光学相干断层成像在斑块破裂导致急性心肌梗死患者中的应用及治疗效果评估

doi:10.3877/cma.j.issn.2095-655X.2025.01.002

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摘要目的探讨光学相干断层成像（OCT）在因斑块破裂导致急性心肌梗死（AMI）患者中的应用及治疗效果。方法选取2019年1月至 2022年10月在吉林市中心医院心血管内科明确诊断为AMI的患者。急诊经皮冠状动脉造影(CAG)，经去除冠脉内血栓治疗（手动血栓抽吸或药物冠脉内溶栓），CAG罪犯冠脉血管血流恢复TIMI 3级，且经直径目测法，对于管腔狭窄＜70.00%，择期（住院7d后）行OCT检查。对于罪犯病变因斑块破裂导致AMI的患者，选择斑块破裂弧度小于90°，破裂斑块长度小于1mm，无大的游离的内膜片的患者不予支架植入，共29例符合上述OCT特征。给予强化药物治疗，经治疗12个月后复查CAG及OCT，比较患者基线及12个月后OCT特征变化，并分析12个月的主要不良心血管事件（MACE）发生情况。结果12个月后复查29例患者OCT结果，与基线OCT特征比较，最薄纤维帽厚度有所增加［（74.66±20.79）μm，（95.21±16.31）μm］，破裂斑块弧度减少［（83.69±6.30）°，（80.38±5.93）°］，破裂斑块长度减少［（0.67±0.16）mm，（0.56±0.17）mm］，最小管腔面积增大［（3.58±0.55）mm2，（3.82±0.69）mm2］，破裂斑块深度减少［（1410.34±214.40）μm，（1251.38±208.22）μm］，面积狭窄率降低［(64.00±4.26)%，(61.79±4.23)%］，巨噬细胞浸润比例减少［68.97%（20/29），34.48%（10/29）］，均差异具有统计学意义（t=11.71，3.59，3.55，6.29，9.84,3.51, χ2=8.10；均P＜0.01）。随访12个月后，有2例（6.90%）患者因心绞痛住院治疗，其中1例CAG检查狭窄病变较基线造影时无进展；另1例住院治疗，CAG后植入支架治疗，植入支架病变并非基线造影斑块破裂部位，是由非罪犯病变进展而来，随访中并未发生严重MACE情况。结论AMI经去除血栓后，CAG管腔狭窄＜70.00%，罪犯病变OCT表现斑块破裂导致AMI。对于斑块破裂弧度小于90°，破裂斑块长度小1mm，无大的游离内膜片的患者采取药物治疗可避免植入支架，减少支架植入后无复流发生以及支架再狭窄的发生。

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关键词 ：急性心肌梗死, 光学相干断层成像, 经皮冠状动脉介入治疗, 斑块破裂

Abstract：ObjectiveTo investigate the application of optical coherence tomography (OCT) in patients with acute myocardial infarction (AMI) caused by plaque rupture and evaluate the therapeutic effect. MethodsThe patients diagnosed with AMI in the Department of Cardiology of Jilin Central Hospital from January 2019 to October 2022 were selected. After emergency percutaneous coronary angiography (CAG) and intracoronary thrombus removal (manual thrombus aspiration or drug intracoronary thrombolysis), the coronary blood flow in CAG confirming culprit vessel returned to TIMI level 3. Moreover, for the patients with visual estimation of culprit lesion stenosis ＜70.00%, OCT examination was performed at a selected time (7 days after hospitalization). Patients meeting the following OCT-defined plaque rupture features were managed without stenting and given intensive drug theraphy (n=29): rupture arc ＜90°; rupture length ＜1mm; absence of large free intimal flaps. CAG and OCT were reviewed 12 months after treatment, and the changes of OCT characteristics at baseline and 12 months after treatment were compared, and the occurrence of major adverse cardiovascular events (MACE) within 12 months were analyzed. ResultsOCT results of 29 patients were reviewed 12 months after treatment. Compared with the baseline OCT features, the thickness of the thin fiber cap increased ［(74.66±20.79)μm, (95.21±16.31)μm］, and the arc of ruptured plaque decreased ［(83.69±6.30)°, (80.38±5.93)°］. The length of ruptured plaque decreased ［(0.67±0.16)mm, (0.56±0.17)mm］, the minimum lumen area increased ［(3.58±0.55)mm2, (3.82±0.69)mm2］, and the depth of ruptured plaque decreased ［(1410.34±214.40)μm, (1251.38±208.22)μm］, the percent area stenosis ［(64.00±4.26)%, (61.79±4.23)%］ and macrophage infiltration rate decreased ［68.97%(20/29), 34.48%(10/29)］, and the differences were statistically significant (t=11.71, 3.59, 3.55, 6.29, 9.84, 3.51, χ2=8.10, all P＜0.01). After 12 months of follow-up, two patients (6.90%) were re-hospitalized for angina pectoris, of whom one patient showed no stenosis progression on follow-up CAG, and the other patient underwent stenting for a non-culprit lesion progression. No serious MACE occurred during follow-up. ConclusionsAfter removal of thrombosis in AMI, CAG lumen stenosis ＜70.00%, and OCT of the offender lesion showed plaque rupture leading to AMI. For patients with a plaque rupture arc less than 90°, a ruptured plaque length less than 1mm, and no large free inner membrane, drug therapy can avoid stent implantation, reduce the occurrence of no reflux and stent restenosis after stent implantation.

Key words： Acute myocardial infarction Optical coherence tomography Percutaneous coronary intervention Plaque rupture

收稿日期: 2024-11-15

基金资助:吉林省卫生健康技术创新项目（2019J04）

通讯作者: 詹景冬, Email: 547227142@qq.com

引用本文:

郭方明颜凡辉刘远航王阳张艳芬赵明俐赵英杰刘萌萌詹景冬. 光学相干断层成像在斑块破裂导致急性心肌梗死患者中的应用及治疗效果评估[J]. 中华诊断学电子杂志, 2025, 13(1): 14-19.
Guo Fangming, Yan Fanhui, Liu Yuanhang,Wang Yang, Zhang Yanfen, Zhao Mingli, Zhao Yingjie, Liu Mengmeng, Zhan Jingdong.. Application and therapeutic effect evaluation of optical coherence tomography in patients with acute myocardial infarction caused by plaque rupture. zhzdx, 2025, 13(1): 14-19.

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