残余SYNTAX评分对ST段抬高型心肌梗死多支血管病变患者预后的影响

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残余SYNTAX评分对左主干病变经皮冠状动脉介入治疗患者预后的影响

中网心血哲病研究 2021 什•3 13第 19 卷 3 Chinese Journal of C ardiovascular Research, March 2021, Vol.l9,No.3•224.临床研究残余SYNTAX评分对左主干病变经皮冠状动脉介入治疗患者预后的影响郭超王心宇许浩博滕浩波袁建松崔锦钢杨伟宪胡奉环吴元乔树宾作者单位:100037北京市，中国医学科学院北京协和医学院国家心血管病中心阜外医院冠心病中心通信作者：乔树资，E-mail:***************【摘要】目的探讨残余SYNTAX评分（residua丨SYNTAX score,rSS)对左主干病变（left main lesion,LM L)接受经皮冠状动脉介入治疗（percutaneous coronary intervention，PC丨）的患5•远期预后的影响方法回顾性分析我院接受LMLCI治疗的患者，收集其临床资料、实验室检查、冠状动脉造影及介人操作资料，并计算其基线SYNTAX评分(baseline SYNTAX score,bSS)和rSS,根据rSS分值进行分为rSS<8、rSS>8两组，所有患荇接受3年随丨方结果高rSS组患荇LM+ T i；病变比例迟高，LM钙化比例电0，左心室射血分数更低、肌酐清除率更低、操作并发症发生率及IABP支持比例更高，预后方面，高rSS与更高的心源性死亡(1.13% 比0.51%，P=0.0458)、支架内血栓(2.36% 比丨.35%,P=0.0440)、所有血运重建（12.43% 比 8.09%,/"=0.0002)、全因死亡+所有心肌梗死+所有的血运重建复合终点（丨9.丨1%比13.29%，/"<0.000丨）和心源性死亡+靶血管相义心肌梗死+靶血管血运重建的M合终点（4.28%比2.789K/MJ.0286)发生率相关回归分析表明，rSSM分、年龄、左心室射血分数是全因死亡+所有心肌梗死+所有的血运®建复合终点发生的独立危险因素结论在接受LM介入治疗的患？[•人群，较巧的残余SYNTAX评分是3年复介终点发生的浊、危险因素【关键词】左主干；经皮冠状动脉介人治疗；预后；SYNTAX评分；残余SYNTAX评分doi ： 10.3969/j.issn. 1672-5301.2021.03.007中图分类号R541.4文献标识码A 文章编号1672-5301(2021)03-0224-07Impact of residual SYNTAX score on prognosis of patients with left main coronary artery diseaseundergoing percutaneous coronary interventionGUO Chao, WANG Xin-yu, XU Hao-bo, TENG Hao-bo, YUAN Jian-song, CU1 Jin-gang, YANG IVei-xian, HUFetig-huan, WLJ Yuan, QIAO S/w-bin. Center o f Coroncny Heart Disease, Fuwai Hospital, National Center forCardiovascular Diseases, Chinese Academy o f Medical Sciences and Peking Union Medical College, Beijing100037, ChinaCorresponding author ： QIAO Shu-bin, E-mail：****************【Abstract】Objective To investigate the impact of residual SYNTAX score on long term prognosis ofpatients with left main coronary artery lesion and received percutaneous coronary intervention. Methods Theclinical data, laboratory examination and characteristics of coronary angiography and intervention of the patientswith left main lesion and received percutaneous coronary intervention were collected and the residual SYNTAXscore were calculated, grouped as rSS<8 and rSS^8. All the patients received follow-up of 3 years. Results Atotal of 3960 cases with LML; and received PCI in our hospital were enrolled in the study. A higher rSS wasrelated with higher incidence of LM and three vessel disease, calcification of LM, procedural complication andIABP support and lower creatinine clearance and LVEF. On long-tenn prognosis, higher rSS was associated withhigher incidences of cardiogenic death ( 1.139f vs. 0.5\c/r,/J=0.0458) , stent thrombosis (2.36^ vs. 1.359f, P=0.0440), any revascularization (12.43% vs. 8.099^, /J=0.0002) and the composite endpoint of all-cause mortality+myocardial infarction + any revascularization (19.1 lCf vs. 13.297r, /)<0.0001 )and the composite endpoint ofcardiovascular mortaIity+ target vessel myocardial infarction +target vessel revascularization (4.289f vs. 2.78%,/,=0.0286). According to multiple regression analysis, rSS^8 and higher age, LVEF were the independent riskfactors of the composite endpoint of all-cause mortality+myocardial infarction+any revascularization. ConclusionI1闺心血管病研究 2021 年3 月第 19 卷第3 朗Chinese Journal o f C ardiovascular Research March 202/ . loU9,No.3In patients with LML and received PCI, a higher residual Syntax Score is an independent risk factor of the 3-year- composite.【Key w o rds】Left main; Percutaneous coronary intervention；Prognosis；SYNTAX score；Residual SYNTAX scoreSYNTAX评分诞生于SYNTAX研究丨丨丨，是基于冠状动脉病变影像学特征而计算得出的评分，可反映病变的范围和复杂程度，作为一种量化工具，有助于血运电建治疗策略的制定，研究证实可较好地预测接受经皮冠状动脉成形术（percutaneous coronary intervention，PCI)患者的远期预后 ;进而衍生出了残余 SYTNAX评分（residual SYNTAX score, rSS)的概念，定义该评分>0为+完全血运重建，rSS n J■客观并量化地体现未经处理的冠状动脉病变程度及复杂性，并反映不完全血运軍:建带来的心肌缺血负担，Li被证实可作为PC丨患者临床预后的预测因素,但目前对左主干(left main,LM)病变人群尚缺少关于rSS对远期预G的相关研究。

SYNTAX评分在经皮冠脉介入治疗患者预后评估中的应用价值观察

SYNTAX评分在经皮冠脉介入治疗患者预后评估中的应用价值观察摘要目的探讨SYNTAXⅡ评分系统在经皮冠状动脉介入（PCI）治疗的急性冠状动脉综合征（ACS）患者临床预后预测中的应用价值.方法选取我院接受PCI且可计算SYNTAXⅡ评分的200例ACS患者为研究对象，根据SYNTAXⅡ评分中位数将患者分入3组,分别为SYNTAXⅡ低分组、中分组、高分组，比较3组患者术后1年的终点事件发生率。

结果SYNTAXⅡ高分组缺血事件、全因死亡发生率高于SYNTAXⅡ低分组和SYNTAXⅡ中分组,差异有统计学意义(P<0.05)；SYNTAXⅡ中分组和SYNTAXⅡ高分组出血事件发生率高于SYNTAXⅡ低分组,差异有统计学意义(P<0.05)。

结论SYNTAXⅡ评分是预测冠心病患者PCI术后临床预后的良好工具,SYNTAXⅡ评分越高,患者预后越差。

关键词：SYNTAX评分；经皮冠脉介入；临床预后SYNTAXⅡ评分系统是一种用于评估冠状动脉病变复杂性的工具，用于指导冠状动脉介入治疗（PCI）和冠状动脉搭桥术（CABG）的选择。

该评分系统是在SYNTAXⅠ评分系统基础上改进而来，通过对冠状动脉病变的解剖学特点进行评估，为临床医生提供了一个量化的决策依据[1]。

SYNTAXⅡ评分系统主要根据以下几个因素对冠状动脉病变进行评估：其一，主干病变。

即评估主动脉冠状动脉（LM）病变的严重程度和长度。

其二，血流动力学。

即评估患者冠状动脉的血流动力学情况，包括左心室功能、心肌梗死的范围和时间等。

其三，病变解剖学复杂性。

即评估冠状动脉病变的多发性和严重程度，包括主干病变、三支病变和非左主干病变。

其四，患者特征。

即评估患者的年龄、性别、危险因素等个体特征。

SYNTAXⅡ评分系统通过对以上因素进行综合计算，得出一个数值作为冠状动脉病变复杂性的评估指标，用于指导临床医生选择合适的介入治疗或外科手术方案。

值得注意的是，SYNTAXⅡ评分系统仅作为辅助工具，临床医生还需结合患者具体的病情和临床表现，综合考虑决定最佳的治疗方案。

SYNTAXⅡ评分对老年ST 段抬高型心肌梗死患者直接经皮冠状动脉介入术后ST 段回落不良的预测分析

㊃临床研究㊃SYNTAXⅡ评分对老年ST段抬高型心肌梗死患者直接经皮冠状动脉介入术后ST段回落不良的预测分析叶慧明㊀任利辉㊀雷力成㊀赵博㊀布伦㊀王佐岩㊀高军毅㊀南京㊀王汝鹏㊀张德贤陈策㊀彭建军100038首都医科大学附属北京世纪坛医院心内科(叶慧明㊁任利辉㊁雷力成㊁赵博㊁布伦㊁王佐岩㊁高军毅㊁张德贤㊁陈策㊁彭建军);100070首都医科大学附属北京天坛医院心内科(南京㊁王汝鹏)通信作者:彭建军,电子信箱:pjj1972@DOI:10.3969/j.issn.1007-5410.2022.04.006㊀㊀ʌ摘要ɔ㊀目的㊀分析老年急性ST段抬高型心肌梗死(STEMI)患者行直接经皮冠状动脉介入治疗(pPCI)后SYNTAXⅡ评分(SS-Ⅱ)对ST段回落(STR)不良的预测作用㊂㊀方法㊀回顾性研究㊂连续入选行pPCI的老年(年龄ȡ60岁)STEMI患者369例,分为SS-Ⅱ低分组(SS-Ⅱ<22)㊁SS-Ⅱ中间分值组(22ɤSS-Ⅱ<28)和SS-Ⅱ高分组(SS-Ⅱȡ28),记录各组pPCI术后1h的STR不良的发生率,通过logistic回归分析SS-Ⅱ对STR不良的预测价值,绘制受试者工作特征曲线分析SS-Ⅱ预测STR不良的最佳界值㊂㊀结果㊀与SS-Ⅱ低分组和SS-Ⅱ中间分值组比较,SS-Ⅱ高分组有更高的STR不良发生率(50.8%比19.8%和27.6%,P=0.001)㊂多元logistic回归分析发现,SS-Ⅱ为STR不良的独立预测因子(OR=1.142,95%CI:1.082~1.325)㊂受试者工作特征曲线分析发现,SS-Ⅱ评分为28是预测STR 不良的最佳界值,敏感度和特异度分别为68%和57%㊂㊀结论㊀SS-Ⅱ评分高对老年STEMI行pPCI 患者术后STR不良有一定的预测价值㊂ʌ关键词ɔ㊀SYNTAXⅡ评分;㊀ST段抬高型心肌梗死;㊀血管成形术,经腔,经皮冠状动脉基金项目:北京市自然科学基金(7162089)Predictive value of SYNTAX scoreⅡon poor ST segment resolution in aged patients with ST segment elevated myocardial infarction underwent primary percutaneous coronary intervention㊀Ye Huiming,Ren Lihui,Lei Licheng,Zhao Bo,Bu Lun,Wang Zuoyan,Gao Junyi,Nan Jing,Wang Rupeng, Zhang Dexian,Chen Ce,Peng JianjunDepartment of Cardiology,Beijing Shijitan Hospital,Capital Medical University,Beijing100038,China(Ye HM,Ren LH,Lei LC,Zhao B,Bu L,Wang ZY,Gao JY,Zhang DX,Chen C,Peng JJ);Department of Cardiology,Beijing Tiantan Hospital,Capital Medical University,Beijing100070,China(Nan J,Wang RP)Corresponding author:Peng Jianjun,Email:pjj1972@ʌAbstractɔ㊀Objective㊀To investigate the predictive value of SYNTAX scoreⅡ(SS-Ⅱ)on poor ST segment resolution(STR)in ST segment elevated myocardial infarction(STEMI)aged patients underwent primary percutaneous coronary intervention(pPCI).㊀Methods㊀We retrospectively reviewed a total of369 consecutive old STEMI patients underwent pPCI.According to SS-Ⅱscore,patients were divided into three group:low score group(SS-Ⅱ<22,SS-Ⅱlow),medium score group(22ɤSS-Ⅱ<28,SS-Ⅱmedium),high score group(SS-Ⅱȡ28,SS-Ⅱhigh),then analyzed the incident rate of poor STR at an hour after pPCI,and used logistic regressive analysis the relationship between SS-Ⅱand poor STR.The predictive value of SS-Ⅱon poor STR was evaluated by receiver operating characteristic curve.㊀Results㊀Compared with the SS-Ⅱlow and SS-Ⅱmedium group,the SS-Ⅱhigh group had a higher rate of poor STR(50.8%vs.19.8%and 27.6%,P=0.001).Logistic regression analysis showed that SS-Ⅱwas the independent predictor of poor STR(OR=1.142,95%CI:1.082-1.325).Receiver operating characteristic curve analysis showed that the best cut-off was28with sensitivity of68%and specificity of57%.㊀Conclusions㊀High SS-Ⅱhas an independent predictive value for the poor STR after pPCI in aged STEMI patients.ʌKey wordsɔ㊀SYNTAX scoreⅡ;㊀ST segment elevation myocardial infarction;㊀Angioplasty, transluminal,percutaneous coronaryFund program:Beijing Natural Science Foundation(7162089)㊀㊀ST段抬高型心肌梗死(ST segment elevation myocardial infarction,STEMI)严重威胁人类健康,对于这些患者,最重要的是开通梗死相关动脉,而直接经皮冠状动脉介入治疗(primary percutaneous coronary intervention,pPCI)成为最有效的治疗手段㊂不过,行pPCI的患者仍有相当一部分出现ST段回落(ST segment resolution,STR)不良,这往往与主要不良心血管事件(major adverse cardiovascular events,MACE)相关[1-5]㊂SYNTAXⅡ评分(SYNTAX scoreⅡ,SS-Ⅱ)包含2个冠状动脉解剖学参数[SYNTAX评分(SS)㊁存在无保护左主干病变]和6个临床参数(年龄㊁肌酐清除率㊁性别㊁左室射血分数㊁慢性阻塞性肺疾病和外周血管疾病),其综合了更多临床参数,比单纯冠状动脉解剖的SS评分对稳定型冠心病多支病变和左主干病变等复杂病变患者的PCI和冠状动脉旁路移植术的长期疗效有更好的预测价值[6-9]㊂但SS-Ⅱ对STR不良预测的研究文献尚少,本研究拟探讨SS-Ⅱ对STR不良的预测价值㊂1㊀对象和方法1.1㊀研究对象本研究为回顾性研究㊂连续入选2015 2020年于首都医科大学附属北京世纪坛医院门㊁急诊诊断为STEMI且行pPCI的老年患者㊂入选标准: (1)年龄ȡ60岁;(2)胸痛ȡ30min持续不缓解;(3)从发病到就诊我院的时间在12h内;(4)到院后的心电图2个及以上相邻导联ST段抬高,其中肢体导联ȡ0.1mV,胸前导联ȡ0.2mV㊂排除标准: (1)陈旧性心肌梗死病史;(2)曾行冠状动脉旁路移植术;(3)合并心肌病或心脏瓣膜病;(4)确诊恶性肿瘤病史,预期寿命不足1年㊂本研究获得北京世纪坛医院伦理委员会的批准[伦理批号:2018年科研伦审第(53)号]㊂1.2㊀研究方法1.2.1㊀一般资料收集㊀收集入选患者的临床资料,包括年龄㊁性别㊁体质指数,吸烟史㊁糖尿病㊁高血压㊁高脂血症等病史,实验室指标㊁超声心动图指标,用药情况,冠状动脉病变和pPCI治疗情况等㊂1.2.2㊀pPCI治疗㊀所有患者pPCI术前给予口服负荷量的阿司匹林肠溶片300mg和氯吡格雷600mg(或替格瑞洛180mg)㊂术前经动脉鞘内给予100U/kg普通肝素㊂术后继续阿司匹林100mg/d,氯吡格雷75mg/d或替格瑞洛90mg2次/d,双联抗血小板治疗1年,之后维持单抗治疗㊂术者均为具有介入资质的心血管医师㊂一般情况下仅处理梗死相关动脉㊂术者酌情使用血栓抽吸装置和(或)糖蛋白Ⅱb/Ⅲa受体拮抗剂㊂pPCI成功标准:梗死相关动脉残余狭窄<20%或恢复TIMI血流2~3级㊂1.2.3㊀分组㊀由两名经验丰富的心血管介入医师分别单独进行SS-Ⅱ评分,如果二者评分有差异,取二者的平均值㊂依据SS-Ⅱ评分[7-9],分为SS-Ⅱ低分组(SS-Ⅱ<22)121例㊁SS-Ⅱ中间分值组(22ɤSS-Ⅱ< 28)116例和SS-Ⅱ高分组(SS-Ⅱȡ28)132例㊂1.2.4㊀STR不良的定义㊀选择基线心电图ST段抬高幅度最大的导联作为STR的观察导联,测量QRS 波群终末后20ms的ST段抬高幅度[4-5]㊂根据文献在pPCI术后1h复查心电图,STRȡ70%为完全回落,STR<70%为回落不良[4,10-11]㊂1.2.5㊀主要终点事件㊀观察院内MACE,包括住院期间的全因死亡㊁非致死性心肌梗死㊁急性支架内血栓形成和心脏破裂[12]㊂1.3㊀统计学方法采用SPSS21.0统计软件进行分析㊂符合正态分布的计量资料以 xʃs表示,组间比较采用t检验;计数资料以百分构成比表示,组间比较使用卡方检验或Fisher确切概率法;多组间比较采用方差分析㊂将可能影响患者预后的P<0.25的变量纳入单因素logistic回归模型,使用逆向logistic回归方法进行危险因素筛选,计算优势比(odds ratio,OR)和95%置信区间(95%confidence interval,95%CI)㊂绘制受试者工作特征(receiver operating characteristic, ROC)曲线分析SS-Ⅱ评分预测老年STEMI患者pPCI术后STR不良的敏感度和特异度㊂P<0.05为差异有统计学意义㊂2㊀结果2.1㊀3组基线资料比较本研究共纳入369例STEMI患者,年龄60~85岁,平均(64.8ʃ5.3)岁,其中女性95例(25.7%),SS-Ⅱ评分7~68分㊂3组临床基线资料比较,年龄㊁糖尿病㊁左室射血分数㊁心功能Killip分级㊁糖化血红蛋白㊁肌酐清除率㊁使用替格瑞洛㊁血管紧张素转换酶抑制剂/血管紧张素Ⅱ受体拮抗剂㊁β受体阻滞剂和替罗非班的比例㊁罪犯血管㊁胸痛-导丝通过时间㊁血栓抽吸使用率等差异均有统计学意义(均为P<0.05)㊂出现STR不良患者共123例(33.3%),平均年龄(65.5ʃ7.4)岁,STR不良的发生率在SS-Ⅱ低分组为19.8%㊁SS-Ⅱ中间分值组为27.6%㊁SS-Ⅱ高分组为51.1%(P=0.001),见表1㊂2.2㊀3组主要终点事件比较3组住院期间的全因死亡㊁心脏破裂和MACE 比较,差异均有统计学意义(均为P<0.05),见表2㊂2.3㊀预测STR不良的logistic回归分析单因素logistic回归分析显示,糖尿病㊁Killip分级㊁胸痛-导丝通过时间和SS-Ⅱ评分与STR不良相表1㊀患者临床基线资料比较项目SS-Ⅱ低分组(121例)SS-Ⅱ中间分值组(116例)SS-Ⅱ高分组(132例)P值a年龄( xʃs,岁)63.1ʃ4.464.2ʃ3.167.2ʃ5.10.001女性[例(%)]32(26.4)28(24.1)35(26.5)0.403吸烟史[例(%)]31(25.6)29(25.0)36(27.3)0.235 BMI( xʃs,kg/m2)25.3ʃ1.225.1ʃ2.325.4ʃ2.40.853糖尿病[例(%)]21(17.4)23(19.8)39(29.5)0.001高血压[例(%)]64(52.9)58(50.0)66(50.0)0.252高脂血症[例(%)]56(46.3)52(44.8)65(49.2)0.221既往脑血管疾病[例(%)]15(12.4)11(9.5)24(18.2)0.121外周血管疾病[例(%)]3(2.5)4(3.4)5(3.8)0.351慢性阻塞性肺疾病[例(%)]12(9.9)9(7.8)14(10.6)0.421左室射血分数( xʃs,%)56.3ʃ1.654.1ʃ2.552.3ʃ2.80.001心功能Killip分级[例(%)]㊀Ⅱ12(9.9)10(8.6)8(6.1)0.042㊀Ⅲ3(2.5)2(1.7)10(7.6)0.135㊀Ⅳ0(0.0)1(0.9)8(6.1)0.016 HbA1c( xʃs,%) 6.8ʃ2.4 6.9ʃ1.67.2ʃ2.70.001肌酐清除率( xʃs,ml/min)61.0ʃ2.965.2ʃ4.466.5ʃ6.10.042阿司匹林[例(%)]119(98.3)116(100.0)131(99.2)0.512氯吡格雷[例(%)]72(59.5)66(56.9)56(42.4)0.023替格瑞洛[例(%)]49(40.5)50(43.1)75(56.8)0.001 ACEI/ARB[例(%)]96(79.3)88(75.9)85(64.4)0.045他汀类药物[例(%)]118(97.5)113(97.4)129(97.7)0.501β受体阻滞剂[例(%)]90(74.4)77(66.4)68(51.5)0.001罪犯血管[例(%)]㊀LAD35(28.9)32(27.6)62(47.0)0.001㊀LCX25(20.7)28(24.1)11(8.3)0.021㊀RCA61(50.4)56(48.3)59(44.7)0.064胸痛-导丝通过时间( xʃs,h) 6.1ʃ2.3 6.2ʃ2.78.9ʃ3.10.001 pPCI操作成功率[例(%)]120(99.2)112(96.6)125(94.7)0.582血栓抽吸[例(%)]21(17.4)19(16.4)46(34.8)0.001术中使用替罗非班[例(%)]18(14.9)15(12.9)38(28.8)0.032 STR不良[例(%)]24(19.8)32(27.6)67(50.8)0.001㊀㊀注:SS-Ⅱ:SYNTAXⅡ评分;BMI:体质指数;HbA1c:糖化血红蛋白;ACEI/ARB:血管紧张素转换酶抑制剂/血管紧张素Ⅱ受体拮抗剂;LAD:前降支;LCX:左回旋支;RCA:右冠状动脉;pPCI:直接经皮冠状动脉介入术;STR:ST段回落;a3组间比较表2㊀住院期间的MACE比较[例(%)]事件总计(369例)SS-Ⅱ低分组(121例)SS-Ⅱ中间分值组(116例)SS-Ⅱ高分组(132例)P值a院内MACE87(23.6)21(17.4)19(16.4)47(35.6)0.001㊀全因死亡21(5.7)1(0.8)6(5.2)14(10.6)0.003㊀非致死性心肌梗死36(9.8)10(8.3)8(6.9)18(13.6)0.236㊀支架内血栓形成10(2.7)2(1.7)3(2.6)5(3.8)0.803㊀心脏破裂12(3.3)0(0.0)1(0.9)11(8.3)0.001㊀㊀注:MACE:主要不良心血管事件;SS-Ⅱ:SYNTAXⅡ评分;a为SS-Ⅱ低分组㊁SS-Ⅱ中间分值组和SS-Ⅱ高分组间比较关(均为P<0.05),进一步行多因素logistic回归发现,糖尿病㊁胸痛-导丝通过时间和SS-Ⅱ评分为STR 不良的独立预测因素(均为P<0.05),其中SS-Ⅱ预测STR不良的OR=1.142,95%CI:1.082~1.325, P<0.05㊂2.4㊀SS-Ⅱ对STR不良的预测价值ROC曲线分析显示,SS-Ⅱ预测STR不良的ROC曲线下面积为0.659(95%CI:0.589~0.697, P<0.01),SS-Ⅱ最佳界值为28分,敏感度为68%,特异度为57%㊂3　讨论本研究对行pPCI的老年STEMI患者的临床资料分析发现,SS-Ⅱ评分越高其临床情况越复杂,表现为年龄更大㊁糖尿病患病率越高㊁射血分数越低㊁心功能Killip分级越差;患者预后也更差,表现为STR不良发生率越高㊁住院期间的MACE发生率更高,与文献报道一致[13-14]㊂经多因素logistic回归分析发现,SS-Ⅱ评分是STR不良发生的独立预测因素㊂SS-Ⅱ是为了优化SS对PCI患者的预后评价而发展起来的[7]㊂新的评分系统在冠状动脉解剖变量的基础上增加了6个临床变量,被证实显著优于单纯冠状动脉解剖变量对MACE的预测价值[7]㊂SIRTAX研究中SS联合年龄㊁肌酐水平和左室射血分数等变量对STEMI患者的MACE预测更好[15],较单纯SS对于5年的全因死亡的预测价值更高[16-17]㊂有研究发现,在接受pPCI的STEMI患者中, SS-Ⅱ与心脏破裂显著相关,SS-Ⅱ是心脏破裂和新发心房颤动的独立预测因子[18-19],本研究结果与之类似,心脏破裂的12例患者绝大部分(91.7%)发生在SS-Ⅱȡ28的患者中㊂STEMI患者pPCI术后TIMI血流3级,不代表真正的心肌得到有效灌注,而无复流现象发生率高(34%~50%),是pPCI的严重并发症,与远期预后不良相关[20-21]㊂STR不良是无复流的一种心电图表现,临床中使用的TIMI血流分级㊁校正的TIMI记帧均不能可靠地评价心肌灌注,而用心肌染色分级(myocardial blush grade,MBG)㊁心电图的STR,甚至用延迟增强磁共振成像㊁核素心肌灌注显像㊁心肌声学造影来评价心肌灌注情况,后三种的准确性和特异性虽高,但操作繁琐㊁经济负担高㊂STR简单㊁易得㊁实用且与预后显著相关,现在大多数学者倾向STRȡ70%为ST段完全回落,STRȡ70%与心肌梗死面积㊁死亡率㊁致残率相关[4,10],与MBG符合率达70%[11],与远期和近期的预后改善相关[22-23]㊂本研究中STR不良发生率高达33.3%,而在SS-Ⅱ高分组更是高达50.8%,但整体平均水平低于既往研究中发生率(44%~50%)[24-25],考虑与本研究中替罗非班和血栓抽吸使用率比较高有关㊂微循环的斑块栓塞㊁微血栓的栓塞㊁血小板和血小板的相互作用㊁血小板与白细胞的相互作用在微循环障碍中起重要作用[26-29]㊂本研究还发现,SS-Ⅱ㊁胸痛-导丝通过时间(h)㊁心功能Killip分级㊁糖尿病与STR不良密切相关㊂因老年患者基础疾病较多,冠状动脉硬化更弥漫和严重,预后欠佳㊂经多因素回归分析发现,SS-Ⅱ是STR不良的独立预测因素,对SS-Ⅱ评分高的患者应采取更积极的措施预防STR不良的发生,如加强吸栓和抗血小板治疗,冠状动脉内溶栓[30],减少支架置入后的高压后扩张,有些弥漫钙化病变在血流恢复㊁无严重夹层老年患者中可以考虑药物球囊植入,以减少反复扩张引起无复流发生,减少支架置入术后的微循环障碍,减少近期和远期不良事件㊂本研究为单中心回顾性研究,入选例数偏少,缺乏远期随访观察结果,研究结果有待于大规模临床研究证实㊂综上,本研究结果提示SS-Ⅱ是老年STEMI行pPCI患者STR不良的独立预测因子㊂对SS-Ⅱ评分高的患者,应提早采取更积极的预防措施㊂利益冲突:无参㊀考㊀文㊀献[1]Giugliano RP,Sabatine MS,Gibson CM,et binedassessment of thrombolysis in myocardial infarction flow grede,myocardial perfusion grade.and ST-segment reselution to evaluateepicardial and myocardial reperfusion[J].Am J 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血清GGT、SYNTAX-Ⅱ评分在急性ST段抬高型心肌梗死患者预后评估中的价值

