UNIVERZITET U NOVOM SADU MEDICINSKI FAKULTET NOVI SAD ZNAČAJ NESELEKTIVNE INTRAKORONARNE PRIMENE NATRIJUM NITROPRUSIDA U PRIMARNOJ PERKUTANOJ KORONARNOJ INTERVENCIJI DOKTORSKA DISERTACIJA Mentori: Prof. dr Robert Jung Kandidat: dr Vladimir Ivanović Prof. dr Pavle Kovačević Novi Sad, 2013. godine
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UNIVERZITET U NOVOM SADU MEDICINSKI FAKULTET NOVI SAD
ZNAČAJ NESELEKTIVNE
INTRAKORONARNE PRIMENE
NATRIJUM NITROPRUSIDA U
PRIMARNOJ PERKUTANOJ
KORONARNOJ INTERVENCIJI
DOKTORSKA DISERTACIJA
Mentori: Prof. dr Robert Jung Kandidat: dr Vladimir Ivanović Prof. dr Pavle Kovačević
Novi Sad, 2013. godine
2
UNIVERZITET U NOVOM SADU
MEDICINSKI FAKULTET NOVI SAD
KLJUČNA DOKUMENTACIJSKA INFORMACIJA
Redni broj:
RBR
Identifikacioni broj:
IBR
Tip dokumentacije:
TD
Monografska dokumentacija
Tip zapisa:
TZ
Tekstualni štampani materijal
Vrsta rada (dipl., mag., dokt.):
VR
Doktorska disertacija
Ime i prezime autora:
AU
Vladimir Ivanović
Mentor (titula, ime, prezime,
zvanje):
MN
Prof. dr Robert Jung
Prof. dr Pavle Kovačević
Naslov rada:
NR
Značaj neselektivne intrakoronarne primene Natrijum-
nitroprusida u primarnoj perkutanoj kornarnoj
intervenciji
Jezik publikacije:
JP
Srpski
Jezik izvoda:
JI
srp. / eng.
Zemlja publikovanja:
ZP
Srbija
Uže geografsko područje:
UGP
AP Vojvodina
Godina:
GO
2013.
3
Izdavač:
IZ
autorski reprint
Mesto i adresa:
MA
Medicinski fakultet , Hajduk Veljkova 3, 21000 Novi Sad
Fizički opis rada:
FO
(8 poglavlja / 121 stranica / 21 grafikon / 283
reference / 54 tabele)
Naučna oblast:
NO
Medicina
Naučna disciplina:
ND
Interna medicina, Kardiologija
Predmetna odrednica, ključne reči:
PO
Infarkt miokarda; Natrijum nitroprusid;
Perkutana koronarna intervencija; No-Reflow
fenomen; Mortalitet; Ishod lečenja;
UDK 616.127-005.8-08-036.8
Čuva se:
ČU
Biblioteka Medicinskog fakulteta U Novom
Sadu
Važna napomena:
VN
Izvod:
IZ
UVOD: Akutni infarkt miokarda sa ST
elevacijom predstavlja jedan od entiteta akutnog
koronarnog sindroma. Primarna perkutana
koronarna intervencija predstavlja
najsavremeniji način lečenja ovog entiteta.
Jedna od potencijalnih komplikacija procedure
predstavlja no reflow fenomen.
CILJ RADA: Da se izvrši evaluacija
intrakoronarne primene natrijum-nitroprusida
na klinički ishod nakon primarne perkutane
koronarne intervencije.
NULTA HIPOTEZA: Neselektivna
intrakoronarna primena Na-nitroprusida nakon
primarne Perkutane Coronarne Intervencije
(pPCI) ne utiče povoljno na klinički ishod
4
lečenja.
METODOLOGIJA: Istraživanje je bilo
prospektivno, otvoreno randomizirano. Pacijenti
su podeljeni u dve grupe: ispitanici-kojima je
ordiniran Natrijum nitroprusid tokom primerne
perkutane intervencije i kontrolna grupa- kojim
nije ordiniran lek. Praćen je niz kliničkih,
laboratorijskih, angiografskih i EKG i EHO
kardiografskih parametara.
REZULTATI: T testom postoji signifikantno
manja u vrednost CPK MB nakon 12 (p 0.003) i
18 (p 0.001) sati od intervencije u korist grupe
ispitanika, kao i signifikantno manja vrednost
LDH nakon 12 sati od intervencije u korist
grupe ispitanika (p 0.03). U ostalim značajnim
laboratorijskim, ehokardiografskim i
angiografskim parametrima ne postoji značajna
razlika između grupa u odnosu na primenenu
Natrijum-nitroprusida.
