血栓弹力图评价急性心肌梗死患者主动脉内球囊反搏术后凝血状态的临床应用

Clinical application of thromboelastography after implantation of IABP in patients with acute myocardial infarction

摘要:

目的 通过凝血功能、血栓弹力图（TEG）、活化凝血时间（ACT）、抗Xa因子活性检测急性心肌梗死（AMI）患者使用主动脉内球囊反搏（IABP）后的凝血状态，评估肝素残余情况、出血及血栓风险，寻找能更好地评估凝血状态的方法。方法 选取2017年2月—11月湖南省人民医院因AMI需行急诊经皮冠状动脉介入术（PCI）并IABP的患者。比较手术前后血常规及凝血功能的差异性；收集并分析术后血小板（PLT）与血栓弹力图枸橼酸化高岭土激活样品肝素酶杯（CKH-TEG）的相关性；CKH-TEG的R差值（△R）与活化凝血时间（ACT）、抗Xa因子活性的相关性；以抗Xa因子活性为低分子肝素浓度标准绘制△R和ACT的诊断价值综合评估的受试者工作特征（ROC）曲线。结果 CKH-TEG参数中PLT与MA、凝固角呈正相关（r?=0.571和0.681，均P?<0.05），与K呈负相关（r?=-0.783，P?<0.05）；△R与抗Xa因子活性呈正相关（r?=0.421，P?<0.05）；ACT与抗Xa因子活性无关（r?=0.214，P?>0.05）；ROC曲线分析结果显示，△R的曲线下面积（AUC）为0.814（95% CI：0.732，0.903），当△R截断值为-0.211时具有最优的诊断价值，敏感性为0.885（95% CI：0.801，0.952），特异性为0.892（95% CI：0.815，0.957）；ACT的AUC为0.556（95% CI：0.474，0.638），当ACT截断值为172.99?s时具有最优的诊断价值，敏感性为0.612（95% CI：0.538，0.719），特异性为0.584（95% CI：0.507，0.673）。△R在评估肝素残留的AUC值大于ACT。结论 IABP术后使用TEG较常规凝血功能凝血状态评估更优，较ACT能更好地评估低分子肝素残余量，对指导肝素类抗凝药物的使用具有临床意义。

Abstract:

Objective To detect the coagulation status of patients with acute myocardial infarction (AMI) after intra-aortic balloon counterpulsation (IABP), to assess heparin residuals, bleeding and thrombosis risk, and to find a better way to assess coagulation status. Method Patients who underwent emergency percutaneous coronary intervention (PCI) and IABP for AMI at the Hunan Provincial People's Hospital from February 2017 to November 2017 were selected. Blood routine and coagulation function were compared before and after surgery; the correlation between postoperative platelet (PLT) and thromboelastography heparinase (CKH-TEG) were collected and analyzed; ROC curves for comprehensive evaluation of diagnostic value of ΔR and ACT were graphed with anti-Xa activity as low heparin concentration standard. Results There were positive correlations between MA, Angle and PLT in all parameters of CK-TEG (r = 0.571 and 0.681, all P??0.05); ROC curve analysis showed that the AUC value of ΔR was 0.814 (95% CI: 0.732, 0.903); when the ΔR cutoff value was -0.211, it has the best diagnostic value; the sensitivity was 0.885 (95% CI: 0.801, 0.952), and the specificity was 0.892 (95% CI: 0.815, 0.957); the AUC of ACT was 0.556 (95% CI: 0.474, 0.638), sensitivity was 0.612 (95% CI: 0.538, 0.719), specificity was 0.584 (95% CI: 0.507, 0.673), when the ACT cutoff value is 172.99 s, which meant the best diagnosis value. The AUC value of ΔR in the evaluation of heparin residues was significantly greater than ACT (P?