血清GGT、SYNTAX-Ⅱ评分在急性ST段抬高型心肌梗死患者预后评估中的价值吕峰峰，赵磊，韩佳，刘媛媛，吕元杰沧州市中心医院，河北沧州061000摘要：目的探讨血清γ-谷氨酰转移酶（GGT）联合SYNTAX-Ⅱ评分对急性ST段抬高型心肌梗死（STEMI）患者预后的评估价值。

方法选取行经皮冠状动脉介入治疗（PCI）的349例患者，根据术后1年内是否发生主要不良心脏事件（MACE）将患者分为预后不良组86例和预后良好组263例。

比较两组一般资料、GGT和SYNTAX-Ⅱ评分，Logistic回归分析STEMI患者PCI术后预后不良的危险因素，分析GGT、SYNTAX-Ⅱ评分对患者预后不良的预测价值。

结果预后不良组GGT、SYNTAX-Ⅱ评分、年龄、冠脉病变血管数目、置入支架数目、Killp分级级别、慢性阻塞性肺疾病比例、外周血管疾病比例、左冠状动脉主干病变比例均高于预后良好组，而左室射血分数（LVEF）低于预后良好组（P均<0.05）。

Logistic回归分析显示，GGT（OR=1.581）、SYNTAX-Ⅱ评分（OR=1.693）、年龄（OR=1.523）、冠脉病变血管数目（OR=2.679）是STEMI患者PCI术后预后不良的危险因素，LVEF（OR=0.754）是其保护因素（P均<0.05）。

GGT、SYNTAX-Ⅱ评分预测STEMI患者PCI术后预后不良的ROC曲线下面积（AUC）分别为0.787、0.779（P均<0.05），GGT联合SYNTAX-Ⅱ评分预测患者预后不良的AUC为0.869（P<0.05），高于GGT和SYNTAX-Ⅱ评分单项指标。

结论血清GGT、SYNTAX-Ⅱ评分联合检查在STEMI患者预后评估中有较高价值。

关键词：急性ST段抬高型心肌梗死；γ-谷氨酰转移酶；SYNTAX-Ⅱ评分；经皮冠状动脉介入治疗；预后doi：10.3969/j.issn.1002-266X.2021.07.014中图分类号：R542.2文献标志码：A文章编号：1002-266X（2021）07-0057-04基金项目：河北省医学科学研究重点课题（20160911）；沧州市重点研发计划指导项目（172302097）。

SYNTAX 积分对左主干和多支冠状动脉病变风险评估的意义

险评估指标正在研究中，见表５。ＧＲＣ（ｇｌｏｂａｌｒｉｓｋｃｌａｓｓｉｆｉｃａｔｉｏｎ）评分系统是联合应用了Ｅｕｒｏｓｃｏｒｅ评估和ＳＹＮＴＡＸ评分系统，分为３类：高（Ｅｕｒｏｓｃｏｒｅ＞６和ＳＹＮＴＡｓｃｏｒｅ＞２６）；中（Ｅｕｒｏｓｃｏｒｅ＞６或ＳＹＮＴＡｓｃｏｒｅ＞２６）；低（Ｅｕｒｏｓｃｏｒｅ＜６和ＳＹＮＴＡｓｃｏｒｅ＜２６）［１６］。ＧＲＣ提高了预测风险的准确性，将其对ＳＹＮＴＡＸ研究的病例重新进行风险评估，显示ＧＲＣ对左主干患者的风险评估，预测死亡和ＭＡＣＣＥ能力方面表现良好，特别是在ＧＲＣ最低分组，２４个月内没有死亡。相反，在ＣＡＢＧ组，ＧＲＣ在死亡的预测方面，各组间无明显差异，在预测ＭＡＣＣＥ发生率上表现更好。
ＤＯＩ：１０畅３８７７／ｃｍａ．ｊ．ｉｓｓｎ．１６７４唱０７８５．２０１２．０９．０３６作者单位：１０００３７中国医学科学院北京协和医学院阜外心血管病医院外科通讯作者：郑哲，Ｅｍａｉｌ：ｚｈａｎｇｙｉｎｇ１９７４＠ｙａｈｏｏ．ｃｏｍ．ｃｎ
狭窄严重程度以及各个血管或节段通常供应左心室血流的比重。左心室血流在右优势型系统中，右冠占１６％，左冠占８４％，在左冠系统中，有６６％进入前降支，３３％进入回旋支。这样设定右冠到左心室的血流为１，左主干血流量接近其５倍，前降支为３畅５倍，回旋支１畅５倍。在左优势型心脏，右冠不提供左心室血流，左主干提供１００％血流，其中前降支提供５８％（比重为３畅５），回旋支提供４２％（比重为２畅５）。
ＳＹＮＴＡＸ评分非常重要的一点是为每一个病变依据其特点进行单独评分。病变特征的描述包括完全闭塞，三分叉，二分叉，主动脉开口病变，严重扭曲，病变长度超过２０ｍｍ，严重钙化，血栓和弥散／小血管病变。对应的分值见表２。大多数病变特征的描述是针对ＰＣＩ操作进行评分的，只有弥散／小血管病变反映的是对外科技术的挑战。评分可以在ｈｔｔｐ：／／ｗｗｗ．ｓｙｎｔａｘ唱ｓｃｏｒｅ．ｃｏｍ／这个网站上进行。

Syntax积分对PCI治疗的指导及预后评估

Syntax积分对PCI治疗的指导及预后评估摘要：目的：通过回顾分析我院150例冠状动脉复杂病变者实施经皮冠状动脉介入治疗的临床资料、病变特征、手术策略、手术方式和PCI治疗效果，分析以上结果与Syntax积分之间的相关性。

方法：连续选取自2013年5月至2015年5月于江西省人民医院心内科就诊，通过血管造影证存在PCI治疗指征患者150例。

根据临床SYNTAX积分总体分布三分位数值，按0-22分为低分组（n=62），23-32分为中分组（n=45），高于33分为高分组（n=43）。

比较不同Syntax积分各组的合并症及冠心病分型情况、冠脉病变特征、PCI并发症发生率、手术用时及术后效果以及PCI技术选择情况。

结果：两两比较分析发现高分组的前降支＋回旋支病变发生比例为53.5%明显高于低分组的32.2%，P<0.05，高分组的分叉病变比例46.5%，明显高于低分组的27.4%，P<0.05，钙化病变高分组的发生率30.2%明显高于低分组的12.9%，P<0.05。

各种常见PCI并发症发生情况中，高分组冠脉夹层及冠脉急性闭塞的发生率分别为9.3%及6.9%，明显高于低分组的0%，P<0.05，冠脉夹层的组间比较同样存在统计学差异，P<0.05。

结论：Syntax积分无论在术前术中以及术后均具有一定的临床价值，从长远来说，仍有着相当的潜力有待挖掘。

关键词：Syntax积分；冠心病；PCI；评估；预后冠状动脉粥样硬化性心脏病（Coronary Heart Disease，CHD）指的是一支或多支冠状动脉由于粥样硬化所引起的血管不同程度的狭窄或阻塞，我国近年冠心病的发病率出现连续多年的高速上升态势，冠心病已逐渐成为威胁国人健康重要疾病。

