| For patients with acute coronary syndromes,especially those with acute ST-segment Elevation Myocardial Infarction(STEMI),the infarct-related vessels should be restored in a timely,rapid and effective manner,so as to achieve the purpose of restoring ischemic Myocardial perfusion,inhibiting Infarction area extension and saving the dying myocardium.Primary PCI(p PCI)is a direct and effective strategy to rapidly open infarct-related vessels,restore myocardial perfusion,and improve cardiac function and prognosis of STEMI patients.Although the success rate of infarct-related vessel opening by Primary PCI was about 90%,one-third of STEMI patients did not achieve effective and adequate myocardial microvascular perfusion after successful p PCI,called coronary microvascular perfusion(CMVO),no reflow Phenomenon(NFR)or slow reflow Phenomenon(SRP).Once CMVO occurs,myocardium cannot obtain effective and sustained blood perfusion,and myocardial ischemia and hypoxia further aggravate,which seriously affects the recovery of cardiac function and increases the incidence of adverse events in and out of the hospital.In addition,about 10～20% of the patients with acute coronary syndrome receiving PCI developed in-stent restenosis within 1 year,which seriously affected the quality of life and clinical prognosis of the patients.Therefore,for patients with acute coronary syndrome,how to effectively protect the downstream coronary microcirculation while rapidly opening the culprit vessels,as well as the prediction of the risk factors for in-stent restenosis in patients receiving PCI have been the focus of clinical research in recent years.Thrombolysis combined with PCI and intracoronary thrombolysis therapy can not only dissolve the big red blood clots in coronary artery system,even for medium,small coronary artery and coronary microcirculation and collateral circulation system function,also can effectively improve the coronary circulation and myocardial perfusion level,reduce the occurrence of no reflow,improve the clinical prognosis of STEMI patients.In recent years,the index of microcirculatory resistance(IMR)has been gradually popularized in the field of cardiovascular intervention.It can not only reflect the coronary microcirculation dysfunction,but associate with heart function and prognosis of STEMI patients.Based on the previous research,this serial study is mainly abou the strategy of revascularization in patients with acute coronary syndrome and the evaluation of risk factors for in-stent restenosis.There are four parts,part one was designed to predict and evaluate the recovery of cardiac function and size of myocardial infarction in patients with STEMI receiving thrombolysis combined with PCI therapy by IMR,part two was designed to evaluate the effect of thrombus aspiration on coronary microcirculation in STEMI patients with mild thrombus load,part three was designed to predict and evaluate the efficacy and safety of intracoronary targeted thrombolysis in STEMI patients,part four was designed to investigate the risk factors of rapid angiographic stenotic progression and in-stent restenosis in patients with acute coronary syndrome.Part One The Index of Microcirculatory Resistance Postpercutaneous Coronory Intervention Predicts Infarction area and Left Ventricular Function and Prognosis in patients with thrombolyzed ST-Segment Elevation Myocardial InfarctionObjective: Patients with acute ST-segment elevation myocardial infarction(STEMI)need to urgently restore infarct-related blood vessels(IRA)to rescue the ischemic heart.Thrombolysis combined with PCI is an effective method for the treatment of ST segment elevation myocardial infarction(STEMI)in China.The index of microcirculatory resistance(IMR),an invasive measure of microvasucular funciton,has been shown to correlate with clinical outcomes in patients with ST segment elevation myocardial infarction.The aim of this study is to evaluate the predictive value of IMR on left ventricular recovery in patients undergoing a pharmacoinvasive strategy for STEMI.Methods:The index of microcirculatory resistance was assessed following percutaneous coronary intervention in 38 patients with STEMI who were initially received with thrombolysis.Other markers of microvascular function such as coronary flow reserve(CFR),TIMI flow grade,corrected TIMI frame count(c TFC),and ST-segment resolution were also recorded.All indices were evaluted against left ventricular function,size of heart infarction and recovery 3 months postindex event.Results:The pharmacoinvasive strategy achieved a good level of myocardial perfusion.90% of the patients achieved TIMI blood flow level 3,only 10% of the patients achieved TIMI blood flow level 2,and patients without TIMI blood flow level 1 and 0 presented.Postoperative IMR level was negatively correlated with LVEF after 3 months(r=-0.419,P=0.009),and positively correlated with WMS after 3 months(r=0.776,P<0.001).There was a significant positive correlation between the IMR level and post-PCI PDA at 7 days(r=0.966,P<0.001).After 3 months,the IMR value of the heart function recovery group was significantly lower than that of the non-recovery group(36.3±2.8Uvs.47.8±6.3,P<0.001).The recovery of left ventricular heart function after 3 months was taken as the dependent variable,only