李凤丽，任法新，董梅

冠心病研究

估算肾小球滤过率与急性ST段抬高型心肌梗死患者心肌无复流的相关性研究

李凤丽*，任法新，董梅

目的：探讨估算肾小球滤过率（eGFR）与急性ST段抬高型心肌梗死（STEMI）患者心肌无复流（MNR）的相关性。

方法：收集2013-01至2015-06期间烟台毓璜顶医院因STEMI接受急诊经皮冠状动脉介入治疗（PCI） 的患者461例，其中男373例，女88例，平均年龄（61.46±12.29）岁。PCI成功开通心外膜血管后仍有部分患者存在心肌灌注不足的表现，即心肌无复流（MNR）。MNR 定义为心肌梗死溶栓治疗临床试验（TIMI）血流分级＜3级或TIMI 3级且心肌呈色分级（MBG）≤2。 461例患者中98例发生MNR（无复流组），363例成功复流（复流组）。根据MDRD（Modification of Diet in Renal Disease）公式计算eGFR。比较两组球囊扩张时间、病变长度变化。

结果：461例患者中共计98例（21.26%）患者发生MNR。410例（88.94%）患者PCI 术后冠状动脉血流达TIMI 3级（复流组363例，无复流组47例）；334例（72.45%）患者 MBG3 级（复流组334 例，无复流组0例），两组比较差异均有统计学意义（P＜0.001）。与复流组相比，无复流组发病至球囊扩张时间较长（P＜0.001），syntax评分较增加（P＜0.001），病变长度较延长（P=0.017），差异均有统计学意义。多因素Logistic回归分析表明收缩压[比值比（OR）：0.984,95%可信区间（CI）:0.970～0.984，P=0.023]、左心室射血分数（OR：0.957, 95% CI：0.913～0.987, P=0.031）、eGFR（OR：0.964,95% CI：0.950～0.964, P＜0.001）、发病至球囊扩张时间（OR：1.004,95% CI：1.002～1.004, P=0.001）是MNR发生的独立危险因素。受试者工作特征 （ROC） 曲线显示eGFR[曲线下面积：0.801,95% CI：0.743～0.859, P＜0.001; 理想阈值74.78 ml/（min·1.73m2）, 敏感性为73.7%，特异性为77.3%］可以较好的预测MNR发生。

结论：eGFR降低与STEMI患者行急诊PCI术后MNR的发生密切相关。

肾小球滤过率；心肌梗死；无复流

Objective: To explore the relationship between estimated glomerular filtration rate (eGFR) and myocardial no-refow (MNR) in patients with ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PCI).

Methods: A total of 461 eligible STEMI patients treated by primary PCI in our hospital from 2013-01 to 2015-06 were enrolled including 373 male and 88 female with the mean age of (61.46±12.29) years. MNR was defned as TIMI＜grade 3 or TIMI grade 3 with myocardial blush grades (MBG)≤2. The patients were divided into 2 groups: MNR group, n=98 (21.26%) and Re-fow group, n=363. eGFR was calculated by MDRD (modifcation of diet in renal disease) equation. The balloon dilatation time and lesion length were compared between 2 groups.

Results: There were 410 (88.94%) patients reached post PCI TIMI grade 3 including 363 in Re-fow group and 47in MNR group; 334 (72.45%) patients with MBG grade 3 including 334 in Re-fow group, 0 in MNR group, all P＜0.001. Compared with Re-fow group, MNR group had prolonged time form onset to balloon dilatation, P＜0.001, increased syntax score, P＜0.001 and extend length of lesion, P=0.017. Multi Logistic regression analysis showed that systolic blood pressure (OR=0.984, 95% CI 0.970-0.84, P=0.023), left ventricular ejection fraction (OR=0.957, 95% CI 0.913-0.987, P=0.031), eGFR (OR=0.964, 95% CI 0.950-0.964, P＜0.001), the time from onset to balloon dilatation (OR=1.004, 95% CI 1.002-1.004, P=0.001) were the independent risk factors for MNR occurrence. The area of ROCeGFR=0.801, (95% CI 0.743-0.859, P＜0.001) and the optimal threshold=74.78 ml/(min•1.73m2) with the sensitivity of 73.7% and specifcity of 77.3% may better predict the incidence of MNR.

Conclusion: Decreased eGFR was closely related to MNR occurrence in STEMI patients after primary PCI.

(Chinese Circulation Journal, 2016,31:1064.)

急诊经皮冠状动脉介入治疗（PCI） 再灌注治疗使急性ST段抬高型心肌梗死（STEMI）患者的死亡率显著下降。但是，心外膜冠状动脉阻塞血管的开通并不意味着心肌组织水平的有效灌注。……