| 1.The research backgroundPercutaneous coronary intervention(PCI)has the important status and make major progress on the treatment of coronary heart disease.However,the acute myocardial infarction(AMI),especially acute ST-elevation myocardial infarction(STEMI)still is the primary cause of death and disability worldwide.According to reports,even if the patients have percutaneous coronary intervention in time and survive.There are still a significant number of patients have decline of left ventricular contraction,Lead to acute or chronic heart failure(HF).They even appear restenosis after coronary stenting,Lead to repeated angina.It is common causes of disability in acute myocardial infarction[1,2,3].Two-thirds cases of systolic heart failure is coronary heart disease.These are the factors that affect the prognosis of patients with STEMI,coronary artery lesions and left ventricular systolic dysfunction,malignant arrhythmia,myocardial necrosis.There are risks lead to myocardial infarction again,heart failure,even death[3,4,5].Therefore,heart failure after PCI has been plagued cardiovascular physician and cardiovascular interventional doctor.Andthen,stent restenosis after PCI is plagued cardiovascular interventional doctor.It is also one of the important reasons lead to heart failure.PCI has a pivotal position in the cardiovascular medicine department.However,stent restenosis still exists.Theuse of drug-eluting stents(des)has brought coronary stent restenosis rate lower than 10%.In complex coronary artery lesions,the incidence of stent restenosis is still in a high level[7.8,9].After acute myocardial infarction(MI),due to the necrosis of myocardial cells,excessive sympathetic nerve function hyperfunction,coronary blood flow drops further,myocardial contraction force fell sharply,leading to the occurrence of acute heart failure.After a time of myocardial infarction,due to the compensatory hypertrophy myocardial cell survival,myocardial cells hibernate,the excessive activation of renin angiotensin system,leading to cardiac remodeling and myocardial apoptosis,resulting in chronic heart failure,and even lead to ischemic cardiomyopathy.In general,myocardial ischemia,myocardial cell death,cardiac remodeling,RAAS hyperthyroidism,impact on long-term prognosis for STEM[3,4,6].Coronary artery stenosis model is the formation of atherosclerotic plaque,and then form a fixed stenosis,plaque rapture eventually lead to the platelet aggregation and thrombosis.In histopathology,stent restenosis is not the same as the original atherosclerosis.On the basis of atherosclerosis,a variety of mechanisms involved in the process of restenosis.Studies suggest that stent restenosis in fact is a kind of excessive repair vessels,Especially endothelial cell apoptosis and proliferation is of out of balance,and finally lead to the loss of the vessel lumen[7,9].Vascular endothelial repair are closely related with generation,engraftment and differentiation of EPCs[10].This clinical study also found,stent restenosis is closely related to the level of plasma aldosterone,it may also be a potential therapeutic target[11].Aldosterone receptor antagonist has clear curative effect in the prevention and treatment of coronary heart disease with heart failure.Large-scale meta-analysis suggests aldosterone receptor antagonist can prevent sudden cardiac death and cardiovascular events,in patients with myocardial infarction and heart failure.Treatment guidelines in acute myocardial infarction and heart failure diagnosis treatment guidelines are advocated use of aldosterone receptor antagonist in coronary heart disease with heart failure.Guideline pointed out that,after STEMI LVEF is less than 0.4,and no contraindications should be use of aldosterone receptor antagonist on the basis of ACEI[5,12,13].But whether all patients with acute myocardial infarction should use of aldosterone receptor antagonist is still controversial[14].On the basis of carefully selected,monitoring serum potassium and kidney function,effective health education,small dose of aldosterone receptor antagonist is safe in patients with coronary heart disease and heart failure[15].2.Research purposeWe selected patients first onset of acute ST elevation myocardial infarction(STEMI)with emergency interventional treatment.On the basis of the secondary prevention of coronary heart disease,in the observation group added with aldosterone receptor antagonist(spironolactone).To investigate the efficacy aldosterone receptor antagonist on cardiac function and prognosis in STEMI patients with absence of heart failure.Investigate whether the aldosterone receptor antagonists have influence on coronary artery restenosis.Discuss it affect on heart function and coronary artery.3.The research methods3.1The experimental group:Inclusion criteria:(1)The first onset and in 12 hours adept interventional treatment of patients with acute ST-elevation myocardial infarction.The diagnosis in accordance with international and domestic guidelines define acute myocardial infarction[5,11];(2)all coronary artery interventional surgery performed by one surgeon team;(3)lesion vessels immediately after the operation,TIMI ? level.Achieve real myocardial revascularization;(4)the decision to use cobalt alloy of rapamycin(sirolimus)or Zotarolimus drug-eluting stents(DES).Exclusion criteria:(1)Left main lesion,bifurcation lesions and use double stents,long lesions with more than three stents,non ST elevation myocardial infarction(MI),right ventricular myocardial infarction,chronic myocardial infarction,cardiac shock and serious arrhythmias.