1材料与方法1.一般资料连续选取自2013年5月至2015年5月于江西省人民医院心内科就诊，通过血管造影证存在PCI治疗指征患者150例。

其中男性89例，女性61例，年龄38-83岁，平均年龄63.67±9.78岁。

SYNTAX-II评分评估冠心病患者PCI术后的作用有哪些

SYNTAX-II评分评估冠心病患者PCI术后的作用有哪些提到冠心病，想必大家都不陌生。

冠心病，也称为冠状动脉性心脏病，是一种由冠状动脉供血不足引起的心血管疾病。

冠状动脉是心脏供应血液和氧气的主要血管，当冠状动脉的血流减少或阻塞时，心肌就会因为缺血而受损。

最常见的冠心病形式是冠状动脉粥样硬化性心脏病，它是由于冠状动脉中的血管壁发生斑块的形成，限制了血流通过的能力。

这些斑块可以由脂质、胆固醇和其他物质组成，形成动脉狭窄或闭塞。

当血管狭窄到一定程度时，心肌可能会在体力或情绪激动时出现供血不足的症状，如胸痛、胸闷或气短，称为心绞痛。

如果冠状动脉血流完全中断，就可能导致心肌梗死，即心肌组织因为长时间缺血而受到严重损害甚至坏死。

冠心病是一种常见的心血管疾病，主要由不良的生活方式和饮食习惯、高血压、高血脂、糖尿病、肥胖等因素引起。

早期发现和积极干预可以避免或延缓发生心血管事件的发生，如心肌梗死或猝死。

治疗冠心病的目标是减轻症状、改善生活质量，并预防和减少心血管事件的发生。

今天主要给大家介绍一下SYNTAX评分评估冠心病患者PCI术后的作用有哪些。

1 冠心病PCI术是怎么回事（1）解读冠心病PCI术的含义冠心病PCI术是指经皮冠状动脉介入治疗。

通过一种穿刺方法将导丝送到靶血管部位，注入造影剂确定狭窄部位，送入球囊至狭窄部位，充气扩张狭窄的部位。

支架植入则是在此基础上再将一个冠脉支架送入狭窄部位，并使用球囊将支架撑开并最终固定于狭窄部位、恢复局部的冠脉直径到正常范围。

这个过程可以恢复冠状动脉的血液流动，缓解供血不足的症状，并帮助预防心肌梗死等严重并发症的发生。

PCI术相较于传统的开胸手术CABG（冠状动脉搭桥手术），它具有创伤小、恢复快、住院时间短等优点，是治疗冠心病的常见选择。

（2）简述冠心病PCI术的方法PCI术通常由心血管专科医生在导管室内进行。

在手术中，医生会在患者的腹股沟或手腕部位通过血管穿刺，送入一根细长的导管（导管一般呈扁平形状），然后引导导管到冠状动脉的狭窄或阻塞区域。

rdw联合syntaxⅡ积分对急性心肌梗死患者行pci后发生不良心血管事件的

ＲＤＷ联合ＳＹＮＴＡＸⅡ积分对急性心肌梗死患者行ＰＣＩ后发生不良心血管事件的预测价值廉铮ꎬ吕峰峰ꎬ王佳旺ꎬ王云飞沧州市中心医院ꎬ河北沧州０６１０００㊀㊀摘要:目的㊀探讨红细胞分布宽度(ＲＤＷ)联合ＳＹＮＴＡＸⅡ积分对急性ＳＴ段抬高心肌梗死(ＳＴＥＭＩ)患者行经皮冠状动脉介入治疗(ＰＣＩ)术后发生主要不良心脏事件(ＭＡＣＥ)的预测价值ꎮ方法㊀选取３３９例行ＰＣＩ治疗的ＳＴＥＭＩ患者ꎬ根据术后１年内是否发生ＭＡＣＥ将患者分为ＭＡＣＥ组８１例和非ＭＡＣＥ组２５８例ꎮ观察两组基线资料㊁ＲＤＷ㊁ＳＹＮＴＡＸⅡ积分差异ꎬ分析ＲＤＷ㊁ＳＹＮＴＡＸⅡ积分与ＳＴＥＭＩ患者ＰＣＩ术后发生ＭＡＣＥ的关系及对ＭＡＣＥ的预测价值ꎮ结果㊀ＳＴＥＭＩ患者ＰＣＩ术后ＭＡＣＥ发生率为２３.８９％(８１/３３９)ꎬＭＡＣＥ组患者ＲＤＷ㊁ＳＹＮＴＡＸⅡ积分高于非ＭＡＣＥ组(Ｐ<０.０５)ꎮＣｏｘ风险回归分析显示ꎬＲＤＷ(ＲＲ＝２.２５２ꎬＰ＝０.００５)㊁ＳＹＮＴＡＸⅡ积分(ＲＲ＝２.５２４ꎬＰ＝０.０００)与ＳＴＥＭＩ患者ＰＣＩ术后ＭＡＣＥ的发生独立相关ꎮＲＤＷ㊁ＳＹＮＴＡＸⅡ积分预测ＰＣＩ术后ＭＡＣＥ的受试者工作特征曲线下面积(ＡＵＣ)分别为０.７１０㊁０.７２９ꎬＲＤＷ联合ＳＹＮＴＡＸⅡ积分预测ＭＡＣＥ的ＡＵＣ为０.８８４ꎬ高于单独ＲＤＷ㊁ＳＹＮＴＡＸⅡ积分指标(Ｐ均<０.０５)ꎮ结论㊀ＲＤＷ㊁ＳＹＮＴＡＸⅡ积分是ＳＴＥＭＩ患者ＰＣＩ术后ＭＡＣＥ发生的独立预测因子ꎬＲＤＷ联合ＳＹＮＴＡＸⅡ积分可提高对ＭＡＣＥ的预测效能ꎮ㊀㊀关键词:急性心肌梗死ꎻ红细胞分布宽度ꎻ经皮冠状动脉介入手术ꎻ主要不良心血管事件㊀㊀ｄｏｉ:１０.３９６９/ｊ.ｉｓｓｎ.１００２￣２６６Ｘ.２０２０.０４.０１７㊀㊀中图分类号:Ｒ５４２.２㊀㊀文献标志码:Ａ㊀㊀文章编号:１００２￣２６６Ｘ(２０２０)０４￣００６６￣０４基金项目:沧州市重点研发计划指导项目(１７２３０２０９７)ꎮ㊀㊀急性ＳＴ段抬高型心肌梗死(ＳＴＥＭＩ)是临床常见的心血管疾病ꎬ行经皮冠状动脉介入手术(ＰＣＩ)再灌注治疗是目前临床挽救缺血心肌㊁保护心功能的首选治疗手段[１]ꎮ但ＰＣＩ术后患者预后仍不尽人意ꎬ主要不良心脏事件(ＭＡＣＥ)发生时有报道[２]ꎬ因此ＳＴＥＭＩ患者接受ＰＣＩ的远期预后是目前临床治疗过程中关注的热点ꎮ红细胞分布宽度(ＲＤＷ)是反映红细胞体积异质性的定量指标ꎬ临床用于贫血的辅助诊断ꎮ近年来ꎬ国内外研究证实ＲＤＷ在心力衰竭㊁冠状动脉粥样硬化性心脏病㊁心律失常㊁高血压等心血管疾病诊断和预后分析中有重要价值[３ꎬ４]ꎮＳＹＮＴＡＸⅡ积分是ＳＹＮＴＡＸ研究开发的新的冠状动脉病变评分系统ꎬ主要用来预测接受ＰＣＩ治疗的患者发生长期心脑血管不良事件独立预测因素[５]ꎮＲＤＷ联合ＳＹＮＴＡＸⅡ积分是否可预测ＳＴＥ￣ＭＩ患者ＰＣＩ术后ＭＡＣＥ发生尚待探讨ꎮ鉴于此ꎬ本研究回顾性收集３３９例行ＰＣＩ治疗的ＳＴＥＭＩ患者临床资料ꎬ观察ＲＤＷ联合ＳＹＮＴＡＸⅡ积分对ＳＴＥ￣ＭＩ患者ＰＣＩ术后发生ＭＡＣＥ的预测价值ꎮ１　资料与方法１.１㊀临床资料㊀选取２０１４年１０月~２０１７年９月于我院就诊的ＳＴＥＭＩ并行ＰＣＩ治疗患者共３３９例ꎮ病例纳入标准:①符合２０１３年美国心脏基金会及美国心脏协会(ＡＣＣＦ/ＡＨＡ)发布ＳＴＥＭＩ治疗指南中的诊断标准[６]ꎻ②发病至入院<６ｈꎻ③既往无慢性心肌梗死病史ꎬ无贫血病史ꎮ排除标准:①既往行冠状动脉旁路移植术患者ꎻ②合并心脏瓣膜疾病㊁心肌炎㊁急性心包炎㊁急性肺动脉栓塞等疾病患者ꎻ③合并严重肝肾功能不全㊁急慢性感染性疾病㊁恶性肿瘤㊁血液疾病㊁自身免疫疾病患者ꎻ④因冠状动脉痉挛所致的变异型心绞痛ꎬ慢性心功能不全ꎬ左心室射血分数(ＬＶＥＦ)低于４０％的患者ꎮ本研究已经获得我院伦理会批准ꎬ患者及家属知情同意且签署知情同意书ꎮ１.２㊀治疗方法㊀所有患者入院当日给予负荷剂量阿司匹林(３００ｍｇ)＋氯吡格雷(３００ｍｇ)㊁负荷剂量肝素(根据体质量计算ꎬ１００μｇ/ｋｇ)治疗ꎬ经桡动脉路径行冠状动脉造影ꎬ确定梗死相关动脉ꎬ了解病变部位血栓负荷和残余狭窄ꎬ由我科２名具有丰富介入操作经验的主任医师参照血管和支架１ʒ１.１比例的直径置入支架ꎮ次日给予双联抗血小板治疗(阿司匹林１００ｍｇ＋氯吡格雷７５ｍｇ)并维持至术后１年ꎬ同时配合他汀类㊁硝酸酯类㊁抗凝㊁血管紧张素转换酶抑制剂类以及β￣受体阻滞剂药物㊁质子泵抑制剂联合治疗ꎮ６６１.３㊀观察指标㊀统计患者临床资料ꎬ包括性别㊁年龄㊁心血管危险因素(如糖尿病㊁原发性高血压㊁高脂血症㊁吸烟史㊁饮酒史等)ꎻ超声心动图:ＬＶＥＦ㊁左房内径(ＬＡＤ)㊁舒张末期左心室内径(ＬＶＥＤＤ)ꎻ实验室指标:ＯｌｙｍｐｕｓＡＵ２７００型(日本)全自动生化分析仪ꎬ采用酶法检测总胆固醇(ＴＣ)㊁三酰甘油(ＴＧ)ꎬ直接法测量低密度脂蛋白胆固醇(ＬＤＬ￣Ｃ)㊁高密度脂蛋白胆固醇(ＨＤＬ￣Ｃ)水平ꎬ氧化酶法测定空腹血糖(ＦＰＧ)ꎬ电极法测定肌酐(Ｃｒ)水平ꎬ试剂盒购自北京九强生物技术股份有限公司ꎮＲＤＷ检测:患者入院后均采集静脉血２ｍＬ于ＥＤＫＡ抗凝试管中ꎬ３０ｍｉｎ内采用ＢａｙｅｒＡＤＶＩＡ１２０全自动血细胞分析仪进行ＲＤＷ检测ꎮ术前Ｇｅｎｓｉｎｉ评分[７]:以冠状动脉造影结果为依据ꎬ根据冠脉病变部分(左主干计５分ꎬ左前降支或回旋支近段计２.５分ꎬ左前降支中段计１.５分ꎬ左前降支远段计１分ꎬ左回旋支中㊁远段计１分ꎬ右冠状动脉计１分ꎬ小分支计０.５分)和狭窄程度(１％~２５％计１分ꎬ２６％~５０％计２分ꎬ５１％~７５％计４分ꎬ７６％~９０％计８分ꎬ９１％~９９％计１６分ꎬ完全堵塞计３２分)进行评分ꎬ病变部位乘以该部位狭窄程度得分为该部位评分ꎬ多支病变血管取各自评分之和ꎻ术前Ｋｉｌｌｉｐ心功能分级[８]:Ⅰ级为无心衰ꎬⅡ级为轻中度心衰ꎬⅢ级为重度心衰ꎬⅣ级为心源性休克ꎻＰＣＩ手术相关指标:支架数目㊁长度㊁直径㊁支架扩张压力ꎮ患者出院后均定期随访ꎬ随访时间自ＰＣＩ术后至门诊或电话随访患者出院后发生ＭＡＣＥ为研究终点ꎬＭＡＣＥ定义[９]:非致死性心肌梗死㊁再次急性心肌梗死及靶血管再次血运重建㊁需住院治疗的心力衰竭和心源性死亡ꎬ时间周期为１年ꎮ根据是否发生ＭＡＣＥ将患者分为ＭＡＣＥ组和非ＭＡＣＥ组ꎮ１.４㊀ＳＹＮＴＡＸⅡ积分计算㊀ＳＹＮＴＡＸ积分计算方法主要是通过计算机程序得出[１０ꎬ１１]ꎬ自网站ｗｗｗ.ｓｙｎ￣ｔａｘｓｃｏｒｅ.ｃｏｍ获得ＳＹＮＴＡＸ和ＳＹＮＴＡＸⅡ积分计算器ꎬ分别赋予ＳＹＮＴＡＸⅠ积分(解剖ＳＹＮＴＡＸ积分)㊁年龄㊁性别㊁是否发生左主干支病变㊁是否合并慢性阻塞性肺疾病(慢阻肺)㊁是否合并外周血管疾病㊁肌酐清除率㊁ＬＶＥＦ８个因素积分权值ꎬ计算每个因素对病死率的影响分值ꎬ相加即ＳＹＮＴＡＸⅡ积分ꎮ１.５㊀统计学方法㊀采用ＳＰＳＳ２５.０统计软件ꎮ计量资料以ｘʃｓ表示ꎬ符合正态分布数据比较采用独立样本ｔ检验ꎮ计数资料以率(％)表示ꎬ比较采用χ２检验ꎮＣｏｘ风险回归分析随访患者ＭＡＣＥ的危险因素ꎮ采用受试者工作特征(ＲＯＣ)曲线分析ＳＹＮ￣ＴＡＸⅡ积分㊁ＲＤＷ对ＡＭＩ患者ＰＣＩ术后ＭＡＣＥ的预测价值ꎮＰ<０.０５为差异有统计学意义ꎮ２　结果２.１㊀ＭＡＣＥ和非ＭＡＣＥ患者临床资料比较㊀３３９例患者ＰＣＩ术后发生ＭＡＣＥ共８１例(ＭＡＣＥ组)ꎬ包括心源性死亡２６例(３２.１０％)㊁非致死性心肌梗死２９例(３５.８０％)㊁再次血运重建１９例(２３.４６％)㊁需住院治疗的心力衰竭７例(８.６４％)ꎮ未发生ＭＡＣＥ共２５８例(非ＭＡＣＥ组)ꎮＭＡＣＥ组男性占比６１.２０％(５２/８１)ꎬ原发性高血压占比５３.０９％(４３/８１)ꎬ糖尿病占比５０.６２％(４１/８１)ꎬ高脂血症占比４８.１５％(３９/８１)ꎬ有吸烟史占比４３.２１％(３５/８１)ꎬ有饮酒史占比４８.１５％(３９/８１)ꎬ梗死相关动脉左前降支占比５０.６２％(４１/８１)ꎬ左回旋支占比２７.１６％(２２/８１)ꎬ右冠状动脉占比２２.２２％(１８/８１)ꎬ左主干支病变占比１９.７５％(１６/８１)ꎬ合并慢阻肺占比１４.８１％(１２/８１)ꎬ合并外周血管疾病占比７.４１％(６/８１)ꎬ术前Ｋｉｌｌｉｐ心功能分级Ⅱ级以上占比４４.４４％(３６/８１)ꎮ非ＭＡＣＥ组男性占比６１.６３％(１５９/２５８)ꎬ原发性高血压占比４８.８４％(１２６/２５８)ꎬ糖尿病占比５１.１６％(１３２/２５８)ꎬ高脂血症占比５０.３９％(１３０/２５８)ꎬ有吸烟史占比３６.８２％(９５/２５８)ꎬ有饮酒史占比３７.２１％(９６/２５８)ꎬ梗死相关动脉左前降支占比５６.９８％(１４７/２５８)ꎬ左回旋支占比２６.７４％(６９/２５８)ꎬ右冠状动脉占比１６.２８％(４２/２５８)ꎬ左主干支病变占比４.２６％(１１/２５８)ꎬ合并慢阻肺占比３.４９％(９/２５８)ꎬ合并外周血管疾病占比１.１６％(３/２５８)ꎬ术前Ｋｉｌｌｉｐ心功能分级Ⅱ级以上占比３１.４０％(８１/２５８)ꎮＭＡＣＥ组和非ＭＡＣＥ组年龄㊁性别㊁高血压史㊁高脂血症㊁糖尿病史㊁吸烟史㊁饮酒史㊁梗死相关动脉比较差异无统计学意义(Ｐ均>０.０５)ꎮＭＡＣＥ组和非ＭＡＣＥ组患者Ｃｒ㊁ＴＧ㊁ＴＣ㊁ＨＤＬ￣Ｃ㊁ＬＤＬ￣Ｃ㊁ＦＰＧ㊁ＬＡＤ和ＬＶＥＤＤ指标比较差异无统计学意义(Ｐ均>０.０５)ꎮＭＡＣＥ组ＬＶＥＦ低于非ＭＡＣＥ组(Ｐ<０.０５)ꎬ左主干支病变㊁合并慢阻肺㊁合并外周血管疾病比例㊁术前Ｇｅｎｓｉｎｉ评分㊁术前Ｋｉｌｌｉｐ心功能分级Ⅱ级以上比例㊁植入支架数目㊁支架长度㊁ＲＤＷ㊁ＳＹＮＴＡＸⅡ积分高于非ＭＡＣＥ组(Ｐ均<０.０５)ꎬ支架直径㊁支架扩张压力低于非ＭＡＣＥ组(Ｐ均<０.０５)ꎬ见表１ꎮ２.２㊀ＰＣＩ术后发生ＭＡＣＥ的因素分析㊀以ＳＴＥＭＩ患者ＰＣＩ术后发生ＭＡＣＥ时间为因变量ꎬＬＶＥＦ㊁术前Ｋｉｌｌｉｐ心功能分级Ⅱ级以上㊁术前Ｇｅｎｓｉｎｉ评分㊁植入支架数目㊁支架长度㊁支架直径㊁支架扩张压力㊁ＲＤＷ㊁ＳＹＮＴＡＸⅡ积分为自变量ꎬ建立Ｃｏｘ风险回归模型ꎬ校正年龄㊁性别混杂因素ꎬ最终ＲＤＷ㊁ＳＹＮ￣７６ＴＡＸⅡ积分㊁ＬＶＥＦ㊁支架长度㊁支架扩张压力与ＭＡＣＥ的发生独立相关ꎬ见表２ꎮ表１㊀ＭＡＣＥ和非ＭＡＣＥ患者临床资料比较( ｘʃｓ)指标ＭＡＣＥ组(ｎ＝８１)非ＭＡＣＥ组(ｎ＝２５８)ｔＰ年龄(岁)５４.３３ʃ９.０３５４.８１ʃ１０.０８０.３８３０.７０２术前Ｇｅｎｓｉｎｉ评分(分)９５.