急性心肌梗塞溶栓后早期介入治疗的疗效

目的:直接经皮冠状动脉腔内成形术(PTCA)和冠状动脉内支架治疗为急性心肌梗塞(AMI)提供了积极有效,并安全的恢复心肌灌注的手段,优于常规溶栓治疗,但冠脉介入仍有时间延误问题。本研究旨在探讨AMI患者在等待经皮冠脉介入治疗(PCI)的时间延误期内,使用重组组织型溶酶原激活剂(rt-PA)常规剂量治疗,促使梗死相关血管(IRA)早期开通的有效性,早期血管开通对左室功能的影响,及溶栓后立即进行PCI的可行性和安全性。方法:75例AMI患者在使用阿斯匹林和肝素情况下接受rt-PA 20 mg 1次静脉推注,随后80 mg在半小时内快速滴入。尽快行急性冠状动脉造影术。无论血管是否再通均行PTCA及支架术(联合治疗组),并和同期进行的88例AMI直接PCI(单纯PCI组)进行对比分析。本试验临床终点包括:到达导管室时血管开通率,PCI的结果,治疗后两周左室功能及不良事件的发生率。结果:到达导管室时, 联合治疗组的血管开通率88%(TIMIⅡ级占26%,TIMIⅢ级占62%),单纯PCI组为36%(自然开通,TIMI Ⅱ级占20%,TIMIⅢ级占16%),P<0.001。两组PCI血管再通率相近,分别为96%,94%。两组IRA恢复TIMIⅢ级者相同,分别为84%,82%。两周后对左室功能(超声EF值)的影响,联合治疗组优于单纯PCI组, 分别为65.4%,54.6%(P<0.05)。两组住院期间不良事件(大出血,脑卒中,再狭窄和死亡)发生率无显著差异。两周住院死亡率联合治疗组为0%,单纯PCI组为3.4 %(P<0.001)。结论:联合治疗组(溶栓+ PCI)和单纯PCI组相比,早期开通率高,住院期间左室功能恢复较好。在等待PCI患者中早期加速进行溶栓可以促进血管早期再通,左室功能恢复;溶栓后随即进行PTCA并不增加PCI的并发症和不良事件发生率。     

国产替非罗斑对急性心肌梗塞介入手术后心肌血流影响

目的:探讨急性心肌梗塞急诊直接冠状主动脉介入治疗(PCI)术前早期应用国产血小板糖蛋白Ⅱb/Ⅲa受体拮抗剂替非罗斑对术后冠脉血流的影响。方法:2005年4月至2005年12月对24例初发ST段抬高急性心肌梗塞患者,于PCI术前推注肝素60IU/kg和10μg/kg替非罗斑,之后静脉持续滴注替非罗斑0.1～0.15μg/kg.min,24～48h。对照组为同期32例PCI,仅用肝素100IU/kg推注。两组术后均皮下注射低分子肝素5～7d.分析两组冠脉造影情况及PCI术后即刻冠脉TIMI血流分级。结果:到达导管室替非罗斑组梗塞相关血管(IRA)开通率为24%(20%TIMI2级,4%TIMI3级).对照组开通率25%(18%TIMI2级,7%TIMI3级)。行PCI术后替非罗斑组IRA开通率为96%(10%TIMI2级,86%TIMI3级),对照组IRA开通率为95%(20%TIMI2级,75%TIMI3级)。两组在术前和术后血管开通率无明显差异(P=0.28)。替非罗斑组术后达TIMI血流3级为86%,明显高于对照组的75%(P<0.05)。结论:替非罗斑在急性心肌梗塞急诊PCI术中可能有改善心外膜血管通畅,减少慢血流现象的作用。     

