【作者】 李娜；

【导师】 赵雷；

【作者基本信息】 吉林大学 ， 临床医学硕士（内科学）（专业学位）， 2022， 硕士

【摘要】 研究目的:ST段抬高型心肌梗死(ST segment elevation myocardial infarction,STEMI)是心血管疾病中的危重疾病,具有较高的致死率和致残率,目前经皮冠状动脉介入术(Percutaneous coronary intervention,PCI)是主要治疗方法,能够及时开通梗死相关动脉并恢复有效心肌再灌注。尽管如此STEMI后心力衰竭的发生率仍然很高,沙库巴曲缬沙坦已然成为心力衰竭(Heart failure,HF)的一线用药,但探究应用于STEMI患者的相关循证医学证据仍然有限,本研究回顾性分析了STEMI合并心功能不全患者早期服用沙库巴曲缬沙坦的临床资料及随访相关指标等,探究沙库巴曲缬沙坦应用STEMI合并心功能不全患者的有效性及安全性,并探究沙库巴曲缬沙坦是否能够逆转心室重构,以期为STEMI患者治疗提供客观的临床依据。研究方法:入选2019年9月至2021年6月期间就诊于吉林大学第二医院心血管内科明确诊断为STEMI伴心功能不全接受PCI术且符合纳入排除标准的患者147例,根据患者口服药物的不同分为两组,一组为口服沙库巴曲缬沙坦77例,另一组为口服贝那普利70例,两组均给予常规标准化治疗(包括双联抗血小板聚集、稳定动脉斑块、β受体拮抗剂、盐皮质激素受体拮抗剂、利尿、扩血管、降低心肌耗氧量等治疗)。根据患者性别和年龄分为两个亚组,进行亚组比较。同时将沙库巴曲缬沙坦组按照左室射血分数50%为界定值分为射血分数较低和射血分数较高两亚组。(1)收集记录并分析比较两组患者一般临床资料,主要包括年龄、性别、高血压病史、糖尿病史、饮酒史、吸烟史、卒中史等;(2)收集记录并分析比较两组患者实验室相关指标、心电图及心脏彩超结果、冠脉介入情况包括冠脉病变以及支架植入数目;(3)比较分析两组患者基线、治疗3个月、6个月心脏彩超指标探究两组组间和组内随着治疗时间的变化心脏彩超指标的变化趋势;(4)比较两组患者基线和治疗3个月、6个月血清钾离子(K~+)、血清肌酐(Serum creatinine,Cr)、肾小球滤过率(Estimated glomerular filtration rate,e GFR)、尿酸(Blood urea nitrogen,UA)、尿素氮(Uric acid,BUN)水平的变化;(5)分别比较两亚组基线、治疗3个月、6个月心脏彩超指标变化;(6)比较两组患者心室重构及逆重构的发生;(7)分析比较两组患者出院后6个月的主要不良心血管事件(Major adverse cardiac event,MACE)和不良反应的发生率;研究结果:1.纳入本研究的患者总共147例,两组均以男性患者居多,沙库巴曲缬沙坦组54例(70.1%),贝那普利组55例(78.6%),对比分析两组患者的一般临床计量资料差异无明显统计学意义,P>0.05。2.两组患者入院时心脏彩超LVEF、LVIDd、LVIDs、LVEDV、LVESV、Killip分级、罪犯血管、冠脉病变数目、冠脉内植入支架数目等临床资料差异无明显统计学意义,P>0.05。3.两组患者Cr、e GFR、K~+、BUN、UA水平的比较,两组患者基线、治疗3个月、治疗6个月水平比较差异无明显统计学意义;沙库巴曲缬沙坦组e GFR水平逐渐升高;两组组内比较,两组Cr水平呈上升但均在正常值范围内,两组BUN随治疗时间延长呈下降趋势,且差异均有统计学意义,P<0.05;两组K~+逐渐升高但数值仍在正常范围内,且治疗6个月与基线相比差异具有统计学意义。4.沙库巴曲缬沙坦组心脏彩超指标LVEF、LVIDd、LVIDs、LVEDV、LVESV、NTpro BNP水平在治疗3个月和6个月均优于贝那普利组,两组比较具有统计学意义,P<0.05。5.在不同性别中,沙库巴曲缬沙坦对心室逆向重构指标改善具有良好效果且优于贝那普利,并且在男性患者中优于女性患者。6.在≤65岁和>65岁年龄中,沙库巴曲缬沙坦对心室逆向重构指标有良好效果,且优于贝那普利,在≤65岁患者中更明显。7.沙库巴曲缬沙坦和贝那普利均可逆转心室重构,随着治疗时间的延长心室逆重构逐渐增多,两组比较差异具有统计学意义,P<0.05。8.两组患者心室重构的发生、出院6个月MACE事件和不良反应发生差异无统计学意义,P>0.05。研究结论:1、沙库巴曲缬沙坦对于STEMI合并心功能不全且行PCI患者的心功能改善优于贝那普利。2、STEMI合并心功能不全患者应用沙库巴曲缬沙坦对于肾脏具有良好保护作用。3、沙库巴曲缬沙坦逆转心室重构作用优于贝那普利,且在男性和年龄较轻患者中逆转心室重构指标改善更显著。更多还原

