冠状动脉非阻塞性心肌梗死患者的临床特征、治疗现状及院内预后分析

目的:探讨冠状动脉非阻塞性心肌梗死(MINOCA)患者的临床特征、治疗现状及院内预后情况。方法:收集同济大学附属第十人民医院2014年1月至2017年6月收治的1 520例急性心肌梗死患者,根据冠状动脉造影结果分为冠状动脉阻塞性心肌梗死(MI-CAD)组和MINOCA组,比较两组患者的临床特征、治疗方法及院内预后情况。结果:MINOCA的发生率为7.0%。与MI-CAD组相比,MINOCA发病年龄更小(P<0.001),女性更多见(P=0.009),且有吸烟史(P=0.045)、高脂血症史(P=0.040)、冠状动脉粥样硬化性心脏病(冠心病)史(P=0.028)和既往行经皮冠状动脉介入术(PCI)史(P<0.001)的比例更低。MINOCA组低密度脂蛋白胆固醇(P=0.019)、血清总胆固醇(P=0.003)、空腹血糖(P<0.001)、肌钙蛋白Ⅰ(P<0.001)和血清肌酸激酶同工酶(P<0.001)水平更低,而左室射血分数(LVEF)更高(P<0.001)。MINOCA患者的心电图中ST段压低更常见(P=0.028),且ST段抬高型心肌梗死(STEMI)的心电图表现以完全性左束支传导阻滞更为常见(P=0.016)。与MI-CAD组相比,MINOCA组他汀类药物(P=0.021)、β受体阻滞剂(P=0.009)及血管紧张素转化酶抑制剂/血管紧张素Ⅱ受体拮抗剂(P=0.023)的使用率偏低,而阿司匹林(P=0.362)和氯吡格雷(P=0.388)的使用率与MI-CAD组相比无明显差异。与MI-CAD组相比,MINOCA组的冠心病重症监护室(CCU)住院时间更短(P<0.001),心力衰竭发生率更低(P=0.023),而院内心血管死亡率(P=0.363)、全因死亡率(P=0.745)、恶性心律失常发生率(P=0.914)及靶病变血运重建率(P=0.896)与MI-CAD组无明显差异。结论:临床中MINOCA较常见,发病年龄更小,女性多见,合并危险因素较少。与MI-CAD相比,MINOCA患者在住院期间发生心力衰竭更为少见,但院内心血管死亡率、全因死亡率、恶性心律失常发生率及靶病变血运重建率并未显著降低,提示基于病因的特异性治疗相对不足。

Analysis of the clinical features,treatment and in-hospital prognosis of patients with myocardial infarction with non-obstructive coronary arteries

Objective:To investigate the clinical features,treatment and in-hospital prognosis of patients with myocardial infaction(MI)with non-obstructive coronary arteries(MINOCA). Methods: From January 2014 to June 2017,1 520 MI patients from Shanghai Tenth People′s Hospital were enrolled and divided into MI with obstructive coronary arteries(MI-CAD)group and MINOCA group based on their coronary angiography results.Clinical characteristics,treatment and in-hospital prognosis of both groups were compared. Results:The prevalence of MINOCA was found to be 7.0%.Compared with MI-CAD group,MINOCA group had younger age of onset(P<0.001)and more female patients (P=0.009).Rates of smoking history(P=0.045),hyperlipidemia(P=0.040),history of coronary heart disease(CHD,P=0.028)and previous percutaneous coronary intervention(PCI)history(P< 0.001)were significantly lower in MINOCA group.Levels of TC (P=0.003),LDL-C (P=0.019), FPG(P<0.001),cTnI(P<0.001)and CK-MB(P<0.001)were significantly lower while LVEF (P<0.001)was higher in MINOCA group than those in MI-CAD group.The ECGs showed higher occurrence of ST segment depression (P=0.028)were seen,and more STEMI(ST-elevation MI) presented complete left bundle branch block(P=0.016)in MINOCA patients.The uses of statins(P= 0.021),beta blockers(P=0.009)and ACEIs/ARBs(P=0.023)were significantly lower in the MINOCA group while the uses of aspirin(P=0.362)and clopidogrel(P=0.388)showed no significant difference between the two groups.MINOCA group patients had shorter periods of hospital stay in CCU (P<0.001)and lower occurrence of heart failure(P=0.023),while had no statistically significant difference of in-hospital cardiovascular mortality(P=0.363),all-cause mortality(P=0.745),incidence of malignant arrhythmia(P=0.914)and target lesion revascularization(P=0.896),as compared with MI-CAD group. Conclusions:MINOCA has a younger age of onset and is more common in women.The risk factors of CHD are relatively less.During hospitalization,occurence of heart failure is less in MINOCA patients,but thre is no significant reduce in long-term prognosis in terms of cardiac vascular mortality,all-cause mortality,malignant arrhythmia and target lesion revascularization.In addition,the management of MINOCA by targeted therapies is relatively inadequate.