摘要：
Objective To analyze clinical characteristics of patients with acute ST segment elevation myocardial infarction(STEMI) with in-hospital high-degree atrioventricular block (HAVB) occurrence.Methods Totally 2 343 cases with STEMI from August 2011 to August 2013 were retrospectively analyzed.According to the occurrence of HAVB,all patients were divided into HAVB group(93 cases) and non-HAVB group(2 250 cases).Clinical data,coronary artery lesions,arhythmia occurrences and major clinical events were recorded,to analyzed the clinical charactcristics of patients with in-hospital HAVB.Results In HAVB group,age[(63 ± 12)years vs (58 ± 12)years,P ＜ 0.001],the proportion of Killip Ⅲ-Ⅳ [50.5％ (47/93) vs 14.0％ (314/2 250),P ＜ 0.001] and the proportion of inferior and right ventricular infarction[68.8％ (64/93) vs 22.7％ (510/2 250),P ＜0.001] were significantly higher than those in non-HAVB group;systolic blood pressure [(101 ± 25) mmHg vs (119 ± 34) mmHg,P ＜ 0.001],diastolic blood pressure[(62 ± 16) mmHg vs (73 ± 14) mmHg,P ＜ 0.001],estimated glomerular filtration rate [71.6 (49.5,95.3) ml/(min · 1.73 m2) vs 88.7 (71.3,107.6) ml/(min · 1.73 m2),P ＜ 0.001] and left ventricular ejection fractions [(51 ± 1 0) ％ vs (53 ± 13) ％,P =0.045] were significantly lower than those in non-HAVB group.For treatment,proportions of using diuretics,vasoactive drugs and intraaortic balloon counterpulsation in HAVB group were significantly higher than those in non-HAVB group [32.3％ (30/93) vs 17.4％ (389/2 250),31.2％ (29/93) vs 10.0％ (224/2 250),66.3％ (61/93) vs 23.3％ (521/2 250)] (all P ＜0.001).Incidences of cardiac shock and sustained ventricular tachycardia or ventficular fibrillation in HAVB group were significantly higher than those in non-HAVB group [38.7％ (36/93) vs 7.0％ (157/2 250),26.9％ (25/93) vs 7.0％ (158/2 250)] (P ＜ 0.001).In-hospital mortality had no significant difference between groups(P ＞ 0.05).Binomial logistic regression analysis showed that diabetes,Killip Ⅲ-Ⅳ,left ventricular ejection fraction,inferior and right ventricular infarctions and using vasoactive drugs were risk factors of in-hospital mortality in patients with HAVB (all P ＜ 0.05);emergency percutaneous coronary intervention and using angiotensin converting enzyme inhibitors/angiotensin Ⅱ receptor antagonists were protective factors of in-hospital mortality in HAVB patients (all P ＜ 0.05).Conclusions Myocardial infarctions are mainly acute inferior and right ventricular myocardial infarctions.Although in-hospital mortality shows no significant increase in HAVB patients,incidences of cardiac shock and sustained ventricular tachycardia or ventricular fibrillation significant increase.%目的 分析院内发生高度房室传导阻滞(HAVB)的急性ST段抬高型心肌梗死(STEMI)患者临床特点以及HAVB对患者院内短期预后的影响.方法 连续收集2011年8月至2013年8月首都医科大学附属北京安贞医院心内科监护病房收治的2 343例急性STEMI患者的临床资料进行回顾性分析.根据是否发生院内HAVB,将患者分为HAVB组(93例)与无HAVB组(2 250例).记录患者基线资料、冠状动脉病变情况、心电监护和心电图记录的心律失常以及院内发生的主要临床事件,分析院内发生HAVB患者的临床特点.结果 与无HAVB组相比,HAVB组患者年龄更大[(63±12)岁比(58±12)岁,P＜0.001],入院时收缩压与舒张压更低[(101±25) mmHg(1 mmHg=0.133 kPa)比(119±34) mmHg、(62±16) mmHg比(73±14) mmHg,P＜0.001],心功能Killip分级Ⅲ～Ⅳ级患者比例更大[50.5％ (47/93)比14.0％ (314/2 250),P＜0.001],估算肾小球滤过率更低[71.6 (49.5,95.3) ml/(min · 1.73 m2)比88.7(71.3,107.6) ml/(min·1.73 m2),P＜0.001],左心室射血分数更低[(51 ±10)％比(53±13)％,P=0.045)].HAVB组梗死区域更多为下壁±有心室[68.8％ (64/93)比22.7％ (510/2 250),P＜0.001].治疗方面,HAVB组住院期间应用静脉利尿剂、血管活性药物,应用主动脉内球囊反搏辅助的患者比例均大于无HAVB组[32.3％(30/93)比17.4％ (389/2 250)、31.2％ (29/93)比10.0％ (224/2 250)、66.3％ (61/93)比23.3％ (521/2 250),均P＜0.001].HAVB组院内心源性休克、持续性室性心动过速或心室颤动发生率大于无HAVB组[38.7％(36/93)比7.0％(157/2 250)、26.9％ (25/93)比7.0％(158/2 250),P＜0.001];而院内病死率2组差异无统计学意义(P＞0.05).二分类Logistic回归分析提示糖尿病、心功能Killip分级Ⅲ～Ⅳ级、左心室射血分数(每减低10％)、下壁±有心室心肌梗死、应用血管活性药物是与死亡相关的危险因素(均P＜0.05),而进行急诊经皮冠状动脉介入治疗以及能够应用血管紧张素转换酶抑制剂/血管紧张素Ⅱ受体拮抗剂为与死亡相关的保护因素(均P＜0.05).结论 院内发生HAVB的急性STEMI患者年龄较高,心功能、肾功能较差,且多为急性下壁及右心室心肌梗死.虽然伴发院内HAVB的患者院内病死率并未见明显升高,但发生心源性休克及持续性室性心动过速或心室颤动比例明显增加.
