王贇,陈静
WANG Yun,CHEN Jing

• 1:武汉大学人民医院心血管内科

摘要(Abstract)：

目的 探讨急诊经皮冠状动脉介入术（PCI）后抗凝治疗对急性ST段抬高型心肌梗死（STEMI）患者预后的影响。方法 446例STEMI患者根据急诊PCI术后是否使用抗凝治疗分为抗凝组和无抗凝组，收集2组STEMI患者术前基线情况（年龄、性别、心脑血管病史及PCI手术史）、术中或住院期间药物治疗情况[抗凝药物、β受体阻滞剂、血管紧张素转化酶抑制剂/血管紧张素Ⅱ受体拮抗剂（ACEI/ARB）、冻干重组人脑利钠肽、糖蛋白Ⅱb/Ⅲa受体拮抗剂（GPI）及主动脉内球囊反搏术的应用情况]及急诊PCI手术治疗情况，并进行危险分层评级（GRACE评分）；抗凝组STEMI患者根据术后抗凝药物的应用情况分为依诺肝素组（n=178）和比伐卢定组（n=45），随访30 d，收集各组STEMI患者在此期间发生的主要不良心脑血管事件（MACCE）和出血事件；采用logistic回归分析STEMI患者术后抗凝治疗的相关因素，采用Cox回归分析急诊PCI术后STEMI患者使用抗凝药物及不同抗凝药物对预后的影响。结果 多因素logistic回归分析表明ACEI/ARB(OR=1.569)及冻干重组人脑利钠肽（OR=1.930）是STEMI患者术后抗凝治疗的独立危险因素（P<0.05），而GRACE评分（OR=0.992）及GPI(OR=0.298)是STEMI患者术后抗凝治疗的独立保护因素（P<0.05）；多因素Cox回归分析显示，术后使用抗凝剂是STEMI患者发生30 d全因死亡（HR=0.229）及MACCE(HR=0.278)的独立保护因素（P<0.05），且急诊PCI术后使用依诺肝素组患者30 d全因死亡（HR=0.215,P=0.014）及MACCE事件发生率（HR=0.291,P=0.013）较无抗凝组降低。结论 术后使用抗凝药物有助于降低接受急诊PCI的STEMI患者30 d全因死亡率及MACCE发生率，且不增加出血风险。
Objective To observe the prognosis of anticoagulant therapy after emergency percutaneous coronary intervention(PCI) in patients with acute ST-segment elevation myocardial infarction(STEMI).Methods A total of 446 STEMI patients who underwent emergent PCI operation were divided into two groups according to whether anticoagulant therapy was used: the anticoagulant group and the nonanticoagulant group. The preoperative baseline data were collected including age, gender, smoking history, hypertension, diabetes, hyperlipidemia, cerebrovascular disease, atrial fibrillation, previous history of myocardial infarction and PCI, treatment during surgery and hospitalization, anticoagulant drugs(enoxaparin or bivalirudin), β-blockers, angiotensin converting enzyme inhibitors/angiotensinⅡ receptor blocker( ACEI/ARB), lyophilized recombinant human brain natriuretic peptide,glycoprotein Ⅱb/Ⅲa receptor antagonist(GPI),and intra-aortic balloon pump and the emergent PCI were evaluated by global registry of acute coronary events(GRACE) scores. According to the use of post-PCI anticoagulant drugs, the anticoagulant group was divided into the enoxaparin group(n= 178)and the bivalirudin group(n= 45). All cases with STEMI in the 3 groups were followed up for 30days, and their major cardiovascular and cerebrovascular adverse events( MACCE) and bleeding events were compared. Logistic regression was used to analyze the factors related to post-PCI anticoagulant therapy. Cox regression was used to detect the effects of anticoagulant therapy and different anticoagulant subgroups after emergent PCI on prognosis.Results Multivariate logistic regression analysis showed that ACEI/ARB(OR= 1. 569) and lyophilized recombinant human brain natriuretic peptide(OR= 1. 930) were independent risk factors for postoperative anticoagulant therapy, while GRACE scores(OR= 0. 992) and GPI(OR= 0. 298) were independent protective factors for postoperative anticoagulant therapy. The difference was statistically significant(P< 0. 05).Multivariate Cox regression analysis showed that postoperative use of anticoagulants was an independent protective factor for 30 d all-cause death(HR= 0. 229) and MACCE(HR= 0. 278). Further subgroup analysis showed that compared with the non-anticoagulant group, the use of enoxaparin after emergenct PCI group was an independent protective factor for 30 d all-cause death(HR= 0. 215,P=0. 014) and the incidence of MACCE events(HR= 0. 291,P= 0. 013), with statistical significance(P< 0. 05).Conclusions The use of anticoagulant therapy after PCI can reduce the incidence of allcause death and MACCE for 30 d without increasing the risk of bleeding, thus effectively improving the prognosis of the patients with STEMI.

关键词(KeyWords)： 预后;危险因素;术后抗凝;急诊经皮冠状动脉介入术;影响;安全性
prognosis;risk factors;post-PCI anticoagulant therapy;emergency percutaneous coronary intervention(PCI);effect;safety

Abstract:

Keywords:

基金项目(Foundation): 国家自然科学基金（81570331）

作者(Author): 王贇,陈静
WANG Yun,CHEN Jing

DOI: 10.19367/j.cnki.2096-8388.2022.04.011

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