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      不同方法治療輕度腎功能不全并發(fā)心絞痛患者的臨床觀察

      2014-12-31 22:22:48楊新濱王明毅張宇靜關(guān)紅徐健
      中國當(dāng)代醫(yī)藥 2014年34期
      關(guān)鍵詞:心絞痛

      楊新濱++++++王明毅++++++張宇靜++++++關(guān)紅++++++徐健

      [摘要] 目的 觀察單純藥物與PCI治療輕度腎功能不全合并心絞痛患者的效果及安全性。 方法 回顧性分析2009年1月~2014年6月入院的輕度腎功能不全并發(fā)心絞痛患者,單純藥物治療66例(藥物組),PCI治療68例(PCI組),PCI組檢測入院時(shí)、術(shù)后及出院時(shí)的血肌酐水平,藥物組檢測入院時(shí)及出院時(shí)血肌酐水平及兩組終點(diǎn)事件發(fā)生率。 結(jié)果 PCI組術(shù)后、出院時(shí)血肌酐水平較基線相比差異無統(tǒng)計(jì)學(xué)意義(P>0.5);兩組基線、出院時(shí)血肌酐水平比較差異均無統(tǒng)計(jì)學(xué)意義(P>0.5)。藥物組復(fù)合終點(diǎn)發(fā)生率(16.67%)高于PCI組(4.41%),差異有統(tǒng)計(jì)學(xué)意義(P=0.04)。 結(jié)論 PCI治療與藥物保守治療相比,臨床癥狀緩解率高,雖有造影劑腎病發(fā)生,但急性腎衰及需透析風(fēng)險(xiǎn)不高,較藥物治療對輕度腎功不全的患者更有益。

      [關(guān)鍵詞] 輕度腎功不全;心絞痛;冠脈介入;造影劑腎病

      [中圖分類號] R692 [文獻(xiàn)標(biāo)識碼] A [文章編號] 1674-4721(2014)12(a)-0044-03

      近年研究發(fā)現(xiàn),輕度腎功不全患者心力衰竭、心肌梗死及腦卒中等事件的發(fā)生率明顯高于正常人群,輕度腎功能不全是心血管事件重要的、獨(dú)立的危險(xiǎn)因素[1-3]。冠心病是終末期腎病的重要死因[4],介入診療技術(shù)的推廣明顯改善了冠心病患者的癥狀及預(yù)后,但造影劑對腎功能的損傷成為選擇的障礙。本研究主要探討兩種治療方法的效果。

      1 資料與方法

      1.1 一般資料

      收集本院2009年1月~2014年6月入院治療患者,存在輕度腎功能不全(腎小球?yàn)V過率在60~89 ml/min)的冠心病、心絞痛患者,所有患者診斷符合中華醫(yī)學(xué)會心血管分會頒布《不穩(wěn)定型心絞痛診斷和治療建議》的標(biāo)準(zhǔn)。排除標(biāo)準(zhǔn):心功能Ⅲ級以上,腎小球?yàn)V過率<60 ml/min,急慢性感染、血液透析中,血糖控制不達(dá)標(biāo),惡性腫瘤及造影劑過敏患者。將所有患者分為兩組,單純藥物治療66例(藥物組),PCI治療68例(PCI組),藥物組男性32例,女性34例,平均年齡(61.44±8.64)歲;PCI組男性37例,女性31例,平均年齡(61.45±8.64)歲,水化治療為43.7%,對比劑腎病發(fā)生3例,發(fā)生率為4.41%。兩組患者的年齡、性別、吸煙、危險(xiǎn)因素(糖尿病史、高血壓病史及腦卒中史)等比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。

      1.2 方法

      住院期間兩組均給予抗心絞痛常規(guī)治療,包括阿司匹林、氯吡格雷、硝酸酯類、低分子肝素等藥物。診斷性造影及介入治療均按標(biāo)準(zhǔn)方法[5]進(jìn)行,手術(shù)時(shí)間及術(shù)式不做限制。根據(jù)臨床醫(yī)生對患者病情進(jìn)行評估,根據(jù)患者血管病變特點(diǎn)采用相應(yīng)的導(dǎo)絲和支架。由臨床醫(yī)生自行決定患者是否進(jìn)行水化,如實(shí)施水化,則按下列方案進(jìn)行:術(shù)前及術(shù)后6~12 h給予等滲生理鹽水,以1 ml/(kg·h)的速度進(jìn)行水化。介入治療術(shù)前避免應(yīng)用腎毒性藥物,如利尿劑、非甾體抗炎藥、二甲雙胍等,造影劑為優(yōu)微顯370(德國先靈公司)。

      1.3 觀察指標(biāo)

      收集PCI組患者入院時(shí),術(shù)后第2、3天(取術(shù)后高值)及出院時(shí)的血肌酐水平,藥物組患者收集入院時(shí)及出院時(shí)的血肌酐水平。研究主要終點(diǎn)為非致死性心肌梗死和全因死亡,次要終點(diǎn)為心絞痛再發(fā)。