ZAKLJUČCI: Neselektivna intrakoronarna
primena Na-nitroprusida pozitivno utiče na
smanjenje vrednosti CPKMB nakon 12 i 18 sati,
kao i vrednosti LDH nakon 12 sati od primarne
perkutane koronarne intervencije. Neselektivna
intrakoronarna primena Na-nitroprusida nije
pokazala povoljnan uticaj na: TIMI protok i
TIMI MPG skor, rezoluciju ST segmenta,
sistolne i dijastolne ehokardiografske
parametre, srčanu slabost i smtrni ishod.
Dimenzije mitralnog anulusa u dijastoli, nakon
šest meseci od infarkta miokarda, su veće u
kontrolnoj grupi pacijenata što je posledica veće
zastupljenosti posteroinferiornih i
posteroinferolateralnih infarkta u ovoj grupi.
Primena Natrijum nitroprusida tokom pPCI nije
5
pokazala očekivani / željeni efekat na značajno
smanjenje mortaliteta nakon STEMI. Smrtnost
u periodu od 90-180 dana i srčana slabost je
veća u grupi ispitanika što je posledica veće
zastupljenosti anteroseptoapikalnih i
anteroseptoapikolateralnih infarkta u ovoj grupi.
Datum prihvatanja teme od strane
NN veća:
DP
20.12.2006.
Datum odbrane:
DO
Članovi komisije:
(ime i prezime / titula / zvanje /
naziv organizacije / status)
KO
predsednik: prof. dr Nada Čemerlić-Ađić,
vanredni profesor, interna medicina, Institut za
kardiovaskularne bolesti Vojvodine
član: prof. dr Gordana Panić, redovni profesor,
interna medicina, Institut za kardiovaskularne
bolesti Vojvodine
član: prof. dr Jadranka Dejanović, vanredni
pofesor, interna medicina, Institut za
kardiovaskularne bolesti Vojvodine
član: doc. dr Milovan Petrović, docent, interna
medicina, Institut za kardiovaskularne bolesti
Vojvodine
član: prof. dr Slobodan Obradović, vanredni
profesor, interna medicina, Vojno-medicinska
akademija, Beograd
6
University of Novi Sad
Faculty of Medicine
Key word documentation
Accession number:
ANO
Identification number:
INO
Document type:
DT
Monograph documentation
Type of record:
TR
Textual printed material
Contents code:
CC
Ph. D. Thesis
Author:
AU
MD Vladimir Ivanović
Mentor:
MN
prof. MD Robert Jung
prof. MD Pavle Kovačević
Title:
TI
SIGNIFICANCE OF UNSELECTED
INTRACORONARY USE OF
SODIUM-NITROPRUSSIDE IN
PRIMARY PERCUTANEOUS CORONARY
INTERVENTION
Language of text:
LT
Serbian
Language of abstract:
LA
eng. / serb.
Country of publication:
CP
Republic of Serbia
Locality of publication:
LP
Province of Vojvodina
7
Publication year:
PY
2013.
Publisher:
PU
Authors reprint
Publication place:
PP
Faculty of Medicine
Hajduk Veljkova 3, 21000 Novi Sad,
Physical description:
PD
8 chapters / 121 pages / 21 graf. / 283
referencess / 54 tab.
Scientific field
SF
Medicine
Scientific discipline
SD
Internal medicine, cardiology
Subject, Key words
SKW
Myocardial Infarction; Nitroprusside;
Percutaneous Coronary Intervention; No-
Reflow Phenomenon; Mortality; Treatment
Outcome;
UC 616.127-005.8-08-036.8
Holding data:
HD
University of Novi Sad Library of the Faculty of Medicine Hajduk Veljkova 3, 21000 Novi Sad, Serbia
Note:
N
Abstract:
AB
INTRODUCTION: Acute ST-elevation
myocardial infarction is an entity of the acute
coronary syndrome. Primary percutaneous
coronary intervention is the latest form of its
treatment. One of the potential procedural
complications is no-reflow phenomenon.
AIM: This paper aims to evaluate the effect of
intracoronary use of sodium-nitroprusside on the
treatment outcome after the primary
percutaneous coronary intervention.
NULL HYPOTHESIS: Unselected
intracoronary use of sodium-nitroprusside after
primary Percutaneous Coronary Intervention
8
(pPCI) does not influence favourably on the
treatment outcome.
