急性ST段抬高型心肌梗死后患者心肌出血和水肿的时间演变：病理生理见解及临床意义
Temporal Evolution of Myocardial Hemorrhage and Edema in Patients After Acute ST-Segment Elevation Myocardial Infarction: Pathophysiological Insights and Clinical Implications.
作者信息
Carrick David, Haig Caroline, Ahmed Nadeem, Rauhalammi Samuli, Clerfond Guillaume, Carberry Jaclyn, Mordi Ify, McEntegart Margaret, Petrie Mark C, Eteiba Hany, Hood Stuart, Watkins Stuart, Lindsay M Mitchell, Mahrous Ahmed, Welsh Paul, Sattar Naveed, Ford Ian, Oldroyd Keith G, Radjenovic Aleksandra, Berry Colin
机构信息
BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK Robertson Center for Biostatistics, University of Glasgow, UK.
West of Scotland Heart and Lung Center, Golden Jubilee National Hospital, Glasgow, UK.
出版信息
J Am Heart Assoc. 2016 Feb 23;5(2):e002834. doi: 10.1161/JAHA.115.002834.
BACKGROUND
The time course and relationships of myocardial hemorrhage and edema in patients after acute ST-segment elevation myocardial infarction (STEMI) are uncertain.
METHODS AND RESULTS
Patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention underwent cardiac magnetic resonance imaging on 4 occasions: at 4 to 12 hours, 3 days, 10 days, and 7 months after reperfusion. Myocardial edema (native T2) and hemorrhage (T2*) were measured in regions of interest in remote and injured myocardium. Myocardial hemorrhage was taken to represent a hypointense infarct core with a T2* value <20 ms. Thirty patients with ST-segment elevation myocardial infarction (mean age 54 years; 25 [83%] male) gave informed consent. Myocardial hemorrhage occurred in 7 (23%), 13 (43%), 11 (33%), and 4 (13%) patients at 4 to 12 hours, 3 days, 10 days, and 7 months, respectively, consistent with a unimodal pattern. The corresponding median amounts of myocardial hemorrhage (percentage of left ventricular mass) during the first 10 days after myocardial infarction were 2.7% (interquartile range [IQR] 0.0-5.6%), 7.0% (IQR 4.9-7.5%), and 4.1% (IQR 2.6-5.5%; P<0.001). Similar unimodal temporal patterns were observed for myocardial edema (percentage of left ventricular mass) in all patients (P=0.001) and for infarct zone edema (T2, in ms: 62.1 [SD 2.9], 64.4 [SD 4.9], 65.9 [SD 5.3]; P<0.001) in patients without myocardial hemorrhage. Alternatively, in patients with myocardial hemorrhage, infarct zone edema was reduced at day 3 (T2, in ms: 51.8 [SD 4.6]; P<0.001), depicting a bimodal pattern. Left ventricular end-diastolic volume increased from baseline to 7 months in patients with myocardial hemorrhage (P=0.001) but not in patients without hemorrhage (P=0.377).
CONCLUSIONS
The temporal evolutions of myocardial hemorrhage and edema are unimodal, whereas infarct zone edema (T2 value) has a bimodal pattern. Myocardial hemorrhage is prognostically important and represents a target for therapeutic interventions that are designed to preserve vascular integrity following coronary reperfusion.
CLINICAL TRIAL REGISTRATION
URL: https://clinicaltrials.gov/. Unique identifier: NCT02072850.
背景
急性ST段抬高型心肌梗死（STEMI）患者心肌出血和水肿的时间进程及关系尚不确定。
方法与结果
接受直接经皮冠状动脉介入治疗的ST段抬高型心肌梗死患者在再灌注后4至12小时、3天、10天和7个月接受了4次心脏磁共振成像检查。在梗死心肌和梗死周边心肌的感兴趣区域测量心肌水肿（T2加权像）和出血（T2加权像）。心肌出血被定义为T2值<20 ms的低信号梗死核心。30例ST段抬高型心肌梗死患者（平均年龄54岁；25例[83%]为男性）签署了知情同意书。心肌出血分别发生在7例（23%）、13例（43%）、11例（33%）和4例（13%）患者中，时间分别为4至12小时、3天、10天和7个月，呈现单峰模式。心肌梗死后前10天心肌出血的相应中位数（占左心室质量的百分比）分别为2.7%（四分位间距[IQR] 0.0 - 5.6%）、7.0%（IQR 4.9 - 7.5%）和4.1%（IQR 2.6 - 5.5%；P<0.001）。所有患者的心肌水肿（占左心室质量的百分比）（P = 0.001）以及无心肌出血患者的梗死区水肿（T2值，单位为ms：62.1 [标准差2.9]、64.4 [标准差4.9]、65.9 [标准差5.3]；P<0.001）也观察到类似的单峰时间模式。相反，在有心肌出血的患者中，梗死区水肿在第3天减少（T2值，单位为ms：51.8 [标准差4.6]；P<0.001），呈现双峰模式。有心肌出血的患者左心室舒张末期容积从基线增加至7个月（P = 0.001），而无出血的患者则无增加（P = 0.377）。
结论
心肌出血和水肿的时间演变呈单峰模式，而梗死区水肿（T2值）呈双峰模式。心肌出血具有预后重要性，是旨在冠状动脉再灌注后维持血管完整性的治疗干预目标。
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