ST段抬高型心肌梗死患者经皮冠状动脉介入治疗后QT离散度与再灌注和住院并发症的关系

摘要(中文译文)

急性心肌梗死是全球主要死亡原因之一，其死亡率主要源于心律失常、心源性休克和心力衰竭等并发症，这些并发症与再灌注治疗的成功与否密切相关。在心电图（ECG）参数中，QT间期反映心室均质性并预测电不稳定性。QT离散度（QTd）即最大与最小校正QT（QTc）间期之差，与致命性心律失常相关。然而，再灌注治疗对QTd的影响仍存在争议。尽管成功再灌注是ST段抬高型心肌梗死（STEMI）预后的主要决定因素，但即使冠状动脉血流恢复，心律失常、心源性休克和心力衰竭等不良并发症仍可能发生。目前尚无特定标志物能可靠预测这些不良事件。评估QTd可能为直接经皮冠状动脉介入治疗（PPCI）后心肌电学恢复提供额外的预后信息。本研究旨在评估STEMI患者PPCI后QTd与再灌注状态及院内并发症之间的关联。共纳入108例接受PPCI的STEMI患者。于PPCI后1小时记录12导联心电图，采用斜率截距法手动测量12个导联的QT间期。QTc间期采用Fridericia公式计算。QTd计算为最大与最小QTc间期之差。平均QTd为67.68 ± 37.88毫秒（ms）。QTd分为两组：>50 ms和≤50 ms。再灌注通过ST段回落（STR）和心肌梗死溶栓（TIMI）血流评估。在QTd >50 ms组中，32%的患者STR ≥70%，68%的患者STR <70%。在QTd ≤50 ms组中，约46.6%的患者STR ≥70%，53.4%的患者STR <70%。这表明QTd与STR之间无统计学显著关联（p = 0.123）。由于样本量小和时间限制，仅2例患者TIMI血流为2级，其余患者TIMI血流为3级。QTd与TIMI血流分级之间未观察到统计学显著性（p = 1.000）。心源性休克、心力衰竭和射血分数（EF）降低在QTd >50 ms组中更常见，分别占48%、12%和52%。在QTd ≤50 ms组中，仅5.2%发生心源性休克，19%存在EF降低但无有症状的心力衰竭。QTd与心源性休克、EF降低及有症状心力衰竭之间存在显著关联，p值分别为0.001、0.001和0.008。QTd与心源性休克、心力衰竭及EF低于50%之间存在显著关联。室性心动过速和梗死后心绞痛发生于QTd >50 ms组，尽管由于样本量有限未达统计学显著性。QTd可能反映心肌电不稳定性，或可作为识别院内不良并发症较高风险患者的无创工具。

Abstract

Acute myocardial infarction is one of the leading causes of death worldwide, with mortality primarily resulting from complications such as arrhythmia, cardiogenic shock, and heart failure, which are closely related to the success of reperfusion therapy. Among electrocardiogram (ECG) parameters, the QT interval reflects ventricular homogeneity as well as predicts electrical instability. QT dispersion (QTd), the difference between maximum and minimum corrected QT (QTc) intervals, is associated with fatal cardiac arrhythmia. However, the effect of reperfusion therapy on QTd remains controversial. Although successful reperfusion is a major determinant of outcome in ST-segment elevation myocardial infarction (STEMI), adverse complications such as arrhythmia, cardiogenic shock, and heart failure may still occur despite restoration of coronary blood flow. Currently, no specific marker can reliably predict these adverse events. Assessment of QTd may provide additional prognostic information regarding myocardial electrical recovery following primary percutaneous coronary intervention (PPCI). This study aimed to evaluate the association between QTd after PPCI and reperfusion status as well as in-hospital complications among patients with STEMI. A total of 108 STEMI patients who underwent PPCI were enrolled. A 12-lead ECG was recorded one hour after PPCI, and QT intervals from 12 leads were manually measured using the slope-intercept method. The QTc interval was calculated using the Fridericia formula. QTd was calculated as the difference between the maximum and minimum QTc intervals. The mean QTd was 67.68 ± 37.88 milliseconds (ms). QTd was categorized into two groups: >50 ms and ≤50 ms. Reperfusion was measured by ST-segment resolution (STR) and thrombolysis in myocardial infarction (TIMI) flow. In the QTd >50 ms group, 32% had STR ≥70%, while 68% had STR <70%. About 46.6% of the QTd ≤50 ms group had STR ≥70%, whereas 53.4% had STR <70%. This demonstrated that there was no statistically significant association between QTd and STR (p = 0.123). Due to the small sample size and time limitation, only two patients had TIMI 2 flow, whereas the remaining patients had TIMI 3 flow. No statistical significance was observed between QTd and TIMI flow grade (p = 1.000). Cardiogenic shock, heart failure, and reduced ejection fraction (EF) were more frequently observed in the QTd >50 ms group, accounting for 48%, 12%, and 52%, respectively. In the QTd ≤50 ms group, only 5.2% had cardiogenic shock, and 19% had reduced EF but no symptomatic heart failure. There was a significant association between QTd and cardiogenic shock, reduced EF, and symptomatic heart failure with p = 0.001, p = 0.001, and p = 0.008, respectively. There was a significant association between QTd and cardiogenic shock, heart failure, and an EF of less than 50%. Ventricular tachycardia and post-infarction angina occurred in the QTd >50 ms group, despite the lack of statistical significance due to the limited sample size. QTd may reflect electrical instability of the myocardium and could be a non-invasive tool to identify patients at higher risk of adverse in-hospital complications.

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