吉林大学学报(医学版)  2018, Vol. 44 Issue (04): 780-785

扩展功能

文章信息

朱涛, 张国明, 严飞, 刘正, 霍强
ZHANG Tao, ZHANG Guoming, YAN Fei, LIU Zheng, HUO Qiang
急性心肌梗死患者PCI术后心率变异性对主要不良心脏事件的评估价值
Values of evaluation of heart rate variability in major adverse cardiac events in patients with acute myocardial infarction after PCI
吉林大学学报(医学版), 2018, 44(04): 780-785
Journal of Jilin University (Medicine Edition), 2018, 44(04): 780-785
10.13481/j.1671-587x.20180416

文章历史

收稿日期: 2017-06-19
急性心肌梗死患者PCI术后心率变异性对主要不良心脏事件的评估价值
朱涛1 , 张国明2 , 严飞1 , 刘正1 , 霍强1     
1. 新疆医科大学第一附属医院心外一科, 新疆 乌鲁木齐 830054;
2. 新疆医科大学第一附属医院小儿外科, 新疆 乌鲁木齐 830054
[摘要]: 目的: 探讨急性心肌梗死(AMI)患者经皮冠状动脉介入治疗(PCI)术后心率变异性(HRV)对评估短期主要不良心脏事件(MACE)的临床价值。方法: 选择接受PCI的AMI患者160例,根据术后3个月内是否发生MACE分为对照组126例(术后3个月内未发生MACE)和研究组34例(术后3个月内发生MACE)。比较2组患者全部正常窦性心搏间期标准差(SDNN)、平均正常窦性心搏间期标准差(SDANN)、每5min正常窦性心搏间期标准差的平均值(SDNNIDX)、相差50ms以上相邻窦性心搏间期数占窦性心搏间期总数的百分比(PNN50)、全程相邻正常窦性心搏间期差的均方根值(rMSSD)、低频(LF)和高频(HF)等HRV主要指标的差异。计算每个患者的冠脉Gensini评分,分析冠脉Gensini评分与HRV主要指标的相关性。随访3个月,应用多元Logistic回归分析HRV主要指标与MACE发生的危险程度。结果: 研究组患者的SDNN、SDANN、SDNNIDX、PNN50、RMSSD和HF水平低于对照组(P < 0.05),而LF水平高于对照组(P < 0.05)。患者冠脉Gensini评分与SDNN、SDANN和SDNNIDX均呈负相关关系(r=-0.827,r=-0.789,r=-0.698,P < 0.05),但冠脉Gensini评分与rMSSD、pNN50、LF和HF无相关关系(P>0.05)。多元Logistic回归分析,SDNN、SDANN和SDNNIDX为MACE发生的保护因素(P < 0.05)。结论: AMI患者PCI术后反映交感神经系统功能的HRV指标能反映冠脉病变程度并对术后短期预后结局判断有预测价值。
关键词: 急性心肌梗死    经皮冠状动脉介入治疗术    心率变异性    主要不良心脏事件    预后    
Values of evaluation of heart rate variability in major adverse cardiac events in patients with acute myocardial infarction after PCI
ZHANG Tao1, ZHANG Guoming2, YAN Fei1, LIU Zheng1, HUO Qiang1     
1. Department of Cardiovascular Surgery, First Affiliated Hospital, Xinjiang Medical University, Xinjiang 830054, China;
2. Department of Pediatric Surgery, First Affiliated Hospital, Xinjiang Medical University, Xinjiang 830054, China
[Abstract]: Objective: To evaluate the clinical value of heart rate variability (HRV) in evaluation on the short-term major adverse cardiac events (MACE) in the patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI). Methods: A total of 160 AMI patients received PCI were collected and divided into control group (126 cases, there was no MACE during 3 months after PCI) and research group (34 cases, there was MACE during 3 months after PCI) according to the occurrence of MACE after operation. The main HRV indexes including SDNN, SDANN, SDNNIDX, PNN50, RMSSD, LF and HF of the patients in two groups were compared. The Gensini scores of coronary artery of each patient were calculated. The relationships of the main HRV indexes and the Gensini scores of coronary artery were analyzed. After 3 months of follow-up, the risk factors of the main HRV indexes to the occurrence of MACE were confirmed by multivariate Logistic analysis. Results: The main HRV indexes including SDNN, SDANN, SDNNIDX, PNN50, RMSSD and HF of the patients in research group were lower than those in control group (all P < 0.05), but LF in research group was higher than that in control group (P < 0.05).The negative relationships between SDNN, SDANN, SDNNIDX and the Gensini scores were confirmed (r=-0.827, r=-0.789, r=-0.698, P < 0.05), but rMSSD, pNN50, LF and HF had no relationship with the Gensini scores (P>0.05). The multivariant Logistic analysis showed that SDNN, SDANN, SDNNIDX were the independent protective factors to the occurrence of MACE (P < 0.05). Conclusion: The HRV indexes indicating the sympathetic nervous system function can inflect the degree of coronary artery stenosis and assess the short-term prognosis in the AMI patients after PCI.
Key words: acute myocardial infarction     percutaneous coronary intervention     heart rate variability     major adverse cardiac event     prognosis    

