目的 通过监测急性ST段抬高型心肌梗死(STEMI)患者行经皮冠状动脉介入治疗(PCI)后动脉血乳酸水平及乳酸清除率,评价其与局部微循环障碍及STEMI患者预后的关系.方法 入选2016年3月~2017年6月就诊于柳州市人民医院CCU接受急诊直接PCI治疗的STEMI患者共91例,根据开通梗死相关动脉时TIMI血流进行分组,TIMI 3级为对照组(71例),TIMI 0-2级为微循环障碍组(20例),比较术前、PCI术后6 h、24 h、7 d动脉血乳酸,心肌钙蛋白I(cTnI)、肌酸激酶同工酶(CKMB)、N末端脑钠肽前体(NT-proBNP)、超敏C反应蛋白(hsCRP)、左室射血分数(LVEF),同时病程中记录以下心血管事件:心源性死亡、心源性休克、心力衰竭、心绞痛/再发心肌梗死、恶性心律失常.结果 研究显示,微循环障碍组术后6 h及7 d的动脉血乳酸值高于对照组,差异具有统计学意义(P<0.05),而术前及术后24 h动脉血乳酸值无明显统计学差异(P>0.05).与对照组比较,微循环障碍组cTnI峰值较高(P<0.05),且微循环障碍组术后第7天CKMB值高于对照组(P<0.05).微循环障碍组超敏C反应蛋白、心源性死亡、心力衰竭、心律失常、心源性休克及总心血管事件高于对照组,差异有统计学意义(P<0.05),而微循环障碍组LVEF低于对照组(P>0.05).两组患者乳酸清除率差异无统计学意义(P>0.05).住院乳酸值与cTnI峰值、第7 d CKMB、NT-proBNP、LVEF、心源性死亡显著相关.结论 围手术期的乳酸监测可以作为评估冠状动脉微循环障碍的心肌梗死患者病情及预后的一种有效的预警指标.
Objective To investigate the value of blood lactate (LA) level and lactate clearance rate in prognostic assessment in acute ST-segment myocardial infarction (STEMI) patients with coronary slow flow (CSF) underwent primary percutaneous coronary intervention (PCI). Methods From March 2016 to June 2017, 91 STEMI patients underwent primary PCI were enrolled. According to the correct of TIMI (thrombolysis in myocardial infarction) frame count (CTFC) of the infarct related artery(IRA) ,71 patients of TIMI 3 were selected as control group, 20 patients of TIMI 0-2 were selected as CSF group. The blood LA, troponine I (cTnI), creatine kinase-MB (CKMB), N-terminal pro-B-type natriuretic peptide (NT-proBNP), hypersensitivity C reactive protein (hsCRP), left ventricular ejection fraction (LVEF)and major adverse cardiovascular events (MACEs) were compared before PCI and at 6 h, 24 h and 7 d after PCI. Results The results showed that arterial blood lactate value at 6 h and 7 d after PCI of CSF group were significantly higher than that of the control group, the difference was statistically significant (4.36±3.02 vs. 3.27±1.42, 3.45±2.27 vs. 2.39±0.79, P<0.05). There was no significant difference of arterial blood lactate level before and 24 h after PCI (3.63±2.37 vs. 3.11±1.52, 3.51±0.64 vs. 3.11±0.94, P>0.05). Compared with control group, cTnI peak level, the level of CKMB at 7th day and hsCRP in CSF group were higher, while the value of LVEF was lower (P>0.05). A significant difference was found with respect of in-hospital death and MACEs between for CSF group with control group (P<0.05). There was no significant difference of the LA clearance rate in CSF group (P>0.05). The level of LA in hospital was significantly related to CKMB at 7th day, NT-proBNP, LVEF, and cardiac care unit (CCU) mortality in CSF group. Conclusion Perioperative lactate monitoring can be used as an effective predictor of disease progression and prognosis in patients with myocardial infarction with coronary microcirculatory disturbances.