      1.4 統(tǒng)計(jì)學(xué)處理

      采用SPSS 20.0統(tǒng)計(jì)軟件對數(shù)據(jù)進(jìn)行分析和處理,計(jì)量資料以x±s表示,采用t檢驗(yàn),計(jì)數(shù)資料采用χ2檢驗(yàn)或Fisher確切概率法,以P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

      2 結(jié)果

      2.1 兩組患者治療前后血肌酐水平的比較

      PCI組術(shù)后、出院時(shí)血肌酐水平較基線相比差異無統(tǒng)計(jì)學(xué)意義(P>0.5);兩組基線、出院時(shí)血肌酐水平比較差異均無統(tǒng)計(jì)學(xué)意義(P>0.5)(表1)。

      2.2 兩組患者終點(diǎn)事件發(fā)生率的比較

      兩組全因死亡、非致死性心肌梗死及心絞痛再發(fā)發(fā)生率比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05);藥物組復(fù)合終點(diǎn)發(fā)生率高于PCI組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)(表2)。

      3 討論

      輕度腎功能不全指腎小球?yàn)V過率在60~89 ml/min,臨床癥狀不明顯的人群。研究發(fā)現(xiàn),腎功能不全和冠心病關(guān)系密切,尤其是早期腎功能不全可作為一個(gè)獨(dú)立的冠心病預(yù)測因子[6]。ESC2014指南提出[7],對于合并輕中度腎臟疾病患者,血運(yùn)重建策略的選擇至關(guān)重要,無論選擇PCI還是CABG,獲益都是明顯的。對于PCI可能會引起腎功能損害,甚至?xí)?dǎo)致造影劑腎病,影響一部分腎功能不全患者手術(shù)的選擇。

      造影劑腎病是經(jīng)血管給予碘造影劑48~72 h內(nèi)出現(xiàn)的血肌酐較原有基礎(chǔ)水平升高25%或絕對值升高>0.5 mg/L(44.2 mmol/L),并除外其他急性腎臟損害性疾病[8]。血肌酐可反映腎小球?yàn)V過率變化,能反映腎功能的早期變化情況[9-12]。本研究回顧性分析了134例輕度腎功能不全合并心絞痛患者分別接受藥物及PCI治療后腎功能變化及6個(gè)月全因死亡、非致死性心肌梗死及心絞痛再發(fā)情況,該臨床研究發(fā)現(xiàn),藥物組患者6個(gè)月復(fù)合終點(diǎn)發(fā)生率明顯高于PCI組,差異有統(tǒng)計(jì)學(xué)意義。輕度腎功能不全患者入院期間行介入治療前后腎功能變化差異無統(tǒng)計(jì)學(xué)意義。本研究充分證明PCI治療的有效性,盡管經(jīng)水化治療后仍有3例患者發(fā)生對比劑腎病,但無一例發(fā)生急性腎衰及透析,以上數(shù)據(jù)均提示該治療對于輕度腎功能不全的患者安全有效。

      [參考文獻(xiàn)]

      [1] Henry RM, Kostense PJ,Bos G,et al.Mild renal insufficiency is associated with increased cardiovascular mortality:the hoorn study[J].Kidney Int,2002,62(4):1402-1407.

      [2] Manjunath G,Tighiouart H,Ibrahim H,et al.Level of kidney function as a risk factor for atherosclerotic cardiovascular outcomes in the community[J].J Am Coll Cardiol,2003,41(1):47-55.

      [3] Ritz E,McClellan WM.Overview:increased cardiovascular risk in patients with minor renal dysfunction:an emerging issue with far-reaching consequences[J].J Am Soc Nephrol,2004,15(3): 513-516.

      [4] Zakeri R,F(xiàn)reemantle N,Barnett V,et al.Relation between mild renal dysfunction and outcomes after coronary artery bypass grafting[J].Circulation,2005,112(9 Suppl):I-270-I-275.

      [5] Silber S,Albertsson P,Avilés F F,et al.Guidelines for percutaneous coronary interventions the task force for percutaneous coronary interventions of the European Society of Cardiology[J].Eur Heart J,2005,26(8):804-847.

      [6] Anavekar NS,McMurray JJ,Velazquez EJ,et al.Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction[J].New Engl J Med,2004,351(13):1285-1295.

      [7] Stephan Windecker,Philippe Kolh,F(xiàn)ernando Alfonso,et al.2014 ESC/EACTS Guidelines on myocardial revascularization:The Task Force on Myocardial Revascularization of the European Society of Cardiology(ESC)and the European Association for Cardio-Thoracic Surgery(EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions(EAPCI)[J].Eur Heart J,2014,35(37):2541-2619.

      [8] Mehran R,Aymong ED,Nikolsky E,et al.A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention[J].J Am Coll Cardiol,2004, 44(7):1393-1399.

      [9] Marenzi G,Lauri G,Assanelli E,et al.Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction[J].J Am Coll Cardiol,2004, 44(9):1780-1785.

      [10] McCullough PA,Sandberg KR.Epidemiology of contrast-induced nephropathy[J].Rev Cardiovasc Med,2003,4(Suppl 5):S3-S9.