METODOLOGY: It was a prospective,
unblinded randomized research. The patients
were divided into two groups. The group of
examinees consisted of patients who received
sodium-nitroprusside during the primary
percutaneous intervention and the ones who did
not receive it formed the control group. Series of
clinical, laboratory, angiography, ECG and
echocardiography parameters were followed-up.
RESULTS: T test showed significantly smaller
value of CPK MB 12 (p 0.003) and 18 (p 0.001)
hours after the intervention in favour of the
group of examinees as well as significantly
lower value of LDH 12 hours after the
intervention also in favour of the group of
examinees (p 0.03). Other significant laboratory,
echocardiography and angiography parameters
showed no significant difference between the
groups when referring to the use of sodium-
nitroprusside.
CONCLUSIONS: Unselected intracoronary use
of sodium-nitroprusside positively influences on
the decrease of CPKMB values after 12 and 18
hours as well as on the values of LDH after 12
hours from the primary percutaneous coronary
intervention. Unselected intracoronary use of
sodium-nitroprusside showed no positive
influence on: TIMI flow and TIMI MPG score,
ST segment resolution, systolic and diastolic
echocardiography parameters, heart failure and
fatal outcome. Six months after the myocardial
infarction the dimensions of mitral annulus in
diastole were larger in the control patient group
9
which is a consequence of the increased presence
of posteroinferior and posteroinferolateral
infarctions in this group. The use of sodium-
nitroprusside during the pPCI did not show
expected / desired effect on the significant
decrease in mortality after STEMI. Mortality in
the period from 90 to 180 days and heart failure
were larger in the group of examinees as a
consequence of having more anteroseptal apical
and anteroseptal apical-lateral infarctions in this
Smrtni ishod od infarkta srca tokom hospitalizacije nije registrovan ni u jednoj od
grupa.
Smrtni ishod od otpusta iz bolnice do 30 dana u kontrolnoj grupi bio je zastupljen
sa 3.3%, dok ga u grupi ispitanika nismo registrovali. Razlika nije signifikantna jer je
Binarnom regresionom analizom p=0.997, a Man Whitney analizom p=0.157.
Smrtni ishod od 30 do 90 dana nije registrovan ni u jednoj od grupa.
Smrtni ishod od 90 do 180 dana je u grupi ispitanika bio zastupljen sa 10%, dok je
u kontrolnoj grupi bio zastupljen sa 6.9%. Razlika nije signifikantna. Binarnom
regresionom analizom p=0.633, a Man Whitney analizom (p=0.633)
Ukupna smrtnost u infarktu srca, bez koronarnog događaja je u ispitanika 10%, a u
kontrolnoj grupi 9,9%. Nema signifikantne razlike
U odnosu na koronarni događaj (smrt usled reinfarkta, srčane slabosti i iznenadna
smrt čije okolnosti navode na ponovni koronarni događaj) – praktično komplikaciju -
tokom hospitalizacije kao i u periodu do 90 dana nije registrovan ni u jednoj od grupa.
101
Smrtni ishod povezan sa koronarnim događajem u periodu od 90 do 180 dana u
grupi ispitanika bio je zastupljen sa 6.7%, dok je u kontrolnoj grupi bio zastupljen sa 6.9%.
Razlika nije signifikantna jer je Binarnom regresionom analizom p=0.968.
Ukupan broj smrtnih ishoda u periodu praćenja u obe grupe je bio 13.3%.
Na osnovu svih ovih podataka može se zaključiti da intrakoronarna primena
Natrijum nitroprusida tokom pPCI nije pokazala očekivani efekat na značajno smanjenje
mortaliteta nakon STEMI.
Na osnovu naših podataka, kao i po podacima u do sada navedenim literaturnim
navodima vidi se da je letalnih ishoda od infarkta srca procentualno bilo više u grupi
ispitanika u periodu od 90 - 180 dana (10% vs 6,9%). Ovakve procente možemo objasniti
lokalizacijom infarkta.
