經(jīng)橈動(dòng)脈入徑直接經(jīng)皮冠狀動(dòng)脈介入治療術(shù)聯(lián)合替羅非班治療急性ST段抬高型心肌梗死的臨床療效研究

張 麗，丁世芳，蔣桔泉，陳志楠，盧 青，付文波，彭 毅

·論著·

經(jīng)橈動(dòng)脈入徑直接經(jīng)皮冠狀動(dòng)脈介入治療術(shù)聯(lián)合替羅非班治療急性ST段抬高型心肌梗死的臨床療效研究

張 麗，丁世芳，蔣桔泉，陳志楠，盧 青，付文波，彭 毅

目的 探討經(jīng)橈動(dòng)脈入徑直接經(jīng)皮冠狀動(dòng)脈介入治療(PCI)術(shù)聯(lián)合替羅非班治療急性ST段抬高型心肌梗死(STEMI)的臨床療效。方法 選取2014年2月—2015年2月在廣州軍區(qū)武漢總醫(yī)院成功行急診PCI術(shù)的STEMI患者95例。根據(jù)入徑方式，將其分為經(jīng)股動(dòng)脈入徑組(n=45)和經(jīng)橈動(dòng)脈入徑組(n=50)。比較兩組的穿刺成功率、PCI術(shù)成功率，術(shù)后遠(yuǎn)端血流心肌梗死溶栓試驗(yàn)(TIMI)血流分級(jí)、血紅蛋白下降幅度，術(shù)后1 h 心電圖ST段回落≥50%比例，術(shù)后1周左心室射血分?jǐn)?shù)(LVEF)，術(shù)后出血情況，術(shù)后入住冠心病重癥監(jiān)護(hù)室(CCU)時(shí)間、總住院時(shí)間，住院期間及隨訪6個(gè)月內(nèi)主要心血管事件(MACE)發(fā)生情況，歐洲生命質(zhì)量量表(EQ-5D)評(píng)價(jià)情況。結(jié)果 兩組穿刺成功率、PCI術(shù)成功率比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。兩組術(shù)后TIMI血流分級(jí)、術(shù)后血紅蛋白下降幅度、術(shù)后1 h心電圖ST段回落≥50%比例、術(shù)后1周LVEF比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。兩組術(shù)后TIMI輕度出血比例比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；而TIMI重度出血比例比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。兩組入住CCU時(shí)間、總住院時(shí)間比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。住院期間及隨訪6個(gè)月內(nèi)，兩組MACE發(fā)生率比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。EQ-5D評(píng)價(jià)中，兩組行動(dòng)能力、日常活動(dòng)能力及焦慮/抑郁3個(gè)維度比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；而自我照顧能力、疼痛/不適2個(gè)維度比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論 經(jīng)橈動(dòng)脈入徑直接PCI術(shù)聯(lián)合替羅非班治療STEMI的臨床療效較好，可以縮短患者入住CCU時(shí)間和總住院時(shí)間，降低術(shù)后TIMI重度出血比例，改善患者預(yù)后和生活質(zhì)量，值得在臨床上推廣應(yīng)用。

心肌梗死；血管成形術(shù)，氣囊，冠狀動(dòng)脈；替羅非班；治療結(jié)果

張麗，丁世芳，蔣桔泉，等.經(jīng)橈動(dòng)脈入徑直接經(jīng)皮冠狀動(dòng)脈介入治療術(shù)聯(lián)合替羅非班治療急性ST段抬高型心肌梗死的臨床療效研究[J].中國(guó)全科醫(yī)學(xué)，2016，19(10)：1156-1160.[www.chinagp.net]

Zhang L,Ding SF,Jiang JQ,et al.Clinical effect of trans-radial primary percutaneous coronary intervention combined with tirofiban in patients with acute ST-elevation myocardial infarction[J].Chinese General Practice，2016，19(10)：1156-1160.

