Abstract: Background　Coronary no-reflow is an important factor associated with the effect of emergency PCI in patients with acute ST-segment elevation myocardial infarction （STEMI），which is also a prognostic factor as it increases the risk of death.So it is essential to identify effective drug treatment to improve the effect of PCI and reduce the possibility of developing coronary no-reflow.Objective　To perform a comparative analysis of intracoronary with intravenous administration of bivalirudin and intravenous administration of bivalirudin in patients with acute STEMI in terms of safety and effects on no-reflow during PCI and short-term outcome.Methods　Participants were 110 inpatients who were diagnosed with acute STEMI and underwent PCI within 12 hours of symptom onset in Xinjiang Medical University Affiliated TCM Hospital from June 2017 to January 2019.They were evenly randomized into observation group with intracoronary with intravenous administration of bivalirudin，and control group with intravenous administration of bivalirudin.Intraoperative and postoperative observation indices（number of diseased coronary artery vessels，infarct-related artery（IRA），preoperative TIMI flow grade of target vessel，Gensini score，door-to-balloon time，number of thrombus aspiration cases，number of implanted stents，rate of poststenotic dilation，rate of postoperatively using ACEIs or ARBs，rate of postoperatively usingβ-blockers），therapeutic evaluation indices〔corrected TIMI frame count（CTFC） of the IRA measured immediately after stent implantation，and rate of coronary no-reflow during PCI，degree of ST-segment depression within four hours after PCI，serum CK-MB and LVEF at 24 hours after PCI〕，and major adverse cardiovascular events（MACE） within 30 days after PCI were compared between the two groups.Multivariate logistic regression analysis was used to investigate the effect of intracoronary and intravenous bivalirudin bolus administration during PCI on some therapeutic indices.Results　There were no significant differences in intraoperative and postoperative observation indices between the two groups（P>0.05）.The CTFC of the IRA measured immediately after stent implantation，rate of coronary no-reflow and degree of ST-segment depression within four hours after PCI differed significantly between the two groups（P<0.05）.Multivariate Logistic regression analysis showed that intracoronary and intravenous bivalirudin bolus administration during PCI was associated with reduced number of CTFC of the IRA measured immediately after stent implantation 〔OR=0.423，95%CI（0.321，0.656），P=0.005〕，reduced possibility of developing coronary no-reflow 〔OR=0.431，95%CI（0.262，0.812），P=0.002〕，and greater degree of ST-segment depression within four hours after PCI〔OR=1.532，95%CI（0.627，2.517），P=0.003〕.Conclusion　The results of this study demonstrate that intracoronary and intravenous bivalirudin administration during PCI could reduce the incidence of coronary no-reflow and the risks of acute heart failure and all-cause death，and improve short-term clinical outcome in acute STEMI patients with good safety.

Key words: Myocardial infarction；Bivalirudin；Angioplasty, Balloon, Coronary；No-Reflow Phenomenon；Prognosis；Root cause analysis

摘要： 背景　冠状动脉无复流是影响急性ST段抬高型心肌梗死（STEMI）患者急诊经皮冠状动脉介入治疗（PCI）效果的重要因素，影响患者预后，增加死亡风险。寻求有效的药物提高PCI手术效果，降低术中无复流的发生率具有重要意义。目的　探讨冠状动脉内直接注入比伐芦定联合静脉泵入对比单静脉泵入比伐芦定对急性STEMI患者术中无复流的影响及其安全性和短期临床预后观察。方法　选取2017年6月—2019年1月于新疆医科大学附属中医医院明确诊断为急性STEMI发病12 h内并行PCI的住院患者110例，随机分为冠状动脉内直接注入联合静脉泵入比伐芦定组（观察组，n=55）和单纯静脉泵入比伐芦定组（对照组，n=55）。比较两组术中、术后观察指标〔病变血管支数、梗死相关血管（IRA）、术前靶血管TIMI血流分级、Gensini评分、门-球（D-to-B）时间、血栓抽吸例数、支架植入数量、后扩张、术后应用血管紧张素转换酶抑制剂（ACEI）或血管紧张素Ⅱ受体拮抗剂（ARB）比例、术后应用β-受体阻滞剂比例〕、疗效评价指标〔术中植入支架即刻造影IRA的校正的TIMI帧数计数（CTFC），无复流/慢血流发生率，术后4 h内心电图ST段回落程度，术后24 h的肌酸激酶同工酶（CK-MB），术后24 h左心室射血分数（LVEF）〕、30 d内主要心血管不良事件（MACE）发生率；采用多因素Logistic回归分析探讨冠状动脉内直接注入比伐芦定联合静脉泵入对部分疗效指标的影响。结果　两组患者术中、术后观察指标比较，差异无统计学意义（P>0.05）。两组PCI术中即刻CTFC、无复流/慢血流发生率及ST段回落情况比较，差异有统计学意义（P<0.05）。多因素Logistic回归分析结果显示，冠状动脉内直接注入比伐芦定联合静脉泵入治疗急性STEMI，可以降低患者术中CTFC〔OR=0.423，95%CI（0.321，0.656），P=0.005〕，是术后无复流/慢血流〔OR=0.431，95%CI（0.262，0.812），P=0.002〕的保护因素，并促进术后4 h内心电图ST段的回落〔OR=1.532，95%CI（0.627，2.517），P=0.003〕。结论　冠状动脉内直接注入比伐芦定联合静脉泵入可降低STEMI患者术后无复流发生率，可降低心力衰竭及死亡风险，且安全性良好，可改善患者短期临床预后。

关键词: 心肌梗死, 比伐芦定, 血管成形术, 气囊, 冠状动脉, 无复流现象, 预后, 影响因素