糖尿病和非糖尿病急性前壁心肌梗死晚期成功血运重建术后左室功能的变化及其与存活心肌的关系

目的:比较糖尿病和非糖尿病前壁急性心肌梗死(AMI)晚期成功血运重建术对心肌梗死后远期左室功能和预后的影响以及与存活心肌的关系.方法:选择依据病史、心电图和心肌损伤标志物等检查证实为首次发作的前壁AMI,并于发病后2周左右接受冠状动脉介入治疗术(PCI)的患者共计125例,其中参照WHO诊断标准确诊为并发糖尿病者(A组)43例,未并发糖尿病者(B组)82例.PCI前行超声心动图检查,了解左室功能和梗死相关区域存活心肌的情况.详细分析和记录PCI前后冠状动脉造影的结果.并分别于PCI前和术后6 h、24 h采取静脉血检测血清CK-MB和肌钙蛋白T水平.术后6个月重复超声心动图检查,了解左室功能和室壁活动异常的变化,并随访其间主要心血管事件的发生情况.结果:冠状动脉造影显示,与B组相比,A组PCI后即刻靶血管TIMI 2级血流所占的比例较多,TIMI 3级较少(分别为P<0.05和P<0.01).术后CK-MB和肌钙蛋白T增高者A组明显多于B组(25.6%∶9.8%,P<0.05).小剂量多巴酚丁胺超声负荷试验结果示A组中62.8%和B组中56.1%的患者有存活心肌,2组相比差异无统计学意义(P>0.05).急性期2组左室射血分数(LVEF)、左室舒张末期容积指数(LVEDVI)、收缩末期容积指数(LVESVI)以及室壁运动积分(WMS)基本相同(均P>0.05).术后6个月随访,B组WMS明显减少,LVEF明显增高;而A组LVEF和WMS均无明显改善,LVEDVI反而增加;2组相比LVEDVI、LVESVI、LVEF和WMS均有明显差异(分别P<0.05和P<0.01).随访期间2组主要心血管事件的发生率差异无统计学意义(18.6%∶11.0%,P>0.05).结论:糖尿病AMI晚期成功血运重建对远期左室功能的改善作用较非糖尿病者差,其结果可能与糖尿病患者晚期PCI后缺血心肌未能得到有效再灌注或再灌注加重心肌损伤有关,而术前存活心肌可能不是影响其疗效的主要原因.

Different effects of late successful reperfusion on left ventricular function and its relationship with viable myocardium after acute anterior wall myocardial infarction in diabetes and non-diabetes patients

Objective:To compare the different effects of late successful reperfusion with percutaneous coronary intervention (PCI) on left ventricular function and its relationship with viable myocardium after acute anterior wall myocardial infarction in diabetes and non-diabetes patients. Method:A total 125 consecutive subjects with acute anterior wall myocardial infarction were selected, and divided into diabetes mellitus (DM) group (n=43) and Non-DM group (n=82) according to WHO diabetes diagnosis criteria. All patients received successful PCI at about 2 weeks after symptom onset. Ischemic viable myocardium was detected with low-dose dobutamine stress echocardiogram, and left ventricular function and wall motion abnormality were also assessed with echocardiogram before PCI. The data of clinical manifestations and angiograms before and after PCI were analyzed. Levels of creatinine kinase-MB (CK-MB), and troponin T (TnT) before PCI, 6 hours and 24 hours after PCI were assessed. All patients received clinic and echocardiogram follow-up at 6 months. Result:Higher rate of TIMI 2 flow, and lower rate of TIMI 3 flow in DM group were demonstrated immediately after PCI, and the rate of elevation of serum CK-MB and/orTnT levels were higher in DM group, compared with Non-DM group(P<0.05). 63% of DM patients and 56% of non-DM patients had viable myocardium before PCI(P>0.05). There were no significant differences of left ventricular ejection fraction (LVEF), left ventricular end diastolic volume index (LVEDVI), left ventricular end systolic volume index (LVESVI), and wall motion score (WMS) between two groups at baseline before PCI(P>0.05). After six months, WMI was decreased and LVEF was increased in Non-DM group, but the WMI and the LVEF did not changed, and the LVEDVI was increased in DM group compared with baseline;the LVEDVI, LVESVI, LVEF, and WMS were significant different between two groups (P<0.05 or P<0.01).Conclusion:Compared with non-diabetics, delayed successful revascularization with PCI in diabetics acute myocardial infarction patient has less benefit effect on the improvement of late phase left ventricular function, and it may be the not in sufficient reperfusion or reperfusion injury to myocardium that.