De Maria Giovanni Luigi, Cuculi Florim, Patel Niket, Dawkins Sam, Fahrni Gregor, Kassimis George, Choudhury Robin P, Forfar John C, Prendergast Bernard D, Channon Keith M, Kharbanda Rajesh K, Banning Adrian P
Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford OX39DU, UK.
Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford OX39DU, UK Department of Cardiology, LuzernerKantonsspital, Luzern, Switzerland.
Eur Heart J. 2015 Dec 1;36(45):3165-77. doi: 10.1093/eurheartj/ehv353. Epub 2015 Aug 7.
Primary percutaneous coronary intervention (PPCI) is the optimal treatment for patients presenting with ST-elevation myocardial infarction (STEMI). An elevated index of microcirculatory resistance (IMR) reflects microvascular function and when measured after PPCI, it can predict an adverse clinical outcome. We measured coronary microvascular function in STEMI patients and compared sequential changes before and after stent implantation.
In 85 STEMI patients, fractional flow reserve, coronary flow reserve, and IMR were measured using a pressure wire (Certus, St Jude Medical, St Paul, MN, USA) immediately before and after stent implantation. Stenting significantly improved all of the measured parameters of coronary physiology including IMR from 67.7 [interquartile range (IQR): 56.2-95.8] to 36.7 (IQR: 22.7-59.5), P < 0.001. However, after stenting, IMR remained elevated (>40) in 28 (32.9%) patients. In 15 of these patients (17.6% of the cohort), only a partial reduction in IMR occurred and these patients were more likely to be late presenters (pain to wire time >6 h). The extent of jeopardized myocardium [standardized beta: -0.26 (IMR unit/Bypass Angioplasty Revascularization Investigation score unit), P: 0.009] and pre-stenting IMR [standardized beta: -0.34 (IMR unit), P: 0.001] predicted a reduction in IMR after stenting (ΔIMR = post-stenting IMR - pre-stenting IMR), whereas thrombotic burden [standardized beta: 0.24 (IMR unit/thrombus score unit), P: 0.01] and deployed stent volume [standardized beta: 0.26 (IMR unit/mm(3) of stent), P: 0.01] were associated with a potentially deleterious increase in IMR.
Improved perfusion of the myocardium by stent deployment during PPCI is not universal. The causes of impaired microvascular function at the completion of PPCI treatment are heterogeneous, but can reflect a later clinical presentation and/or the location and extent of the thrombotic burden.
直接经皮冠状动脉介入治疗（PPCI）是ST段抬高型心肌梗死（STEMI）患者的最佳治疗方法。微循环阻力指数（IMR）升高反映微血管功能，在PPCI后测量时，它可以预测不良临床结局。我们测量了STEMI患者的冠状动脉微血管功能，并比较了支架植入前后的连续变化。
在85例STEMI患者中，在支架植入前后立即使用压力导丝（Certus，美国明尼苏达州圣保罗市圣犹达医疗公司）测量血流储备分数、冠状动脉血流储备和IMR。支架置入显著改善了所有测量的冠状动脉生理参数，包括IMR从67.7[四分位间距（IQR）：56.2 - 95.8]降至36.7（IQR：22.7 - 59.5），P < 0.001。然而，支架置入后，28例（32.9%）患者的IMR仍升高（>40）。在这些患者中的15例（占队列的17.6%），IMR仅部分降低，这些患者更可能是延迟就诊者（疼痛至导丝时间>6小时）。危险心肌范围[标准化β：-0.26（IMR单位/旁路血管成形术血运重建研究评分单位），P：0.009]和支架置入前IMR[标准化β：-0.34（IMR单位），P：0.001]可预测支架置入后IMR的降低（ΔIMR = 支架置入后IMR - 支架置入前IMR），而血栓负荷[标准化β：0.24（IMR单位/血栓评分单位），P：0.01]和置入支架体积[标准化β：0.26（IMR单位/支架mm³），P：0.01]与IMR潜在有害的增加相关。
PPCI期间通过支架置入改善心肌灌注并非普遍现象。PPCI治疗完成时微血管功能受损的原因是异质性的，但可反映就诊延迟和/或血栓负荷的位置及范围。
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