      [11] Marenzi G,Lauri G,Assanelli E,et al.Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction[J].J Am Coll Cardiol,2004,44(9):1780-1785.

      [12] Thomsen HS.Guidelines for contrast media from the European Society of Urogenital Radiology[J].AJR Am J Roent-genol,2003,181(6):1463-1471.

      (收稿日期:2014-10-14 本文編輯:李亞聰)

      [2] Manjunath G,Tighiouart H,Ibrahim H,et al.Level of kidney function as a risk factor for atherosclerotic cardiovascular outcomes in the community[J].J Am Coll Cardiol,2003,41(1):47-55.

      [3] Ritz E,McClellan WM.Overview:increased cardiovascular risk in patients with minor renal dysfunction:an emerging issue with far-reaching consequences[J].J Am Soc Nephrol,2004,15(3): 513-516.

      [4] Zakeri R,F(xiàn)reemantle N,Barnett V,et al.Relation between mild renal dysfunction and outcomes after coronary artery bypass grafting[J].Circulation,2005,112(9 Suppl):I-270-I-275.

      [5] Silber S,Albertsson P,Avilés F F,et al.Guidelines for percutaneous coronary interventions the task force for percutaneous coronary interventions of the European Society of Cardiology[J].Eur Heart J,2005,26(8):804-847.

      [6] Anavekar NS,McMurray JJ,Velazquez EJ,et al.Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction[J].New Engl J Med,2004,351(13):1285-1295.

      [7] Stephan Windecker,Philippe Kolh,F(xiàn)ernando Alfonso,et al.2014 ESC/EACTS Guidelines on myocardial revascularization:The Task Force on Myocardial Revascularization of the European Society of Cardiology(ESC)and the European Association for Cardio-Thoracic Surgery(EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions(EAPCI)[J].Eur Heart J,2014,35(37):2541-2619.

      [8] Mehran R,Aymong ED,Nikolsky E,et al.A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention[J].J Am Coll Cardiol,2004, 44(7):1393-1399.

      [9] Marenzi G,Lauri G,Assanelli E,et al.Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction[J].J Am Coll Cardiol,2004, 44(9):1780-1785.

      [10] McCullough PA,Sandberg KR.Epidemiology of contrast-induced nephropathy[J].Rev Cardiovasc Med,2003,4(Suppl 5):S3-S9.

      [11] Marenzi G,Lauri G,Assanelli E,et al.Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction[J].J Am Coll Cardiol,2004,44(9):1780-1785.

      [12] Thomsen HS.Guidelines for contrast media from the European Society of Urogenital Radiology[J].AJR Am J Roent-genol,2003,181(6):1463-1471.

      (收稿日期:2014-10-14 本文編輯:李亞聰)

      [2] Manjunath G,Tighiouart H,Ibrahim H,et al.Level of kidney function as a risk factor for atherosclerotic cardiovascular outcomes in the community[J].J Am Coll Cardiol,2003,41(1):47-55.

      [3] Ritz E,McClellan WM.Overview:increased cardiovascular risk in patients with minor renal dysfunction:an emerging issue with far-reaching consequences[J].J Am Soc Nephrol,2004,15(3): 513-516.

      [4] Zakeri R,F(xiàn)reemantle N,Barnett V,et al.Relation between mild renal dysfunction and outcomes after coronary artery bypass grafting[J].Circulation,2005,112(9 Suppl):I-270-I-275.

      [5] Silber S,Albertsson P,Avilés F F,et al.Guidelines for percutaneous coronary interventions the task force for percutaneous coronary interventions of the European Society of Cardiology[J].Eur Heart J,2005,26(8):804-847.

      [6] Anavekar NS,McMurray JJ,Velazquez EJ,et al.Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction[J].New Engl J Med,2004,351(13):1285-1295.

      [7] Stephan Windecker,Philippe Kolh,F(xiàn)ernando Alfonso,et al.2014 ESC/EACTS Guidelines on myocardial revascularization:The Task Force on Myocardial Revascularization of the European Society of Cardiology(ESC)and the European Association for Cardio-Thoracic Surgery(EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions(EAPCI)[J].Eur Heart J,2014,35(37):2541-2619.

      [8] Mehran R,Aymong ED,Nikolsky E,et al.A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention[J].J Am Coll Cardiol,2004, 44(7):1393-1399.

      [9] Marenzi G,Lauri G,Assanelli E,et al.Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction[J].J Am Coll Cardiol,2004, 44(9):1780-1785.

      [10] McCullough PA,Sandberg KR.Epidemiology of contrast-induced nephropathy[J].Rev Cardiovasc Med,2003,4(Suppl 5):S3-S9.

      [11] Marenzi G,Lauri G,Assanelli E,et al.Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction[J].J Am Coll Cardiol,2004,44(9):1780-1785.

      [12] Thomsen HS.Guidelines for contrast media from the European Society of Urogenital Radiology[J].AJR Am J Roent-genol,2003,181(6):1463-1471.

      (收稿日期:2014-10-14 本文編輯:李亞聰)

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