(2)Renal insufficiency(Serum creatinine>130 umol/L,and Calculated creatinine clearance?50ml/min).(3)Hyperkalemia(Serum potassium>5.5mmol/L).(4)Unable to standard treatment.(5)After intervention operation slow flow or no reflow.(6)after acute myocardial infarction,left ventricular ejection fraction is less than 0.4,and have apparent cardiac insufficiency.Set the exit mechanism.All the people sign the consent form to be included in the test.Between January 2012 and June 2016,all cases were randomly divided into two groups.3.2 Method:two groups were performed percutaneous coronary intervention.Using cobalt chromium alloy rapamycin drug-eluting stents(DES).The norms for secondary prevention of coronary heart disease treatment.Observation group in the treatment of foundation specifications,combined with oral spironolactone 20 mg/day.During regular review of potassium,serum creatinine,prevent the risk of adverse reactions caused by high potassium and renal insufficiency.3.3 Observe the indicators:(1)Coronary angiography(for the first time,after 1 year):the ACC/AHA coronary lesion parting,lesion counts,the degree of criminal vascular restenosis,imaging,the types of restenosis(Merhan type).(2)Echocardiography(onset after 1 week,1 year),the measurement of Left ventricular ejection fraction(Left ventricular ejection fraction,LVEF),etc.(3)Serum Brian-type Natriuretic Peptide(BNP):the first day,the seventh day,and one year.(4)The Electrocardiogram(ECG),serum potassium,serum creatinine.(5)Cardiovascular events,unplanned hospitalization and mortality in one year.3.4 Statistical processing:Use of statistical software package SPSS 19 were analyzed.Measurement data was expressed with 'meanąstandard deviation(Normal distribution).Enumeration data was expressed with rate.The comparison of mean by t test.Enumeration data were compared by chi-square test.Difference was statistically.significant with P<0.05.4.The results of the study4.1 Baseline data:observation group(181 cases in the group,actual finish review angiography cases N = 159,1 case death,21 cases lost to follow-up)and control group(190 cases in the group,the actual cases of complete N = 170,death in 2 cases,18 cases lost to follow-up).Two groups in age,gender,history of hypertension,hypercholesterolemia,coronary heart disease family history,history of diabetes,smoking history and other aspects of comparison,no difference(P>0.05).Both groups choose cobalt alloy rapamycin drug-eluting stents(DES).4.2 Coronary artery intervention data for the first time:The coronary artery lesion counts,Infarction Related Artery,ACC/AHA lesions.Chi-square test,P>0.05,a baseline coronary angiography contrast between the two groups have no obvious difference.Number average diameter,length of stents,stents,stent according to measurement data processing,gives the T test,no statistical differences in the two groups.4.3 Main observation indexes to compare the two groups:Between the two groups,LVEF of the seventh day have no difference(P>0.05).A year after,LVEF of observation group was obviously higher than that of control group(P<0.05).Data of BNP using logarithmic transformation.On the seventh day and oneyear after,BNP of observation group was obviously higher than that of control group(P<0.05).After one year,all coronary restenosis rate of observation group is lower than the control group,but no significant statistical significance(P>0.05).Restenosis rate of observation group is lower than the control group,with statistical significance(P<0.05).Observation group 1 case died within one year became seriously ill,in the control group were 2 cases died within one year,no statistical difference(P =0.605).Two groups of hospitalization rates,the rate of cardiovascular events again no difference(P>0.05).4.4 Two groups of adverse reactions:two groups of patients during the treatment,there is no standard treatment drug intolerance happens.Observation group and control group were not found new hyperkalemia and renal failure.It can be thought that small doses of spironolactone of not increase the incidence of hyperkalemia.5.Conclusion:5.1 Patients with acute ST-elevation myocardial infarction without merge heart failure patients,Who were accepted emergency coronary intervention,on the basis of conventional treatment,use of small doses of spironolactone.It can reduce blood BNP level on the seventh day and on one year,and has a better LVEF after one year.May help the recovery of left ventricular and reduce the occurrence of heart failure.5.2 Under close monitoring,in patients with normal renal function,small doses of spironolactone does not increase the incidence of renal failure and hyperkalernia.5.3 Plasma aldosterone levels associated with stent restenosis,the use of aldosterone antagonists in patients with coronary artery restenosis rate is low,but did not reach statistical significance.May be a potential way for the treatment of coronary stent restenosis. |
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