急性心肌梗死(AMI)是冠心病患者的主要死亡原因之一，臨床治療原則為盡早開通梗死動(dòng)脈，恢復(fù)冠狀動(dòng)脈血流灌注，挽救瀕死心肌，縮小梗死心肌范圍。循證醫(yī)學(xué)證據(jù)表明，及時(shí)再灌注治療可明顯改善AMI患者的預(yù)后情況，降低患者病死率和再梗死發(fā)生率[1-2]，而直接經(jīng)皮冠狀動(dòng)脈介入治療(PCI)術(shù)開創(chuàng)了AMI現(xiàn)代治療的新紀(jì)元。AMI患者多處于高凝、高血栓負(fù)荷狀態(tài)，聯(lián)合應(yīng)用抗凝、抗血小板藥物治療，對(duì)保持患者血管開通后的血流持續(xù)暢通、減少PCI術(shù)引起的血栓脫落和血栓形成事件有重要作用。替羅非班是一種血小板膜糖蛋白Ⅱb/Ⅲa受體拮抗劑，可阻斷纖維蛋白原與血小板表面活化膜糖蛋白Ⅱb/Ⅲa受體結(jié)合，從而抑制血栓形成，被廣泛應(yīng)用于PCI圍術(shù)期的血栓處理，但可增加出血和血小板減少等的發(fā)生風(fēng)險(xiǎn)[3]。與傳統(tǒng)經(jīng)股動(dòng)脈入徑直接PCI術(shù)相比，經(jīng)橈動(dòng)脈入徑直接PCI術(shù)具有創(chuàng)傷小、局部出血和血管并發(fā)癥少等優(yōu)點(diǎn)。本研究旨在探討經(jīng)橈動(dòng)脈入徑直接PCI術(shù)聯(lián)合替羅非班治療急性ST段抬高型心肌梗死(STEMI)的臨床療效，以期為STEMI患者的臨床治療和預(yù)后改善提供參考。

1 對(duì)象與方法

1.1 研究對(duì)象 選取2014年2月—2015年2月在廣州軍區(qū)武漢總醫(yī)院行急診PCI術(shù)的STEMI患者97例，以其中穿刺成功的95例為研究對(duì)象。STEMI診斷標(biāo)準(zhǔn)參照美國(guó)心臟病協(xié)會(huì)和美國(guó)心臟學(xué)會(huì)制定的《ST段抬高型心肌梗死指南》[4]。納入標(biāo)準(zhǔn)：(1)年齡≥17歲；(2)STEMI時(shí)間≤12 h。排除標(biāo)準(zhǔn)：(1)心功能Killip分級(jí)為Ⅳ級(jí)，或心源性休克、血流動(dòng)力學(xué)不穩(wěn)定；(2)溶栓后行補(bǔ)救性PCI術(shù)；(3)存在抗凝、抗血小板治療禁忌證；(4)嚴(yán)重肝腎功能不全；(5)對(duì)替羅非班過(guò)敏；(6)橈動(dòng)脈搏動(dòng)細(xì)弱，尺動(dòng)脈通暢(Allen′s)試驗(yàn)陰性或疑似陽(yáng)性；(7)術(shù)中變更穿刺入徑。根據(jù)直接PCI術(shù)的入徑方式，將患者分為經(jīng)股動(dòng)脈入徑組(n=45)和經(jīng)橈動(dòng)脈入徑組(n=50)。研究通過(guò)了本院倫理委員會(huì)批準(zhǔn)，開始前患者均簽署知情同意書。

