早期应用重组人B型利钠肽对ST段抬高型心肌梗死患者急诊冠状动脉介入术后心肌梗死面积的影响
조기응용중조인B형리납태대ST단태고형심기경사환자급진관상동맥개입술후심기경사면적적영향
Effects of pretreatment with recombinant human B-type natriuretic peptide on infarct size in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention
  • 万方数据
    中华心血管病杂志 중화심혈관병잡지
    Chinese Journal of Cardiology
    2015年 11期 954-959 ,共6页

    李世强%傅向华%代玉涵%刘晨%汪雁博%李伟%吴伟力%谷新顺%郝国桢

    리세강%부향화%대옥함%류신%왕안박%리위%오위력%곡신순%학국정

    心肌梗死%利钠肽,脑%血管成形术,经腔,经皮冠状动脉%心肌再灌注损伤 心肌梗死%利鈉肽,腦%血管成形術,經腔,經皮冠狀動脈%心肌再灌註損傷
    심기경사%리납태,뇌%혈관성형술,경강,경피관상동맥%심기재관주손상
    Myocardial infarction%Natriuretic peptide,brain%Angioplasty,transluminal,percutaneous coronary%Myocardial reperfusion injury
    目的 前瞻性探讨早期应用重组人B型利钠肽(rhBNP)对急性前壁ST段抬高型心肌梗死(STEMI)患者直接经皮冠状动脉介入治疗(PCI)后梗死相关动脉(IRA)血流灌注、心肌梗死面积及左心室早期重构的影响.方法 为前瞻性病例对照研究,连续入选2011年1月至2013年12月就诊于河北医科大学第二医院的发病时间＜12h的急性前壁STEMI病例,采用随机数字表法分为静脉注射rhBNP组48例(PCI术前至少5min开始应用,首剂给予冲击量1.5μg/kg弹丸式静脉注射,随后以0.0075～0.03μg·kg-1·min-1维持静脉注射5d)和静脉注射硝酸甘油(NIT)组45例(至少PCI术前5min开始应用,10～100μg/min维持静脉注射5d),PCI术中均采用缺血后适应(PC)技术.比较两组患者IRA开通时TIMI血流、校正TIMI血流帧数、TIMI心肌灌注分级,住院期间心肌坏死标志物变化和超声心动图指标;随访6个月,通过超声心动图比较两组左心室形态、功能情况.结果 两组患者基线临床特点、IRA开通时间及PCI术中选择的支架长度、直径等差异均无统计学意义;PCI术后rhBNP组IRA的TIMI3级血流获得率及TIMI心肌灌注3级获得率差异均无统计学意义[95.8％(46/48)比86.7％(39/45),P=0.162;72.9％(35/48)比62.2％(28/45),P=0.500],而rhBNP组校正TIMI血流帧数明显低于NIT组(21.0±8.7比28.2±14.8,P=0.005);计算机辅助测定PCI术后72h的血清肌酸磷酸激酶MB型同工酶(CK-MB)曲线下面积,rhBNP组较NIT组减少27％[(3249±1101)U/L比(4474±1661)U/L,P=0.010],血清肌钙蛋白Ⅰ(TnI)曲线下面积亦较NIT组减少18％[(3670±942)μg/L比(4541±1098)μg/L,P=0.021];术后1周,rhBNP组患者左心室射血分数(LVEF)较NIT组有升高趋势,rhBNP组患者E/e'指数较NIT组有显著改善(11.95±3.31比14.60±4.09,P=0.030),比较两组患者室壁运动积分指数(WMSI),rhBNP组优于NIT组(1.74±0.17比2.40±0.55,P＜0.001);入院即刻两组患者B型利钠肽(BNP)水平差异无统计学意义[(147.7±84.3)ng/L比(160.2±78.8)ng/L,P=0.723],rhBNP组PCI术后7d的BNP水平低于NIT组[(68.3±37.8)ng/L比(129.4±64.4)ng/L,P＜0.001];随访6个月,复查超声心动图,rhBNP组患者的LVEF(51.7％±12.7％比46.9±9.6％,P=0.024)和WMSI(1.69±0.35比1.92±0.47,P=0.020)均优于NIT组.结论 对于在急诊PCI术中已采用PC技术治疗的前壁STEMI患者,早期应用rhBNP可在PC基础上进一步发挥心肌保护作用,改善心肌灌注,缩小心肌梗死面积,改善心室功能,阻抑左心室早期和后期重构.
    목적 전첨성탐토조기응용중조인B형리납태(rhBNP)대급성전벽ST단태고형심기경사(STEMI)환자직접경피관상동맥개입치료(PCI)후경사상관동맥(IRA)혈류관주、심기경사면적급좌심실조기중구적영향.방법 위전첨성병례대조연구,련속입선2011년1월지2013년12월취진우하북의과대학제이의원적발병시간＜12h적급성전벽STEMI병례,채용수궤수자표법분위정맥주사rhBNP조48례(PCI술전지소5min개시응용,수제급여충격량1.5μg/kg탄환식정맥주사,수후이0.0075～0.03μg·kg-1·min-1유지정맥주사5d)화정맥주사초산감유(NIT)조45례(지소PCI술전5min개시응용,10～100μg/min유지정맥주사5d),PCI술중균채용결혈후괄응(PC)기술.비교량조환자IRA개통시TIMI혈류、교정TIMI혈류정수、TIMI심기관주분급,주원기간심기배사표지물변화화초성심동도지표;수방6개월,통과초성심동도비교량조좌심실형태、공능정황.결과 량조환자기선림상특점、IRA개통시간급PCI술중선택적지가장도、직경등차이균무통계학의의;PCI술후rhBNP조IRA적TIMI3급혈류획득솔급TIMI심기관주3급획득솔차이균무통계학의의[95.8％(46/48)비86.7％(39/45),P=0.162;72.9％(35/48)비62.2％(28/45),P=0.500],이rhBNP조교정TIMI혈류정수명현저우NIT조(21.0±8.7비28.2±14.8,P=0.005);계산궤보조측정PCI술후72h적혈청기산린산격매MB형동공매(CK-MB)곡선하면적,rhBNP조교NIT조감소27％[(3249±1101)U/L비(4474±1661)U/L,P=0.010],혈청기개단백Ⅰ(TnI)곡선하면적역교NIT조감소18％[(3670±942)μg/L비(4541±1098)μg/L,P=0.021];술후1주,rhBNP조환자좌심실사혈분수(LVEF)교NIT조유승고추세,rhBNP조환자E/e'지수교NIT조유현저개선(11.95±3.31비14.60±4.09,P=0.030),비교량조환자실벽운동적분지수(WMSI),rhBNP조우우NIT조(1.74±0.17비2.40±0.55,P＜0.001);입원즉각량조환자B형리납태(BNP)수평차이무통계학의의[(147.7±84.3)ng/L비(160.2±78.8)ng/L,P=0.723],rhBNP조PCI술후7d적BNP수평저우NIT조[(68.3±37.8)ng/L비(129.4±64.4)ng/L,P＜0.001];수방6개월,복사초성심동도,rhBNP조환자적LVEF(51.7％±12.7％비46.9±9.6％,P=0.024)화WMSI(1.69±0.35비1.92±0.47,P=0.020)균우우NIT조.결론 대우재급진PCI술중이채용PC기술치료적전벽STEMI환자,조기응용rhBNP가재PC기출상진일보발휘심기보호작용,개선심기관주,축소심기경사면적,개선심실공능,조억좌심실조기화후기중구.
