微创医学

目的探讨急性ST段抬高型心肌梗死(STEMI)患者接受转运经皮冠脉介入(PCI)治疗的术前药物干预(Ph-I)安全性和有效性。方法纳入由广西胸痛中心二级网络医院确诊且发病时间在6 h内的STEMI并送至广西壮族自治区人民医院接受转运PCI的患者共212例，采用随机数字表法分为减半剂量尿激酶溶栓组(Ph-I 1组，68例)、替罗非班组(Ph-I 2组，62例)、常规治疗组(non-Ph-I组，82例)，另选取同期76例STEMI且发病6 h内在广西壮族自治区人民医院接受直接PCI治疗的患者作为对照组。采集各组患者的临床基线资料、胸痛中心质控数据、PCI手术资料，对所有研究对象进行随访，比较并评价各组患者院内死亡率、30 d主要心脑血管不良事件(MACCE)及出血事件发生率。结果各组间术前心肌梗死溶栓治疗（TIMI）血流存在显著差异，其中Ph-I 1组和Ph-I 2组术前TIMI血流2级、3级比例明显高于对照组(均P＜0.05)，但各组术后TIMI血流分级差异无统计学意义（均P＞0.05）。Ph-I 1组有63例完成随访，Ph-I 2组60例完成随访，non-Ph-I组79例完成随访，对照组76例均完成随访，总体失访率为3.5%，总体随访时间为（28.5±7.3）d。随访结果显示，4组院内死亡率、30 d联合终点事件发生率、脑卒中发生率、出血学术研究会（BARC）1型出血事件发生率、BARC 2～5型出血事件发生率差异均无统计学意义（均P＞0.05）。Kaplan-Meier生存分析提示，肌酐升高和多支血管病变是STEMI患者出现MACCE的危险因素。Ph-I 1组与对照组术后30 d的累计生存率差异无统计学意义（P＞0.05）。结论减半剂量尿激酶溶栓治疗并接受转运PCI与直接PCI的MACCE风险相当，且不增加出血风险。替罗非班预处理患者术后30 d MACCE风险高于直接PCI，且BARC 1型出血风险增加。

ObjectiveTo explore the safety and effectiveness of preoperative pharmaco-invasive (Ph-I) in acute ST-segment elevation myocardial infarction（STEMI） patients transferring for percutaneous coronary intervention (PCI). MethodsA total of 212 STEMI patients confirmed by Secondary Network Hospital of Guangxi Chest Pain Center and within 6 h of the onset, and then transferred for PCI in the People′s Hospital of the Guangxi Zhuang Autonomous Region, were enrolled, and they were assigned to thrombolysis with half-dose urokinase group (Ph-I 1 group, 68 cases), tirofiban group (Ph-I 2 group, 62 cases), and routine treatment group (non-Ph-I group, 82 cases) according to the random number table method; in addition, 76 STEMI patients received direct PCI within 6 h of the onset in the People′s Hospital of Guangxi Zhuang Autonomous Region during the same period were selected as control group. The clinical baseline data, quality control data of Chest Pain Center, operative data of PCI in each group were collected, all of the research objects were followed up, and the in-hospital mortality, the incidence of 30-day major adverse cardiovascular and cerebrovascular events (MACCE) and bleeding events were compared and evaluated between each group. ResultsThere were statistically significant differences in preoperative thrombolysis in myocardial infarction (TIMI) blood flows between each group, among which the Ph-I 1 and Ph-I 2 groups yielded higher proportions in 2 and 3 grades of preoperative TIMI blood flows as compared with the control group (all P＜0.05); however, there were no statistically significant differences in postoperative TIMI blood flow classifications between each group (all P＞0.05). The Ph-I 1 group completed a follow-up of 63 cases, the Ph-I 2 group with 60 cases, the non-Ph-I group with 79 cases, the control group with all 76 cases, and the overall loss of follow-up rate was 3.5%, as well as the overall time of follow-up was (28.5±7.3) d. The results of follow-up revealed that there were no statistically significant differences in in-hospital mortality, the incidence of 30-day composite end-point events, the incidence of cerebral stroke, the incidence of bleeding events in Bleeding Academic Research Consortium (BARC) type 1, and incidence of bleeding events in BARC type 2-5 between the 4 groups (all P＞0.05). Kaplan-Meier survival analysis presented that the increase of creatinine and multivessel disease were the risk factors for MACCE in STEMI patients. There was no statistically significant difference in cumulative survival rate 30 d after operation between the Ph-I 1 group and the control group (P＞0.05). ConclusionThrombolysis with half-dose urokinase followed by transferring for PCI was comparable to the risk of MACCE with direct PCI, which does not increase the bleeding risk. Patients pretreated with tirofiban have a higher risk of postoperative 30-day MACCE than patients with direct PCI, which increases the bleeding risk of BARC type 1.