STEMI患者行PPCI的总缺血时间分析与区域协同救治体系优化策略研究综述

Total Ischemic Time in STEMI Patients Undergoing Primary Percutaneous Coronary Intervention: A Narrative Review of Current Evidence and Optimization Strategies for Regional Coordinated Care Systems

摘要: ST段抬高型心肌梗死(ST-segment elevation myocardial infarction, STEMI)是急性冠状动脉综合征中最危重的类型之一，其病理基础多为冠状动脉急性完全闭塞所致的持续性透壁心肌缺血与坏死。尽早、充分、持续地恢复梗死相关动脉血流，是降低STEMI患者死亡率、减少心力衰竭发生和改善远期预后的关键。直接经皮冠状动脉介入治疗(primary percutaneous coronary intervention, PPCI)是目前指南推荐的首选再灌注策略，但其治疗获益具有明显的时间依赖性。既往研究显示，治疗延迟时间越长，心肌梗死面积、微循环灌注障碍和死亡风险越高。近年来，随着我国胸痛中心建设的持续推进，以门–球时间和入门–导丝通过时间为代表的院内救治流程不断优化。然而，全国胸痛中心质控数据显示，STEMI患者症状发作至首次医疗接触时间仍然较长，院前延迟已成为制约整体救治效果进一步提升的主要瓶颈。总缺血时间(total ischemic time, TIT)是指从症状发作至梗死相关动脉恢复有效血流的全过程时间，能够比单一院内时间指标更全面地反映心肌缺血负荷和救治链条效率。本文围绕STEMI患者行PPCI过程中TIT的定义、构成、临床意义、影响因素及其与预后的关系进行系统综述，并进一步探讨以TIT为核心的区域协同救治体系优化策略。基于女性、老年及糖尿病等特殊群体的院前延迟特征，以及超大城市、中等城市、农村和偏远地区在TIT优化中的差异化矛盾；同时从管理、技术、资金和政策层面分析各项策略的实施路径与现实挑战，以期为胸痛中心内涵建设、区域急救体系完善及STEMI患者预后改善提供参考。

Abstract: ST-segment elevation myocardial infarction (STEMI) is one of the most critical forms of acute coronary syndrome, usually caused by acute complete occlusion of a coronary artery, resulting in persistent transmural myocardial ischemia and necrosis. Early, complete, and sustained restoration of blood flow in the infarct-related artery is essential for reducing mortality, preventing heart failure, and improving long-term prognosis. Primary percutaneous coronary intervention (PPCI) is the guideline-recommended first-line reperfusion strategy for eligible STEMI patients. However, the clinical benefit of PPCI is highly time-dependent. Previous studies have shown that prolonged treatment delay is associated with larger infarct size, impaired microvascular perfusion, and increased mortality. In recent years, with the continuous development of chest pain centers in China, in-hospital treatment processes represented by door-to-balloon time and door-to-wire time have been significantly improved. Nevertheless, national quality control data from chest pain centers indicate that the time from symptom onset to first medical contact remains prolonged, and pre-hospital delay has become a major bottleneck limiting further improvement in STEMI outcomes. Total ischemic time (TIT), defined as the total interval from symptom onset to restoration of effective coronary blood flow, provides a more comprehensive assessment of cumulative myocardial ischemic burden and the efficiency of the entire treatment chain than isolated in-hospital process indicators. This review summarizes the definition, components, clinical significance, influencing factors, and prognostic value of TIT in STEMI patients undergoing PPCI. Particular attention is given to pre-hospital delay among women, older adults, and patients with diabetes, as well as to differences in TIT optimization among megacities, medium-sized cities, rural areas, and remote regions. The implementation pathways and practical challenges of each optimization strategy are also discussed from managerial, technological, financial, and policy perspectives.