IMR was used as the predictor(P=0.009),OR value was 1.263(95% CI 1.059-1.507).The level of IMR could predict the size of myocardial infarction.The PDA of IMR≥40.5 group was 28.58±7.22,and that of IMR < 40.5 group was 16.16±3.82,P<0.001.Summary:1.IMR can be safely and effectively used to measure the physiological indexes of coronary microcirculation in patients with acute STEMI.The clinical application has strong repeatability and is not affected by blood pressure,heart rate,vascular stenosis and hemodynamics,which is a reliable index for invasive evaluation of myocardial microcirculation perfusion at present.2.Thrombolysis combined with PCI can effectively improve myocardial coronary microcirculation perfusion,reduce IMR level,and protect and improve myocardial microcirculation perfusion.3.In STEMI patients with thrombolytic therapy combined with PCI,IMR value was positively correlated with myocardial infarction area and negatively correlated with short-term cardiac function recovery.IMR ≥40.5U suggested poor myocardial microcirculation perfusion,large infarction area,and poor ventricular function recovery and prognosis.Part Two The use of IMR to evaluate the effect of thrombus aspiration on coronary microcirculationObjective:In this study,IMR and SPECT imaging were designed to evaluate the microcirculation perfusion and myocardial infarction area for mild thrombus STEMI patients with thrombus aspiration,so as to improve the treatment effect of such STEMI patients.Methods:A total of 103 STEMI patients with a coronary thrombosis score of 1-3 were randomly assigned to either the conventional treatment group(RT group)or the thrombosis aspiration group(TA group).The conventional group received conventional treatment,and TA received interventional therapy after thrombus aspiration.The peak levels of CK,CK-MB,c TNI and ST-segment resolution were measured After PCI IMR was evaluated.ALL patients received cardiac SPECT after 7days,major adverse cardiac events(MACE)and bleeding events were followed up for 3 months and occurred.Results : There was no statistical difference in basic clinical data,angiographic data and intervention data between the two groups(P>0.05).Contrast dosage in RI group(132.41±43.27)compared with TA group(164.98±56.15),P=0.001.The operative time of RT group(2.3±0.5)was less than that of TA group(2.6±0.7),P=0.014.c Tn I in RT group 80(75,93)was lower than TA group 88(78,100),P<0.001.Within 24 hours,LVEF in RT group(52.06±5.48)was higher than TA group(47.39±7.26),P< 0.001.PDA in RT group(18.35±6.97)was lower than RTgroup(22.08±9.81),P=0.028.There was no statistical difference in MACE events or bleeding events between the two groups during the 90-day follow-up.Summary:1.For acute STEMI patients with mild thrombotic load received routine thrombotic aspiration,the operation time is longer and the contrast dose is increased.2.Compared with conventional interventional therapy,thrombus aspiration during p PCI in STEMI patients with mild thrombus load can cause damage to coronary microcirculation and reduce effective coronary microcirculation perfusion.3.For STEMI patients with a mild thrombotic load,routine thrombotic aspiration increases myocardial infarction area and worsens cardiac function,but does not increase the incidence of stroke.Part Three The value and significance of microcirculation protection in treatment of STEMI by catheter-targeted thrombolysisObjective: Patients with acute ST-segment elevation myocardial infarction(STEMI)need to open the infarct related artery(IRA)immediately to save the ischemic myocardium and improve the prognosis.However,some patients still have cardiac dilatation and heart failure after PCI,which may be related to microvascular dysfunction(MVD).The purpose of this study was to elucidate the effect of low dose intracoronary recombinant urokinase(prourokinase)administered through a thrombus aspiration catheter before primary PCI.Methods:Forty STEMI patients with thrombus score≥3 were randomly assigned to receive intracoronary prourokinase groups(IT group n=25)and routine thrombus aspiration groups(TA group n=25).The stent implantation was performed according to the results of the angiography,and the index of microcirculatory resistance(IMR)were measured by a temperature-pressure wire.The peak levels of CK,CK-MB,c TNI and ST-segment resolution were measured.Echocardiography was performed after 1 day and 3 months.The major adverse events(MACE)were followed up in three months.Results:There was no significant difference in the basic deomograhpci,clinical,angiographic and procedural characteristic between the two groups(P>0.05).The peak value of CK,CK-MB and c TNI in IT group were significantly lower than the TA group(1159.12 ± 617.89 vs.1661.18 ± 1079.60;123.19 ± 31.08 vs.181.56 ± 112.85;38.83 ± 12.52 vs.51.71± 26.32;P<0.05).There was no significant difference between the TIMI grade and CTFC in the two groups after PCI(P>0.05),but the IT group was significantly higher than the TA group in TMPG 3 grade(P=0.005).In IT group,the complete STR was significantly better than the TA group(P=0.005).There was no significant difference in FFR and CFR between the two groups(P>0.05),but the IMR value of IT group(35(29,40))was significantly lower than the TA group(49(41,57)).There was no