尼可地尔对老年糖尿病并STEMI患者直接PCI缺血再灌注的心肌保护效应

目的:探讨尼可地尔对老年糖尿病并急性ST段抬高心肌梗死(STEMI)患者直接经皮冠状动脉介入(PCI)缺血-再灌注损伤(IRI)的心肌保护效应。方法:选取老年糖尿病并STEMI患者124例,均符合直接PCI适应证,按照分层区组随机化原则分为对照组(62例)和尼可地尔组(62例)。对照组患者行常规PCI;尼可地尔组在对照组治疗的基础上,术前给予注射用尼可地尔以0.06 mg·kg^-1(限制3~4 mg/次)静注,术中2 mg冠状动脉内给药,并以4 mg·h^-1静脉泵注24 h,之后尼可地尔片5 mg/次,3次/d,口服6个月。于术前及术后监测两组患者:(1)心肌IRI指标:血清心肌肌钙蛋白I(cTnI)及超敏肌钙蛋白T(hs-cTnT);心力衰竭指标:N末端脑钠肽前体(NT-pro BNP);(2)冠状动脉微循环灌注指标:心肌梗死溶栓试验(TIMI)血流分级和校正的TIMI帧数(CTFC);(3)再灌注心律失常(RA);(4)超声心动图检查左心室室壁运动评分指数(WMSI)和左室射血分数(LVEF);(5)术后6个月内主要不良心血管事件(MACE);(6)术后6个月内药物不良反应。结果:(1)于PCI术后0,6,12,24 h及术后3,7 d,尼可地尔组的血清cTnI水平均明显低于对照组(F_组间=62.537,P_组间<0.01);(2)PCI术后尼可地尔组TIMI血流分级优于对照组(Z=-2.227,P=0.026),CTFC低于对照组(t=5.937,P<0.001);(3)PCI后14 d尼可地尔组的WMSI低于对照组(t=14.974,P<0.001),LVEF高于对照组(t=-5.268,P<0.001);(4)于术后1,3,7,14 d,尼可地尔组的血清NT-proBNP水平均低于对照组(F_组间=54.818,P_组间<0.01);(5)IRA开通后4 h内尼可地尔组RA的发生率低于对照组(χ~2=9.325,P=0.002);(6)术后6个月内尼可地尔组MACE发生率低于对照组(χ~2=4.613,P=0.032);(7)两组患者药物不良反应发生率比较(χ~2=0.614,P=0.433),差异无统计学意义。结论:尼可地尔对老年糖尿病并STEMI患者直接PCI的IRI具有心肌保护效应,能有效改善PCI后的心脏血流灌注,减轻心肌的IRI,改善室壁运动及左心功能,减少RA的发生,降低短期MACE发生率,且安全性好。

Myocardial protective effect of nicodil on direct PCI ischemia reperfusion in elderly diabetic patients with STEMI

OBJECTIVE To investigate the myocardial protective effect of nicodil on direct percutaneous coronary intervention(PCI) ischemia reperfusion in elderly patients with diabetes mellitus and acute ST-elevation myocardial infarction (STEMI).METHODS 124 elderly patients with diabetes and STEMI were selected and divided into control group (62 cases) and nicorandil group (62 cases) according to the principle of stratified block randomization.Patients in the control group underwent conventional PCI;patients in the nicorandil group were given nicorandil for injection 0.06 mg·kg^-1 (limited 3 to 4 mg/time) intravenously before surgery,2 mg intracoronary during surgery,and 4 mg·h^-1 intravenously pumped for 24 h,followed by nicorandil tablets 5 mg/time,3 times/d,orally for 6 months on the basis of treatment in the control group.Two groups of patients were monitored before and after surgery:(1) myocardial IRI indicators:serum cardiac troponin I (cTnI) and high-sensitive cardiac troponin T (hs-cTnT);heart failure indicators:N-terminal pro-brain natriuretic peptide (NT-pro BNP);(2) coronary microcirculation perfusion indicators:thrombolysis in myocardial infarction (TIMI) blood flow grade and corrected TIMI frame count (CTFC);(3) reperfusion arrhythmia (RA);(4) echocardiography examination of left ventricular wall motion score index (WMSI) and fractional shortening (LVEF);(5) major adverse cardiovascular events (MACE) within 6 months after surgery;(6) adverse drug reactions within 6 months after surgery.RESULTS (1)0 h,6 h,12 h,24 h after PCI and 3 d,7 d after PCI,serum cTnI levels in the nicodil group were significantly lower than those in the control group(F_inter-group=62.537,P_inter-group<0.01);(2)TIMI blood flow grade in nicodil group was better than that in control group after PCI(Z=-2.227,P=0.026),CTFC in the nicodil group were significantly lower than those in the control group(t=5.937,P<0.001);(3)WMSI of nicodil group was lower than that of control group 14 days after PCI(t=14.974,P<0.001),LVEF in the nicodil group were significantly higher than those in the control group(t=-5.268,P<0.001);(4)At 1,3,7,and 14 days after surgery,the serum levels of NT-proBNP in the nicodil group were lower than those in the control group(Between groups:F=54.818,P<0.01);(5)The incidence of RA in the nenicardil group was lower than that in the control group 4 h after IRA initiation(χ²=9.325,P=0.002);(6)The incidence of MACE in the nicodil group was lower than that in the control group within 6 months after operation(χ²=4.613,P=0.032);(7)The incidence of adverse drug reactions was compared between the two groups(χ²=0.614,P=0.433),the difference was not statistically significant.CONCLUSION Nicorandil has myocardial protective effect on IRI after primary PCI in elderly patients with diabetes mellitus and STEMI.It can effectively improve cardiac blood perfusion after PCI,reduce myocardial IRI,improve ventricular wall motion and left ventricular function,reduce the occurrence of RA,reduce the incidence of short-term MACE,and has good safety.