| Objective: Intracoronary diltiazem was given to the patients immediately appearing blood flow after ballon exponding the culprit lesion.As increasing the dose,the size of microcirculation was bigger to reach the maximization in everybody.The aim of the study is to investigate whether the impact microcoronary open manxization could further improve the enhancement of myocardial perfusion and early prognosis in the patients with acute ST-segment elevation myocardial infarction,during primary percutaneous coronary intervention.Methods: A total of 105 consecutive patients were firstly diagnosed clearly as STEMI in the Third Hospital of hebei Medical University from the November 2013 to November 2015,according with the primary pereutaneous coronary intervention standard,excluding chronic arrhythmia,hypotension,heart failure and so on,which affected the observations severely.These patients were eligible for enrollment and randomly assigned to either conventional-dose diltiazem group(n=34),or saline(control group,n=35),or maximum tolerant-dose diltiazem group(n=36).After the preoperative preparation,the diltiazem and saline were given immediately appearing blood flow after ballon exponding the culprit lesion.The control group was given 8ml saline,while the others were given 8ml diltiazem diluent(125ug/ml)within three to five minutes,with observing the heart rate,blood pressure and other indicators.After giving the 8ml diltiazem diluent,if the patient did not feel special discomfortable,the drug would be given until reaching the withdrawal standard in the drug groups.All teams could continue to treat as the conventional operation steps after diltiazem or saline management.if patients appearing coronary no reflow after stent implanted,the operator can chose drugs according the patients condition,such as tirofiban,sodium nitroprussside,diltiazem and so on.All patients were implanted drug eluting stents.The chief of cardiovascular department who has more than 10 years' experience in interventional cardiology,finished the operation of every patient.The cardiovascular physicians,with more than 5 years' clinic experience,managed all patients and collected the information.(1)the baseline characteristics :such as age,gender,body mass index,blood lipids,hypertension,diabetes,preoperative heart rate,blood pressure,the onset to first medical contact hours,door-to-balloon time,the number of stent,infarction related artery,and other information;(2)the data of coronary angiography: the number and length of stent,the TIMI(thromboiysis in myocardial infarction)flow grade,TMPG(TIMI myocardial perfusion grade)and so on;the post-PPCI characteristics:the heart rate and mean blood pressure after operation,ST-segment resolution in 90 minutes after operation,the left ventricle ejection fraction at 1 week and 3month after operation and the incidence of the major adverse cardial events after 3months.The diltiazem administration and withdrawal criterion:when appearing the following station:(1)the ventricular rate<55beats per minute and/or blood pressure<90/60mmHg(2)Morbiz?type or total atrioventricular block(3)the dizziness and other cerebral insufficiency symptoms.Stop infusion immediately and observe the above index.If patient could be recovered in five minute,we would continue to use drugs in the following manners :(1)diltiazem dilution one time,slowing the infusion rate(2)small dose dopamine or atropine to increase the blood pressure and heart rate,then follow the(1)method.Which one would choose was only depended on the operator according with the patient's basic condition.The withdrawal criterion for conventional-dose group is accumulated to 1 ~ 2mg diltiazem.But for the maximum tolerant-dose group,we can give drug until the dose is accumulated to 10 mg or the recovery time is more than 5minutes.Thus,taking into account factors,such as drug safety window,the body's tolerance,almost every patient in maximum tolerant-dose group are up to the maximum amount of medication,at the same time,the state of microcirculation,known as the maximum.CNR is defined as the IRA reopened fully,the TIMI blood flow?2 and TIMI3 with TMPG?2,there are still barriers or insufficient blood supply to the blood stream phenomenon,except vascular spasm,dissection and other factors which can compete blood.Results:1The basic Baseline characteristics of 105 patients,the average of 59.66±8.27,were similar through three groups,such as male(61.90%),body mass index,blood lipids,hypertension,diabetes,preoperative heart rate,blood pressure,the onset to first medical contact hours,door-to-balloon time,and so on.2The data of coronary angiography: No-reflow immediately after stent was seen 11(31.43%)patients in the control group,significantly different from 5.88%in the conventional-dose group and 2.78% maximum tolerant-dose group(both P<0.001).Compare to the control group,the TMPG blood flow was improved in the conventional-dose group(P=0.012<0.017)and maximum tolerant-dose group(P= 0.002<0.017),the last two team without difference(P= 0.536>0.017).As for TIMI,there were no significant different among three groups(P=0.052).3The post-PPCI:STR after 90 min in the maximum tolerant-dose group(55.19±13.42%)and conventional-dose group(50.35± 8.03%)were significantly different from the control group(45.46± 7.90%,conventional-dose group vs.control group,P=0.048 < 0.05 and maximum tolerant-dose group vs.control group,P<0.001),with a dose-dependent pattern(P=0.049<0.05);Compared to the left ventricular ejection fraction(LVEF)in control group,the data has no different in the three groups at one week(P>0.05),but LVEF in the maximum tolerant-dose group was increased significantly at three months(maximum tolerant-dose group vs.control group,65.72±7.60% vs.62.09±4.79%,P=0.017<0.05 and maximum tolerant-dose group vs.conventional-dose group,65.72±7.60% vs.62.65±6.19%,P=0.044 <0.017).There was no difference regarding MACEs at 3months or hospital among these groups.(both P>0.05)Conclusion: Intracoronary diltiazem administration might reduce the incidince of on-reflow preventability.Under the tolerance of everybody,continue to add the dose to open microcoronary maximizely,it can further improve myocardial perfusion and left ventricular systolic function,without increasing the incidence of the MACEs. |
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