急性心肌梗死(acute myocardial infarction,AMI)的病理基础是冠脉斑块不稳定破裂或侵蚀,急性形成完全闭塞性血栓。目前,临床上已普遍予以AMI患者急诊经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI),以早期确保血管的再通。但临床研究[1-2]显示:即便给予AMI患者即时急诊PCI,仍有部分患者发生主要不良心脏事件(major adverse cardiac events,MACE),预后结局较差。因此寻找适宜的临床指标预见性地对AMI患者进行危险分层,对AMI患者治疗策略的确定和预后结局预判有重要临床意义[3-6]。AMI患者由于急性心肌缺血缺氧,心脏自主神经功能均会发生紊乱,心率变异性(heart rate variability,HRV)是临床常用的评价心脏自主神经功能状况的无创性指标[7]。近年来有研究者[8]提出:应用HRV对PCI术后AMI患者预后进行评估以此指导临床治疗,但目前尚无相关临床报道。本研究旨在分析HRV与PCI术后AMI患者短期预后结局的相关性,为临床进一步改善AMI患者预后提供依据。

1 资料与方法 1.1 研究对象

选取2015年1月—2017年3月在本院住院接受PCI术的160例AMI患者作为研究对象,其中男性94例,女性66例,平均年龄(61.4±4.6)岁,均书面签署知情同意书,并通过本院伦理委员会审核。纳入标准:①AMI诊断标准均符合中华医学会心血管病分会制订的《急性ST段抬高型心肌梗死诊断和治疗指南》(2015年)的诊断标准[9];②年龄18~65岁;③能完成随访,临床资料完善。排除标准:①罹患心肌炎、肥厚性心肌病、瓣膜病、主动脉瘤、急性心源性休克和心脏填塞等严重疾病;②有脑、肺、肝和肾等严重脏器功能不全;③罹患心房颤动和起搏心律等异位心律;④存在甲状腺功能异常;⑤2周内发生急性感染、创伤或手术。

1.2 分组

所有患者根据术后3个月内是否发生MACE分为2组:对照组126例,术后3个月内未发生MACE;研究组34例,术后3个月内发生MACE。2组患者术后均按照治疗指南要求,予以强化抗血小板、抗凝、调脂和改善微循环等治疗措施。2组患者年龄、性别比、体质量指数(BMI)、支架数目和种类以及主要生化指标等临床因素比较差异均无统计学意义(P>0.05)。

1.3 冠状动脉病变积分评定标准

所有患者均在入院后急诊行PCI,根据术中冠状动脉造影结果,应用计算机采用Gensini评分标准对每个患者的冠脉病变程度进行定量评定[6],具体标准为:①1分,冠脉狭窄程度为0%~25%;②2分,冠脉狭窄程度为26%~50%;③4分,冠脉狭窄程度为51%~75%;④8分,冠脉狭窄程度为76%~90%;⑤16分,冠脉狭窄程度为91%~99%;⑥32分,冠脉狭窄程度为100%。不同冠状动脉病变节段其相应的系数不同:①左主干病变为5倍;②左前降支近段为2.5倍、中段为1.5倍;③对角支病变D1为1倍、D2为0.5倍;④回旋支近段为2.5倍、远段为1倍,⑤后降支为1倍、后侧支为0.5倍;⑥右冠状动脉近、中、远段均为1倍。冠脉Gensini评分为各分支病变程度与其系数乘积之和。冠脉Gensini评分越高,表示患者冠脉病变越严重。