1.2 研究方法

1.2.1 治療方法 (1)確診后，兩組均給予替羅非班注射液(武漢遠(yuǎn)大制藥集團(tuán)有限公司生產(chǎn)，生產(chǎn)批號(hào)：140901)，冠狀動(dòng)脈造影提示存在明顯血栓者采用冠狀動(dòng)脈內(nèi)用藥，無(wú)明顯血栓者采用靜脈內(nèi)用藥。先以10 μg/kg靜脈推注，3 min內(nèi)推注完畢，而后以0.15 μg·kg-1·min-1微量泵持續(xù)泵入36 h。(2)所有患者行直接PCI術(shù)前，均給予阿司匹林腸溶片(拜耳醫(yī)藥保健有限公司生產(chǎn)，生產(chǎn)批號(hào)：BJ25152)300 mg嚼服，氯吡格雷(杭州賽諾菲制藥有限公司生產(chǎn)，生產(chǎn)批號(hào)：5A431)600 mg頓服。(3)手術(shù)的實(shí)施及干預(yù)血管徑路、介入治療策略等由心臟專科介入醫(yī)生決定。術(shù)者有10年以上心臟介入治療經(jīng)驗(yàn)(≥150例/年)，包括選擇性經(jīng)橈動(dòng)脈造影及PCI術(shù)，但缺乏對(duì)AMI患者經(jīng)橈動(dòng)脈行直接PCI術(shù)的經(jīng)驗(yàn)。術(shù)中所用支架為西羅莫司藥物涂層支架(山東吉威醫(yī)療制品有限公司生產(chǎn))。(4)術(shù)后給予無(wú)禁忌證患者拜阿司匹靈(100 mg/次、1次/d)，氯吡格雷(75 mg/次、1次/d)等治療，至少維持12個(gè)月。

1.2.2 一般資料收集 采用查閱電子病歷的方法，收集患者的一般資料，包括性別、年齡、血壓、血肌酐水平、既往PCI術(shù)史、心功能分級(jí)、合并癥及冠狀動(dòng)脈造影結(jié)果。

1.2.3 觀察指標(biāo) (1)穿刺成功率(以成功置入鞘管為穿刺成功)、PCI術(shù)成功率〔以罪犯血管開通，遠(yuǎn)端血流心肌梗死溶栓試驗(yàn)(TIMI)2～3級(jí)，術(shù)后無(wú)主要心血管事件(MACE)發(fā)生為PCI術(shù)成功〕[5]。(2)術(shù)后TIMI血流分級(jí)、血紅蛋白下降幅度，術(shù)后1 h 心電圖ST段回落≥50%比例，術(shù)后1周左心室射血分?jǐn)?shù)(LVEF)。(3)術(shù)后出血情況：TIMI嚴(yán)重出血，術(shù)后血紅蛋白下降幅度≥30 g/L，心包填塞，顱內(nèi)出血，輸血，穿刺相關(guān)部位出血(包括腹膜后血腫、假性動(dòng)脈瘤等需要輸血)；TIMI輕度出血，術(shù)后血紅蛋白下降幅度<30 g/L，皮膚黏膜出血，自發(fā)性肉眼血尿、嘔血、咯血[6-7]。(4)術(shù)后入住冠心病重癥監(jiān)護(hù)室(CCU)時(shí)間、總住院時(shí)間。(5)住院期間及隨訪6個(gè)月內(nèi)MACE發(fā)生情況，包括死亡、再發(fā)心肌梗死、支架內(nèi)血栓形成、靶血管重建(PCI術(shù)或冠狀動(dòng)脈旁路移植術(shù))及卒中。(6)生活質(zhì)量評(píng)價(jià)：PCI術(shù)后24 h，采用歐洲生命質(zhì)量量表(EQ-5D)[8]健康描述系統(tǒng)對(duì)患者的生活質(zhì)量進(jìn)行評(píng)價(jià)。量表共包括行動(dòng)能力、自我照顧能力、日常活動(dòng)能力、疼痛/不適、焦慮/抑郁5個(gè)維度，每個(gè)維度包括無(wú)困難、中度困難、重度困難3個(gè)水平。

2 結(jié)果

2.1 兩組一般資料比較 (1)兩組性別、平均年齡、血壓、血肌酐、既往PCI術(shù)史、心功能分級(jí)及合并癥比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05，見表1)。(2)兩組罪犯血管、病變血管數(shù)目、平均置入支架數(shù)及支架總長(zhǎng)度比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05，見表2)。

