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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6h、24h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TIMI2级血流所占的比例较多,TIMI3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。
OBJECTIVE: To compare the effects of late successful revascularization on acute left ventricular function and prognosis after myocardial infarction with diabetic and non-diabetic anterior wall acute myocardial infarction (AMI) and its relationship with viable myocardium. METHODS: A total of 125 patients with AMI who were confirmed as first-episode anterior wall disease by medical history, electrocardiogram and myocardial injury markers and who underwent coronary artery interventional therapy (PCI) about 2 weeks after onset were selected according to WHO diagnostic criteria Forty-three patients were diagnosed as complicated with diabetes mellitus (group A) and 82 patients without diabetes mellitus (group B). PCI before echocardiography to understand left ventricular function and myocardial infarction-related survival of the area. The results of coronary angiography before and after PCI were analyzed and recorded in detail. Serum CK-MB and troponin T levels were measured by venous blood before PCI and at 6h and 24h after surgery respectively. At 6 months after operation, echocardiography was repeated to find out the abnormal changes of left ventricular function and ventricular wall motion, and follow-up of the occurrence of major cardiovascular events. Results: Coronary angiography showed that the ratio of TIMI2 grade blood flow in target vessel immediately after PCI was higher in group A than in group B, and TIMI3 level was less (P <0.05 and P <0.01, respectively). The postoperative CK-MB and troponin T increased more in group A than in group B (25.6% vs 9.8%, P <0.05). Low-dose dobutamine stress test results showed that 62.8% in group A and 56.1% in group B had viable myocardium, there was no significant difference between the two groups (P> 0.05). The left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume index (LVEDVI), end-systolic volume index (LVESVI) and wall motion score (WMS) in the acute phase were basically the same (all P> 0.05). After 6 months of follow-up, there was a significant decrease in WMS and a significant increase in LVEF in group B. However, LVEF and WMS in group A were not significantly improved and LVEDVI was increased. LVEDVI, LVESVI, LVEF and WMS were significantly different in group B (P <0.05 and P <0.01). There was no significant difference in the incidence of major cardiovascular events between the two groups during follow-up (18.6% vs11.0%, P> 0.05). Conclusion: The successful revascularization of advanced AMI in diabetic patients has a better effect on long-term left ventricular function than non-diabetic patients. The results may be related to the failure to obtain effective reperfusion or reperfusion myocardial injury after advanced PCI in diabetic patients, Preoperative surviving myocardium may not affect the main reason for its efficacy.