２５ʃ１３.２１７２.５１ʃ１０.２４１６.２０５０.０００Ｃｒ(μｍｏｌ/Ｌ)１０３.４４ʃ１０.８５１０４.７０ʃ１０.５２０.９９９０.３５１ＴＧ(ｍｍｏｌ/Ｌ)１.７４ʃ０.３５１.７８ʃ０.３６０.８７８０.３８１ＴＣ(ｍｍｏｌ/Ｌ)４.８７ʃ１.９９４.６２ʃ１.０４１.４７８０.１４１ＬＤＬ￣Ｃ(ｍｍｏｌ/Ｌ)２.６５ʃ０.６８２.６３ʃ０.５７０.２６３０.７９３ＨＤＬ￣Ｃ(ｍｍｏｌ/Ｌ)０.９９ʃ０.２２１.０１ʃ０.３１０.２３９０.５９０ＦＰＧ(ｍｍｏｌ/Ｌ)９.１２ʃ２.６４９.２０ʃ２.７１０.２３３０.８１６ＬＡＤ(ｃｍ)３.６７ʃ０.３５３.５８ʃ０.５６１.３６４０.１７３ＬＶＥＤＤ(ｃｍ)５.６９ʃ１.４９５.６６ʃ１.４００.１６６０.８６９ＬＶＥＦ(％)５３.４８ʃ７.１０４３.２９ʃ８.０２１０.２４２０.０００支架数目(枚)１.７６ʃ０.６９１.２１ʃ０.３２９.８７８０.０００支架长度(ｍｍ)３３.５１ʃ６.６２２６.６２ʃ４.１５１１.１５００.０００支架直径(ｍｍ)２.８１ʃ０.８５３.２３ʃ０.７２４.３８００.０００支架扩张压力(ａｔｍ)１３.１０ʃ４.８５１８.１５ʃ６.５２６.４３２０.０００ＲＤＷ(％)１２.３５ʃ３.２６１３.９６ʃ３.３９３.７６３０.０００ＳＹＮＴＡＸⅡ积分(分)３３.２６ʃ６.５１２３.１５ʃ４.０９１６.６１８０.０００表２㊀ＰＣＩ术后发生ＭＡＣＥ的Ｃｏｘ回归分析因素βＳＥＷａｌｄχ２ＲＲ９５％ＣＩＰＲＤＷ０.８１２０.２６５９.３８９２.２５２１.３５２~１２.５９１０.００５ＳＹＮＴＡＸⅡ积分０.９２６０.２４１１４.７６３２.５２４１.０３５~１１.５９４０.０００ＬＶＥＦ０.６８１０.２０５１１.０３５１.９７６１.３５２~８.５４２０.００３支架长度０.５９８０.１９５９.４０４１.８１８１.０３５~６.５９４０.０１９支架扩张压力－０.５１６０.１７１９.１０６１.６７５１.１２５~５.３８１０.０２２２.３㊀ＲＤＷ㊁ＳＹＮＴＡＸⅡ积分对ＰＣＩ术后ＭＡＣＥ的预测价值㊀ＲＯＣ曲线分析ＲＤＷ㊁ＳＹＮＴＡＸⅡ积分㊁ＲＤＷ联合ＳＹＮＴＡＸⅡ积分预测ＳＴＥＭＩ患者ＰＣＩ术后发生ＭＡＣＥ的曲线下面积(ＡＵＣ)分别为０.７１０㊁０.７２９㊁０.８８４ꎬＲＤＷ联合ＳＹＮＴＡＸⅡ积分的ＡＵＣ大于ＲＤＷ㊁ＳＹＮＴＡＸⅡ积分单独指标(Ｐ均<０.０５)ꎮＲＤＷ㊁ＳＹＮＴＡＸⅡ积分㊁ＲＤＷ联合ＳＹＮＴＡＸⅡ积分预测ＳＴＥＭＩ患者ＰＣＩ术后发生ＭＡＣＥ的效能见表３ꎮ表３㊀ＲＤＷ㊁ＳＹＮＴＡＸⅡ积分预测ＳＴＥＭＩ患者ＰＣＩ术后发生ＭＡＣＥ的效能因素最佳阈值ＡＵＣ９５％ＣＩ灵敏度特异度ＲＤＷ１３.２３％０.７１００.６５２~０.７６９６４.２０％６６.６７％ＳＹＮＴＡＸⅡ积分２７.５分０.７２９０.６６３~０.７９５５９.２６％６４.７３％ＲＤＷ联合ＳＹＮＴＡＸⅡ积分/０.８８４０.８４９~０.９１８７７.７８％７５.５８％３㊀讨论㊀㊀ＰＣＩ是ＡＭＩ治疗指南中推荐的ＳＴＭＥＩ患者发病１２ｈ内的治疗方法[１２]ꎬ由于ＰＣＩ术后冠状动脉粥样硬化性心脏病危险因素仍存在ꎬ因此仍有较高ＭＡＣＥ发生风险ꎮ本研究观察到ＰＣＩ术后发生ＭＡＣＥ患者左心室射血功能偏低ꎬ冠脉病变程度较重㊁Ｋｉｌｌｉｐ心功能分级级别偏高ꎬＰＣＩ手术植入支架数目较多ꎬ长度较长ꎬ支架直径和扩张压力较低ꎬ说明ＰＣＩ术后发生ＭＡＣＥ的患者病情较重ꎬ存在明显的心功能低下[１３]ꎮ目前用于ＭＡＣＥ的预后评估方法有ＴＩＭＩ积分㊁Ｚｗｏｌｌｅ评分和ＧＲＡＣＥ风险评分[１４]ꎬＧＲＡＣＥ评分适用于急性冠脉综合征患者ꎬ可预测其发病３０ｄ㊁１年的心血管事件ꎮＴＩＭＩ积分㊁Ｚｗｏｌｌｅ评分可用于ＳＴＭＥＩ患者ＰＣＩ术后ＭＡＣＥ事件的预测ꎬ但预测价值并不理想ꎮ㊀㊀ＳＹＮＴＡＸ积分是首个针对ＰＣＩ不良心脑血管事件发生评估的积分系统ꎬ精确度高ꎬ涵盖了病变血管数目㊁冠脉优势型㊁病变特征㊁血管病变程度等[１５]ꎬＳＹＮＴＡＸⅡ积分系统是ＳＹＮＴＡＸ积分系统的改良版ꎬ将患者的危险因素融入改良版本中ꎬ临床应用价值更高ꎮＸｕ等[１６]回顾性分析行ＰＣＩ的左主干病变患者４年病死率ꎬ发现ＳＹＮＴＡＸⅡ积分是冠状动脉左主干病变患者ＰＣＩ术后死亡的独立预测因素ꎮ目前国内ＳＹＮＴＡＸⅡ积分在国内的应用较为少见ꎬ冉晨光等[１７]报道显示ꎬＳＹＮＴＡＸⅡ积分越高ꎬＡＭＩ患者ＰＣＩ术后无复流㊁不良心脑血管事件发生率越高ꎬ但该研究仅局限于住院期间不良心脑血管事件ꎬ缺乏长期随访ꎬＳＹＮＴＡＸⅡ积分对我国冠状动脉粥样硬化性心脏病患者长期预后的预测价值尚不清楚ꎮ本研究以我院收治的３３９例ＳＴＭＥＩ患者为研究对象ꎬ患者均追踪至ＰＣＩ术后１年ꎬ发现ＭＡＣＥ组ＳＹＮＴＡＸⅡ积分高于非ＭＡＣＥ组ꎬ经Ｃｏｘ风险回归分析证实ꎬＳＹＮＴＡＸⅡ积分与ＳＴＭＥＩ患者ＰＣＩ术后ＭＡＣＥ的发生独立相关ꎬ与Ｒｙａｎ等[１８]报道结果８６一致ꎮ㊀㊀炎性反应在冠脉粥样硬化发生发展过程中发挥重要作用ꎬ大量炎性因子可增加红细胞异质性ꎬ抑制骨髓造血功能ꎬ导致促红细胞生长素合成减少ꎬ铁代谢紊乱ꎬ骨髓生成大量幼稚红细胞ꎬ导致外周血ＲＤＷ增高ꎬＲＤＷ升高可引起红细胞变形性降低ꎬ进而引起微循环障碍ꎬ导致机体缺氧ꎬ加快冠状动脉粥样硬化进程ꎮＲＤＷ升高是冠状动脉粥样硬化性心脏病独立危险因素ꎬ其水平与冠状动脉病变程度密切相关ꎮ近年来ＲＤＷ作为冠状动脉粥样硬化性心脏病临床预测指标ꎬ在冠状动脉粥样硬化性心脏病危险分层㊁指导临床治疗㊁预后判断中均有重要价值ꎮ张冬花等[１９]报道显示ꎬＲＤＷ是冠状动脉粥样硬化性心脏病ＰＣＩ术后６~１２个月支架内再狭窄的独立预测因子ꎬＣｈａｎｇ等[２０]发现ꎬＲＤＷ是预测ＰＣＩ术后ＭＡＣＥ的独立预测因子ꎮ本研究结果显示ꎬＲＤＷ在ＳＴＭＥＩ患者ＰＣＩ术后发生ＭＡＣＥ患者和未发生ＭＡＣＥ患者间存在统计学差异ꎬＣｏｘ风险回归分析结果显示ꎬＲＤＷ是ＳＴＭＥＩ患者ＰＣＩ术后发生ＭＡＣＥ的独立预测因子ꎬ可提示其远期临床结局ꎮ㊀㊀本研究ＲＯＣ曲线分析ＲＤＷ联合ＳＹＮＴＡＸⅡ积分预测ＳＴＥＭＩ患者ＰＣＩ术后发生ＭＡＣＥ的ＡＵＣ为０.８８４ꎬ均大于ＲＤＷ㊁ＳＹＮＴＡＸⅡ积分单独指标预测效能ꎬ提示ＲＤＷ检测和ＳＹＮＴＡＸⅡ积分评估联合可弥补单项指标灵敏度和特异度偏低的弊端ꎬ实现优势互补ꎬ提高预测效能ꎮＲＤＷ结果容易获得ꎬ检测方便快捷ꎬ颇具应用前景ꎬＳＹＮＴＡＸⅡ积分在临床尚未大范围推广应用ꎬ其预测ＰＣＩ术后ＭＡＣＥ价值尚待考证ꎮ本研究的不足之处在于未动态监测ＲＤＷ水平和ＳＹＮＴＡＸⅡ积分ꎬ因此其预测ＳＴＥＭＩ患者ＰＣＩ术后发生ＭＡＣＥ的最佳时间窗尚待进一步研究探讨ꎮ㊀㊀综上所述ꎬＲＤＷ㊁ＳＹＮＴＡＸⅡ积分是ＳＴＥＭＩ患者ＰＣＩ术后ＭＡＣＥ发生的独立预测因子ꎬＲＤＷ联合ＳＹＮＴＡＸⅡ积分可提高对ＭＡＣＥ的预测效能ꎬ有助于ＳＴＥＭＩ患者ＰＣＩ术后远期预后预测ꎮ参考文献:[１]张克良ꎬ刘晓堃.重组人脑利钠肽对行补救ＰＣＩ术的急性前壁心肌梗死患者预后的影响[Ｊ].医学研究杂志ꎬ２０１６ꎬ４５(７):１６３￣１６６.[２]王翎羽ꎬ马国娣ꎬ林平ꎬ等.急性冠脉综合征患者ＰＣＩ术后心脏不良事件发生情况[Ｊ].中华现代护理杂志ꎬ２０１６ꎬ２２(３０):４３１１￣４３１５.[３]ＭａｇｒｉＣＪꎬＴｉａｎＴＸꎬＣａｍｉｌｌｅｒｉＬꎬｅｔａｌ.Ｒｅｄｂｌｏｏｄｃｅｌｌｄｉｓｔｒｉｂｕｔｉｏｎｗｉｄｔｈａｎｄｍｙｏｃａｒｄｉａｌｓｃａｒｂｕｒｄｅｎｉｎｃｏｒｏｎａｒｙａｒｔｅｒｙｄｉｓｅａｓｅ[Ｊ].ＰｏｓｔｇｒａｄＭｅｄＪꎬ２０１７ꎬ９３(１１０４):６０７￣６１２.[４]ＱｉａｎＨꎬＬｕｏＺꎬＸｉａｏＣꎬｅｔａｌ.Ｒｅｄｃｅｌｌｄｉｓｔｒｉｂｕｔｉｏｎｗｉｄｔｈｉｎｃｏｒｏ￣ｎａｒｙｈｅａｒｔｄｉｓｅａｓｅ:ｐｒｅｄｉｃｔｉｏｎｏｆｒｅｓｔｅｎｏｓｉｓａｎｄｉｔｓｒｅｌａｔｉｏｎｓｈｉｐｗｉｔｈｉｎｆｌａｍｍａｔｏｒｙｍａｒｋｅｒｓａｎｄｌｉｐｉｄｓ[Ｊ].ＰｏｓｔｇｒａｄＭｅｄＪꎬ２０１８ꎬ９４(１１１５):４８９￣４９４.[５]高阅春ꎬ玉献鹏ꎬ何继强ꎬ等.ＳＹＮＴＡＸ积分对经皮冠状动脉介入治疗的临床疗效与预测作用研究[Ｊ].心肺血管病杂志ꎬ２０１４ꎬ３３(２):２０９￣２１３.[６]杨文慧ꎬ杨莉ꎬ何燕ꎬ等.外周动脉粥样硬化与冠状动脉病变Ｇｅｎｓｉｎｉ评分的相关性[Ｊ].中国老年学杂志ꎬ２０１５ꎬ３５(９):２３９１￣２３９３.[７]ＭｅｌｌｏＢＨꎬＯｌｉｖｅｉｒａＧＢꎬＲａｍｏｓＲＦꎬｅｔａｌ.ＶａｌｉｄａｔｉｏｎｏｆｔｈｅＫｉｌｌｉｐ￣Ｋｉｍｂａｌｌｃｌａｓｓｉｆｉｃａｔｉｏｎａｎｄｌａｔｅｍｏｒｔａｌｉｔｙａｆｔｅｒａｃｕｔｅｍｙｏｃａｒｄｉａｌｉｎ￣ｆａｒｃｔｉｏｎ[Ｊ].ＡｒｑＢｒａｓＣａｒｄｉｏｌꎬ２０１４ꎬ１０３(２):１０７￣１１７. [８]ＰａｌｍｅｒｉｎｉＴꎬＢｉｏｎｄｉｚｏｃｃａｉＧꎬＤｅｌｌａＲＤꎬｅｔａｌ.Ｃｌｉｎｉｃａｌｏｕｔｃｏｍｅｓｗｉｔｈｄｒｕｇ￣ｅｌｕｔｉｎｇａｎｄｂａｒｅ￣ｍｅｔａｌｓｔｅｎｔｓｉｎｐａｔｉｅｎｔｓｗｉｔｈＳＴ￣ｓｅｇｍｅｎｔｅｌｅｖａｔｉｏｎｍｙｏｃａｒｄｉａｌｉｎｆａｒｃｔｉｏｎ:ｅｖｉｄｅｎｃｅｆｒｏｍａｃｏｍｐｒｅｈｅｎｓｉｖｅｎｅｔ￣ｗｏｒｋｍｅｔａ￣ａｎａｌｙｓｉｓ[Ｊ].ＪＡｍＣｏｌｌＣａｒｄｉｏｌꎬ２０１３ꎬ６２(６):４９６￣５０４.[９]丛占春ꎬ赵昕ꎬ荆全民.急性ＳＴ段抬高型心肌梗死患者靶血管非梗死相关病变处理策略选择及预后[Ｊ].中国介入心脏病学杂志ꎬ２０１８ꎬ２６(５):２４７￣２５４.[１０]ＢｒｉｅｄｉｓＫꎬＰｒａｎｅｖｉｃｉｕｓＲꎬＺａｐｕｓｔａｓＮꎬｅｔａｌ.ＣＲＴ￣１００.７２ＳｙｎｔａｘＳｃｏｒｅ:ＰｒｅｄｉｃｔｉｎｇＯｕｔｃｏｍｅｓＡｆｔｅｒＰＣＩＦｏｒＣＴＯ[Ｊ].ＪａｃｃＣａｒｄｉＩｎ￣ｔｅｒꎬ２０１７ꎬ１０(３):Ｓ２３.[１１]尤建鹏.ＳＹＮＴＡＸ￣Ⅱ积分在急性心肌梗死患者ＰＣＩ预后预测中的应用[Ｊ].检验医学与临床ꎬ２０１７ꎬ１４(７):９７６￣９７８. [１２]王飞ꎬ李灵芝ꎬ朱士俊ꎬ等.急诊ＰＣＩ与择期ＰＣＩ治疗急性心肌梗死的临床对比分析[Ｊ].中国循证心血管医学杂志ꎬ２０１６ꎬ８(７):８６２￣８６４.[１３]马云飞ꎬ王洪娟ꎬ王俊峰ꎬ等.急性心肌梗死患者ＰＣＩ术后的心脏康复现状及进展[Ｊ].中国老年学ꎬ２０１７ꎬ３７(７):１７７８￣１７７９. [１４]廖火城ꎬ钟思干ꎬ刘凌ꎬ等.冠心病预测评分系统的建立及评价[Ｊ].山东医药ꎬ２０１６ꎬ５６(３１):５８￣６０.[１５]ＢａｃｈＲＧ.ＳＹＮＴＡＸｓｃｏｒｅⅡｐｒｅｄｉｃｔｅｄｍｏｒｔａｌｉｔｙａｆｔｅｒＰＣＩｏｒＣＡＢＧｉｎｃｏｍｐｌｅｘＣＡＤｂｅｔｔｅｒｔｈａｎＳＹＮＴＡＸｓｃｏｒｅ[Ｊ].ＡｎＩｎｔＭｅｄꎬ２０１３ꎬ１５９(２):ＪＣ５.[１６]ＸｕＢꎬＧéｎéｒｅｕｘＰꎬＹａｎｇＹꎬｅｔａｌ.Ｖａｌｉｄａｔｉｏｎａｎｄｃｏｍｐａｒｉｓｏｎｏｆｔｈｅｌｏｎｇ￣ｔｅｒｍｐｒｏｇｎｏｓｔｉｃｃａｐａｂｉｌｉｔｙｏｆｔｈｅＳＹＮＴＡＸＳｃｏｒｅ￣ⅡＡ￣ｍｏｎｇ１ꎬ５２８ｃｏｎｓｅｃｕｔｉｖｅｐａｔｉｅｎｔｓｗｈｏｕｎｄｅｒｗｅｎｔｌｅｆｔｍａｉｎｐｅｒｃｕｔａ￣ｎｅｏｕｓｃｏｒｏｎａｒｙｉｎｔｅｒｖｅｎｔｉｏｎ[Ｊ].ＪＡｍＣｏｌｌＣａｒｄｉｏｌＩｎｔｖꎬ２０１４ꎬ７(１０):１１２８￣１１３７.[１７]冉晨光ꎬ张玉辉ꎬ王晨ꎬ等.ＳＹＮＴＡＸＳｓｃｏｒｅⅡ积分在急性心肌梗死患者急诊直接ＰＣＩ中的应用价值[Ｊ].海南医学院院报ꎬ２０１６ꎬ２２(１９):２２６６￣２２６８.[１８]ＲｙａｎＮꎬＮｏｍｂｅｌａ￣ＦｒａｎｃｏＬꎬＪｉｍéｎｅｚ￣ＱｕｅｖｅｄｏＰꎬｅｔａｌ.ＴｈｅＶａｌｕｅｏｆｔｈｅＳＹＮＴＡＸＳｃｏｒｅⅡｉｎＰｒｅｄｉｃｔｉｎｇＣｌｉｎｉｃａｌＯｕｔｃｏｍｅｓｉｎＰａ￣ｔｉｅｎｔｓＵｎｄｅｒｇｏｉｎｇＴｒａｎｓｃａｔｈｅｔｅｒＡｏｒｔｉｃＶａｌｖｅＩｍｐｌａｎｔａｔｉｏｎ[Ｊ].ＲｅｖＥｓｐＣａｒｄｉｏｌ(ＥｎｇｌＥｄ)ꎬ２０１８ꎬ７１(８):６２８￣６３７.[１９]张冬花ꎬ李志忠ꎬ张京梅ꎬ等.红细胞分布宽度与冠心病患者经皮冠状动脉介入治疗术后支架内再狭窄的相关性研究[Ｊ].中国综合临床ꎬ２０１７ꎬ３３(１２):１０８４￣１０８８.[２０]ＣｈａｎｇＸＷꎬＺｈａｎｇＳＹꎬＷａｎｇＨꎬｅｔａｌ.Ｃｏｍｂｉｎｅｄｖａｌｕｅｏｆｒｅｄｂｌｏｏｄｃｅｌｌｄｉｓｔｒｉｂｕｔｉｏｎｗｉｄｔｈａｎｄｇｌｏｂａｌｒｅｇｉｓｔｒｙｏｆａｃｕｔｅｃｏｒｏｎａｒｙｅ￣ｖｅｎｔｓｒｉｓｋｓｃｏｒｅｏｎｐｒｅｄｉｃｔｉｎｇｌｏｎｇ￣ｔｅｒｍｍａｊｏｒａｄｖｅｒｓｅｅａｒｄｉｃａｅ￣ｖｅｎｔｓｉｎＳＴＥＭＩｐａｔｉｅｎｔｓｕｎｄｅｒｇｏｉｎｇｐｒｉｍａｒｙＰＣＩ[Ｊ].Ｏｎｃｏｔａｒｇｅｔꎬ２０１８ꎬ９(１７):１３９７１￣１３９８０.(收稿日期:２０１９￣０８￣３１)９６。