Kao i kod srčane slabosti više anteroseptalnih i anteroseptaloapiko-lateralnih
infarkta bilo je u grupi ispitanika (ispitanici 43.4% vs kontrolna grupa 26.7%). Naši podaci
su u saglasnosti i sa podacima iz literature – gde se navodi da je smrtnost od akutnog
infarkta sa zahvaćenim prednjim zidom miokarda, i tokom boravka u koronarnoj jedinici i
nakon 28 dana, dvostruko viša u odnosu na zahvaćen zadnji zid miokarda.(279)
U literaturi(212) se nalazi podatak da je nakon selektivne intrakoronarne primene
Natrijum nitroprusida (perfuzionim kateterom se prošlo mesto okluzije i distalno je
ordiniran lek) klinički ishod kod pacijenata bio bolji. Imali su nakon šest meseci manju
stopu ponovne revaskularizacije infarktne arterije, manju učestalost reinfarkta ili smrtnih
ishoda (6.3% u grupi koja je dobila lek i 20% u grupi koja nije dobila lek (p=0.05)). U
istom radu se nalazi da su bolesnici koji su dobili Natrijum nitroprusid imali manju stopu
rehospitalizacije, ali bez signifikantne razlike. Autori ovog rada ovakve rezultate delimično
objašnjavaju time što su u grupu pacijenata koji su dobili lek korišćeni kraći stentovi
(manja stopa restenoza), a ne samo efektom primene leka. U našem radu što se tiče dužine
i dijametra stenta grupe su bile homogene (srednja vrednost dužine stenta između
ispitanika i kontrolne grupe 19.26 vs 18.03 i srednja vrednost u dijametru stenta između
ispitanika i kontrolne grupe 2.937 vs 2.933), tako da dužina stenta nije uticala na klinički
ishod.
Korišćeni su i drugi lekovi tokom pPCI za prevenciju no reflow fenomena kao što
su pexelizumab, humana monoklonska antitela koja se vezuju za C5 komponentu
komplementa i FX06 deo peptida iz humanog fibrina, kojima se pokušao smanjiti
mortalitet. U studiji gde je korišćen pexelizumab(280) nije postojala razlika u mortalitetu i
TIMI III protoku između grpe koja je dobila leki i grupe kojoj je ordiniran placebo. U
F.I.R.E. studiji FX06 nije uspeo da smanji infarktnu zonu i smrtnost, ali je imao neki efekat
102
na poboljšanje mikrovaskuarne obstrukcije procenjivano magnetnom rezonancom.(281)
Nikoradil ordiniran pre PPCI pokazalo se da popravlja angiografske pokazatalje no reflow
fenomena i klinički ishod.(282) Kao što se vidi i ostali lekovi korišćeni u prevenciji no reflow
fenomena nisu imali apsolutno pozitivan efekat na klinički ishod.
U radu Stona i autora pokazalo se da je mortalitet kod pacijenata kod kojih je
ostvaren TIMI MPG 3 (6,8%), kod pacijenata kod kojih je ostvaren TIMI MPG 2
mortaliteta je 13.2%, dok je kod bolesnika sa TIMI MPG 1 ili 0 mortalitet 18.3%
(p=0.004).(283)
U našem radu dobijene su sledeće vrednosti TIMI MPG u grupi ispitanika i
kontrolnoj grupu TIMI MPG 2 (13.3% vs 20%)-nesignifikantna razlika, TIMI MPG 3
(86.7% vs 80%)-nesignifikantna razlika. I iz ovih podataka se može zaključiti da primena
leka ne utiče povoljno na smrtni ishod.
CILJ RADA - da se izvrši evaluacija intrakoronarne primene natrijum-nitroprusida
na klinički ishod nakon primarne perkutane koronarne intervencij, smo evaluirali i time
potvrdili postavljenu NULTU HIPOTEZU da neselektivna intrakoronarna primena
natrijum-nitroprusida nakon primarne Perkutane Coronarne Intervencije (pPCI) nema
povoljan uticaj na klinički ishod lečenja.
103
7. Zaključci
1. Neselektivna intrakoronarna primena Na-nitroprusida pozitivno utiče na
smanjenje vrednosti CPKMB nakon 12 i 18 sati, kao i na vrednosti LDH nakon 12 sati od
primarne perkutane koronarne intervencije.
2. Neselektivna intrakoronarna primena Na-nitroprusida nije pokazala povoljan
uticaj na:
a) TIMI protok i TIMI MPG skor
b) rezoluciju ST segmenta
c) sistolne i dijastolne ehokardiografske parametre
d) srčanu slabost i smtrni ishod
3. Dimenzije mitralnog anulusa u dijastoli, nakon šest meseci od infarkta miokarda,
su veće u kontrolnoj grupi pacijenata što je posledica veće zastupljenosti
posteroinferiornih i posteroinferolateralnih infarkta u ovoj grupi.
4. Primena Natrijum nitroprusida tokom pPCI nije pokazala očekivani / željeni
efekat na značajno smanjenje mortaliteta nakon STEMI.
5. Smrtnost u periodu od 90-180 dana i srčana slabost je veća u grupi ispitanika, što
je posledica veće zastupljenosti anteroseptoapikalnih i anteroseptoapikolateralnih infarkta
u ovoj grupi.
104
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