山东医药

目的 探讨罪犯血管再灌注后定量血流分数（QFR）、微血管阻力（AMR）与ST段抬高型心肌梗死（STEMI）患者经皮冠状动脉介入治疗（PCI）术后远期预后的关系。方法 选取成功接受PCI的STEMI患者387例，于罪犯血管再灌注后基于冠状动脉造影图像计算QFR、AMR。随访2年，记录患者不良心血管事件发生情况，随访期间发生不良心血管事件则为不良预后。采用多因素Logistic回归分析STEMI患者PCI术后远期不良预后的影响因素，受试者工作特征（ROC）曲线和决策曲线分析（DCA）评价QFR、AMR对STEMI患者PCI术后远期不良预后的预测效能及临床净获益。结果 随访2年，387例STEMI患者PCI术后共有135例（34.88%）预后不良。与不良预后良好患者比较，预后不良患者年龄、糖尿病比例、Gensini评分、心肌肌钙蛋白I、肌酸激酶同工酶MB水平及AMR更高，冠状动脉病变支数更多，支架长度更长，支架直径更短，QFR更低（P均<0.05）。多因素Logistic回归分析显示，年龄增大、Gensini评分升高、冠状动脉多支病变、AMR升高为STEMI患者PCI术后远期不良预后的独立危险因素，QFR升高为独立保护因素（P均<0.05）。构建QFR与AMR的联合预测模型为Logit(P)=3.209-1.517×QFR+0.317×AMR。QFR联合AMR及二者单独预测STEMI患者PCI术后远期不良预后的ROC曲线下面积（AUC）分别为0.898、0.808、0.835，灵敏度分别为85.19%、72.59%、80.74%，特异度分别为82.54%、70.63%、71.83%，二者联合预测的AUC更高（P均<0.05）。DCA结果显示，在3%～95%阈值概率内，二者联合预测的临床净获益高于QFR、AMR单独预测。结论 罪犯血管再灌注后QFR降低和AMR升高为STEMI患者PCI术后远期不良预后的独立影响因素，二者联合评估对不良预后的预测价值及临床净获益更高。

Objective To investigate the relationships of quantitative flow ratio(QFR) and angiography-derived microvascular resistance(AMR) after culprit vessel reperfusion with long-term prognosis in patients with ST-segment elevation myocardial infarction(STEMI) after percutaneous coronary intervention(PCI).Methods A total of 387 patients with STEMI who successfully underwent PCI were enrolled.QFR and AMR were calculated based on coronary angiographic images after culprit vessel reperfusion.All patients were followed up for 2 years.Major adverse cardiovascular events occurring during follow-up were recorded, and patients who experienced major adverse cardiovascular events(MACEs) were classified as having a poor prognosis.Multivariate Logistic regression analysis was performed to identify the factors associated with poor long-term prognosis after PCI in patients with STEMI.Receiver operating characteristic(ROC) curve and decision curve analysis(DCA) were used to evaluate the predictive performance and clinical net benefit of QFR and AMR for poor long-term prognosis after PCI.Results During the 2-year follow-up, 135 of the 387 patients(34.88%) experienced poor prognosis.Compared with patients with good prognosis, those with poor prognosis were older, had a higher proportion of diabetes mellitus, higher Gensini scores, higher levels of cardiac troponin I, creatine kinase-MB, and AMR, more diseased coronary vessels, longer stent length, smaller stent diameter, and lower QFR(all P<0.05).Multivariate Logistic regression analysis showed that older age, higher Gensini score, multivessel coronary artery disease, and increased AMR were independent risk factors for poor long-term prognosis after PCI in patients with STEMI, whereas increased QFR was an independent protective factor(all P<0.05).The areas under the ROC curve(AUCs) for the combined assessment of QFR and AMR, QFR alone, and AMR alone were 0.898, 0.808, and 0.835, respectively, with sensitivities of 85.19%, 72.59%, and 80.74%, and specificities of 82.54%, 70.63%, and 71.83%, respectively.The combined model showed a significantly higher AUC than either QFR or AMR alone(both P<0.05).DCA demonstrated that the combined assessment provided a greater clinical net benefit than either QFR or AMR alone across threshold probabilities ranging from 3% to 95%.Conclusions Decreased QFR and increased AMR after culprit vessel reperfusion are independent factors associated with poor long-term prognosis after PCI in patients with STEMI.The combined assessment of QFR and AMR provides superior predictive performance and greater clinical net benefit for predicting poor long-term prognosis.