1.4 HRV检测

所有患者均在急诊行PCI术后接受24h动态心电图监测(Holter),仪器购自美国DMS公司。受检者胸部常规置放7个电极,连续心电记录24h,佩戴前均予以常规12导联心电图检查。应用Holtwin 7.0 Gold Recorder分析系统对每个受检者的24h动态心电监测数据进行分析,得到以下主要指标[10]。(1)时域指标:①SDNN,全部正常窦性心搏间期(NN)的标准差,单位为ms;②SDANN,每5min正常NN平均值的标准差,单位为ms;③SDNNIDX,每5min正常NN标准差的平均值,单位为ms;④rMSSD,全程相邻正常NN差的均方根值,单位为ms;⑤pNN50,相差50ms以上的相邻NN数占NN总数的百分比。(2)频域指标:①LF,低频成分0.04~0.15Hz;②HF,高频成分0.15~0.40Hz。其中SDNN、SDANN、SDNNIDX和LF指标反映交感神经系统功能,而rMSSD、pNN50和HF则反映副交感神经系统功能。

1.5 生化指标检测

所有患者在住院期间均在清晨空腹抽取肘静脉血2mL,采用全自动生化分析仪检测空腹血糖(FBG)、总胆固醇(TC)、甘油三酯(TG)、低密度脂蛋白胆固醇(LDL)和高密度脂蛋白胆固醇(HDL),同时对白蛋白(Alb)和血肌酐(SCr)等肝肾功能指标进行检测。

1.6 预后结局指标

术后出院随访时间平均4个月,最长为6个月,最短2个月,随访间隔2周,随访采取电话和门诊复诊相结合方式进行。160例研究对象均参加随访,失访3例,随访率为98.13%(157/160)。

记录并比较2组患者MACE发生率,其中MACE的一级终点为心源性或全因死亡,二级终点为包括室性心动过速及室颤等恶性心律失常、严重心力衰竭、再发心肌梗死和再次接受PCI术。

1.7 统计学分析

采用SPSS 23.0统计软件进行统计学分析。符合正态分布的计量资料,包括年龄和BMI等一般基础指标、冠状动脉Gensini评分、HRV各指标和各生化检测指标均以x±s表示,组间比较采用两独立样本t检验。计数资料,包括性别比和DES所用比例等指标采取百分率表示,2组间比较采用χ2检验。HRV主要指标与冠脉Gensini评分的相关性分析。采用Pearson直线相关分析。应用多元Logistic回归分析影响MACE发生率的危险因素。以α=0.05为检验水准。

2 结果 2.1 2组患者一般观察指标和生化指标

与对照组比较,研究组患者年龄、性别比、BMI和FBG、TG、TC、LDL、HDL、Cr、Alb水平及Gensini评分等差异均无统计学意义(P>0.05)。见表 1

表 1 2组患者一般观察指标和生化指标 Table 1 General observation and biochemical indexes of patients in two groups
Group n Age(year) Gender
(Male/Female)
BMI
(kg·m-2)
DES ratio
(η/%)
Stent number FBG
[cB/ (mmol·L-1)]
TG
[cB/(mmol·L-1)]
TC
[cB/(mmol·L-1)]
LDL
[cB/(mmol·L -1)]
HDL
[cB/(mmol·L-1)]
Cr
[cB/(μmol·L-1)]
Alb
[ρB/(g·L-1)]
Gensini score
Control 126 60.3±4.1 72/54 22.4±1.9 40.5 2.1±0.6 5.51±0.68 1.37±0.27 4.01±0.58 1.82±0.43 1.02±0.17 81.4±9.1 43.9±4.7 7.7±0.9
Research 34 61.8±4.9 22/12 23.0±2.2 41.2 1.9±0.7 5.69±0.87 1.29±0.31 3.88±0.66 1.93±0.35 0.98±0.14 79.2±9.8 45.5±5.3 7.9±1.1
t/χ2 1.814 3.864 1.579 3.256 1.663 1.287 1.485 1.126 1.373 1.261 1.231 1.714 1.095
P 0.072 0.097 0.116 0.189 0.098 0.200 0.140 0.262 0.172 0.209 0.220 0.089 0.275
2.2 2组患者HRV主要指标

