Changes Of Sympathetic Nerve Activity In Patients With Acute ST-segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention And Its Relationship With In-hospital Adverse Cardiovascular Events

Objective: To investigate the changes of sympathetic activity and its relationship with adverse cardiovascular events in patients with acute ST segment elevation myocardial infarction treated by direct percutaneous coronary intervention.Methods: Patients with acute ST segment elevation myocardial infarction(ST-segment elevation myocardial infarction,STEMI)who received direct percutaneous coronary intervention(percutaneous coronary intervention,PCI)in the first affiliated Hospital of China Medical University within 24 hours from October 1,2019 to January 31,2020 were collected.Patients with non-sinus rhythm,drugs affecting autonomic nervous activity after PCI treatment,and long-term history of oral β-blockers due to old myocardial infarction were excluded.The sympathetic nerve changes were evaluated according to the difference Δ of the average values of blood pressure and heart rate before and after PCI.The sympathetic nerve activity was divided into two groups:increased sympathetic nerve activity group: the heart rate increased Δ value ≥ 20 beats /min,or systolic blood pressure and diastolic blood pressure increased Δ value ≥ 20 mm Hg before and after PCI,and the sympathetic nerve activity group: the heart rate increased Δvalue < 20 beats / min before and after PCI,and the systolic blood pressure and diastolic blood pressure increased Δ value < 20 mmHg.The subgroup analysis of the enrolled cases from January 1,2020 to January 31,2020 was carried out.The blood pressure and heart rate Δ difference before and after PCI were recorded,and 24-hour ambulatory blood pressure monitoring(ambulatory blood pressure monitoring,ABPM)was completed within 72 hours of onset.Urinary vanillic mandelic acid(vanillyl mandelic acid,VMA)was detected after 24 hours urine was collected on the same day.Excluding adrenal mass,secondary hypertension,malignant tumor and other diseases,or eating phenoxy acids can increase the false positive of urine VMA,such as chocolate,coffee,banana,lemon and other foods.Before and after PCI,the heart rate increased Δ value ≥ 20 beats / min and /or blood pressure increased Δ value ≥ 20 mm Hg,24 hABPM nocturnal blood pressure decrease rate < 10%,and 24-hour urine VMA > 10mg/24 h three indicators of sympathetic nerve activation were divided into three groups: strong positive group,weak positive group and negative group.The occurrence of malignant arrhythmia,new heartfailure,recurrent ischemic events,sudden cardiac death and total adverse cardiovascular events(major adverse cardiovascular events,MACE)in hospital were recorded,and the statistical significance of MACE in each group was analyzed.The relationship between the difference of blood pressure and heart rate before and after PCI as a variable reflecting sympathetic activity and MACE in hospital was evaluated.Results:1.The incidence of malignant arrhythmias in hospital(40.7% vs 19.6%,P <0.05),new heart failure(28.4% vs13.0%,P<0.05),recurrent ischemic events(28.4%vs13.0%,P<0.05)and adverse cardiovascular events in hospital(70.4%vs26.1%,P<0.01)increased significantly in sympathetic activity enhancement group.Although there was no significant difference in cardiogenic death between the two groups,the deaths occurred in the sympathetic activity enhancement group(7.4%vs0.0%,P=0.059>0.05).2.Multivariate Logistics regression analysis showed that Δ value increased(OR=1.124,95%CI:1.053～1.29,P < 0.01),that is,the Δ value of heart rate and blood pressure before and after reperfusion reflected the increase of sympathetic activity,which was a predictor of in-hospital adverse events in patients with STEMI after direct PCI.3.In the combined multi-index subgroup study,the total incidence of MACE events was not the same among the three groups.Pairwise comparison was made among the three groups,and the results showed that there was significant difference in the total adverse cardiovascular events in hospital between the strong positive group and the negative group(P < 0.002 < 0.017).All the three indexes showed that the probability of MACE in the strongly positive group with increased sympathetic activity was significantly higher than that in the group with increased sympathetic activity.4.The comparison of the efficacy of the three indexes showed that the trend of sympathetic activity reflected by the increase of heart rate and blood pressure before and after PCI was similar to that of the relative objective index of 24-hour urinary VMA,and the evaluation effect of combined index on hospital MACE was better(AUC=0.88,P<0.05).Conclusion: The difference of heart rate and blood pressure before and after PCI,as an index for evaluating the increase of sympathetic activity,is a predictor of nosocomial MACE in patients with STEMI after direct PCI.The trend of sympathetic activity reflected by the increase of heart rate and blood pressure Δ before and after PCI is similarto the relatively objective and accurate index of 24-hour urinary VMA,which can reflect that it is related to the occurrence of total MACE,and the evaluation effect of combined index is better.