老年急性心肌梗死患者临床特点和直接经桡动脉介入治疗疗效评价

胡红云　王岳松　邵旭武　王学忠　董学滨



老年急性心肌梗死患者临床特点和直接经桡动脉介入治疗疗效评价

胡红云王岳松邵旭武王学忠董学滨

目的分析老年急性ST段抬高型心肌梗死(STEMI)患者临床和冠脉病变特点,评价经桡动脉直接介入治疗的可行性和安全性。方法选取2011年1月至2015年5月因STEMI在我院行冠状动脉介入治疗的患者,年龄≥65岁为老年组共105例,年龄<65岁为对照组,共102例。观察2组临床特征和冠脉病变特点以及直接经桡动脉介入治疗效果。结果(1)临床特征:老年组典型胸痛症状比例低于对照组(P<0.05),明确诱因比例高于对照组(P<0.05),发病至入院时间长于对照组(P<0.05),术中行临时起搏和电复律的比例高于对照组(P<0.05);(2)冠脉病变特点和手术效果:老年组多支病变和球囊预扩张比例高于对照组(P<0.05),单支病变、血栓抽吸和使用糖蛋白Ⅱb/Ⅲa受体抑制剂(GPI)的比例低于对照组(P<0.05);桡动脉穿刺成功率、手术成功率和手术时间组间比较无统计学差异(P>0.05),门-球囊时间长于对照组(P<0.05),但2组间门-球囊时间<90 min的患者比例并无差异(P>0.05);(3)并发症和心脏不良事件:2组出血和支架内血栓发生率无统计学性差异(P>0.05),老年组心脏功能Killip≥Ⅲ级者多于对照组(P<0.05),术后24 h左室射血分数(LVEF)低于对照组(P<0.05),但住院期间2组病死率差异无统计学意义 (P>0.05)。结论虽然老年STEMI患者临床和冠脉病变特点与年轻患者相比有所不同,但经桡动脉直接冠状动脉介入治疗与年轻患者一样是安全有效的。

经皮冠状动脉介入治疗; 老年人; 临床特点; 桡动脉; 疗效

直接经皮冠状动脉介入治疗(PCI)是急性ST段抬高型心肌梗死(STEMI)最有效的治疗方法,能早期持续有效地开通梗死相关动脉,恢复心肌有效灌注[1]，经桡动脉直接冠脉内介入治疗由于具有创伤小、局部出血和血管并发症少,尤其是术后拔除鞘管时不需中断肝素等抗凝药物治疗等诸多优点,更适合于老年冠心病患者,尤其是STEMI患者[2]。但老年患者因桡动脉和头臂干动脉扭曲发生率较高[3],而且在临床和冠脉病变方面有些不同特点[4],选择桡动脉路径是否延迟门-球囊时间而影响患者预后国内相关报道文献不多,本文通过对老年和年轻患者的临床和冠脉病变特点以及手术效果的对比研究,评价老年STEMI患者经桡动脉直接冠脉内介入治疗的可行性和安全性。

1　资料与方法

1.1研究对象连续入选2011年1月至2015年5月因急性STEMI在我院行直接冠状动脉介入治疗的患者207例,年龄≥65岁的分为老年组，共105例,年龄65～86岁,平均(73.9±4.9)岁,<65岁的为对照组，共102例,年龄35～64岁,平均(52.8±6.5)岁。入选标准:llen’s试验阳性,符合急性STEMI诊断和直接PCI治疗指征[6]。

1.2介入手术方法术前予肠溶阿司匹林300 mg、氯吡格雷300 mg(手术前未曾服用氯吡格雷者予600 mg)、阿托伐他汀80 mg顿服[6]。经桡动脉进行选择性冠状动脉造影和冠状动脉介入治疗,见参考文献[7]。术后2 h皮下注射低分子肝素,连续使用3 d;血栓抽吸和慢血流患者术中冠脉内缓慢注射替罗非班10 μg/kg,在3 min内推注完毕,术毕以0.15 μg/(kg·min)的速率维持滴注36 h。

1.3观察指标术中专人记录2组桡动脉穿刺成功率,桡动脉介入手术成功率,桡动脉穿刺时间(自穿刺部位麻醉至置入动脉鞘管的时间),门-球囊时间(自进入急诊室至球囊开始扩张或抽吸导管开始血栓抽吸的时间),手术时间(自进入导管室至手术完成的时间);2组临床和冠脉病变特点,术后24 h超声检查结果,手术相关并发症及住院期间不良事件等。

