STEMI患者炎症反应水平及罪犯斑块特征与PCI术前TIMI血流分级的关系

目的明确ST段抬高型心肌梗死(STEMI)患者的炎症反应水平及罪犯斑块形态特征与经皮冠状动脉介入治疗(PCI)术前心肌梗死溶栓(TIMI)血流分级的关系。方法本研究为回顾性研究。选取1268例PCI术前对罪犯斑块行光学相干断层成像(OCT)检查的STEMI患者,按照TIMI血流分级分为TIMI 0~1组964例(76.0%)和TIMI 2~3组304例(24.0%)。收集2组的基线临床资料;采集血样检测炎症反应标志物高敏C反应蛋白(hsCRP)、心肌损伤标志物及血脂等指标;行心脏超声检测左心室射血分数;行冠状动脉造影及OCT检查,收集梗死相关动脉的病变长度、狭窄程度,有无复杂病变,以及罪犯斑块类型、狭窄程度及易损性相关指标并比较。采用多因素logistic回归模型分析TIMI 0~1级的独立相关因素,并确定其最佳截断值。结果1268例STEMI患者年龄为(57.6±11.4)岁,男性923例(72.8%)。与TIMI 2~3组相比,TIMI 0~1组患者年龄较大,N末端B型钠尿肽原水平较高,左心室射血分数及肌钙蛋白I水平较低,hsCRP水平较高5.16(2.06,11.78)mg/L比3.73(1.51,10.46)mg/L],且斑块破裂亚组中TIMI 0~1组患者hsCRP水平较高(P均<0.05)。冠状动脉造影结果显示与TIMI 2~3组相比,TIMI 0~1组梗死相关动脉为右冠状动脉的比例较高,血管病变长度更长,最小管腔直径更小,直径狭窄度更大(P均<0.05)。OCT显示TIMI 0~1组罪犯斑块破裂发生率(75.8%比61.2%)和斑块易损性高于TIMI 2~3组,斑块易损性更高表现为平均脂质角度更大(241.27±46.78)°比(228.30±46.32)°],薄纤维帽粥样硬化斑块更多(72.4%比57.9%),具有更多的巨噬细胞聚集(84.4%比70.7%)和胆固醇结晶(39.1%比25.7%);最小血流面积更小1.3(1.1~1.7)mm²比1.4(1.1~1.9)mm²]且血流面积狭窄更严重(78.2±10.6)%比(76.3±12.3)%,P均<0.05]。多因素分析结果显示,平均脂质角度>255.55°、胆固醇结晶、病变长度>16.14 mm和hsCRP>3.29 mg/L是STEMI患者TIMI血流分级降低(TIMI 0~1级)的独立相关因素。结论斑块易损性和炎症反应与STEMI患者PCI术前TIMI血流分级降低密切相关。

Impact of inflammatory reaction levels and culprit plaque characteristics on preprocedural thrombolysis in myocardial infarction flow grade in patients with ST-segment elevation myocardial infarction

Objective To determine the impact of inflammatory reaction levels and the culprit plaque characteristics on preprocedural Thrombolysis in Myocardial Infarction(TIMI)flow grade in patients with ST-segment elevation myocardial infarction(STEMI)undergoing primary percutaneous coronary intervention(PCI).Methods The is a retrospective study.A total of 1268 STEMI patients who underwent pre-intervention optical coherence tomography(OCT)examination of culprit lesion during emergency PCI were divided into 2 groups by preprocedural TIMI?ow grade(TIMI 0-1 group(n=964,76.0%)and TIMI 2-3 group(n=304,24.0%)).Baseline clinical data of the 2 groups were collected;blood samples were collected for the detection of inflammatory markers such as high sensitivity C-reactive protein(hsCRP),myocardial injury marker,blood lipid,etc.;echocardiography was used to determine left ventricular ejection fraction;coronary angiography and OCT were performed to define the lesion length,diameter stenosis degree of the infarct-related arteries,presence or absence of complex lesions,culprit lesion type,area stenosis degree and vulnerability of culprit plaques.Multivariable logistic regression analysis was performed to identify independent correlation factors.The receiver operating characteristic(ROC)curve of continuous independent correlation factors was analyzed,and the best cut-off value of TIMI 0-1 was respectively determined according to the maximum value of Youden index.Results The mean age of 1268 STEMI patients were(57.6±11.4)years old and 923 cases were males(72.8%).Compared with TIMI 2-3 group,the patients in TIMI 0-1 group were older and had higher N-terminal-pro-B-type natriuretic peptide level,lower cardiac troponin I(cTnI)level,lower left ventricular ejection fraction,and higher hsCRP level(5.16(2.06,11.78)mg/L vs.3.73(1.51,10.46)mg/L).Moreover,the hsCRP level of patients in TIMI 0-1 group was higher in the plaque rupture subgroup(all P<0.05).Coronary angiography results showed that compared with TIMI 2-3 group,the proportion of right coronary artery(RCA)as the infarct-related artery was higher,the angiographical lesion length was longer,minimal lumen diameter was smaller,and diameter stenosis was larger in TIMI 0-1 group(all P<0.05).The prevalence of plaque rupture was higher(75.8%vs.61.2%)in TIMI 0-1 group.Plaque vulnerability was significantly higher in TIMI 0-1 group than that in TIMI 2-3 group with larger mean lipid arc(241.27°±46.78°vs.228.30°±46.32°),more thin-cap fibroatheroma(TCFA,72.4%vs.57.9%),more frequent appearance of macrophage accumulation(84.4%vs.70.7%)and cholesterol crystals(39.1%vs.25.7%).Minimal flow area was smaller1.3(1.1-1.7)mm² vs.1.4(1.1-1.9)mm²,all P<0.05]and flow area stenosis was higher(78.2%±10.6%vs.76.3%±12.3%)in TIMI 0-1 group.Multivariable analysis showed that mean lipid arc>255.55°,cholesterol crystals,angiographical lesion length>16.14 mm,and hsCRP>3.29 mg/L were the independent correlation factors of reduced preprocedural TIMI flow grade in STEMI patients.Conclusions Plaque vulnerability and inflammation are closely related to reduced preprocedural TIMI flow grade in STEMI patients.