【Abstract】 Objective:ST-segment elevation myocardial infarction(STEMI)is a critical disease in cardiovascular diseases,with a high mortality and disability rate.Percutaneous coronary intervention(PCI)is the principal treatment method for STEMI at present.It can open infarct-related arteries in time and restore effective myocardial reperfusion.Even so the incidence of STEMI heart failure remains high.Sacubitril valsartan has become a first-line drug for heart failure(HF),but evidence-based medical evidence is still limited to explore the application of sacubitril valsartan in STEMI patients.This study retrospectively analyzed the clinical data and follow-up related indicators of sakobactral valsartan in STEMI patients with cardiac dysfunction in the early stage.To investigate the efficacy and safety of sacubitril valsartan in STEMI patients with cardiac dysfunction,and to explore whether sacubitril valsartan can reverse ventricular remodeling,in order to provide objective clinical evidence for the treatment of STEMI patients.Method:A total of 147 patients with STEMI accompanied by cardiac dysfunction who received PCI and met the inclusion and exclusion criteria were enrolled in the cardiovascular department of The Second Hospital of Jilin University from September 2019 to June 2021.According to different oral medications,the patients were divided into two groups:77 patients in the sacubitril valsartan group and 70patients in the Benazepril group,respectively.Namely on the basis of conventional standardized treatment(including double inhibition platelet aggregation,artery plaque stabilization,diuresis and vasodilation,reduce myocardial oxygen consumption and other treatment),Patients were divided into two subgroups according to gender and age,and compared between subgroups.At the same time,the sacubitril valsartan group was divided into two subgroups with lower and higher ejection fractions according to the defined Left ventricular ejection fraction of50%.General clinical baseline data of two groups were collected,recorded and analyzed,including(1)gender,age,history of diabetes,history of hypertension,history of smoking,history of drinking,history of stroke,etc.(2)Laboratory test indicators,admission results of Echocardiography and electrocardiogram,coronary intervention,coronary artery lesions and the number of stent implantation were collected and analyzed.(3)The changes of Echocardiography indicators and NTpro BNP in the two groups were compared and analyzed baseline,3 months and 6months after treatment,and the change trend of Echocardiography indicators between and within the two groups with the change of treatment time was explored.(4)The levels of serum creatinine(Cr),serum potassium ion(K+),glomerular filtration rate(e GFR),uric acid(UA)and urea nitrogen(BUN)were compared between two groups at baseline and 3 months and 6 months after treatment;(5)The changes of Echocardiography indicators at baseline,3 months and 6 months of treatment were compared between the two subgroups;(6)The incidence of ventricular remodeling and left reverse remodeling was compared between the two groups;(7)The incidence of major adverse cardiovascular events(MACE)and Incidence of adverse reactions 6 months after discharge was analyzed and compared between the two groups;Results:1、147 patients were included in the study,most of which were male patients in the two groups,54 patients(70.1%)in the sacubitril valsartan group and 55 patients(78.6%)in the Benazepril group.There was no significant difference in general clinical measurement data between the two groups(P>0.05).2、There were no statistically significant differences between the two groups in Echocardiography indicators,Killip grading,number of coronary artery lesions,criminal vessels,number of stent implantation in coronary arteries and other clinical data at admission,P>0.05.3、There was no significant difference in the levels of Cr,e GFR,K+,UA and BUN between 2 groups at baseline,3 months and 6 months.The level of e GFR in Sacubitril valsartan group increased gradually.Within the two groups,Cr levels in the two groups increased but were within the normal range.BUN in the two groups decreased with the extension of treatment time,and the differences were statistically significant(P<0.05).K~+in both groups increased gradually but remained within the normal range,and the difference was statistically significant 6 months after treatment compared with baseline.4、Echocardiography indicators(LVEF,LVIDd,LVIDs,LVEDV and LVESV)in the sacubitril valsartan group were better than those in the Benazepril group at 3and 6 months of treatment,with statistical significance(P<0.05).5、In different genders,sacubitril valsartan were better than benazepril in improving the indicators of ventricular reverse remodeling,and better than women in male patients.6、In≤65 years and>65 years,sacubitril valsartan had a better effect on ventricular reverse remodeling than benazepril,especially in≤65 years.7、Both sacubitril valsartan and benazepril could reverse ventricular remodeling,and the reverse remodeling gradually increased with the extension of treatment time.The difference between the two groups was statistically significant(P<0.05).8、There were no significant differences in the incidence of ventricular remodeling and MACE events 6 months after discharge between the two groups,P>0.05.Conclusion:1、Sacubitril valsartan improved cardiac function better than benazepril in STEMI patients with cardiac dysfunction undergoing PCI.2、Sacubitril valsartan has a good effect on kidney improvement in STEMI patients with cardiac dysfunction.3、Sacubitril valsartan reverses ventricular remodeling and is superior to benazepril,and the indicators of reversed ventricular remodeling improved more significantly in male and younger patients.更多还原