微创医学

目的对比60岁以下高危急性冠脉综合征患者介入治疗早期及即刻联合在常规使用阿司匹林和氯吡格雷基础上静脉应用替罗非班的临床疗效。方法对拟行介入治疗的高危急性冠脉综合征110例患者,随机分为介入治疗早期使用组55例和介入治疗前即刻使用组55例,观察两组患者的基本临床情况、介入治疗术前和术后即刻靶血管TIMI分级、TIMI心肌灌注分级(TMPG)、术后30 d内出血并发症、主要不良心脏事件(MACE)的发生情况和术后30 d心脏彩超左室舒张末期内径(LVEDD)及左室射血分数(LVEF)。结果与即刻使用组比较,早期使用组介入治疗前TIMI 3级血流和TMPG 3级比例明显升高(30.9%VS 12.7%、34.5%VS 12.7%,P<0.05);早期使用组介入治疗后TMPG 3级明显升高(80%VS 52.7%,P<0.05),轻度出血并发症明显增多(P<0.05),重度出血并发症增多但无统计学意义(P>0.05);介入治疗早期使用组和即刻使用组术后30 d MACE发生率分别为7.2%VS 16.4%(P>0.05);术后30 d早期使用组的LVEDD显著小于即刻使用组,而LVEF则显著大于即刻使用组,其差异具有统计学意义。结论在阿司匹林和氯吡格雷常规抗血小板治疗的基础上,60岁以下高危急性冠脉综合征患者介入治疗前早期应用替罗非班比介入治疗前即刻应用能及早强化抗血小板治疗,改善TIMI及TMPG分级,从而有效保护心功能,其临床应用是安全有效的。

Objective To evaluate the effect of upstream tirofiban versus downstream tirofiban in patients with high-risk acute coronary syndromes( ST segment elevation myocardial infarction，STEMI-ACS) with age less than 60 treated with percutaneous coronary interventions ( PCI ) ． Method Based on pretreatment with aspirin and clopidogrel，110 STEMI-ACS patients were randomized to receive upstream ( upstream group，n = 55) and downstream( downstream group，n = 55) tirofiban． Thrombolysis in myocardial infarction ( TIMI) flow grade the TIMI myocardial perfution ( TMP) grade of target artery before and after PCI， bleeding complications rates within 30 days，major adverse cardiac events ( MACE ) ，left ventricular end-diastolic diameter ( LVEDD) and left ventricular ejection fraction ( LVEF) 30 days after PCI were measured and compared． Results The proportions of TIMI3 and TMP3 in upstream group before PCI were higher than those in downstream group( 30． 9% vs 12． 7%，34． 5% vs 12． 7%，P ＜ 0． 05) ， the proportion of TMP3 in upstream group after PCI was higher than that in downstream group ( 80% vs 52． 7%) ，all with statistical difference( P ＜ 0． 05) ． The incidences of minor bleeding complications in the upstream group was much higher than that in the downstream group ( P ＜ 0． 05) ， the incidences of major bleeding complications as well as mild thrombocytopenia during tirofiban treatment were similar between the two groups( P ＞ 0． 05) ． There existed no statistically significant difference in the rate of the MACE between the two group( 7． 2% vs 16． 4%，P ＞ 0． 05) ． The LVEDD of upstream group at 30 th day after PCI was less than that of downstream group，and its LVEF was better． Conclusion Based on pretreatment with aspirin and clopidogrel，early tirofiban administration can increase platelet aggregation inhibition，improve TIMI and TMP grade，and protect heart function for patients with high-risk acute coronary syndromes with age less than 60 before treated with percutaneous coronary interventions． Early application of tirofiban is safe and effective．