残存SYNTAX评分对311例冠心病PCI患者长期预后评价

㊃论著㊃基金项目:内蒙古自治区科技计划项目(20140149)通信作者:韩雅君,E m a i l :j u n ya h a n 123456@163.c o m 残存S Y N T A X 评分对311例冠心病P C I 患者长期预后评价韩雅君,赵平,朱慧,赵炜祎,王燕芳,刘志宏(内蒙古自治区人民医院老年心血管内科,内蒙古呼和浩特010017) 摘要:目的评价残存S Y N T A X 评分对冠心病经皮冠状动脉介入治疗(p e r c u t a n o u sc o r o n a r y in t e r v e n t i o n ,P C I )患者长期预后的预测能力㊂方法连续入选2013年1月至2014年5月于内蒙古自治区人民医院心内科一病区住院冠心病并行P C I 患者311例,收集性别㊁年龄㊁临床诊断㊁血脂㊁肾功能等临床资料,进行S Y N T A X 评分和残存S Y N Y T A X 评分,同时进行2~4年临床随访,随访不良心脑血管事件(MA C C E ),包括全因死亡㊁卒中㊁血运重建㊁心力衰竭㊂结果 311例患者发生MA C C E48例,其中全因死亡14例;再次血运重建23例;缺血性卒中9例;心力衰竭2例㊂MA C C E 组与无MA C C E 组比较年龄大(64.13ʃ8.45岁v s60.79ʃ10.12岁,P =0.03)㊁糖尿病患者比例高(39.58%v s 18.63%,P =0.001)㊁S Y N T A X 评分高(15.16ʃ6.53v s 12.94ʃ7.44,P =0.017)和残存S Y N T A X 评分高(7.52ʃ6.54v s 4.23ʃ5.50,P =0.000)㊂S Y N T A X 评分㊁残存S Y N T A X 评分㊁目测冠状动脉病变预测终点事件的曲线下面积分别为0.608(P =0.018)㊁0.665(P =0.000)㊁0.668(P =0.000)㊂完全血运重建组与不完全血运重建组MA C C E 发生率分别为5.98%和20.42%(P =0.003),两组再次血运重建率分别为0.85%和12.37%(P =0.000)㊂糖尿病患者和非糖尿病患者S Y N T A X 评分为15.09ʃ7.69和12.78ʃ7.17(P =0.026),残存S Y N T A X 评分为6.15ʃ6.32和4.34ʃ5.57(P =0.016)㊂糖尿病患者和非糖尿病患者M A C C E 发生率分别为27.9%和11.8%(P =0.001),再次血运重建率分别为19.1%和4.9%(P =0.000)㊂结论 ①冠心病P C I 患者完全血运重建优于不完全血运重建,残存冠状动脉病变越多MA C C E 发生率越高㊂②残存S Y N T A X 评分㊁S Y N T A X 评分和冠状动脉病变均能预测长期预后㊂③糖尿病患者冠状动脉病变程度重,MA C C E 发生率高,主要原因是再次血运重建㊂关键词:冠心病;残存S Y N T A X 评分;再次血运重建;主要不良心脑血管事件中图分类号:R 541.4 文献标志码:A 文章编号:1004-583X (2018)08-0670-05d o i :10.3969/j.i s s n .1004-583X.2018.08.006E v a l u a t i o n t o l o n g -t e r m p r o g n o s i s b y re s i d u a l S Y N T A Xs c o r e t o 311p a t i e n t s w i t h p e r c u t a n e o u s c o r o n a r y a r t e r yi n t e r v e n t i o n H a nY a j u n ,Z h a oP i n g ,Z h uH u i ,Z h a o W e i y i ,W a n g Y a n f a n g ,L i uZ h i h o n gD e p a r t m e n t o fE l d e r l y C a r d i o l o g y o f I n n e rM o n go l i aA u t o n o m o u s R e g i o nP e o p l e sH o s pi t a l ,H o h h o t 010017,C h i n a C o r r e s p o n d i n g a u t h o r :H a nY a j u n ,E m a i l :j u n ya h a n 123456@163.c o m A B S T R A C T :Ob j ec t i v e T oe v a l u a t e t h ea b i l i t y o f r e s id u a lS Y N T A Xt o p re d i c t l o n g -t e r m p r o g n o s i s i n p a t i e n t s w i t hc o r o n a r y a r t e r y d i s e a s e .M e t h o d s At o t a l of 311p a t i e n t sw i t h c o r o n a r y a r t e r y d i s e a s e u n d e rg o i n g c o r o n a r y a r t e r yd i se a s ew e r ee n r o l l e di nt h eD e p a r t m e n to fC a r d i o l o g y ,I n n e r M o n g o l i a A u t o n o m o u sR e g i o n H o s p i t a lf r o m J a n u a r y2013t o M a y 2014.C l i n i c a l d a t a i n c l u d i n g s e x ,a g e ,c l i n i c a l d i a g n o s i s ,b l o o d l i pi da n dr e n a l f u n c t i o nw e r ec o l l e c t e d .M a i n a d v e r s e c a r d i o v a s c u l a r a n d c e r e b r o v a s c u l a r e v e n t s (MA C C E ),i n c l u d i n g a l l -c a u s ede a t h ,s t r o k e ,r e p e a t r e v a s c u l a r i z a t i o n ,a n dh e a r tf a i l u r e ,w e r e f o l l o w e du p fo r2t o4y e a r s .R e s u l t s O f t h e311p a t i e n t s ,t h e r ew e r e48c a s e s o fMA C C E ,i n c l u d i n g 14c a s e s o f a l l c a u s e d e a t h ,23c a s e s o f r e p e a t r e v a s c u l a r i z a t i o n ,9c a s e s o f i s c h e m i c s t r o k e a n d 2c a s e s o f h e a r t f a i l u r e .MA C C E g r o u p w a s o l d e r t h a nn o n -MA C C E g r o u p (64.13ʃ8.45v s 60.79ʃ10.12,P =0.03),a n d t h er a t i oo f p a t i e n t sw i t hd i a b e t e sm e l l i t u sw a sh i g h e r t h a nt h a to f t h en o n -MA C C E g r o u p (39.58%v s 18.63%,P =0.001),S Y N T A Xs c o r e s (15.16ʃ6.53a n d 12.94ʃ7.44),a n d r e s i d u a l S Y N T A Xs c o r e s (7.52ʃ6.54a n d 4.23ʃ5.50,P =0.000)w e r e s i g n i f i c a n t l y h i g h e r i nMA C C E g r o u p t h a n t h o s ew i t h o u tMA C C E g r o u p .T h e a r e a u n d e r t h e c u r v e f o r p r e d i c t i n g t h e e n d p o i n t e v e n t s a b o u t S Y N T A Xs c o r e ,r e s i d u a l S Y N T A Xs c o r e ,v i s u a l i z e d c o r o n a r ya r t e r y d i s e a s ew e r e0.608(P =0.018),0.665(P =0.000),0.668(P =0.000)r e s p e c t i v e l y .T h ei n c i d e n c eo f MA C C Ew a s 5.98%a n d20.42%i n c o m p l e t e r e v a s c u l a r i z a t i o n g r o u p a n d i n c o m p l e t e r e v a s c u l a r i z a t i o n g r o u p,w i t hP b e i n g 0.003.T h e r e v a s c u l a r i z a t i o nr a t e so f t h et w o g r o u p sw e r e0.85%a n d12.37%,r e s p e c t i v e l y (P =0.000).T h e S Y N T A Xs c o r e s f o r p a t i e n t sw i t hd i a b e t e sm e l l i t u s a n dn o n -d i a be t i cw e r e 15.09ʃ7.69a n d 12.78ʃ7.17,P =0.026,㊃076㊃‘临床荟萃“ 2018年8月5日第33卷第8期 C l i n i c a l F o c u s ,A u gu s t 5,2018,V o l 33,N o .8Copyright ©博看网. All Rights Reserved.a n d t h e r e s i d u a l S Y N T A Xs c o r e sw e r e6.15ʃ6.32a n d4.34ʃ5.57,P=0.016.T h e i n c i d e n c e o fMA C C E i n d i ab e t ic sa n dn o n-d i ab e t ic p a t i e n t sw a s27.9%a n d11.8%(P=0.001),a nd t he r e p e a t r e v a s c u l a r i z a t i o n r a t e sw e r e19.1%a n d4.9%,r e s p e c t i v e l y(P=0.000).C o n c l u s i o n①T h ec o m p l e t er e v a s c u l a r i z a t i o no f p a t i e n t s w i t hc o r o n a r y h e a r td i se a s e i s s u p e r i o r t o i n c o m p l e t e r e v a s c u l a r i z a t i o n,a n d t h em o r e l e s i o n s t h e r e s i d u a l c o r o n a r y a r t e r y h a s,t h e h i g h e r t h e i n c i d e n c e of MA C C Ei s.②R e s i d u a lS Y N T A X s c o r e,S Y N T A X s c o r ea n dv i s u a l i z e dc o r o n a r y a r t e r y d i s e a s ec a n p r e d i c t l o n g-t e r m p r og n o s i s.③Th e d e g r e e o f c o r o n a r y a r t e r y di s e a s e i n p a t i e n t sw i t hd i a b e t e s i s h e a v y,a n d t h em a i n r e a s o n f o r t h eh i g h i n c i d e n c e o fMA C C E i s r e v a s c u l a r i z a t i o n.K E Y W O R D S:c o r o n a r y d i s e a s e;r e s i d u a l S Y N T A Xs c o r e;r e p e a t r e v a s c u l a r i z a t i o n;M a i na d v e r s e c a r d i o v a s c u l a r a n d c e r e b r o v a s c u l a r e v e n t s冠心病多支病变患者血运重建方式目前仍是争议的话题㊂多项研究表明完全血运重建患者不良心脑血管事件(m a i n a d v e r s e c a r d i o v a s c u l a r a n d c e r e b r o v a s c u l a r e v e n t s,MA C C E)发生率低于不完全血运重建㊂N a g a r a j a等[1]发表一篇荟萃分析,分析了38项关于多支病变血运重建研究,包括156240例患者,结果完全血运重建患者的死亡㊁心肌梗死和不良心脏事件明显低于不完全血运重建患者㊂而临床实践中多种因素包括患者的临床状况㊁病变特征㊁经皮冠状动脉介入治疗(p e r c u t a n o u s c o r o n a r y i n t e r v e n t i o n,P C I)失败㊁医生和患者的意愿等导致不完全血运重建㊂在E R A C I I V研究中仅对重度狭窄病变进行P C I治疗,随访2年结果MA C C E死亡/心肌梗死/中风的发生率并不高(3.9%),血运重建率4%,而未干预的中度狭窄病变的靶血管重建率仅为1.3%[2]㊂在F AM E研究中血流分数储备(f r a c t i o n a l-f l o wr e s e r v e,F F R)指导功能性完全血运重建随访中,无缺血的冠状动脉病变并不影响预后,功能性血运重建更优于解剖上血运重建[3],因此对于多支血管病变血运重建方式孰优孰劣仍不确定,通过对311例冠心病行P C I患者进行3年临床随访,观察不良心脑血管事件,进一步评价发生MA C C E与临床危险因素和解剖病变的相关性,同时通过残存S Y N T A X评分评价完全和不完全血运重建与MA C C E的相关性㊂1资料与方法1.1病例选择2013年1月至2014年5月我院心内科一病区进行P C I治疗冠心病患者311例,男226例,女85例,平均年龄(61.31ʃ9.95)岁㊂合并高血压164例;糖尿病68例;卒中史25例;临床诊断稳定性冠心病3例,不稳定性冠心病159例,急性心肌梗死149例;单支病变119例,双支病变109例,3支病变83例㊂1.2临床资料收集收集患者信息,包括年龄㊁性别㊁体重㊁肾功能㊁左心室射血分数㊁外周血管疾病㊁慢性阻塞性肺疾病(C O P D)病史㊁既往手术史㊁合并高血压㊁合并糖尿病等㊂收集介入光盘,签署患者随访知情同意书㊂1.3冠状动脉病变分析 ①目测冠状动脉病变:根据冠状动脉造影结果3支血管每1支血管目测狭窄程度ȡ50%,即为该血管病变,分为单支病变㊁双支病变㊁3支病变㊂②S Y N T A X评分:进入S Y N T A X 评分网站(h t t p//w w w.S T N T A X.c o m)对每一位患者的冠状动脉造影中血管直径ȡ1.5mm,狭窄ȡ50%血管进行S Y N T A X在线评分㊂③残存S Y N T A X评分和分组:评价P C I术前和术后的S Y N T A X评分,术前和术后S Y N T A X评分差值为残存S Y N T A X评分㊂根据残存S Y N T A X评分进行分组:一是残存S Y N T A X评分=0为完全血运重建组,>0为不完全血运重建组㊂二是对残存S Y N T A X评分进行3分位分组,用以评价残存冠状动脉解剖病变程度对预后的影响㊂1.4终点事件收集入选患者每6个月随访1次,平均随访(36.22ʃ12.06)个月㊂包括临床用药指导,一般问卷调查,常规肝功能㊁血脂㊁血常规检查, MA C C E(包括全因死亡㊁再次血运重建㊁心力衰竭㊁卒中)㊂1.5统计学方法采用S P S S17.0统计软件进行分析㊂计量资料采用均数ʃ标准差(x-ʃs)表示,计数资料的比较采用χ2检验,计量资料两组样本比较采用独立样本t检验或秩和检验,S Y N T A X评分㊁残存S Y N T A X评分和目测冠状动脉病变对预后判断能力采用R O C曲线分析㊂对M A C C E相关危险因素进行l o g i s t i c回归分析,P<0.05为差异有统计学意义㊂2结果2.1MA C C E 311例患者发生MA C C E48例,其中全因死亡14例;再次血运重建23例;缺血性卒中9例;心力衰竭2例㊂累计发生事件次数55次,其中7例患者发生2次MA C C E事件,见表1㊂实际发生缺血性卒中事件11次,再次血运重建事件26次,心力衰竭事件4次㊂㊃176㊃‘临床荟萃“2018年8月5日第33卷第8期 C l i n i c a l F o c u s,A u g u s t5,2018,V o l33,N o.8Copyright©博看网. All Rights Reserved.表1发生2次M A C C E患者列表病例序号随访时间(月)事件病例序号随访时间(月)事件10.5缺血性卒中136死亡218心力衰竭245再次血运重建327再次血运重建344死亡43再次血运重建429再次血运重建53心力衰竭523再次血运重建618再次血运重建626再次血运重建727缺血性卒中737再次血运重建2.2MA C C E组和无MA C C E组一般资料比较MA C C E组年龄高于无MA C C E组(P=0.032)㊂MA C C E组患糖尿病比例(39.6%)高于无MA C C E 组(18.6%)(P=0.001)㊂MA C C E组冠状动脉病变支数构成比与非MA C C E组比较差异有统计学意义㊂MA C C E组S Y N T A X评分和残存S Y N T A X评分明显高于无MA C C E组(P值分别为0.017和0.000)㊂见表2㊂表2两组一般资料比较项目MA C C E组(n=48)无MA C C E组(n=263)统计值P值年龄(岁)64.13ʃ8.4560.79ʃ10.12t=2.1480.032性别[例(%)]女性13(27.1)72(27.4)χ2=0.0020.967临床诊断[例(%)]稳定性冠心病03(1.1)不稳定型心绞痛28(58.3)131(49.8)χ2=1.5860.452急性心肌梗死20(41.7)129(49.0)高血压病史[例(%)]28(58.3)136(51.7)χ2=0.7140.398糖尿病病史[例(%)]19(39.6)49(18.6)χ2=10.4300.001卒中病史[例(%)]6(12.5)13(4.9)χ2=0.0530.817冠状动脉病变[例(%)]单支病变10(20.8)3(1.1)双支病变13(27.1)131(49.8)χ2=19.2500.000 3支病变25(52.1)129(49.0)胆固醇水平(mm o l/L)4.19ʃ1.084.25ʃ1.07t=0.3850.701肌酐清除率(m l/m i n)92.27ʃ29.5194.23ʃ30.32t=0.4220.674 S Y N T A X评分(分)15.16ʃ6.5312.94ʃ7.44Z=2.3770.017残存S Y N T A X评分(分)7.52ʃ6.544.23ʃ5.50Z=3.7310.000 2.3冠状动脉病变㊁S Y N T A X评分㊁残存S Y N T A X评分对MA C C E的预测能力冠状动脉病变程度(单支病变㊁双支病变㊁3支病变)㊁S Y N T A X评分㊁残存S Y N T A X评分均能预测MA C C E,但三者比较差异无统计学意义,见图1,表3㊂2.4不同程度残存冠状动脉病变对MA C C E的影响对残存S Y N T A X评分进行3分位分组,组1残存S Y N T A X评分=0;组2残存S Y N T A X评分为> 0~<5;组3残存S Y N T A X评分ȡ5㊂残存S Y N T A X评分越高,发生MA C C E概率越高,P= 0.004㊂见表4㊂图1不同评分方法预测终点事件的R O C曲线表3目测冠状动脉病变㊁S Y N T A X评分㊁残存S Y N T A X评分预测M A C C ER O C曲线下面积评分方法曲线下面积P值95%可信区间下限上限目测冠状动脉病变0.6680.0000.5830.754 S Y N T A X评分0.608*0.0180.5240.692残存S Y N T A X评分0.665*0.0000.5800.749注:与目测冠状动脉病变比较,Z=1.400,0.0983,P=0.162, 0.922;与S Y N T A X评分比较,Z=1.568,P=0.117表4不同残存S Y N T A X评分对M A C C E的影响[例(%)]组别例数残存S Y N T A X评分0分0~<5分ȡ5分MA C C E组489(18.8)24(29.2)25(52.1)无MA C C E组263105(39.9)79(30.4)79(30.4)χ2值10.874P值0.0042.5糖尿病患者冠状动脉病变和MA C C E分析糖尿病患者3支病变率明显高于非糖尿病患者,糖尿病患者基础S Y N T A X评分明显高于非糖尿病患者,经过P C I术后残存S Y N T A X评分也明显高于非糖尿病患者㊂糖尿病患者MA C C E发生率高于非糖尿病患者,主要源于血运重建率升高㊂见表5,6㊂2.6 L o g i s t i c回归分析对MA C C E相关危险因素如年龄㊁临床诊断㊁糖尿病史㊁肌酐清除率㊁冠状动脉病变㊁S Y N T A N评分㊁残存S Y N T A X评分进行l o g i s t i c回归分析,结果表明冠状动脉病变和糖尿病史是发生MA C C E的危险因素㊂见表7㊂㊃276㊃‘临床荟萃“2018年8月5日第33卷第8期 C l i n i c a l F o c u s,A u g u s t5,2018,V o l33,N o.8Copyright©博看网. All Rights Reserved.表5 糖尿病患者冠状动脉病变分析组别例数冠状动脉病变[例(%)]单支病变双支病变3支病变S Y N T A X 评分(分)残存S Y N T A X 评分(分)糖尿病患者 6821(30.9)18(26.5)29(42.6)15.09ʃ7.696.15ʃ6.32无糖尿病患者24398(40.3)91(37.4)54(22.2)12.78ʃ7.174.34ʃ5.57统计值χ2=11.371Z =2.225Z =2.419P 值0.0030.0260.016表6 糖尿病患者M A C C E 分析[例(%)]组别例数总MA C C E全因死亡缺血性卒中再次血运重建心力衰竭糖尿病患者 6819(27.9)2(2.9)4(5.9)13(19.1)2(2.9)无糖尿病患者24329(11.9)12(4.9)7(2.9)12(4.9)2(0.8)χ2值10.430.4931.40314.4511.878P 值0.0010.4830.23600.171表7 M A C C E 危险因素l o gi s t i c 回归分析因素自变量W a l d χ2回归系数标准误P 值O R 值95%可信区间下限上限糖尿病史6.2020.8660.3480.0132.3771.2134.698冠状动脉病变12.2240.7410.2120.0002.0991.3853.1813 讨论冠状动脉多支血管病变完全血运重建的定义存在差异,造成研究结果的不同,S a n d o v a l 等[4]近期发表综述对完全血运重建定义进行归纳总结:①解剖或传统意义的完全血运重建,即对直径ȡ1.5mm ㊁狭窄>50%的冠状动脉进行旁路移植或支架治疗(支架定义在直径2.25mm 以上血管)㊂②功能性完全血运重建,所有缺血心肌区域进行旁路移植或支架治疗㊂③评分基础上的完全血运重建,对不同血管病变进行评分,根据血管供血范围评分不同,残存评分为0相当于完全血运重建㊂④生理学基础上完全血运重建,所有冠状动脉病变进行F F R 测定,对F F Rȡ0.75~0.8血管进行旁路移植或支架治疗㊂不同的定义之间有重叠㊂G én ér e u x 等[5]为评价不完全血运重建P C I 术后残留的冠状动脉病变的复杂性和严重性,采用基础S Y N T A X 评分和术后S Y N T A X 积分差值即残存S Y N T A X 评分定量表述残存的冠状动脉病变,S Y N T A X 评分是在解剖基础上形成的评分方法,残存S Y N T A X 评分为0即为解剖与评分基础上的完全血运重建㊂利用残存S Y N T A X 评分观察冠心病多支血管病变患者完全血运重建长期预后优于不完全血运重建[6-7]㊂我们通过对311例冠心病P C I 术后患者进行长期随访,根据入选时的残存S Y N T A X 评分评价完全和不完全血运重建,311例患者中残存S Y N T A X 为0患者占36.7%,其中以单支病变为主,3支血管病变达到完全血运重建仅占3.4%,多支血管病变不能达到完全血运重建是多种因素所致,包括临床因素(如高龄㊁并存疾病㊁心功能状态等)㊁解剖因素(如C T O 病变㊁弥漫病变㊁分叉病变等)㊁医生的意见(对不同病变的认识不同导致治疗策略不同)和患者的意愿(不愿意接受多个支架以及二次手术)等,残存S Y N T A X 评分越高MA C C E 发生率越高,不仅残存S Y N T A X评分可以预测MA C C E 发生,冠状动脉病变和基础S Y N T A X 评分也可以预测MA C C E 发生,MA C C E主要为再次血运重建㊂基础冠状动脉病变范围越广㊁P C I 术后残存病变越多再次血运重建发生率越高,这和其他研究报道一致[6-7]㊂张敬霞和刘吉园等[8-9]通过残存S Y N T A X 评分评价冠心病患者血运重建的预后,结果表明完全血运重建患者预后优于不完全血运重建,残存S Y N T A X 评分是评估预后的良好指标㊂S Y N T A X 评分包括ȡ1.5mm 并>50%狭窄血管,而<2.0~2.5mm 血管很少进行P C I 治疗,是导致残存S Y N T A X 评分升高主要原因之一,目前针对这些小血管的血运重建治疗包括药物涂层球囊㊁药物涂层支架治疗,但是尚缺乏远期预后的证据,因此针对小血管病变的合理治疗仍不明确[10-12]㊂残存S Y N T A X 评分增高的其他原因包括慢性闭塞病变㊁钙化病变㊁分叉病变,也是P C I 成功率降低的因素之一,随着介入器械的改进和技术进步,对复杂冠状动脉病变的治疗适应证越来越广泛,达到解剖上完全血运重建的概率会逐渐增多,但是真实世界中更多的支架植入是否带来良好的预后仍需要更多的临床实践证实,采取什么样的血运重建方式更加适合每一位患者仍然是一个巨大的挑战㊂近十余年糖尿病研究显示糖尿病患者冠状动脉病变复杂[13],常合并心功能不全和肾功能不全,P C I治疗再狭窄和支架内血栓发生率明显升高,长期不良心血管事件明显升高,尤其在胰岛素治疗的糖尿病患者明显,主要原因是再次血运重建㊂因此针对糖尿病合并冠心病患者P C I 术后需要更加强化抗血小板和抗动脉粥样硬化治疗,新一代支架如生物可吸收支架或无多聚酯膜支架可能改善长期结果[14-17]㊂我们观察68例糖尿病患者中3支病变占42.6%,糖尿病患者的S Y N T A X 评分和残存S Y N T A X 评分明显高于㊃376㊃‘临床荟萃“ 2018年8月5日第33卷第8期 C l i n i c a l F o c u s ,A u gu s t 5,2018,V o l 33,N o .8Copyright ©博看网. All Rights Reserved.非糖尿病患者,MA C C E事件高于非糖尿病患者,主要原因是再次血运重建,与其他研究结论一致[18-19], J i mén e z-N a v a r r o等[20]观察5350例冠心病P C I治疗患者,糖尿病患者完全血运重建长期不良心血管事件明显低于不完全血运重建患者,糖尿病患者即使行完全血运重建其不良心血管事件发生率高于非糖尿病患者㊂多因素分析结果表明糖尿病是MA C C E的主要危险因素之一㊂结论:①冠心病P C I患者完全血运重建优于不完全血运重建,残存冠状动脉病变越多MA C C E发生率越高㊂②残存S Y N T A X评分㊁S Y N T A X评分和目测冠状动脉病变程度均能预测长期预后㊂③糖尿病患者冠状动脉病变程度重,MA C C E发生率高,主要原因是再次血运重建㊂参考文献[1] N a g a r a j aV,O o iS Y,N o l a nJ,e ta l.I m p a c to fi n c o m p l e t ep e r c u t a n e o u s r e v a s c u l a r i z a t i o n i n p a t i e n t s w i t h m u l t i v e s s e lc o r o n a r y a r t e r yd i se a s e:a s y s t e m a t i c r e v i e wa n dm e t a-a n a l y s i s[J].JA m H e a r tA s s o c,2016,5(12):e004598.[2] H a i e kC,F e r n췍n d e z-P e r e i r aC,S a n t a e r aO,e t a l.S e c o n dv s.F i r s t g e n e r a t i o nd r u g e l u t i n g s t e n t s i n m u l t i p l ev e s s e ld i s e a s ea n d l e f t m a i n s t e n o s i s:t w o-y e a r f o l l o w-u p o f t h eo b s e r v a t i o n 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cI n t e r v,2015,8(6):e002328.[20]J i mén e z-N a v a r r o M F,L췍p e z-J i m췍n e z F,B a r s n e s s G,e ta l.L o n g-t e r m p r o g n o s i s o f c o m p l e t e p e r c u t a n e o u s c o r o n a r y r e v a s c u l a r i s a t i o ni n p a t i e n t s w i t h d i a b e t e s w i t h m u l t i v e s s e ld i se a s e[J].H e a r t,2015,101(15):1233-1239.收稿日期:2018-01-05编辑:张卫国㊃476㊃‘临床荟萃“2018年8月5日第33卷第8期 C l i n i c a l F o c u s,A u g u s t5,2018,V o l33,N o.8Copyright©博看网. All Rights Reserved.。