与对照组比较,研究组患者SDNN、SDANN、SDNNIDX、PNN50、RMSSD和HF水平明显降低(P < 0.05),而LF水平明显升高(P < 0.05)。见表 2

表 2 2组患者HRV主要指标水平 Table 2 Levels of main indexes of HRV of patients in two groups
(x±s)
Group n SDNN
(t/ms)
SDANN
(t/ms)
SDNNIDX
(t/ms)
RMSSD
(t/ms)
PNN50
(η/%)
LF
(f/Hz)
HF
(f/Hz)
Control 126 122.3±23.6 119.1±21.2 54.1±9.3 34.6±8.5 13.1±3.8 386.6±73.5 137.7±29.5
Research 34 109.5±19.3 107.7±19.5 49.7±8.5 30.3±9.1 11.5±3.4 428.2±84.8 125.3±27.4
t 2.909 2.828 2.491 2.579 2.226 2.832 2.207
P 0.004 0.005 0.014 0.011 0.027 0.005 0.029
2.3 冠状动脉Gensin评分与HRV指标的直线相关分析

Pearson相关性分析结果显示:患者冠状动脉Gensini评分与SDNN、SDANN和SDNNIDX均呈负相关关系(P < 0.05),但与rMSSD、pNN50、LF和HF无相关关系(P>0.05)。见表 3

表 3 冠状动脉Gensini评分与HRV主要指标的直线相关分析 Table 3 Linear correlation analysis of main HRV indexes and Gensini scores
Index r P
SDNN -0.827 0.008
SDANN -0.789 0.010
SDNNIDX -0.698 0.027
RMSSD -0.237 0.074
PNN50 -0.311 0.063
LF 0.092 0.116
HF -0.112 0.098
2.4 HRV指标与MACE发生率相关因素多元Logistic回归分析

研究组34例发生MACE患者中, 心源性或全因死亡4例,室性心动过速3例,室颤1例,3级及以上心力衰竭13例,再发心肌梗死6例,再次接受PCI术7例。

以MACE发生为应变量,以上述HRV主要指标为自变量,应用全模型多元Logistic回归分析方法进行回归分析,结果显示:SDNN、SDANN、SDNNIDX为MACE发生的保护因素(P < 0.05)。见表 4

表 4 HRV指标多元Logistic回归分析 Table 4 Multivariate Logistic analysis of HRV indexes
Index β Wald SE OR P
Gensini score 0.099 3.013 0.057 1.104 0.079
SDNN -1.165 26.561 0.226 0.312 0.042
SDANN -0.697 19.224 0.159 0.498 0.036
SDNNIDX -0.456 10.905 0.138 0.634 0.029
RMSSD -0.514 27.527 0.098 0.598 0.075
PNN50 -0.207 3.743 0.107 0.813 0.086
LF 1.289 12.963 0.358 3.629 0.054
HF -0.648 8.840 0.218 0.523 0.098
3 讨论

AMI患者发病时多伴有心前区剧烈疼痛及强烈濒死恐惧感,交感神经活性明显上调,导致儿茶酚胺类物质大量释放,致使狭窄的冠脉进一步收缩,心率明显增加,心肌耗氧量也明显增加,加重心室负荷,进一步加重心肌缺血程度[11-13]。同时,在交感神经系统过度激活环境下,会促进血小板在不稳定斑块部位聚集,促使血栓形成,因此患者的MACE发生的风险会明显增加[14-15]。尽管近年来AMI的临床治疗已有较大的进步,但是仍有部分患者即便予以及时的急诊PCI治疗,术后短期预后仍不佳[1]。临床上根据冠脉造影检查情况即Gensini评分确定冠脉狭窄程度,以此来评估AMI患者PCI术后MACE的发生率,但临床实践表明Gensini评分的短期预测价值较差[16]。因此寻找一种准确性较好、相关性较好且简单易行的检测指标来评估AMI患者PCI术后预后结局已成为临床研究热点之一。

