作者：史恩源，赵金标 ，王硕 ，刘迎午 ，黄雷

单位：

1.300170天津市第三中心医院急诊科　2.300170天津市重症疾病体外生命支持重点实验室　3.300170天津市人工细胞 工程技术研究中心　4.300170天津市肝胆研究所　5.300170天津市第三中心医院心脏中心

Units：

1.Emergency Department, the Third Central Hospital of Tianjin, Tianjin 300170, China 2.Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin 300170, China 3.Artificial Cell Engineering Technology Research Center, Tianjin 300170, China 4.Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, China 5.Heart Center, the Third Central Hospital of Tianjin, Tianjin 300170, China

关键词：

ST段抬高型心肌梗死；经皮冠状动脉介入治疗；无复流现象；影响因素分析

Keywords：

ST segment elevation myocardial infarction; Percutaneous coronary intervention; No-reflow phenomenon; Root cause analysis

CLC：

R 542.22

DOI：

10.12114/j.issn.1008-5971.2023.00.253

Funds：

天津市科技计划项目（21JCYBJC01590，16ZXMJSY00200）

摘要：

目的　探讨中青年急性ST段抬高型心肌梗死（STEMI）患者经皮冠状动脉介入治疗（PCI）后发生无 复流现象的影响因素，并构建其预测模型。方法　回顾性选取2018年1月至2022年9月在天津市第三中心医院行PCI的 中青年急性STEMI患者237例为研究对象。收集患者的临床资料，根据PCI后无复流现象发生情况将患者分为无复流现 象组和对照组。采用多因素Logistic回归分析探讨中青年急性STEMI患者PCI后发生无复流现象的影响因素，并构建其预 测模型；采用ROC曲线分析该预测模型对中青年急性STEMI患者PCI后发生无复流现象的预测价值。结果 237例患者 中，发生无复流现象28例（11.8%）。两组有吸烟史者占比、有糖尿病史者占比、入院时收缩压、入院时白细胞计数、 入院时脑钠肽、入院时超敏C反应蛋白、Killip分级≥Ⅱ级者占比、PCI前发生心室颤动者占比、行气管插管机械通气者 占比、急诊植入冠状动脉支架者占比、行主动脉内球囊反搏（IABP）者占比比较，差异有统计学意义（P＜0.05）。 多因素Logistic回归分析结果显示，糖尿病史、入院时收缩压、入院时血小板计数为中青年急性STEMI患者急诊PCI后 发生无复流现象的独立影响因素（P＜0.05）。基于上述指标，同时纳入Killip分级≥Ⅱ级、发病至球囊开通时间以构 建预测模型：P=2.459×糖尿病史-0.08×入院时收缩压+0.032×入院时血小板计数+1.264×Killip分级≥Ⅱ级+0.301×发 病至球囊开通时间-5.7。ROC曲线分析结果显示，该预测模型预测中青年急性STEMI患者PCI后发生无复流现象的AUC 为0.76〔95%CI（0.61，0.90）〕，最佳截断值为370.5，灵敏度为70.6%，特异度为76.7%。选取2022年10—12月在天津 市第三中心医院行PCI的中青年急性STEMI患者46例作为外部验证组，其中发生无复流现象6例（13.0%），ROC曲线分 析结果显示，该预测模型预测外部验证组中青年急性STEMI患者PCI后发生无复流现象的AUC为0.74〔95%CI（0.57， 0.90）〕，最佳截断值为377.7，灵敏度为100.0%，特异度为52.5%。结论　糖尿病史、入院时收缩压、入院时血小板 计数为中青年急性STEMI患者PCI后发生无复流现象的影响因素，本研究基于上述因素及Killip分级≥Ⅱ级、发病至球囊 开通时间构建的预测模型对中青年急性STEMI患者急诊PCI后发生无复流现象有一定预测价值。

Abstract：

　Objective To explore the influencing factors of no-reflow phenomenon after percutaneous coronary intervention (PCI) in young and middle-aged patients with acute ST segment elevation myocardial infarction (STEMI) , and construct its prediction model. Methods A retrospective study was conducted on 237 young and middle-aged patients with acute STEMI who underwent PCI in the Third Central Hospital of Tianjin from January 2018 to September 2022. The clinical data of the patients were collected, and the patients were divided into no-reflow phenomenon group and control group according to the occurrence of no-reflow phenomenon after PCI. Multivariate Logistic regression analysis was used to explore the influencing factors of no-reflow phenomenon after PCI in young and middle-aged patients with acute STEMI, and a prediction model was constructed. The ROC curve was used to explore the predictive value of the prediction model for no-reflow phenomenon after PCI in young and middle-aged patients with acute STEMI. Results Among the 237 patients, 28 (11.8%) had no-reflow phenomenon. There were significant differences in the proportion of smoking history, proportion of diabetes history, systolic blood pressure at admission, white blood cell count at admission, brain natriuretic peptide at admission, hypersensitive C-reactive protein at admission, proportion of Killip grading of ≥ Ⅱ, proportion of ventricular fibrillation before PCI, proportion of endotracheal intubation and mechanical ventilation, proportion of emergency implantation of coronary stent, and proportion of intra-aortic balloon pump (IABP) between the two groups (P < 0.05) . Multivariate Logistic regression analysis showed that diabetes history, systolic blood pressure at admission, platelet count at admission were independent influencing factors of no-reflow phenomenon after PCI in young and middle-aged patients with acute STEMI (P < 0.05) . Based on the above indicators, the Killip grading of ≥ Ⅱ and the time from onset to balloon opening were included to construct the prediction model, and the prediction model was: P=2.459×diabeties history-0.08×systolic blood pressure at admission+0.032×platelet count at admission+1.264×Killip grading of ≥ Ⅱ+0.301×time from onset to balloon opening-5.7. ROC curve analysis showed that the AUC of the prediction model for predicting no-reflow phenomenon after PCI in young and middle-aged patients with acute STEMI was 0.76 [95%CI (0.61, 0.90) ] . The optimal cut-off value was 370.5, the sensitivity was 70.6% and the specificity was 76.7%. Forty-six young and middle-aged patients with acute STEMI who underwent PCI in the Third Central Hospital of Tianjin from October to December in 2022 were selected as external validation group, among which 6 cases (13.0%) had no-reflow phenomenon. ROC curve analysis showed that the AUC of the prediction model for predicting no-reflow phenomenon after PCI in young and middle-aged patients with acute STEMI in the external validation group was 0.74 [95 %CI (0.57, 0.90) ] . The optimal cut-off value was 377.7, the sensitivity was 100.0% and the specificity was 52.5%. Conclusion Diabetes history, systolic blood pressure at admission, platelet count at admission are independent influencing factors of no-reflow phenomenon after PCI in young and middle-aged patients with acute STEMI. The predictive model constructed based on above indicators and Killip grading of ≥ Ⅱ, and the time from onset to balloon opening in this study has certain predictive value for no-reflow phenomenon after PCI in young and middle-aged patients with acute STEMI.

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