中国血液净化

中国血液净化 ›› 2013, Vol. 12 ›› Issue (03): 130-133.

• 临床研究 • 上一篇    下一篇

CRRT对急性心肌梗死后心功能不全低血压状态患者疗效分析

宋艳东,李志忠,张京梅   

  1. 首都医科大学附属北京安贞医院
  • 收稿日期:2012-10-22 修回日期:2013-01-14 出版日期:2013-03-12 发布日期:2015-10-08
  • 通讯作者: 宋艳东 E-mail:syd022@sohu.com

Efficacy evaluation of continuous renal replacement therapy for patients with cardiac insufficiency in conjunction with hypotension after acute myocardial infarction

  • Received:2012-10-22 Revised:2013-01-14 Online:2013-03-12 Published:2015-10-08

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摘要： 目的：探讨持续性肾脏替代治疗（continuous renal replacement therapy ，CRRT）对急性心肌梗死后心功能不全伴低血压状态患者的疗效分析。方法：收集2008 年6 月—2011年12月在我院住院的急性心肌梗死患者，共281例，其中92例患者在急诊介入治疗、开通罪犯血管后出现急性心功能不全、低血压状态，并有急性左心衰发作，患者心功能按Killip分级为II-III级。全部心衰患者首先采用内科常规治疗，并随机分为两组，一组继续标准药物治疗，静脉补液、血管活性药物支持、利尿剂以减轻心脏前后负荷。另一组在静脉补液、血管活性药物支持下行CRRT治疗。探索CRRT对急性心肌梗死后心功能不全低血压状态患者的疗效。结果：46例常规药物治疗患者，经过积极补液，血管活性药物支持，静脉应用利尿剂及对症治疗，心功能较前逐渐改善，急性左心衰发作次数逐渐减少，电解质逐渐维持于正常水平，但改善情况均较CRRT组缓慢。 4例患者于1月内死于心源性猝死。标准治疗组平均重症监护时间为30.75±6.68天，一个月死亡率8.7%，平均住院时间38±7.61天。出院后继续严格药物治疗，根据病情强心并改善心肌重塑，随访至发病后一年，15.22%（7/46）患者间断有劳累性呼吸困难及阵法夜间呼吸困难。46例行CRRT患者中，2例因血小板进行性减少而中止CRRT，停止CRRT后患者血小板逐渐恢复至8×109/L。血压过低患者给予补液，血管活性药物支持。1例因收缩压低于90 mmHg且有脏器灌注不足临床表现,末梢循环差,肢端皮肤湿冷,少尿,终止CRRT。43例行CRRT患者生命体征平稳，心衰症状明显减轻。CRRT治疗后血电解质较治疗前显著改善，BNP、CRP明显降低（P<0.05），一周后复测LVEF有所改善（P<0.05），超滤液BNP水平极低,且差异无统计学意义(P>0?05)。2例患者于住院1月内死于心源性猝死，其余41例，均在住院20-39天后出院，随访至发病后1年，心功能无恶化，无需长期透析。CRRT组平均重症监护时间22.5±4.48天，一个月死亡率4.35%，平均住院时间30±4.68天。出院后继续严格药物治疗，根据病情强心并改善心肌重塑，随访一年，无心衰再次发作，心功能无恶化，无需长期透析。两组患者一个月死亡率、平均重症监护时间、平均住院时间均有显著差异（P<0.05）。随访一年中，再发心衰患者人数有显著差异。结论：急性心肌梗死后心功能不全并发低血压状态的患者行CRRT是一种相对安全而有效的治疗方法。不仅能在较短时间内稳定内环境，而且能干预心肌梗死后左心衰的发展和预后，使平均重症监护时间、平均住院时间、1年随访期间心衰发生率显著降低。

关键词: 急性心肌梗死, 急性心功能不全, 低血压状态, 持续性肾脏替代治疗( CRRT)

Abstract: Objective: The aim of this study was to evaluate the efficacy of continuous renal replacement therapy (CRRT) for patients with cardiac insufficiency in conjunction with hypotension after acute myocardial infarction (AMI). Method: We collected patients who had AMI in our hospital from June 2008 to December 2011. After primary percutaneous coronary intervention (PCI), 92 patients presented with cardiac insufficiency, hypotension, and acute left heart failure. All heart failure patients received routine internal treatment at first, and were randomly divided into two groups. One in which patients continued medications and another in which patients applied CRRT. Result: The cardiac function of 46 patients who received standard drug therapy gradually improved. However, compared with the CRRT group, the improvement was slow. In the 46 patients who received CRRT, 2 cases stopped CRRT due to progressive decrease of platelets. One patient with systolic blood pressure lower than 90 mmHg, clinical manifestations of organ hypoperfusion, poor peripheral circulation, cool clammy skin and oliguria, terminated CRRT. Vital signs of the 43 patients who underwent CRRT were stable. The symptoms of heart failure were significantly relieved. After CRRT, the serum electrolytes significantly improved. A week after, left ventricular ejection fraction (LVEF) also improved. The differences of the two groups in one month mortality, mean time with intensive care and mean hospital stay were significant. The numbers of patients with recurrent heart failure during one year follow-up were also significantly different. Conclusion: CRRT is a relatively safe and effective strategy for patients with cardiac insufficiency and hypotension after AMI.

Key words: acute myocardial infarction, acute cardiac insufficiency, hypotension, continuous renal replacement therapy