1.4统计学处理采用SPSS 17.0软件包进行统计分析,计量资料以均数±标准差表示,采用t检验。计数资料以频数和率表示,2组比较采用χ2检验或Fisher精确概率法。P<0.05为差异有统计学意义。

2　结果

2.12组临床资料及冠脉病变特点2组患者合并高血压、糖尿病和高脂血症的比例差异无统计学意义(P>0.05),老年组在有明确诱因、发病至入院时间、多支病变以及需要临时心脏起搏和紧急电复律等方面比例高于对照组(P<0.05)。2组罪犯血管分布、置入支架比例及个数比较差异无统计学意义(P>0.05),但在置入支架前,老年组进行球囊预扩张的比例较高(P<0.05),而对照组进行血栓抽吸以及冠脉内使用糖蛋白Ⅱb/Ⅲa受体抑制剂(GPI)比例较高(P<0.05),见表1。

表1　2组临床及冠状动脉病变特点

注:与老年组比较,*P<0.05

2.22组介入治疗效果比较2组在桡动脉穿刺成功率、穿刺时间、桡动脉改为股动脉以及手术成功率等方面差异无统计学意义(P>0.05);在手术时间、放射剂量、透视时间以及对比剂用量等方面老年组虽然有增高的趋势,但2组差异无统计学意义(P>0.05);门-球囊时间老年组虽然长于对照组(P<0.05),但门-球囊时间<90 min患者的比例2组间差异无统计学意义(P>0.05),见表2。

表2　2组介入治疗效果比较

注:与老年组比较,*P<0.05

2.3介入治疗并发症及心脏不良事件老年组和对照组分别有5例(4.8%)和4例(3.9%)发生出血并发症(P>0.05),住院期间老年组心脏功能Killip≥Ⅲ级比例高于对照组(P<0.05),术后24 h心脏超声检查左室射血分数(LVEF)低于对照组(P<0.05),支架内急性血栓和住院期间病死率2组间差异无统计学意义(P>0.05)，见表3。

表3　2组介入治疗并发症及心脏不良事件

注:与老年组比较,*P<0.05

3　讨论

有研究表明,老年急性心肌梗死患者在危险因素、临床症状、诱发因素以及发病时间等方面与年轻人相比较存在较大差异[8]。本研究发现,年轻患者,早发冠心病家族史比例较高,男性吸烟患者较多,胸痛症状明显。而老年患者胸痛症状多不典型,发病至入院时间较长,大多有诱发因素。冠状动脉造影提示罪犯血管分布基本一致,好发部位最多见于左前降支,其次为右冠状动脉,回旋支少见。但在冠脉病变方面有些差异,老年患者多支病变较多[9],罪犯血管狭窄较重,血栓负荷较轻,因此,多数患者需要对罪犯血管进行球囊预扩张之后才能顺利置入支架,且术中容易合并严重心律失常,需要临时心脏起搏和电复律的患者较多;年轻患者单支病变较多,罪犯血管狭窄较轻,血栓负荷较重,部分患者只需对罪犯血管进行血栓抽吸即可支架置入,少数患者,血栓抽吸之后,血管狭窄程度<50%,且TIMI血流达到3级,不进行支架置入也是安全的,国外已有这方面的研究[10]。

近年来,大量证据表明,与经股动脉路径PCI相比,经桡动脉路径的PCI能够显著降低出血风险和改善生存率[11]。本研究结果表明,急性STEMI患者直接经桡动脉介入治疗,成功率为94.7%,出血并发症为4.3%,路径交叉率为5.3%。死亡3例,均为2支冠状动脉同时闭塞合并心源性休克患者,死亡率为1.4%，与国外研究结果基本一致。老年患者由于桡动脉和头臂干扭曲发生率较高[3],可能影响桡动脉穿刺成功率、手术成功率以及门-球囊时间,从而影响到患者的预后。本研究发现,与对照组相比,老年组桡动脉穿刺成功率和手术成功率无显著差异,门-球囊时间虽然长于对照组,但有99%的患者均能满足指南要求的时间(门-球囊时间<90 min)[5],和对照组一样,只有1例患者因术中发生“电风暴”，门-球囊时间>90 min。

综上所述,老年急性心肌梗死患者,虽然临床和冠脉病变特点与年轻患者有所不同,门-球囊时间相对较长,但绝大部分患者均能够在指南规定的时间内完成再灌注治疗,成功率高,并发症少,与年轻患者同样安全有效。

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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

马鞍山市科技计划基金资助项目(2011-03-08)

243000安徽省马鞍山市，安徽医科大学马鞍山临床学院

心内科(胡红云)；243000安徽省马鞍山市，马鞍山市人民医院心内

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，王学忠，董学滨)