significant difference in cardiac function(LVEF),left ventricular end diastolic diameter(LVED)and ventricular wall motion score(WMSI)at 1 day after PCI(P>0.05).The PDA of IT group(15.35±4.73)was significantly lower than the TA group(18.58±5.44),P=0.030.After three months,LVEF(60.84±2.29 vs.59.18±2.44),LVED(4.73±0.19 vs.4.89± 0.25,)and WMSI(1.84± 0.16 vs.1.95± 0.15)in IT group were better than the TA group.However,there was no evidence of a difference between the two groups in bleeding complication,and the major adverse cardiac events(MACE).Summary:1.For STEMI patients with high thrombus load,targeted intra-coronary thrombolysis can effectively reduce the thrombus load,restore forward blood flow,improve the level of coronary microcirculation perfusion,and play a better role in myocardial protection..2.For STEMI patients,targeted intra-coronary thrombolysis can significantly reduce the size of myocardial infarction and improve cardiac function3.The index of microcirculatory resistance is a quantitative and effective indicator to evaluate the coronary microcirculation perfusion status for the STEMI patients.Part Four Related research of stenotic progression in non-stent implantaion vessel and stent restenosis for acute coronary syndrome patientsObjective: This study aimed to explore the correlation of baseline,procedural and post-procedure characteristics with the risk of rapid angiographic stenotic progression(RASP)and restenosis in ACS patients after PCI with drug eluting stents implantation.Methods: 214 patients underwent PCI with drug-eluting stents implantation were consecutively enrolled.Baseline,procedural and postprocedure characteristics of patients were collected for analysis.Coronary angiography was performed to evaluate coronary stenosis before PCI and at 12 months after PCI.RASP of non-target lesions and restenosis of stentimplanted target lesions were then assessed.Results:37.8% ACS patients occurred RASP at 12 months after PCI,and compared to non-RASP group,RASP group presented with increased diabetes mellitus(DM)complication,higher concentration of serum uric acid(SUA),cardiac troponin I,N-terminal probrain natriuretic peptide and high sensitive C-reactive protein(hs-CRP)as well as elevated occurrence of multivessel artery lesions.In addition,DM(P=0.022),SUA(P=0.011),hs-CRP(P<0.001)and multivessel artery lesions(P=0.010)and bifurcation lesion(P=0.001)independently predicted high RASP risk.For restenosis,21.0 % patients occurred restenosis at 12 months after PCI,and patients in restenosis group presented with increased hypertension and DM occurrence,higher concentrations of SUA,LDL-C and hs-CRP,as well as longer target lesion and length of stent in surgery compared to non-restenosis group.Also,DM(P<0.001),LDL-C(P<0.001),hs-CRP(P<0.001)and length of target lesion(P=0.002),stent diameter(P=0.047)and bifurcation lesion(P=0.009)independently predicted increased restenosis risk.Summary:1.Despite the acceptance of standardized and optimized interventional procedures and drug therapy,the incidence of atherosclerotic stenosis aggravation in non-interventional lesions within one year was approximately 37.8% and that in stent restenosis within one year was approximately 21.0%.2.Increased levels of DM,and hs-CRP are common risk factors for rapid angiographic stenotic progression and instent restenosis in patients with coronary heart disease.3.Target lesion length and bifurcation lesions is a risk factor for stent restenosis.For long lesions,it is neccesory to choose short stent for accurate positioning.The stent diameter was matched with the vessel diameter to avoid too small a stent.For bifurcation lesions,it is neccesory to select the appropriate operation strategy and more optimized drug treatment according to anatomical shape of the disease.Conclusions:1.Thrombolysis combined with PCI can effectively improve myocardial coronary microcirculation perfusion,reduce IMR level,and protect and improve myocardial microcirculation perfusion.IMR value was positively correlated with myocardial infarction area and negatively correlated with cardiac function.In patients receiving thrombolysis combined with PCI,IMR ≥40.5indicated poor myocardial microcirculation perfusion,large infarction area,and poor ventricular function recovery and prognosis..2.Thrombus aspiration during primary PCI in STEMI patients with mild thrombus load can achieve similar TIMI blood flow,but may have adverse effects on coronary microcirculation and myocardial infarction area.3.For STEMI patients with high thrombus load,targeted intra-coronary thrombolysis can effectively reduce the thrombus load,restore forward blood flow,improve the level of coronary microcirculation perfusion,,thus reducing the myocardial infarction area and improving the cardiac function.4.The index of microcirculatory resistance is a quantitative and effective indicator to evaluate the coronary microcirculation perfusion status for the STEMI patients.5.Increased levels of DM,and hs-CRP are common risk factors for rapid angiographic stenotic progression and instent restenosis in patients with coronary heart disease..6.Target lesion length,smaller stent diameter and bifurcation lesions are the risk factors for stent restenosis. |
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