2.2 兩組觀察指標(biāo)比較 (1)兩組穿刺成功率、PCI術(shù)成功率比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。(2)兩組術(shù)后TIMI血流分級(jí)、術(shù)后血紅蛋白下降幅度、術(shù)后1h心電圖ST段回落≥50%比例、術(shù)后1周左心室射血分?jǐn)?shù)比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。(3)兩組術(shù)后TIMI輕度出血比例比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；而TIMI重度出血比例比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。(4)兩組入住CCU時(shí)間、總住院時(shí)間比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05，見表3)。(5)住院期間及隨訪6個(gè)月內(nèi)，經(jīng)股動(dòng)脈入徑組死亡5例，再發(fā)心肌梗死2例，靶血管重建1例，卒中1例，MACE發(fā)生率為20.0%(9/45)；經(jīng)橈動(dòng)脈入徑組再發(fā)心肌梗死1例，支架內(nèi)血栓形成1例，MACE發(fā)生率為4.0%(2/50)。兩組MACE發(fā)生率比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。(6)EQ-5D評(píng)價(jià)中，兩組行動(dòng)能力、日常活動(dòng)能力及焦慮/抑郁3個(gè)維度比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；而自我照顧能力、疼痛/不適2個(gè)維度比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05，見表4)。

3 討論

隨著介入技術(shù)的開展和不斷進(jìn)步，直接PCI術(shù)成為STEMI患者快速血運(yùn)重建的首選方法。近年來(lái)由于經(jīng)橈動(dòng)脈介入專用器械(如親水性鞘管及導(dǎo)絲)的出現(xiàn)，經(jīng)橈動(dòng)脈入徑直接PCI術(shù)已不僅僅局限于簡(jiǎn)單冠狀動(dòng)脈病變。既往研究結(jié)果表明，對(duì)于高容量心臟介入中心和熟練掌握經(jīng)橈動(dòng)脈入徑的PCI術(shù)者，可以選擇經(jīng)橈動(dòng)脈徑路對(duì)AMI等急癥患者進(jìn)行PCI術(shù)[9]。也有研究結(jié)果表明，對(duì)于AMI患者，直接PCI術(shù)聯(lián)合阿昔單抗或替羅非班等血小板膜糖蛋白Ⅱb/Ⅲa受體拮抗劑，可顯著改善患者的冠狀動(dòng)脈血流和心肌再灌注，降低PCI術(shù)后無(wú)復(fù)流風(fēng)險(xiǎn)[10-11]。本研究結(jié)果顯示，經(jīng)橈動(dòng)脈入徑組患者的穿刺成功率、PCI術(shù)成功率及術(shù)后TIMI血流3級(jí)比例高于經(jīng)股動(dòng)脈入徑組，術(shù)后1h心電圖ST段回落≥50%比例也高于經(jīng)股動(dòng)脈入徑組，但差異無(wú)統(tǒng)計(jì)學(xué)意義，這與Jinnouchi等[12]的研究結(jié)果一致。另外，本研究結(jié)果顯示，經(jīng)橈動(dòng)脈入徑組患者的入住CCU時(shí)間和總住院時(shí)間縮短，這也在一定程度上反映出經(jīng)橈動(dòng)脈入徑直接PCI術(shù)可以減少患者的醫(yī)療負(fù)擔(dān)。