CHA2DS2-VASc_评分、血清肌酐对急性ST_段抬高型心肌梗死介入术后发生院内不良事件的预测价

CHA2DS2-VASc评分、血清肌酐对急性ST段抬高型心肌梗死介入术后发生院内不良事件的预测价值毛雨，沈童童，费亮，王健，陈良余安徽医科大学附属滁州医院心血管内科，安徽滁州 239000摘要：目的　探讨CHA2DS2-VASc评分联合血清肌酐（Scr）在预测急性ST段抬高型心肌梗死（STEMI）患者行经皮冠状动脉介入（PCI）术后发生院内不良事件（HAE）的价值。

方法　选取因STEMI行直接PCI术患者189例，根据住院期间是否发生HAE分为HAE组及非HAE组。

比较两组临床病史、一般情况、PCI情况、血液学指标、GRACE评分及CHA2DS2-VASc评分。

Logistic分析HAE发生的独立危险因素。

绘制受试者工作特征（ROC）曲线行单个及联合危险因素预测价值分析，采用ROC曲线下面积（AUC）比较不同指标的预测价值。

结果　与非HAE组相比，HAE 组年龄、Scr、超敏C反应蛋白、胸痛发作至球囊通过时间>240 min比例、前降支或左主干作为梗死相关动脉比例、使用氯吡格雷为负荷药物比例、肌钙蛋白阳性比例、CHA2DS2-VASc评分及GRACE评分更高，而收缩压、甘油三酯水平较低（P均<0.05）。

多因素Logistic回归分析显示，CHA2DS2-VASc评分高（OR=1.882，95% CI：1.497~2.366，P<0.001）和Scr高（OR=1.017，95% CI：1.005~1.030，P=0.006）是HAE发生的独立危险因素。

CHA2DS2-VASc评分可较好预测HAE发生（AUC=0.769），以CHA2DS2-VASc评分4分为界值，预测HAE发生的灵敏度63.2%，特异度81%。

与CHA2DS2-VASc相比，CHA2DS2-VASc评分联合Scr可进一步提高预测价值（AUC 0.803 vs.0.769，P<0.05），与GRACE评分在预测HAE发生的价值相当（AUC 0.803 vs. 0.852，P>0.05）。

TIMI危险评分对脑血管病合并急性心肌梗死患者预后的评估作用

【摘要】目的研究TIMI 危险评分对脑血管病合并急性ST 段抬高型心肌梗死PCI 术后患者预后的评估作用。

方法回顾性分析河南省人民医院2018-09—2019-02经急诊收住院并诊断为脑血管病合并急性ST 段抬高型心肌梗死（STEMI ）患者222例，按照TIMI 危险评分分为低危组（0~3分）71例（32.0%）、中危组（4~6分）87例（39.2%）和高危组（7~14分）64例（28.8%）。

患者术前均给予负荷剂量阿司匹林联合氯吡格雷或替格瑞洛抗血小板以及抗凝药物，并进行经皮冠状动脉介入治疗（PCI ），记录患者出院后1a 内主要不良心血管事件（MACE ）发生率，分析不同组别间患者预后与TIMI 危险评分的相关性。

结果TIMI 危险评分低危组、中危组、高危组1a 内MACE 发生率分别为2.8%（2/71）、5.7%（5/87）、15.6%（10/64），高危组MACE 发生率显著高于中危组与低危组，差异有统计学意义（P <0.05）。

结论TIMI 危险评分对脑血管病合并STEMI患者PCI 预后评估具有一定临床意义。

【关键词】脑血管病；ST 段抬高型心肌梗死；经皮冠状动脉介入治疗；TIMI 危险评分；不良事件【中图分类号】R743【文献标志码】A 【文章编号】1673-5110（2021）08-0653-05TIMI risk score for prognosis of myocardial infarction complicated with cerebrovascular disease patientPENG Hailin ，CUI Yingjie ，ZHAO Xiangmei ，XU Yaxin ，ZHANG Shenglong ，BAI Weimin ，QIN Lijie Henan University People ’s Hospital /Henan Provincial People ’s Hospital ，Zhengzhou 450003，China【Abstract 】ObjectiveTo evaluate the prognosis of patients with cerebrovascular disease complicated with acute ST-segmentelevation myocardial infarction after PCI by TIMI risk score.MethodsRetrospective analysis was performed on 222patientsadmitted to Henan Provincial People s Hospital from September 2018to February 2019who were diagnosed as cerebrovascular diseases complicated with acute ST-segment elevation myocardial infarction （STEMI ），of which 161men （72.5%）and 64women （27.5%）.According to the TIMI risk score ，71patients （32.0%）in the low-risk group （0-3points ），87patients （39.2%）in the middl e-risk group （4-6points ）and 64patients （28.8%）in the high-risk group （7-14points ）were divided into three groups.All patients were preoperatively given load-dose aspirin combined with clopidogrel or ticagrelor antiplatelet and anticoagulant drugs ，and underwent percutaneous coronary intervention （PCI ）.Major adverse cardiovascular events （MACE ）happened one year afterdischarge was recorded ，and the relation between prognosis and TIMI risk score which were among three groups was analyzed.ResultsThe MACE ratios of 2.8%（2/71），5.7%（5/87）and 15.6%（10/64）were in the low-risk ，middle-risk and high-risk groupsof TIMI risk scores for 1year ，severally.High risk group mace incidence was the highest among the three groups.All tests were P <0.05considered statistically significant.C onclusion The TIMI risk score is of significance to the PCI prognostic assessment ofSTEMI patients with cerebrovascular diseases.【Key words 】Cerebrovascular disease ；ST-segment elevation myocardial infarction ；Percutaneous coronary intervention ；TIMIrisk score ；Adverse eventsDOI ：10.12083/SYSJ.2021.08.021·论著临床诊治·TIMI 危险评分对脑血管病合并急性心肌梗死患者预后的评估作用彭海林崔英杰赵香梅徐雅欣张胜龙白伟民秦历杰△河南大学人民医院河南省人民医院，河南郑州450003基金项目：河南省科技攻关项目（编号：172102310066）作者简介：彭海林，Email ：△通信作者：秦历杰，Email ：随着经济的发展、人口老龄化和生活行为方式的改变，以心脑血管疾病为主的慢性非传染性疾病逐渐成为影响人类健康的主要疾病。

Syntax积分及其优缺点

Syntax积分及其优缺点1 前言近年来，随着人民生活水平的不断提高，我国冠心病的发病率和死亡率也逐年升高，并呈现患者年轻化趋势。

目前的主要治疗手段包括生活方式干预、药物治疗、器械治疗即血管成形术[1]。

在血管成形术中，包括经皮冠状动脉介入术（PCI）和冠状动脉旁路移植术（CABG）两种主要手段[2]。

在部分冠脉病变的血管成形术术式的选择上，PCI与CABG的选择问题一直存在争论。

随着药物支架的广泛应用，PCI的治疗范围不断突破禁区[1] ，而微创技术、更加完善的术后护理，也使得部分病人对CABG的接受度得以提高，应该说两种手术方法都是安全和有效的，但又有各自的优缺点。

因此，对于部分病人如何选择术式的争论从未停止。

到目前为止，何种病人适合何种术式，尚无定论[4] 。

如何正确的选择术式，提高成功率，减少并发症，内外科的争论急需一种方法进行引导。

在欧洲心脏病学会（ESC[5]）2008年会上公布的心脏外科与介入治疗狭窄冠脉研究（SYNTAX），就是针对上述问题进行选择及立项设计的，是首个针对左主干病变和/或三支病变的随机对照试验。

结果一经公布，立即受到世界的瞩目[6, 7]。

SYNTAX研究的一项重要贡献，是提出了SYNTAX积分的概念，这是一种新的根据冠状动脉病变解剖特点进行危险分层的积分系统，根据病变位置、严重程度、分叉、钙化等解剖特点定量评价冠脉病变的复杂程度，以期作为手术方式选择的初步判断手段[1,2]。

SYNTAX积分已越来越广泛地引起人们的关注，自其一年和两年结果公布后已引起广泛的讨论。

我们预测SYNTAX积分将对今后我国血管成形术的选择与预后判断产生重要的影响。

因此，本文将就SYNTAX的实验设计、计分方法、主要试验结果及其局限性进行综述，以期为正确解读和应用SYNTAX 积分方法和为我国血管成形术的选择有一个较客观的标准提供理论依据。