目前大量临床研究[17-18]已证实:心肌缺血会使AMI患者的心脏自主神经功能紊乱,具体体现在患者的交感神经活性过度兴奋,而迷走神经活性明显减弱,即HRV水平降低。近年来研究[19-20]显示:AMI患者心肌缺血会导致自主神经功能发生紊乱,进而对窦房结功能的调控失衡,使得HRV水平降低。目前认为HRV也被是评估心脏自主神经活动的最佳无创伤检测技术,能间接评估心脏交感、迷走神经张力及其平衡[21]。而急诊PCI术已被公认为是最有效的冠脉血运重建技术,能明显改善AMI患者的心肌缺血状态,也能明显改善AMI患者HRV,因此通过检测AMI患者PCI术后的HRV能有效评估患者短期预后结局[22-23]。目前24 h动态心电图通过24 h连续记录并分析机体心脏电活动,以此记录HRV的各项指标[24-25]。但是目前尚无AMI患者PCI术后HRV与患者短期MACE发生率的相关性的研究。

本研究中无论是否发生MACE,接受PCI的AMI患者的一般观察指标以及主要生化指标比较差异均无统计学意义,同时2组患者接受的支架种类及数量比较差异也无统计学意义,表明本研究分组对象基线水平无明显差异,研究系统误差控制较好;同时,2组患者Gensini积分比较差异无统计学意义,提示临床上反映冠脉病变程度指标不能有效评估患者的预后结局;PCI术后发生MACE的AMI患者HRV主要指标均低于未发生MACE的AMI患者,提示预后结局较差的AMI患者HRV水平较低。应用Pearson相关性分析结果显示:反映交感神经活性的HRV主要指标,包括SDNN、SDANN、SDNNIDX和LF与冠脉Gensini积分均呈负相关关系,而反映迷走神经活性的指标,包括rMSSD、pNN50和HF则与冠脉Gensini积分无相关关系,表明PCI治疗后AMI患者血供改善会明显提高HRV中反映交感神经活性部分指标。进一步应用全模型多元Logistic回归分析方法显示:SDNN、SDANN、SDNNIDX为MACE发生的保护因素,提示动态监测接受PCI治疗的AMI患者SDNN、SDANN和SDNNIDX等HRV指标,可对患者的短期预后进行有效评估。

