冠状动脉内应用国产替罗非班对急性ST段抬高心肌梗死急诊介入治疗后心肌灌注和临床预后的影响

目的 探讨急性ST段抬高心肌梗死急诊PCI时国产替罗非班的不同应用途径（静脉内／冠状动脉内）对心肌组织水平灌注与临床预后影响的差异。方法 连续选择60例急性ST段抬高心肌梗死拟行急诊PCI的患者，随机分为替罗非班静脉内应用组（静脉组，n=30）与替罗非班冠状动脉内应用组（冠状动脉组，n=30），比较两组术后即刻造影结果、住院期间以及随访期间主要不良心脏事件（MACE）发生的差异。结果共有54例完成试验，其中男性43例，女性11例，年龄29～75（58．80±12．57）岁，冠状动脉组在术后心外膜TIMI分级、TIMI心肌灌注分级（TIMI Myocardial Perfusion，TMP）、心电图ST段回落、梗死相关血管远端末梢栓塞、以及治疗后5～7天的心脏彩超射血分数值、左室舒张末期容积（LVEDV）、左室收缩末期容积（LVESV）等方面均显著优于静脉组，虽然心脏肌钙蛋白I（cTnI）与肌酸激酶同工酶（CK-MB）峰值浓度两组无差异，但是冠状动脉组CK-MB达峰值的时间显著缩短，两组院内MACE事件发生未达到统计学差异，平均住院日亦相同，但是30～90（平均57±21）天随访期间冠状动脉组总的MACE事件发生显著少于静脉组（7．1％与30．8％，P=0．02）。应用Cox回归比例风险模型在校正年龄、性别、高血压、糖尿病、家族史、吸烟等危险因素以及心肌梗死部位、胸痛至球囊扩张时间后，计算冠状动脉组在平均57天随访期间发生总的MACE事件的相对危险度为0．14（P=0．03）。冠状动脉组发生轻度出血与严重出血并发症有增多的趋势，但未达到统计学差异。结论 对于急性ST段抬高心肌梗死行急诊PCI治疗的患者，冠状动脉内应用替罗非班安全、有效，与静脉内应用相比可以进一步改善心肌水平再灌注状态并能提高临床预后，这对于在急诊室因为各种原因未能提前应用替罗非班的患者来说具有特殊的临床意义。

Effects of intracoronary or intravenous tirofiban administration in patients with acute ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

OBJECTIVE: To compare the effects on MACE of intracoronary or intravenous tirofiban bolus administration in patients with acute ST-elevation myocardial infarction (STEMI). METHODS: A total of 60 consecutive STEMI patients ready to receive primary PCI were randomly assigned to intracoronary tirofiban bolus (10 microg/kg) prior to the first balloon inflation (Group IC) or to intravenous tirofiban bolus at the same dose prior to coronary angiography (Group IV), followed by a 36-hours IV tirofiban (0.15 microg . kg(-1) . min(-1)) infusion for all patients. Clinical and angiographic features between 2 groups before and after PCI were analyzed. RESULTS: Fifty-four out of 60 STEMI patients accomplished the study. Group IC was superior to Group IV in terms of TIMI flow grade, TIMI myocardial perfusion grade, ST-segment resolution, the distal embolism of IRA immediately after PCI and ejection fraction at 5 - 7 days after the PCI. The in-hospital MACE rate and bleeding complications were similar between the groups while, the combined incidence of MACE during follow-up was significantly lower in the Group IC compared with Group IV (7.1% versus 30.8%; P = 0.02). CONCLUSION: Intracoronary bolus application of tirofiban is associated with superior clinical prognosis compared with the standard intravenous bolus application of tirofiban in patients with STEMI undergoing primary PCI.