2 SYNTAX实验设计研究在欧美84家医院进行，共入选来自欧洲和美国的3075例左主干和/或三支病变患者。

SYNTAX Ⅱ积分对急性ST段抬高型心肌梗死患者预后的预测价值

作者简介：郗科，本科学历，主治医师。

作者单位：1．100089北京，解放军总医院京西医疗区为公桥门诊部保健科；2．100121，北京市公安医院医务科通讯作者：刘辉，E-mail ：189****0912@163．com SYNTAX Ⅱ积分对急性ST 段抬高型心肌梗死患者预后的预测价值郗科1，王莉2，刘辉1【摘要】目的探讨SYNTAX Ⅱ积分对急性ST 段抬高型心肌梗死（ST-segment elevation myocardial infarction ，STEMI ）患者预后的预测价值。

方法采用回顾性分析方法，收集解放军总医院第三医学中心2014-01至2016-06确诊为急性STEMI ，且行直接经皮冠状动脉介入治疗（primary percutaneous coronary intervention ，PPCI ）的患者445例。

每例患者用SYNTAX Ⅱ积分系统评分，并记录发生主要不良心血管事件（major adverse cardiac events ，MACE ）的情况。

根据评分将患者分为SYNTAX Ⅱ低分组和高分组。

比较各临床因素对两组患者的影响；比较两组间终点事件的发生率和死亡率；分析急性STEMI 患者全因死亡的影响因素和独立影响因素。

结果两组患者在年龄、性别、吸烟史、射血分数和Killip 分级的比较中差异有统计学意义（P ＜0．05）。

两组间终点事件发生率和死亡率比较，差异有统计学意义（P ＜0．05）。

单因素分析显示：年龄、吸烟史、射血分数、血肌酐值、Killip 分级Ⅱ—Ⅳ级和SYNTAX Ⅱ积分是急性STEMI 患者全因死亡的影响因素。

COX 回归分析表明：年龄（OＲ=1．696，95%CI 1．037 2．359）、射血分数（OＲ=0．810，95%CI 0．713 0．907）和SYNTAX Ⅱ积分（OＲ=1．309，95%CI 1．132 1．317）是急性STEMI 患者全因死亡的独立危险因素。

SYNTAX、GRACE评分对急性心肌梗死三支血管病变患者预后的评价意义的开题报告

SYNTAX、GRACE评分对急性心肌梗死三支血管病变患者预后的评价意义的开题报告背景：
急性心肌梗死是一种严重的心脏疾病，三支血管病变的患者预后更加严峻。

SYNTAX评分和GRACE评分是目前用于评价心血管疾病患者预后的评分系统，通过对这两种评分在急性心肌梗死三支血管病变患者中的应用进行研究，可以评估其对该病患者预后的评价意义。

研究目的：
本研究旨在探讨SYNTAX评分和GRACE评分对急性心肌梗死三支血管病变患者预后的评价意义。

研究方法：
1.文献综述：对文献数据库（如PubMed、Embase、CNKI等）进行检索，筛选出与本研究相关的文献，对其进行综述和分析。

2.病例回顾研究：选择2010年至2020年期间在某医院急诊科收治的符合研究入选标准的急性心肌梗死三支血管病变患者，记录其临床资料、通路情况、心脏超声等检查结果和治疗方案，并对其进行SYNTAX 评分和GRACE评分。

3.统计分析：通过对收集的数据进行统计学分析，探究SYNTAX评分和GRACE评分在预测急性心肌梗死三支血管病变患者预后方面的评价意义。

研究预期结果：
本研究预计能够证实SYNTAX评分和GRACE评分在评估急性心肌梗死三支血管病变患者预后方面有重要的评价意义，这将为进一步优化治疗方案、提高治疗效果提供依据。

SYNTAX

SYNTAX评分对直接行经皮冠脉介入的ST段抬高心肌梗死患者“无复流”的预测作用•关注Usefulness of the SYNTAX Score to Predict “No Reflow” in Patients Treated With Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction2012-02-28 13:33:28 发布于心内科 | 期刊论文【详细信息】Michael Magro, Sjoerd T. Nauta, Cihan Simsek, Eric Boersma, Elco van der Heide, Evelyn Regar, Ron T. van Domburg, Felix Zijlstra, Patrick W. Serruys, Robert Jan van Geuns | 2012/2/2415:04:00American Journal of Cardiology | 2012 | Volume 109 Issue 5The no-reflow phenomenon has been shown to have a significant effect on clinical outcomes in patients with acute ST-segment elevation myocardial infarction. Angiographic features incorporated in the SYNTAX Score (SXScore) obtained on diagnostic angiography during primary percutaneous coronary intervention (PPCI) may be associated with the occurrence of myocardialno-reflow. The aim of this study was to assess the ability of the SXScore to predict no-reflow during PPCI. The SXScore was applied to 669 consecutive patients presenting with acute ST-segment elevation myocardial infarction from November 2006 to February 2008. Angiographic analysis of the PPCI procedure was used to determine no-reflow. The median SXScore was 16 (range 9.5 to 23). No-reflow occurred in 77 patients (12%). On univariate logistic regression analysis, the SXScore showed a strong association (for each 10-unit increase in SXScore, odds ratio 1.42, 95% confidence interval 1.16 to 1.76, p <0.001). On multivariate logistic regression in a model including clinical variables, SXScore was an independent predictor of no-reflow (odds ratio 1.29, 95% confidence interval 1.02 to 1.63, p <0.001). Classification and regression tree analysis identified SXScore >21 as the best cutoff, with patients having double the risk for no-reflow compared to those with SXScore ≤21 (events 9% vs 18%, p = 0.006). In conclusion, the SXScore obtained in the diagnostic phase of PPCI for acute ST-segment elevation myocardial infarction can identify patients at risk for developing no-reflow.Myocardial no-reflow after primary percutaneous coronary intervention (PPCI) is associated with a increased incidence of clinical events and a poor survival rate after acute ST-segment elevation myocardial infarction(STEMI). [1] and [2] Patients at high risk for no-reflow include older subjects, those with previous coronary artery bypass surgery, and those presenting with higher Killip classes and longer ischemic times. Angiographic characteristics of patients with STEMI at higher risk for subsequent no-reflow include occlusion of the infarct-related artery (IRA), a high thrombus burden, saphenous graft as the culprit vessel, and multivessel disease.3 Such angiographic characteristics can be quantified by the SYNTAX Score (SXScore).4 The SXScore obtained in the diagnostic phase of PPCI, incorporates information including the patency ofthe IRA, the area of myocardium at risk supplied by the culprit vessel at the level of occlusion, as well as information on the complexity of the lesion and extent and severity of coronary artery disease.5 Patients with STEMI with high SXScores are at increased risk for adverse events, including mortality, and the prognostic value of the score is independent and additive to other risk scores based on clinical variables such as the Thrombolysis In Myocardial Infarction (TIMI) and Primary Angioplasty in Myocardial Infarction (PAMI)scores. [4], [6], [7] and [8] The mechanisms that relate a high SXScore to adverse cardiovascular events in this patient population are unclear and may in part be mediated by a higher rate of failure to achieve adequate myocardial reperfusion during PPCI. We hypothesized that with its additional angiographic characterization of patients presenting for PPCI, the SXScore can stratify patients at risk for developing myocardial no-reflow.MethodsFrom November 2006 to February 2008, 736 consecutive patients who underwent PPCI for STEMI at our institution were screened for inclusion in the MI SXScore study.4 All patients in the referral area of the Thoraxcenter, Erasmus Medical Center (Rotterdam, The Netherlands) who had symptoms of acute myocardial infarction (<12 hrs duration) were assessed clinically and using 12-lead electrocardiography by paramedical personnel or peripheral hospital medical staff members. Pretreatment with aspirin, clopidogrel, and heparin was administered before hospital admission. Urgent diagnostic angiography was followed by PPCI using standard techniques. Drug-eluting stents were implanted as the first-line choice of stent. Treatment for complications such as cardiogenic shock and cardiac arrest was performed according to guidelines.The SXScore was calculated as previously described.4 In short, SXScore I was obtained from the diagnostic angiogram before any intervention, and SXScore II was calculated after wiring the IRA. The principal difference between SXScore I and SXScore II is a reduction of 5 points attributed to total occlusion of the IRA in patients in whom simple wiring of the occluded vessel resulted in restoration of TIMI flow of 2 or 3. Patients with previous coronary artery bypass grafting in whom the SXScore could not be calculated were excluded from the study. All coronary lesions with diameter stenoses ≥50% in vessels ≥1.5 mm were scored using the SXScore algorithm, which is availableat. The SXScore for each patient was calculated by a team of 2 interventional cardiologists. In case of disagreement with regard to the significance of a lesion, quantitative coronary angiography was applied, and the lesion was included if it was ≥50% stenosis. On agreement between the 2 cardiologists, the data were entered into a dedicated software program. The investigators calculating the SXScores were blinded to patients' clinical characteristics. The scoring was done prospectively at each stage so that theinvestigators were blinded to the next-stage film, to the procedural data, and to the clinical outcomes. No changes in values were allowed once scores were assigned. In this study, SXScore I was the score of interest, because we hypothesized that the score obtained in the diagnostic or preintervention phase is associated with no-reflow. Therefore, unless stated otherwise, “SXScore” refers to SXScore I.TIMI flow and corrected TIMI frame count were assessed as previously reported.9Myocardial blush grade was assigned as described by van 't Hof et al.10 Angiographic epicardial artery no-reflow was defined as an acute temporary or persistent reduction in coronary flow (TIMI flow grade 0 or 1) in the absence of dissection, thrombus, spasm, or high-grade residual stenosis at the target lesion. Slow flow was recorded if there was a temporary reduction from TIMI flow grade 3 to grade 2. Distal embolization was defined as visible downstream movement of a contrast filling defect from the site of the culprit lesion. Distal occlusion was defined as a distal filling defect with an abrupt “cutoff” in one of the peripheral coronary artery branches of the infarct-related vessel distal to the site of angioplasty.Survival data for all patients were obtained from the municipal registry. A health questionnaire was subsequently sent to all living patients with specific questions on re-admission and major adverse cardiac events. For patients with adverse events at other centers, medical records, discharge summaries and, when necessary, angiographic films were systematically reviewed. General practitioners, referring cardiologists, and patients were contacted as necessary for additional information. Events were adjudicated by 2 experienced interventional cardiologists according to the following definitions. STEMI was diagnosed when patients had symptoms of acute myocardial infarction lasting ≥30 minutes and accompanied by >1-mm (0.1-mV) ST-segment elevation in ≥2 contiguous leads and later confirmed by creatine kinase and creatine kinase-MB increases and/or troponin increase. Target vessel revascularization was defined as any percutaneous coronary intervention of the index IRA. Major adverse cardiac events were defined as a composite of death, recurrent myocardial infarction, and target vessel revascularization.The no-reflow phe nomenon was defined by ≥1 of the following: final TIMI flow grade <3, final myocardial blush grade <2, temporary epicardial coronaryno-reflow, distal coronary occlusion, and a final corrected TIMI frame countof >100 frames/s.9Continuous variables are expressed as mean ± SD or as medians and interquartile ranges, and categorical variables are presented as absolute numbers and percentage. Continuous variables were compared using Student's unpaired t tests or Mann-Whitney nonparametric U tests. Categorical variables were compared using chi-square statistics or Fisher's exact tests as appropriate. Observed unadjusted and adjusted measures of association were obtained using logistic regression models and are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Separate logistic regression analyses wereperformed to identify independent predictors of no-reflow using all clinical variables. These univariate predictors were entered into a second logistic regression model to obtain the adjusted OR. The multivariate model consisted of SXScore and the clinical variables: age, gender, out-of-hospital cardiac arrest, Killip class, cardiogenic shock, pulse rate, and blood pressure. The effects of procedural characteristics, including thrombus aspiration, glycoprotein IIb/IIIa inhibitor use, and balloon predilatation and postdilatation, on no-reflow and on the relation of SXScore and no-reflow were further explored using a Cox regression model including these variables. Classification and regression tree analysis was performed to determine the best SXScore value cutoff that stratified patients at high versus low risk for developing no-reflow. To assess which of the angiographic characteristics best affected the association of SXScore and no-reflow, a separate logistic regression analysis in a multivariate model with the angiographic variables IRA, TIMI flow before wiring, thrombus grade after wiring, number of vessels diseased, chronic total occlusion, and bifurcation was performed.The cumulative incidence of adverse events according to the presence ofno-reflow was estimated according to the Kaplan-Meier method, and curves were compared using the log-rank test. A p value <0.05 was considered to indicate statistical significance. All statistical analyses were performed using SPSS version 17.0 (SPSS, Inc., Chicago, Illinois).ResultsFrom the initial 736 patients screened, 27 were excluded because of unavailability of a complete diagnostic coronary angiogram, and 21 were excluded because they had undergone previous coronary artery bypass grafting. Survival status and follow-up could not be obtained in 19 patients. Thus, the final number of patients included in our analysis was 669. The median SXScore was 16 (range 9.5 to 23). Differences in the baseline clinical characteristics in patients with low and high SXScores are listed in Table 1. Patients with a higher SXScores (≥16) were older, more often male, and more often had type 2 diabetes, and smoking and previous myocardial infarction were more prevalent in this group. Patients presenting in the acute phase with higher pulse rates, cardiogenic shock, and higher Killip classes more often had higher SXScores.Table 1. Baseline and presenting characteristics of patients with acute myocardial infarction according to low or high SYNTAX ScoreVariable Lower SXScore(<16)Higher SXScore(≥16)pValue (n = 332)(n = 337)Age (years)63 ± 1367 ± 12<0.01 Men221 (67%)248 (74%)0.047 Diabetes mellitus22 (7%)41 (12%)0.014Variable Lower SXScore(<16)Higher SXScore(≥16)pValue (n = 332)(n = 337)Type I11 (3%)17 (5%)0.26Type II12 (4%)25 (7%)0.03Hypertension101 (30%)123 (37%)0.096Hypercholesterolemia⁎64 (19%)76 (23%)0.3SmokersCurrent155 (47%)125 (37%)0.012Former46 (14%)45 (13%)0.036Renal failure† 4 (1%)14 (4%)0.018Family history of coronaryartery disease121 (36%)89 (26%)<0.01 Body mass index (kg/m2)27 ± 427 ± 40.74Previous myocardial infarction25 (8%)60 (18%)<0.01Previous percutaneous coronaryintervention30 (9%)34 (10%)0.64Symptom onset–to–balloontime >90 minutes257 (84%)264 (87%)0.27 Out-of-hospital cardiac arrest13 (4%)18 (5%)0.38Pulse rate (beats/min)77 ± 1680 ± 190.037Blood pressure (mm Hg)Systolic124 ± 26123 ± 270.29Diastolic75 ± 1475 ± 160.45Cardiogenic shock19 (6%)36 (11%)0.02Killip class 2–418 (5%)34 (10%)0.024 Data are expressed as mean ± SD or as number (percentage); percentages are rounded.⁎Fasting total serum cholesterol level >5.5 mmol/L (210 mg/dl) or use oflipid-lowering therapy.†Creatinine clearance <70 ml/min.Full-size tableTable 2 lists the differences in angiographic and procedural characteristics between patients with low and high SXScores. The left main stem and the left anterior descending coronary artery were more commonly the culprit vessels in patients with high SXScores, whereas the left circumflex coronary artery and the right coronary artery were more commonly the IRAs in low-SXScore patients. Furthermore, the IRA more often had poor anterograde flow (TIMIgrade 0 or 1) in patients with high SXScores. Multivessel disease, chronic total occlusions, and bifurcations were more often present in patients with higher scores, and this reflected a higher rate of multivessel and bifurcation stenting and a longer total stent length implanted. There was no difference in the procedural use of thrombectomy, glycoprotein IIb/IIIa inhibitors, or balloon predilatation or postdilatation between the 2 groups. The use of an intra-aortic balloon pump was necessary in twice as many patients with SXScores ≥16 compared with those with scores <16.Table 2. Angiographic characteristics, procedural characteristics, and management of patients with acute myocardial infarction with low and high SYNTAX ScoresVariable Lower SXScore(<16)Higher SXScore(≥16)pValue (n = 332)(n = 337)Anterior STEMI127 (38%)177 (53%)<0.001 Infarct-related coronaryarteryLeft main 6 (2%)36 (11%)<0.01 Left anterior descending111 (34%)169 (50%)<0.01 Left circumflex63 (19%)46 (14%)0.06 Right156 (47%)119 (35%)<0.01 Initial TIMI flow grade 0 or1 in IRA157 (48%)253 (75%)<0.01 Stent thrombosis (cause)12 (4%)13 (4%)0.86 Number of diseased coronaryarteries1222 (67%)59 (18%)<0.01 291 (27%)115 (34%)0.06 3⁎18 (5%)163 (48%)<0.01 Left main disease 6 (2%)36 (11%)<0.01 Chronic total occlusion 4 (1%)42 (13%)<0.01 Stent implantation311 (94%)305 (91%)0.096 Balloon predilatation60 (18%)60 (17%)0.91 Total stent length (mm)28 (18–40)30 (23–51)<0.01 Stent diameter (mm) 3.0 ± 0.5 3.0 ± 0.50.83 Bifurcation treatment inIRA47 (14%)76 (23%)<0.01 Balloon postdilatation63 (19%)61 (18%)0.73 Thrombectomy62 (19%)62 (19%)0.93 Glycoprotein IIb/IIIa 73 (22%)74 (22%)0.99Variable(<16)(≥16)p Value(n = 332)(n = 337) inhibitorsInotropic agents14 (4%)17 (5%)0.61Intra-aortic balloon pump15 (5%)30 (9%)0.024Multivessel stenting26 (8%)43 (13%)0.036Final TIMI flow grade 0 or 17 (2%)21 (6%)<0.01Corrected TIMI frame countat end (frames/s)24 (16–36)26 (18–40)0.052Myocardial blush grade 0 or13 (1%)19 (6%)<0.01 Data are expressed as mean ± SD, as median (interquartile range), or as number (percentage); percentages are rounded.⁎Includes patients with left main disease plus 1-vessel disease.Full-size tableThe no-reflow phenomenon occurred in 77 patients (12%) included in the analysis. The components used to define the composite end point are listed in Table 3. On univariate logistic regression analysis, the SXScore showed a strong association with no-reflow (for each 10-unit increase in SXScore, unadjusted OR 1.42, 95% CI 1.16 to 1.76, p <0.001). The other univariate predictors of no-reflow were age, gender, out-of-hospital arrest, Killip class, shock, pulse rate, and blood pressure. After adjusting for these predictors in multivariate logistic regression, the SXScore was an independent predictor of no-reflow (per 10-unit increase in SXScore, adjusted OR 1.29, 95% CI 1.02 to 1.63, p <0.001;Table 4).Table 3. Differences in angiographically detected complications between patients presenting with low versus high SYNTAX ScoresAngiographic Complication Lower SXScore(<16)Higher SXScore(≥16)p Value (n = 332)(n = 337)Dissection17 (5%)12 (4%)0.322 Perforation 6 (2%) 4 (1%)0.51 Distal embolization16 (5%)15 (5%)0.82 Slow flow7 (2%)14 (4%)0.13 Angiographic no-reflow⁎ 6 (2%)11 (3%)0.23 TIMI flow grade 0 or 1 final⁎7 (2%)21 (6%)<0.001 Corrected TIMI framecount >100 frames/s⁎5 (2%)24 (7%)<0.001Angiographic Complication (<16) (≥16) p Value(n = 332)(n = 337) Myocardial blush grade 0 or 1⁎3 (1%) 19 (6%) <0.001 Composite no-reflow 29 (9%) 48 (14%) 0.026 Percentages are rounded.⁎Parameters included in composite end point no-reflow in this study. Full-size tableTable 4. Predictors of myocardial no-reflow on multivariate analysis in model with clinical characteristics and SYNTAX ScorePredictor OR (95% CI) p ValueSXScore (per 10-unit increase)1.29 (1.02–1.63) <0.001 Age (per 10-year increase) 1.23 (0.99–1.54) 0.058 Pulse rate (per 10 beats/min increase) 1.02 (1.01–1.03) 0.012 Full-size tableClassification and regression tree analysis identified SXScore >21 as the best cutoff, with patients having twice the risk for no-reflow compared to those with SXScores ≤21 (events 9% vs 18%, p = 0.006). The relation of SXScore II was also explored in a separate but similar multivariate model, and as with SXScore I, it also showed an independent association with no-reflow (OR 1.53, 95% CI1.24 to 1.89, p <0.001; adjusted OR 1.29, 95% CI 1.03 to 1.63, p = 0.009). Assessment of the relation of angiographic characteristics and no-reflow is listed in Table 5. Angiographic characteristics that were independent predictors of no-reflow on multivariate analysis included left main stem involvement, TIMI flow grade on presentation, and thrombus grade after wiring. Of the procedural characteristics, only patients with predilatation had a trend toward a higher risk for developing no-reflow (OR 1.7, 95% CI 0.99 to2.99, p = 0.054). Adjustment for predilatation by entering it in a multivariate model did not significantlyinfluence the OR of the SXScore for no-reflow (OR 1.29, 95% CI 1.03 to 1.63, p = 0.029). The Kaplan-Meier curves in Figure 1 and Figure 2 show the increased mortality rate (31% vs 10%, p <0.001) and rate of major adverse cardiac events (35% vs 14%, p <0.001) at 18 months in patients who developed no-reflow.Table 5. Angiographic predictors of no-reflowPredictor Univariate Analysis Multivariate AnalysisOR (95% CI) p Value OR (95% CI) p ValueInfarct-related coronary arteryPredictorUnivariate Analysis Multivariate Analysis OR (95% CI) pValue OR (95% CI) pValueLeft main stem 3.46 (1.69–7.08) 0.001 2.42 (0.96–6.09) 0.06 Left anterior descending1.50 (0.93–2.41) 0.098 1.37 (0.80–2.35) 0.25 Leftcircumflex0.41 (0.17–0.95) 0.037 0.56 (0.22–1.43) 0.22 Right 0.96 (0.59–1.56) 0.86Number ofcoronaryarteries with significantdisease20.71 (0.41–1.23) 0.218 — — 3 1.54 (0.94–1.54) 0.094 1.18 (0.63–2.22) 0.6 Chronic total occlusion1.99 (0.92–4.29) 0.081 1.03 (0.40–2.65) 0.95 Bifurcation at IRA 0.80 (0.42–1.53) 0.497 — — TIMI flow before wiring0.66 (0.53–0.82) <0.001 0.71 (0.56–090) 0.004 Thrombus grade after wiring1.73 (1.43–2.10)<0.001 1.60 (1.32–1.95) <0.001 The univariate model consists of the angiographic parameters described in the text. The multivariate model contains angiographic parameters that were significant (p <0.05) on univariate analysis.Full-size tableFigure 1. Kaplan-Meier curves of survival in patients with and without no-reflow (control). At 18-month follow-up, the mortality rate was 31% versus 10% (log-rank p <0.001).View high quality image (106K)Figure 2. Kaplan-Meier curves of survival free of major adverse cardiac events (MACE; including death, repeat myocardial infarction, and target vessel revascularization) in patients with and without no-reflow. At 18-monthfollow-up, the MACE rate was 35% versus 14% (log-rank p <0.001).View high quality image (108K)DiscussionThe SXScore is an independent predictor of myocardial no-reflow in patients with STEMI. An SXScore >21 carries a double risk for developing no-reflow. Myocardial no-reflow carries a poor prognosis and an increased mortality rate. Thus, intraprocedural measures that can prevent this phenomenon would be especially beneficial in patients at high risk as identified by the SXScore. Preventive measures may include pharmacologic agents such as glycoprotein IIb/IIIa inhibitors, adenosine, nitroprusside, and nicorandil as well as mechanical measures such as thrombus aspiration.In this study, no-reflow was identified by changes in TIMI flow in the epicardial artery, which directly affects myocardial perfusion, as well as more direct imaging of myocardial perfusion as measured by the myocardial blush grade. TIMI flow grade is a crude but accurate indicator for myocardial reperfusion if this is suboptimal (i.e., <3). The corrected TIMI frame count adds more sensitivity for categorizing no-reflow for patients in whom TIM I flow ≥2 is achieved. A cutoff of 100 frames/s was chosen on the basis of data from previous studies.9One of the major components of the SXScore that enhances its predictive value on the eventual achievement of microvascular perfusion is the patency (or otherwise) of the IRA. An occluded IRA has been shown to be associated with a worse postprocedural myocardial perfusion (TIMI myocardial perfusion gradeof 3, 54.9% vs 18.7%, p <0.0001). Patency of the IRA often signifies earlier spontaneous reperfusion, which reduces the actual ischemic time. As a result, infarction size is limited, and improvement in the left ventricular ejection fraction is greater in such patients, which is reflected in improved 1-year outcomes.11 The SXScore adds 5 points if the IRA has TIMI grade 0 or 1 flow, reflecting the importance of IRA patency in no-reflow and short- and long-term mortality. Poor anterograde flow is also often associated with a higher thrombus load, and this in turn has been associated with slow flow and the no-reflow phenomenon.12Embolization of atherothrombotic material has been implicated as an important pathophysiologic mechanism leading to poor microvascular perfusion. Antithrombotic, thrombolytic or thrombus aspiration have all been shown to reduce the incidence of the no-reflow phenomenon. [13], [14] and [15] Given the associated risks associated with these adjunctive therapeutic measures, such as bleeding and cerebrovascular accidents, limiting use in patients who may benefit most from these treatments is desirable.The difference in the myocardial area at risk is also an important component of the SXScore, and the different weighting given to the coronary arteries does influence the occurrence of no-reflow. Although infarction in the left circumflex coronary artery is less likely to result in detectable no-reflow, that in the proximal left coronary artery, especially the left main stem, carries a 3.5-fold risk for no-reflow.In the present study, the presence of a chronic total occlusion and 3-vessel disease had a non-significant trend of association with no-reflow. Although the lack of statistical significance can be attributed to a lack of power, the incorporation of these parameters in the SXScore ensures appropriate consideration of these parameters in the risk stratification of no-reflow. In contrast, chronic total occlusion and multivessel disease are not as important as TIMI flow and the location of the occlusion. No-reflow as an angiographic marker of myocardial perfusion focuses on the territory at risk, which although as expected is affected mostly by the characteristics pertinent to the IRA, can be affected by the presence and extent of disease elsewhere. Diffuse disease often signifies an impaired microcirculatory resistance index.16 Moreover, collateral circulation to the microvascular bed, which is considered protective, would be poorly developed or insufficient if the contributing artery is also diseased.Although observers scoring the SXScore were blinded to the next-step angiographic film and changes to the score were not allowed after film review, bias of scoring no-reflow in patients with high SXScores may still have affected our observations. However the post hoc analytic nature of the study derived from the MI SXScore study database guarantees to a limited extent the validity of our findings. The relation of the SXScore and the outcome is unlikely to have been influenced by operator-dependent choice of treatment. In fact, in our study, patients with higher scores were not treated differently, especially withregard to predilatation, stenting, thrombectomy, and glycoprotein IIb/IIIa inhibitor use. In determining no-reflow, we chose to use only angiographic parameters. ST-segment resolution as another measure of no-reflow was not available in all patients. Moreover, we could not determine the effect of the SXScore and the occurrence of no-reflow on final infarct size, because neither enzymatic infarct size nor infarct size by noninvasive imaging modalities was available in all patients. Nonetheless, the SXScore has significant predictive value for the occurrence of angiographically defined no-reflow.。