综上所述,HRV指标能反映AMI患者PCI术后冠脉病变程度,对患者术后短期预后结局有预测价值。但本研究的样本量较少,因此仍需要大样本多中心的临床研究进一步证实。

参考文献
[1] Ernst G, Watne LO, Frihagen F, et al. Decreases in heart rate variability are associated with postoperative complications in hip fracture patients[J]. PLoS One, 2017, 12(7): e0180423. DOI:10.1371/journal.pone.0180423
[2] Erdogan E, Akkaya M, Bacaksiz A, et al. Short-term effect of percutaneous recanalization of chronic total occlusions on QT dispersion and heart rate variability parameters[J]. Med Sci Monit, 2013, 19: 696–702. DOI:10.12659/MSM.889511
[3] Heldeweg ML, Liu N, Koh ZX, et al. A novel cardiovascular risk stratification model incorporating ECG and heart rate variability for patients presenting to the emergency department with chest pain[J]. Crit Care, 2016, 20(1): 179. DOI:10.1186/s13054-016-1367-5
[4] Hamm W, Stülpnagel L, Vdovin N, et al. Risk prediction in post-infarction patients with moderately reduced left ventricular ejection fraction by combined assessment of the sympathetic and vagal cardiac autonomic nervous system[J]. Int J Cardiol, 2017, 249: 1–5. DOI:10.1016/j.ijcard.2017.06.091
[5] 王银, 刘悦, 莫钟铃, 等. 三维斑点追踪技术在评价急性心肌梗死经皮冠状动脉治疗术后近期左室壁运动和收缩功能中的应用及其价值[J]. 吉林大学学报:医学版, 2017, 43(2): 429–434.
[6] Chen J, Zhang Y, Liu J, et al. Role of lipoprotein (a) in predicting the severity of new on-set coronary artery disease in type 2 diabetics:A Gensini score evaluation[J]. Diab Vasc Dis Res, 2015, 12(4): 258–264. DOI:10.1177/1479164115579004
[7] Yuan MJ, Pan YS, Hu WG, et al. A pilot study of prognostic value of non-invasive cardiac parameters for major adverse cardiac events in patients with acute coronary syndrome treated with percutaneous coronary intervention[J]. Int J Clin Exp Med, 2015, 8(12): 22440–22449.
[8] Muhadi, Nasution SA, Putranto R, et al. The ability of detecting heart rate variability with the photoplethysmography to predict major adverse cardiac event in acute coronary syndrome[J]. Acta Med Indones, 2016, 48(1): 48–53.
[9] 中华医学会心血管病分会. 急性ST段抬高型心肌梗死诊断和治疗指南[J]. 中华心血管病杂志, 2015, 43(5): 380–393.
[10] 孙瑞龙, 吴宁, 杨世豪, 等. 心率变异性检测临床应用的建议[J]. 中华心血管病杂志, 1998, 26(4): 12–15.
[11] Sookan T, McKune AJ. Heart rate variability in physically active individuals:reliability and gender characteristics[J]. Cardiovasc J Afr, 2012, 23(2): 67–72.
[12] Schäfer D, Nil M, Herzig D, et al. Good reproducibility of heart rate variability after orthostatic challenge in patients with a history of acute coronary syndrome[J]. J Electrocardiol, 2015, 48(4): 696–702. DOI:10.1016/j.jelectrocard.2015.04.004
[13] Yiadom MY, Baugh CW, McWade CM, et al. Performance of emergency department screening criteria for an early ECG to identify ST-segment elevation myocardial infarction[J]. J Am Heart Assoc, 2017, 6(3): e003528. DOI:10.1161/JAHA.116.003528
[14] Moses DA, Johnston LE, Tracci MC, et al. Estimating risk of adverse cardiac event after vascular surgery using currently available online calculators[J]. J Vasc Surg, 2018, 67(1): 272–278. DOI:10.1016/j.jvs.2017.06.105
[15] Heldeweg ML, Liu N, Koh ZX, et al. A novel cardiovascular risk stratification model incorporating ECG and heart rate variability for patients presenting to the emergency department with chest pain[J]. Crit Care, 2016, 20(1): 179. DOI:10.1186/s13054-016-1367-5
[16] Zhang J, He S, Wang X, et al. Effect of trimetazidine on heart rate variability in elderly patients with acute coronary syndrome[J]. Pak J Med Sci, 2016, 32(1): 75–78.
[17] Compostella L, Lakusic N, Russo N, et al. Functional parameters but not heart rate variability correlate with long-term outcomes in St-elevation myocardial infarction patients treated by primary angioplasty[J]. Int J Cardiol, 2016, 224: 473–481. DOI:10.1016/j.ijcard.2016.09.070
[18] Compostella L, Lakusic N, Compostella C, et al. Does heart rate variability correlate with long-term prognosis in myocardial infarction patients treated by early revascularization[J]. World J Cardiol, 2017, 9(1): 27–38. DOI:10.4330/wjc.v9.i1.27
[19] Harris PR, Stein PK, Fung GL, et al. Heart rate variability measured early in patients with evolving acute coronary syndrome and 1-year outcomes of rehospitalization and mortality[J]. Vasc Health Risk Manag, 2014, 10: 451–464.
[20] Princip M, Scholz M, Meister-Langraf RE, et al. Can illness perceptions predict lower heart rate variability following acute myocardial infarction?[J]. Front Psychol, 2016, 7: 1801.
[21] Yaghini Bonabi S, El-Hamad F, Müller A, et al. Recording duration and short-term reproducibility of heart rate and QT interval variability in patients with myocardial infarction[J]. Physiol Meas, 2016, 37(11): 1925–1933. DOI:10.1088/0967-3334/37/11/1925
[22] Harris PR, Sommargren CE, Stein PK, et al. Heart rate variability measurement and clinical depression in acute coronary syndrome patients:narrative review of recent literature[J]. Neuropsychiatr Dis Treat, 2014, 10: 1335–1347.
[23] Liu Y, Syed Z, Scirica BM, et al. ECG morphological variability in beat space for risk stratification after acute coronary syndrome[J]. J Am Heart Assoc, 2014, 3(3): e000981. DOI:10.1161/JAHA.114.000981
[24] Aires R, Pimentel EB, Forechi L, et al. Time course of changes in heart rate and blood pressure variability in rats with myocardial infarction[J]. Braz J Med Biol Res, 2017, 50(1): e5511.
[25] Compostella L, Lakusic N, Russo N, et al. Functional parameters but not heart rate variability correlate with long-term outcomes in St-elevation myocardial infarction patients treated by primary angioplasty[J]. Int J Cardiol, 2016, 224: 473–481. DOI:10.1016/j.ijcard.2016.09.070