    Objectives To investigate whether the administration of recombinant human B-type natriuretic peptide (rhBNP) before primary percutaneous coronary intervention (PCI) could further limit the infract size,improve left ventricular function,and alleviate cardiac dilation in patients with acute ST-segment elevation myocardial infarction (STEMI).Methods A total of 93 consecutive patients presenting chest pain within 12 hours from the onset,suspicious of first STEMI located at anterior wall undergoing primary PCI,were eligible for enrollment and randomly assigned to either rhBNP group (rhBNP administration starting at 5 min before PCI,1.5μg/kg bolus intravenous injection followed by 0.0075-0.03μg·kg-1·min-1 for up to 120 hours,n=48) or nitroglycerin (NIT) group (NIT treatment starting at 5 min before PCI,10-100μg/min intravenous infusion for 120 hours,n=45).Primary PCI was performed in both groups using post-conditioning (PC) technique.TIMI flow grade,corrected TIMI frame count,and TIMI myocardial perfusion grade were compared between the two groups at the time of infarct related artery (IRA) re-patency.The levels of serum creatine kinase MB isoenzyme (CK-MB) and troponin I (TnI) were measured.Echocardiography was performed at baseline 7 days and 6 months later.Results Baseline characteristics were similar between the two groups.The percentage of TIMI grade 3 and TIMI myocardial perfusion grade 3 after PCI both tended to be higher in rhBNP group than those in NIT group(95.8％ (46/48) vs.86.7％ (39/45),P=0.162) and (72.9％ (35/48) vs.62.2％ (28/45),P=0.500).The corrected TIMI frame count was significantly decreased in rhBNP group (21.0±8.7 vs.28.2±14.8,P=0.005).The myocardial infarct size expressed as the AUC of CK-MB ((3249±1101)U/L vs.(4474±1661)U/L,P=0.010) or AUC of TnI ((3670±942)μg/L vs.(4541±1098)μg/L,P=0.021) was significantly decreased in rhBNP group compared with those in NIT group.At 7 days after primary PCI,the left ventricular ejection fraction (LVEF) tended to be higher (P＞0.05),while the E/e' index and wall motion score index (WMSI) ((11.95±3.31 vs.14.60±4.09,P=0.030) and (1.74±0.17 vs.2.40±0.55,P＜0.001))were significantly improved in rhBNP group compared with those in NIT group.BNP level was also significantly lower in rhBNP group compared that in NIT group ((68.3±37.8)ng/L vs.(129.4±64.4)ng/L,P＜0.001).During 6-month follow-up,LVEF and WMSI were significantly improved in rhBNP group compared those in NIT group(51.7％±12.7％ vs.46.9％±9.6％,P=0.024 and 1.69±0.35 vs.1.92±0.47,P=0.020).Conclusion Administration of rhBNP before PCI with postconditioning procedure can further improve myocardial perfusion,limit myocardial infarct size,ameliorate cardiac dysfunction and postpone left ventricular early-stage and long-term remodeling in STEMI patients undergoing primary PCI.
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