表1 兩組基本情況比較

注：a為t值；PCI=經(jīng)皮冠狀動(dòng)脈介入治療；1 mm Hg=0.133 kPa

表2 兩組冠狀動(dòng)脈造影結(jié)果比較

注：a為t值

表3 兩組觀察指標(biāo)比較

注：a為t值；TIMI=遠(yuǎn)端血流心肌梗死溶栓試驗(yàn)，CCU=冠心病重癥監(jiān)護(hù)室

表4 術(shù)后24 h兩組EQ-5D量表評(píng)價(jià)情況比較〔n(%)〕

注：EQ-5D=歐洲生命質(zhì)量量表

強(qiáng)化抗凝、抗血小板藥物治療及傳統(tǒng)的經(jīng)股動(dòng)脈入徑直接PCI術(shù)，可以降低AMI患者的缺血事件復(fù)發(fā)風(fēng)險(xiǎn)，但增加患者的出血風(fēng)險(xiǎn)。目前，國(guó)際上尚無(wú)統(tǒng)一的臨床終點(diǎn)事件(包括缺血和出血)定義。根據(jù)不同出血定義和研究對(duì)象納入標(biāo)準(zhǔn)，經(jīng)橈動(dòng)脈入徑直接PCI術(shù)是否可以減少患者的術(shù)后出血風(fēng)險(xiǎn)尚無(wú)定論。Cantor等[13]對(duì)50例經(jīng)橈動(dòng)脈或股動(dòng)脈行急診或補(bǔ)救性PCI術(shù)AMI患者(血小板膜糖蛋白Ⅱb/Ⅲa 受體拮抗劑使用率為94.0%，溶栓藥物使用率為66.0%)的臨床資料進(jìn)行分析，發(fā)現(xiàn)不同入徑方式患者的嚴(yán)重出血發(fā)生率無(wú)差異，而其使用的嚴(yán)重出血定義為術(shù)后血紅蛋白下降>50 g/L或血細(xì)胞比容下降≥15.0%。Romagnoli等[14]進(jìn)行的隨機(jī)對(duì)照研究結(jié)果顯示，經(jīng)橈動(dòng)脈入徑直接PCI術(shù)可以降低患者的嚴(yán)重出血和穿刺部位出血風(fēng)險(xiǎn)，其使用的嚴(yán)重出血定義為術(shù)后血紅蛋白下降幅度>30 g/L。既往研究結(jié)果顯示，在接受PCI術(shù)的患者中，相比于肝素加血小板膜糖蛋白Ⅱb/Ⅲa 受體拮抗劑，比伐盧定具有降低患者出血風(fēng)險(xiǎn)和死亡率的優(yōu)勢(shì)，且不增加患者M(jìn)ACE發(fā)生率[15]。本研究發(fā)現(xiàn)，與經(jīng)股動(dòng)脈入徑組患者相比，經(jīng)橈動(dòng)脈入徑組的術(shù)后TIMI嚴(yán)重出血比例較低。這可能與經(jīng)股動(dòng)脈入徑組患者的年齡、心功能Ⅲ級(jí)比例及血清血肌酐水平有關(guān)；也可能是因?yàn)楸狙芯繉儆^察性研究，存在一定的選擇偏倚。

血小板膜糖蛋白Ⅱb/Ⅲa受體拮抗劑可以提供有效的抗血小板作用，減少血栓負(fù)荷和繼發(fā)的遠(yuǎn)端微循環(huán)栓塞，降低PCI 術(shù)后的MACE發(fā)生率，從而改善患者預(yù)后[16]。Mehta等[17]對(duì)STEMI患者進(jìn)行亞組分析發(fā)現(xiàn)，與經(jīng)股動(dòng)脈入徑直接PCI術(shù)相比，經(jīng)橈動(dòng)脈入徑患者的30 d主要終點(diǎn)事件(死亡、心肌梗死、卒中、非冠狀動(dòng)脈動(dòng)脈旁路移植術(shù)主要出血)及全因死亡發(fā)生率較低，但這在急性非SIEMI患者中并無(wú)明顯差異。Mamas等[18]對(duì)46 128例STEMI患者的臨床資料進(jìn)行分析，發(fā)現(xiàn)隨訪30 d后，經(jīng)橈動(dòng)脈入徑直接PCI術(shù)患者的死亡率和住院期間MACE發(fā)生率降低。本研究結(jié)果也顯示，住院期間及隨訪6個(gè)月后，經(jīng)橈動(dòng)脈入徑組患者的MACE發(fā)生率低于經(jīng)股動(dòng)脈入徑組，其中死亡率也低于經(jīng)股動(dòng)脈入徑組。Koltowski等[19]采用EQ-5D量表對(duì)STEMI患者的PCI術(shù)后生活質(zhì)量進(jìn)行評(píng)估，發(fā)現(xiàn)經(jīng)橈動(dòng)脈入徑患者的術(shù)后生活質(zhì)量較高，行動(dòng)能力和自我照顧能力等維度均優(yōu)于經(jīng)股動(dòng)脈入徑患者。本研究也采用EQ-5D量表對(duì)患者的術(shù)后24 h生活質(zhì)量進(jìn)行評(píng)價(jià)，結(jié)果顯示，經(jīng)橈動(dòng)脈入徑組患者在量表5個(gè)維度中的存在中/重度困難比例均低于經(jīng)股動(dòng)脈入徑組，但只有自我照顧能力和疼痛/不適2個(gè)維度的差異有統(tǒng)計(jì)學(xué)意義。

