入院前对性心肌梗死患者进行远程缺血预处理，作为血管成形术的补充，以及对心肌挽救的影响：一项随机试验

入院前对性心肌梗死患者进行远程缺血预处理，作为血管成形术的补充，以及对心肌挽救的影响：一项随机试验

贵州医科大学     麻醉与心脏电生理课题组

翻译：陈锐 编辑：张中伟  审核：曹莹

罂 粟 摘 要 

背景：远程缺血预处理可减轻择期手术和血管成形术中的心脏损伤。 本文验证了以下假设，即在ST段抬高心肌梗塞期间，并在初次经皮冠状动脉介入治疗之前进行远程缺血调节，可减轻心肌损伤。

方法：333名疑似首次急性心肌梗死的成年患者随机以 1:1 的比例分配，166名患者接受经皮冠状动脉介入治疗167名患者接受远程缺血预处理（间歇性手臂缺血：通过四个周期的 5分钟充气和5分钟的血压袖带放气）。 分配通过不透明的密封信封隐藏。患者在转运到医院期间接受远段缺血调节，并在医院进行初级经皮冠状动脉介入治疗。 主要结果指标是初次经皮冠状动脉介入治疗后30天的心肌挽救指数，通过心肌灌注成像测量治疗挽救的风险区域的比例； 分析是按照协议进行的。 该研究已在ClinicalTrials.gov 注册，编号为：NCT00435266。

结果：

82名患者在到达医院时因不符合纳入标准被排除，32名患者失访，77名患者未完成对挽救指数数据的随访。 远段缺血预处理调节组的中位挽救指数为0.75（IQR 0.50–0.93，n=73），对照组为0.55（0·35–0·88，n=69），中位值0.10 的差异（95% CI 0·01–0·22；p=0·0333）； 平均挽救指数为0.69 (SD 0.27) 与 0.57 (0.26)，平均差异为0.12 (95% CI 0·01–0·21；p=0·0333)。 主要不良冠状动脉事件是死亡（每组n = 3）、再梗死（每n = 1）和心力衰竭（每组n =3）。

结论：入院前进行远程缺血预处理可增加心肌挽救率，并具有良好的安全性。 本研究结果需要进行更大规模样本的试验，以确定远端缺血调节对临床结果的影响。

原始文献来源：Bøtker H E, Kharbanda R, Schmidt M R, et al. Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: A randomised Trial[J]. The Lancet, 2010, 375(9716): 727–734.

英文原文 

Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: A randomised Trial

Background：Remote ischaemic preconditioning attenuates cardiac injury at elective surgery and angioplasty. We tested the hypothesis that remote ischaemic conditioning during evolving ST-elevation myocardial infarction, and done before primary percutaneous coronary intervention, increases myocardial salvage.

Methods ：333 consecutive adult patients with a suspected first acute myocardial infarction were randomly assigned in a 1:1 ratio by computerised block randomisation to receive primary percutaneous coronary intervention with (n=166 patients) versus without (n=167) remote conditioning (intermittent arm ischaemia through four cycles of 5-min inflation and 5-min deflation of a blood-pressure cuff). Allocation was concealed with opaque sealed envelopes. Patients received remote conditioning during transport to hospital, and primary percutaneous coronary intervention in hospital. The primary endpoint was myocardial salvage index at 30 days after primary percutaneous coronary intervention, measured by myocardial perfusion imaging as the proportion of the area at risk salvaged by treatment; analysis was per protocol. This study is registered with ClinicalTrials.gov, number NCT00435266.

Findings ：82 patients were excluded on arrival at hospital because they did not meet inclusion criteria, 32 were lost to follow-up, and 77 did not complete the follow-up with data for salvage index. Median salvage index was 0·75 (IQR 0·50–0·93, n=73) in the remote conditioning group versus 0·55 (0·35–0·88, n=69) in the control group, with median difference of 0·10 (95% CI 0·01–0·22; p=0·0333); mean salvage index was 0·69 (SD 0·27) versus 0·57 (0·26), with mean difference of 0·12 (95% CI 0·01–0·21; p=0·0333). Major adverse coronary events were death (n=3 per group), reinfarction (n=1 per group), and heart failure (n=3 per group).

 Interpretation ：Remote ischaemic conditioning before hospital admission increases myocardial salvage, and has a favourable safety profile. Our findings merit a larger trial to establish the effect of remote conditioning on clinical outcomes.

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