this series of studies will focus on three parts.The first part discusses the safety and effectiveness of prourokinase combined with early PCI in the treatment of STEMI patients with mild renal insufficiency.The second part analyzed and evaluated the efficacy and safety of complete revascularization compared to criminal revascularization alone for STEMI patients with multiple vessel disease with renal insufficiency.Part 3:To establish a clinical model for predicting AKI in AMI patients(including AMI patients without interventional therapy)using common indicators.Part One Clinical comparison of thrombolysis combined with PCI and primary PCI in patients with STEMI complicated with mild renal insufficiencyObjective: This study sought to explore the efficacy and safety of thrombolysis combined with PCI in patients with STEMI complicated with mild renal insufficiency.Methods: Clinical data of 127 patients with acute STEMI complicated with mild renal insufficiency were retrospectively analyzed,including 97 males and 30 females,aged from 30 to 74 years old,with an average of58.18±11.66 years old.STEMI patients were divided into two groups according to whether they had received prourokinase intravenous thrombolytic therapy before emergency coronary angiography: Fibrinolytic therapy combined with PCI group(F-PCI group,n=41)and direct PCI group(P-PCI group,n=86).Coronary blood flow,Coronary blood flow,thrombus load,myocardial perfusion,number and length of stent implantation,serum creatinine before and after surgery,bleeding,Hospital mortality rate,MACE events 1 year after discharge were compared between the two groups.Results: The time from onset to balloon dilation in F-PCI group was significantly longer than that in P-PCI group(8.20±2.61 h vs.6.51±2.14 h,P<0.01).However,the time from onset to thrombolysis in the F-PCI group was significantly shorter than the time from onset to balloon dilation in the P-PCI group(4.52±1.13 h vs.6.51±2.14 h,P<0.01).During emergency coronary angiography,the proportion of TIMI level 3 before PCI in the F-PCI group was significantly higher than that in the P-PCI group(65.9% vs.14.0%,P<0.01).The proportion of high thrombus load in the F-PCI group was significantly lower than that in the P-PCI group(29.3% vs.84.8%,P<0.01).The proportion of TMPG3 grade in the F-PCI group was significantly higher than that in the P-PCI group(75.6% vs.55.8%,P<0.01).The amount of contrast agent in F-PCI group was less than that in P-PCI group(65.85±21.68 m Lvs.73.60±19.15 m L,P<0.05).There were no significant differences in hospital mortality,incidence of hemorrhage,ejection fraction and incidence of contrast-induced nephropathy between the two groups..There was no statistical difference in the incidence of MACE 1 year after discharge between the two groups.Conclusions: For STEMI patients with mild renal insufficiency,compared with primary PCI,thrombolysis combined with PCI can achieve better myocardial perfusion and reduce the amount of contrast agent and did not increase the risk of major bleeding.Part Two Clinical comparison between staged complete revascularization and only infarct-associated vascular revascularization in patients with STEMI complicated with multi-vessel coronary disease and renal insufficiencyObjective: To compare the long-term outcomes of staged complete revascularization with infarct-associated vascular revascularization alone in STEMI patients with multiple vessel lesions and renal insufficiency.Methods: The clinical data of 152 patients with STEMI complicated with multi-vessel lesions complicated with renal insufficiency who underwent emergency PCI were retrospectively analyzed,including 94 males and 58 females,aged from 33 to 81 years old,with an average of 61.11±9.23 years old.Patients were divided into Complete revascularization(CR)group(n=87)and infarct-related artery revascularization(IRA)group(n=65).The cumulative incidence of MACE events at 3 years after discharge was observed.Results: The average length of stay in CR group was longer than that in IRA group(11.98±3.77 vs.10.65±4.03,P<0.01).The CR group had more stents per patient than the IRA group on average(2.61±0.62 vs.1.25±0.59,P<0.01).The average stent length per patient in CR group was longer than that in IRA group(56.25±13.28 mm vs.28.45±18.75 mm,P<0.01).The MACE event rate in CR group was significantly lower than that in IRA group(11.7% vs.22.7%,P=0.039).There was no significant difference in 3-year mortality between the two groups(P>0.05).The rate of ischemia-driven revascularization in CR group was significantly lower than that in IRA group(4.8% vs.15.2%,P<0.05).There was no significant difference in the incidence of former Infarct-related artery between the two groups(P>0.05).The revascularization rate of former non-infarct atery in CR group was significantly lower than that in IRA group(2.1% vs.10.6%,P<0.01).There was no significant difference in e FFR between the two groups at admission and discharge(P>0.05).Conclusions: For STEMI patients with multivessel lesion and renal dysfunction,staged complete revascularization can reduce the incidence of MACE events in 3 years compared with only culprit vessel revascularization,mainly by reducing ischemia-driven repeat revascularization,and has no significant effect on renal function.Part Three Predicting AKI in Patients With AMI: development and assessment of a new predictive nomogramObjective: Acute kidney injury(AKI)is a common complication of acute myocardial infarction(AMI)associated with both long-term and short-term consequences.This study aimed to investigate relevant risk variables and create a nomogram that predicts the probability of AKI in patients with AMI so that prophylaxis could be commenced as early as possible.Methods: Data were gathered from the Medical Information Mart for Intensive Care IV(MIMIC-IV)database.We included 1520 patients with AMI who had been admitted to the coronary care unit or cardiac vascular intensive care unit.The primary outcome was AKI during hospitalization.Independent risk factors for AKI were identified by applying the least absolute shrinkage and selection operator regression model and multivariate logistic regression analyses.Multivariable logistic regression analysis was applied to build a predicting model.Discrimination,calibration,and clinical usefulness of the predicting model were assessed using the C-index,calibration plot,and decision curve analysis.Internal validation was assessed using the bootstrapping validation.Results: Of the 1520 patients,731(48.09%)developed AKI during hospitalization.Haemoglobin,estimated glomerular filtration rate(e GFR),sodium,bicarbonate,bilirubin total,age,heart failure,and diabetes were identified as predictive factors for nomogram construction(P<0.01).The model displayed good discrimination with a C-index of 0.857(95% CI:0.807-0.907)and good calibration.A high C-index value of 0.847 could still be reached in the interval validation.Decision curve analysis showed that the AKI nomogram was clinically useful when intervention was decided at the AKI possibility threshold of 10%.Conclusions: The nomogram constructed herein can successfully predict the risk of AKI in patients with AMI and provide critical information that can facilitate prompt and efficient intervention. |