綜上所述，經(jīng)橈動(dòng)脈入徑直接PCI術(shù)聯(lián)合替羅非班治療STEMI的臨床療效較好，可以縮短患者的入住CCU時(shí)間和總住院時(shí)間，減少術(shù)后TIMI嚴(yán)重出血率，降低MACE發(fā)生率，并有利于提高患者的術(shù)后生活質(zhì)量。但本研究樣本量較小，隨訪時(shí)間較短，故存在一定的局限性，所得結(jié)果仍需要大規(guī)模臨床研究的證實(shí)。

作者貢獻(xiàn)：張麗進(jìn)行試驗(yàn)設(shè)計(jì)與實(shí)施、撰寫論文、成文并對(duì)文章負(fù)責(zé)；張麗、彭毅進(jìn)行試驗(yàn)實(shí)施、評(píng)估、資料收集；丁世芳、蔣桔泉、陳志楠、盧青、付文波進(jìn)行質(zhì)量控制與審校。

本文無(wú)利益沖突。

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Clinical Effect of Trans-radial Primary Percutaneous Coronary Intervention Combined With Tirofiban in Patients With Acute ST-elevation Myocardial Infarction

ZHANGLi,DINGShi-fang,JIANGJu-quan,etal.GraduateSchool,SouthernMedicalUniversity,Guangzhou510515,China

Objective To evaluate the clinical efficacy of trans-radial primary percutaneous coronary intervention(PCI) combined with tirofiban in patients with acute ST-elevation myocardial infarction(STEMI).Methods From February 2014 to February 2015,we enrolled 95 STEMI patients who underwent successful emergency PCI in Wuhan General Hospital of Guangzhou Military Area Command.According to entry method,the patients were divided into femoral artery entry group(n=45) and radial artery entry group(n=50).Comparison was made between the two groups in the success rate of puncture,the success rate of PCI,thrombolysis in myocardial infarction trial of distal blood flow(TIMI) grade of blood flow after surgery,the decrease degree of hemoglobin,the proportion of patients with≥50% resolution of ST-segment involved in infarction one hour after surgery,LVEF one week after surgery,postoperative bleeding status,postoperative coronary intensive care unit(CCU) time,total hospitalization time,major adverse cardiac event(MACE) during hospitalization and 6-month follow-up and EQ-5D results.Results The two groups were not significantly different in the success rate of puncture and the success rate of PCI(P>0.05).The two groups were not significantly different in TIMI grade of blood flow,the decrease degree of hemoglobin after surgery,the proportion of patients with ≥50% ST-segment resolution one hour after surgery and LVEF one week after surgery(P>0.05).The two groups were not significantly different in the proportion of patients with mild TIMI bleeding(P>0.05) but were significantly different in the proportion of severe TIMI bleeding(P<0.05).The two groups were significantly different in CCU time and total hospitalization time(P<0.05).The two groups were significantly different in the incidence of MACE during hospitalization and 6-month follow up(P<0.05).In the evaluation of EQ-5D,the two groups were not significantly different in the three dimensions of movement ability,ability of daily activity and anxiety/depression(P>0.05),while the two groups were significantly different in self-care ability and pain/discomfort(P<0.05).Conclusion Trans-radial primary PCI combined with tirofiban has good clinical efficacy,reduces CCU time and total hospitalization time,reduces the proportion of patients with severe TIMI bleeding after surgery and improves prognosis and quality of life of patients.Therefore,the therapy is worth clinical promotion and application.

Myocardial infarction;Angioplasty,balloon,coronary;Tirofiban;Treatment outcome

510515廣東省廣州市，南方醫(yī)科大學(xué)研究生學(xué)院(張麗，丁世芳)；廣州軍區(qū)武漢總醫(yī)院心血管內(nèi)科(蔣桔泉，陳志楠，盧青，付文波，彭毅)

丁世芳，510515廣東省廣州市，南方醫(yī)科大學(xué)研究生學(xué)院；E-mail：DSFWH@163.com

R 542.22

A

10.3969/j.issn.1007-9572.2016.10.011

2015-12-03；修回日期：2016-02-15)

王鳳微)