对 ST 段抬高型心肌梗死后并发心律失常危险因素实施护理干预效果评价

对 ST 段抬高型心肌梗死后并发心律失常危险因素实施护理干预效果评价陈卓芳;林雪英;梁菊艳【摘要】[目的]探讨急性 ST 段抬高型心肌梗死后并发心律失常的危险因素干预效果。

[方法]将88例急性 ST 段抬高型心肌梗死并发心律失常病人随机分为两组各44例。

对照组给予临床路径护理，观察组在临床路径护理基础上对心律失常危险因素进行护理干预，比较两组护理效果。

[结果]两组心律失常发生率、总有效率、住院时间、健康知识达标率、满意度比较差异有统计学意义(P <0.05)。

[结论]对ST 段抬高型心肌梗死后并发心律失常病人的危险因素进行护理干预可提高护理服务质量。

【期刊名称】《全科护理》【年(卷),期】2015(000)017【总页数】3页(P1619-1621)【关键词】心肌梗死;心律失常;护理干预;危险因素【作者】陈卓芳;林雪英;梁菊艳【作者单位】524003，广东医学院第二附属医院;524003，广东医学院第二附属医院;524003，广东医学院第二附属医院【正文语种】中文【中图分类】R473.5急性心肌梗死主要是由于冠状动脉粥样硬化斑块破裂，引起血栓栓塞所致持久而严重的心肌缺血及心肌急性坏死，临床表现为剧烈而持久的胸骨后疼痛，休息和含服硝酸甘油不能完全缓解，伴有白细胞增高、发热、红细胞沉降率加快，血清心肌酶活性增高及进行性心电图变化，可并发心律失常、休克或心力衰竭等合并症，严重者可危及生命。

流行病学调查显示，急性ST段抬高型心肌梗死（STEMI）死亡病例中约有50%以上病人在发病后3h内死亡，多是由于致命性心律失常所致。

STEMI后易发生室性心律失常，尤其是恶性室性心律失常，是影响病人预后的重要因素。

研究表明，引起恶性心律失常的危险因素有：白细胞计数、心电图的T波峰－末间期（Tp-Tc间期）和QT间期离散度（QTd）、肌钙蛋白Ⅰ、肌酸激酶（CK）、肌酸激酶同工酶（CK-MB）峰值、左室射血分数（LVEF）［1］，因此，在发病早期及疾病发展过程严密观察生命体征及各项危险相关因素的演变，加强对危险因素风险评估，给予积极系统得当处理，对于提高抢救成功率、降低死亡率，改善病人预后具有十分重要价值。

关于SYNTAX评分的病例讨论

第一锐缘支起始部至第二锐缘支起始部左优势中为第二锐缘支起始部以后部分；右冠优势中为第二锐缘支起始部至后降支起始部
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1
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后降支
来自右冠后侧支来自右冠后侧支后降支发出以后部分，只存在右优势型
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来自右冠后侧支左主干前降支近段前降支开口至第一对角支

SYNTAX评分系统
SYNTAX评分系统主要根据冠状造影
结果，采用冠脉树16段法，结合冠状动脉分布优势类型、病变部位、狭窄程度、病变数目及病变的具体特征对直径≥1.5mm，狭窄程度 ≥50%的病变进行综合分析而最终得到的一个评分。
SYNTAX评分系统
该评分系统包括12个问题，包括优
势类型、病变数目、累及节段和病变特征（完全闭塞病变、三分叉、分叉病变、开口病变、严重迂曲病变、病变长度＞20mm、严重钙化病变、血栓病变、弥散/小血管病变）。
SYNTAX评分系统
SYNTAX评分过程中，每个病变应该
独立进行评分，最终所有病变评分的相加的总和定义为该患者冠脉病变复杂程度的积分。
辅助检查

心脏彩超：左室增大，LVd 55.7mm，升主动脉增宽，主动脉瓣反流（少量），EF 58.5%。
辅助检查

冠状动脉造影：冠状动脉分布呈右优势型， LAD近中段弥漫性病变，最重处70%狭窄，中段可见瘤样扩张，远端70%局限狭窄，LCX开口 70%狭窄，近段70%局限狭窄，主OM近段40%狭窄，RAD中段节段性病变，最重处80%狭窄，远段70%狭窄。

残余SYNTAX积分在急性心肌梗死中的应用研究进展

残余SYNTAX积分在急性心肌梗死中的应用研究进展
尤然;王宪沛;唐熠达
【期刊名称】《河南医学研究》
【年(卷),期】2022(31)9
【摘要】残余SYNTAX积分(RSS)可以预测急性心肌梗死(AMI)患者血管斑块易损性,定量评估AMI患者经皮冠状动脉介入治疗(PCI)术后残余病变并且获得良好的术后近期预后预测效果,AMI患者的运动耐量以及心型脂肪酸结合蛋白(H-FABP)等预后相关指标与RSS变化情况有关。

AMI患者的PCI预后不良风险可以通过炎症作用与RSS变化相关联,并随着RSS的降低而相应降低,RSS可以准确预测AMI患者的血运重建结果,AMI患者的再次血运重建风险与RSS的变化相关,且随着RSS的升高而相应升高,不完全血运重建(RSS>8分)AMI患者的预后较差,在RSS基础上衍生的SYNTAX血运重建指数、临床RSS亦可准确预测AMI患者预后,可作为后续临床研究的一个新兴方向进行深入探索。

【总页数】4页(P1717-1720)
【作者】尤然;王宪沛;唐熠达
【作者单位】郑州大学人民医院/河南省人民医院心内科;阜外华中心血管病医院心内科;北京大学第三医院心内科
【正文语种】中文
【中图分类】R542.22
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1.残余SYNTAX评分在中国冠心病介入患者中的应用价值研究
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3.残余SYNTAX评分对急性心肌梗死患者经皮冠状动脉介入治疗术后不良预后的预测价值
4.SYNTAX scoreⅡ积分在急性心肌梗死患者急诊直接PCI中的应用价值
5.血清GGT、SYNTAX-Ⅱ评分在急性ST段抬高型心肌梗死患者预后评估中的价值
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syntax评分系统方法及意义

s y n t a x评分系统方法及意义(总7页)-CAL-FENGHAI.-(YICAI)-Company One1-CAL-本页仅作为文档封面，使用请直接删除08年长城会上听专家讲了Syntax score评分方法，这评分方法比较复杂，主要是依据冠脉造影的结果来判断。

在准备阅读之前，先要熟悉冠脉解剖的节段分布情况：（上图为左优势型冠脉解剖分布，下图为右优势型解剖分布）Figure 1. Definition of the coronary tree segments（冠脉束血管段的识别）1. RCA proximal: From the ostium to one half the distance to the acute margin of the heart.2. RCA mid: From the end of first segment to acute margin of heart.3. RCA distal: From the acute margin of the heart to the origin of the posterior descending artery.4. Posterior descending artery: Running in the posterior interventricular groove.16. Posterolateral branch from RCA: Posterolateral branch originating from the distal coronary artery distal to the crux.16a. Posterolateral branch from RCA: First posterolateral branch from segment 16. 16b. Posterolateral branch from RCA: Second posterolateral branch from segment 16. 16c. Posterolateral branch from RCA: Third posterolateral branch from segment 16.5. Left main: From the ostium of the LCA through bifurcation into left anterior descending and left circumflex branches.6. LAD proximal: Proximal to and including first major septal branch.7. LAD mid: LAD immediately distal to origin of first septal branch and extending to the point where LAD forms an angle (RAO view). If thisangle is not identifiable this segment ends at one half the distance from the first septal to the apex of the heart.8. LAD apical: Terminal portion of LAD, beginning at the end of previous segment and extending to or beyond the apex.9. First diagonal: The first diagonal originating from segment 6 or 7.9a. First diagonal a: Additional first diagonal originating from segment 6 or 7, before segment 8.10. Second diagonal: Originating from segment 8 or the transition between segment 7 and 8.10a. Second diagonal a: Additional second diagonal originating from segment 8.11. Proximal circumflex artery: Main stem of circumflex from its origin of left main and including origin of first obtuse marginal branch.12. Intermediate/anterolateral artery: Branch from trifurcating left main other than proximal LAD or LCX. It belongs to the circumflex territory.12a. Obtuse marginal a: First side branch of circumflex running in general to the area of obtuse margin of the heart.12b. Obtuse marginal b: Second additional branch of circumflex running in the same direction as 12.13. Distal circumflex artery: The stem of the circumflex distal to the origin of the most distal obtuse marginal branch, and running along the posteriorleft atrioventricular groove. Caliber may be small or artery14. Left posterolateral: Running to the posterolateral surface of the left ventricle. May be absent or a division of obtuse marginal branch.14a. Left posterolateral a: Distal from 14 and running in the same direction.14b. Left posterolateral b: Distal from 14 and 14 a and running in the same direction.15. Posterior descending: Most distal part of dominant left circumflex when present. It gives origin to septal branches. When this arteryis present, segment 4 isusually absent。

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残余SYNTAX评分对ST段抬高型心肌梗死多支血管病变患者预后的影响
H一一C ak D iology
IntJ Cardiol, 2017,
243: 21-26.. Hypertension J Hypertens, 2017,
35(11): 2150-2160.
N Engl J Med, 2017,
377(16): 1513-1524.
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降压治疗对正常高值和正常血压个体预后的影响
H莳还不济楚血f K f t 120-丨沖/80-册m m i l g的个体，是否S I从降压治疗中获&.逛否成获益坫况依帻子心血性M昤水在枯线尤抗饵咖故荇物和近期太发生心机梗圯、左心笼功能不全的怙况下.收枭正常饥托成正常佔仇E A降卅治疗对凡心血订结局肜响r t:j随枞对掛.试验（K C T s)数ttL川郎机效应楨琍i|-f f M险比,95%_i i U V K N及心l i L1P H A_M绝对W险降低和全W死产。

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