药物治疗对急性前壁心肌梗死患者早期再灌注后左心室重构的影响

目的 探讨血管紧张素转换酶抑制剂(ACEI)/血管紧张素Ⅱ受体拮抗剂(ARB)及β受体阻滞剂对急性前壁心肌梗死患者通过经皮冠状动脉介入治疗( PCI)早期开通梗死相关血管后左心室重构的影响.方法 连续性选取我院2009年1月至2010年12月因首次急性ST段抬高的前壁心肌梗死住院,经PCI术成功开通梗死相关动脉(IRA)且出院时心电图显示V1～V6至少2个导联出现病理性Q波的患者232例,选出入院至出院半年后临床资料[包括年龄、性别、合并疾病、心率、血压、心电图Q波数目、超声心动图左心室舒张末期内径、射血分数、节段性室壁运动异常数目(17段分区)、药物治疗等]完整的患者202例,根据心脏是否扩大分为心脏扩大组(53例)和心脏未扩大组(149例),观察入院至出院半年后ACEI/ARB、β受体阻滞剂使用情况,回顾性分析药物对心室重构的影响.结果 随访率87.1％(202/232),平均随访时间6个月.随访结束时,心脏扩大组ACEI/ARB的服用率明显低于心脏未扩大组,组间比较差异有统计学意义[79.2％ (42/53)比92.6％( 138/149),P＜0.05].入院、出院、随访结束时,心脏扩大组β受体阻滞剂的实际使用剂量与基数剂量比值均低于心脏未扩大组,组间比较差异均有统计学意义(入院时:1.4±1.1比2.0±1.4,P＜0.01;出院时:2.4±2.0比3.2±2.4；随访结束时:2.9±1.7比3.7±2.2,均P＜0.05)；随访结束时,心脏扩大组ACEI/ARB的实际使用剂量与基数剂量比值低于心脏未扩大组,组间比较差异有统计学意义(1.3±0.9比1.7±0.9,P ＜0.01).Logistic回归分析显示,随诊结束时ACEL/ARB剂量不足是心脏扩大的独立危险因素.结论 经直接PCI治疗但已有明显Q波形成的前壁心肌梗死患者,发生心脏扩大的可能性较大,药物剂量不足不利于阻止心室重构进程.

The effect of medical therapy on ventricular remodeling after early reperfusion in patients with acute anterior myocardial infarction

Objective To investigate the use of ACE inhibitors/angiotensin type 1 receptor blokers（ ACEI/ ARB） and 13 receptor blockers（13-B） in patients with acute anterior myocardial infarction（MI） after infarct related artery （IRA） were opened by percutaneous coronary intervention （PCI）. Methods Totally 232 consecutive patients with acute anterior MI who admitted to our hospital from 2009. 1 to 2012. 12 were enrolled. These patients fulfilled the following criterion： IRA were opened by immediate PCI and there were at least two leads of V1 - V6 having Q waves. In hospital clinical data [ including age, gender, combined disease, heart rate, blood pressure, number of Q wave, left ventricular end diastolic diameter（ LVEDD）, left ventricular eject fraction, number of abnormal motione regional walls, in hospital therapy, etc. ] were collected and the out-patient electronic medical records were reviewed. The status of the use of ACEI/ARB and 13-B were observed. The effect on left ventricular remodeling was analyzed retrospectively. Results The follow-up were completed in 202 （87.1%） patients and the average follow- up time was 6 months. At the end of follow up, the proportion of ACEI/ARB use was significantly lower in patients with enlarged LVEDD compared to patients with normal LVEDD（79. 2% vs. 92. 6% ,P 〈0.05）, and the dose was also significantly lower（ 1.3±0. 9 vs. 1.7±0. 9 ,P 〈0. 01 ）. The use of 13-B in patients with enlarged LVEDD were significantly lower than that in patients with normal LVEDD on admission, discharge and at the end of follow up. Logistic regression analysis showed that low dose of ACEL/ARB was an independent risk factor of left ventricular remodeling. Conclusion Patients with obvious Q waves are more likely to develop a enlarged left ventricular despite immediate PCI. Insufficient medical therapy fails to prevent ventricular remodeling.