目的 探討重組人尿激酶原與替羅非班聯(lián)用病灶內(nèi)或冠脈內(nèi)對(duì)ST段抬高型心肌梗死（STEMI）急診經(jīng)皮冠狀動(dòng)脈介入治療（PCI）患者術(shù)后心肌微循環(huán)、血管內(nèi)皮功能和血清心肌酶、白細(xì)胞介素-18（IL-18）、基質(zhì)金屬蛋白酶-9（MMP-9）、丙二醛（MDA）水平的影響。方法 回顧性選擇 2018 年 7 月—2021 年 10 月于合肥市第八人民醫(yī)院接受急診 PCI 治療的 120 例STEMI患者作為研究對(duì)象，根據(jù)治療方案不同分為對(duì)照組（n＝60）和試驗(yàn)組（n＝60）。其中試驗(yàn)組于病灶內(nèi)聯(lián)用重組人尿激酶原與替羅非班治療，對(duì)照組則于冠脈內(nèi)聯(lián)用重組人尿激酶原與替羅非班治療。分別于急診PCI前后比較兩組患者的心肌梗死溶栓治療（TIMI）血流分級(jí)、TIMI心肌灌注分級(jí)（TMPG）以及校正TIMI血流幀數(shù)計(jì)數(shù)（cTFC）。記錄術(shù)后24 h內(nèi)兩組心肌酶［肌酸激酶及其同工酶（CK、CK-MB）、心肌肌鈣蛋白T（cTnT）］峰值。分別于急診PCI術(shù)前和術(shù)后24 h、7 d時(shí)檢測(cè)兩組患者的血管內(nèi)皮功能指標(biāo)［內(nèi)皮素-1（ET-1）、一氧化氮（NO）］以及血清 IL-18、MMP-9、MDA水平。統(tǒng)計(jì)兩組急診 PCI術(shù)后 6個(gè)月隨訪期間主要不良心腦血管事件（MACCE）發(fā)生情況，以及住院期間出血事件發(fā)生率。結(jié)果 試驗(yàn)組急診 PCI術(shù)后即刻 TIMI 3級(jí)、TMPG 3級(jí)患者占比（96.67%、95.00%）均顯著高于對(duì)照組（86.67%、83.33%，P＜0.05）。兩組急診PCI術(shù)后即刻cTFC均較術(shù)前顯著降低（P＜0.05），且以試驗(yàn)組下降更顯著（P＜0.05）。兩組術(shù)后24 h內(nèi)各項(xiàng)心肌酶指標(biāo)（LDH、CK、CK-MB）的峰值均較術(shù)前顯著升高（P＜0.05），且試驗(yàn)組術(shù)后 24 h 內(nèi)各項(xiàng)心肌酶指標(biāo)（LDH、CK、CK-MB）的峰值均顯著低于對(duì)照組（P＜0.05）。與術(shù)前相比，兩組術(shù)后24 h血清ET-1、IL-18、MMP-9、MDA水平均顯著升高（P＜0.05），術(shù)后7 d以上指標(biāo)則均顯著降低（P＜0.05）。兩組術(shù)后24 h血清NO濃度均較術(shù)前顯著下降（P＜0.05），而術(shù)后7 d均較術(shù)前顯著升高（P＜0.05）。且術(shù)后24 h、7 d，試驗(yàn)組血清ET-1、IL-18、MMP-9、MDA水平均顯著低于同期對(duì)照組（P＜0.05），血清NO濃度則均顯著高于同期對(duì)照組（P＜0.05）。6個(gè)月隨訪期間，試驗(yàn)組MACCE發(fā)生率（5.00%）比對(duì)照組（16.67%）顯著降低（P＜0.05）。住院期間，試驗(yàn)組出血事件發(fā)生率（6.67%）與對(duì)照組（10.00%）比較，差異無統(tǒng)計(jì)學(xué)意義（P＞0.05）。結(jié)論 病灶內(nèi)或冠脈內(nèi)聯(lián)用重組人尿激酶原與替羅非班均能改善STEMI急診PCI患者術(shù)后心肌微循環(huán)，減輕血管內(nèi)皮損傷及心肌損傷，降低機(jī)體炎癥及氧化應(yīng)激水平，但病灶內(nèi)給藥的效果更為明顯。

Objective Human recombinant urokinase original and for class had combination of different dosage of ST segment elevation myocardial infarction (STEMI) emergency percutaneous coronary intervention (PCI) in patients with postoperative myocardial microcirculation, endothelial function and serum myocardial enzymes, interleukin (IL) - 18, matrix metalloproteinases 9 (MMP-9), malondialdehyde (MDA). Methods 120 STEMI patients who received emergency PCI in The Eighth People's Hospital from July 2018 to October 2021 were selected as the research objects and divided into observation group (n= 60) and control group (n=60) according to the random number table method. The observation group was treated with recombinant prourokinase and tirofiban in the lesion, while the control group was treated with recombinant prourokinase and tirofiban in the coronary artery. Thrombolysis in myocardial infarction (TIMI) blood flow grade, TIMI myocardial perfusion grade (TMPG) and corrected TIMI blood flow frame count (cTFC) were compared between the two groups before and after emergency PCI. The peak values of myocardial enzymes [creatine kinase and its isoenzyme (CK and CK-MB), cardiac troponin T (cTnT)] in the two groups were recorded within 24 hours after operation.The vascular endothelial function indexes [endothelin-1 (ET-1), nitric oxide (NO)] and serum levels of IL-18, MMP- 9 and MDA were detected before and 24 h and 7 d after emergency PCI. The incidence of major adverse cardiovascular and cerebrovascular events (MACCE) and the incidence of bleeding events in the two groups during the six-month follow-up after emergency PCI were analyzed. Results The proportion of TIMI grade three and TMPG grade three in the observation group after emergency PCI (96.67% , 95.00%) were significantly higher than those in the control group (86.67%, 83.33%, P＜0.05). The cTFC of the two groups immediately after PCI was significantly lower than that before PCI (P＜0.05), and the decrease was more significant in the observation group (P＜0.05).Within 24 h after operation, the peak values of various myocardial enzyme indexes (CK, CK-MB, cTnT) in the observation group were significantly lower than those in the control group (P＜0.05). Compared with before operation, the serum levels of ET-1, IL-18, MMP-9 and MDA in the two groups were significantly increased at 24 h after operation (P＜0.05), and the indexes above 7 d after operation were significantly decreased (P＜0.05).The serum NO concentration of the two groups at 24 h after operation was significantly decreased compared with that before operation (P＜0.05), and the serum NO concentration at 7 d after operation was significantly increased compared with that before operation (P＜0.05). At 24 h and 7 d after operation, the serum levels of ET-1, IL-18, MMP-9 and MDA in the observation group were significantly lower than those in the control group (P＜0.05), and the serum concentration of NO in the observation group was significantly higher than that in the control group (P＜0.05). During the 6-month follow-up, the incidence of MACCE in the observation group was significantly lower than that in the control group (5.00% vs 16.67%, P＜0.05). During hospitalization, the incidence of bleeding events in the observation group was 6.67% vs 10.00% in the control group, and the difference was not statistically significant (P＞0.05). Conclusions Intralesional or intracoronary administration of recombinant prourokinase and tirofiban can improve myocardial microcirculation, reduce vascular endothelial injury and myocardial injury, and reduce the level of inflammation and oxidative stress in patients with STEMI after emergency PCI, but intralesional administration is more effective.

R972

合肥職業(yè)技術(shù)學(xué)院重點(diǎn)項(xiàng)目（2023FSYYKJA01）