AMI静脉溶栓后即行PTCA与直接冠状动脉支架术的疗效比较

目的 比较rt-PA(50mg)静脉溶栓后即刻行经皮腔内冠状动脉成形术与直接冠状动脉支架术治疗急性心肌梗死(AMI)的临床疗效.方法119例AMI患者随机分为AB两组.A组65例行rt-PA半量(50mg)静脉溶栓后即刻行冠状动脉血管造影,及经皮冠状动脉腔内血管成行术,B组54例行直接冠状动脉支架术.术后观察20天.结果(1)首次冠状动脉造影显示:A组梗塞相关动脉(IRA)69支,开通为54%:B组IRA 57支,开通率为15%.两组开通率相比有非常显著性差异(P<0.01).(2)A,B两组行PTCA和支架置入术后对IRA恢复TIMI Ⅲ级血流效果相同,A组100%,B组98%,两者相比无显著性差异(P>0.05).(3)病人住院10～20天,二维超声心动图显示,左心室射血分数(LVEF)达到或超过60%者,A组为88%,而B组仅占69%.两者相比有显著性差异(P<0.05).(4)脑卒中或大出血并发症两组病例均未发生.(5)住院病死率,A组3%(2/65),B组3.7%(2/54),两者相比无显著性差异(P>0.05).结论小剂量rt-PA静脉溶栓后即刻行冠状动脉成形及支架置入术与直接冠状动脉支架置入术治疗AMI临床疗效相比,前者较后者具有更早地使IRA前向血流再灌注,减低冠状动脉支架置入术中并发症发生,从而具有较好的左心室功能保护,且不增加不良事件的发生.     

重组组织型纤溶酶原激活剂加补救性冠状动脉介入术与直接冠状动脉介入术对急性心肌梗死的疗效研究

目的：为比较急性心肌梗死（AMI）患应用重组组织型纤溶酶原激活剂（rt-PA)50mg治疗，加补救性经皮冠状动脉腔内成形术（PTCA）或冠状动脉内支架（Stent）置入术与直接PTCA／Stent置入术临床疗效。方法：135例首次AMI患随机给予以静脉rt-PA溶栓加补救性PTCA／Stent(A组）和直接PTCA／Stent(B组）。68例患用阿司匹林和肝素后，接受rt-PA50mg治疗，67例直接PTCA和支架。行急诊冠状动脉造影 （CAG），以TIMI血流分级法评估，必要时做PTCA／Stent。本研究终点包括分析两组患的梗死相关血管（IRA）开通率，并发症发生率、病死率及左心室功能。结果：A组IRA开通率为91．0％，B组IRA开通率95．5％。患于首次PTCA前及在3周后用超声心电图测定两组患左心室射血分数（LVEF）。两组患到达导管室时IRA血流已达TIMI3级（n=34其中A组24例，B组10例），最初和恢复期EF值分别为60．8％和62．5％，经介入治疗后变为TIMI3级（n=80），其中A组75％（33／44），B组为84．2％（47／57），最初EF57．0％和恢复期EF57．2％。从未获TIMI3级（n=21），其最初EF54．1％和恢复期EF53．2％为最低。结论：溶栓剂rt-PA50mg治疗加补救性PTCA／Stent与直接PTCA／Stent,在AMI中的疗效比较，可使IRA开通，有利于保护AMI患的左心室功能和不增加副作用。     

急性心肌梗塞溶栓并早期介入治疗对左室功能的影响

目的:探讨急性心肌梗塞(AMI)患者在等待经皮冠脉介入治疗(PCI)的时间内,早期给予重组组织型纤溶酶原激活剂(rt-PA)常规剂量治疗,促进梗塞相关血管(IRA)早期开通,改善左室功能的长期影响(2年)。方法:75例AMI患者在使用阿司匹林和肝素情况下接受rt-PA溶栓治疗。其方法:①所有病人都在发生症状6h内进行治疗,溶栓加PCI;②以快速"首次冲击量方案"给药,于最初5min内给予rt-PA20mg,其余80mg于30min内快速给予;③早期持续给予静脉肝素治疗;④无论血管有无再通,只要梗塞相关血管有≥50%狭窄,均行PCI;⑤在术后2周内和2年,以心脏超声心动图行左室功能检测,并和同期88例AMI直接进行PCI的AMI患者进行对比分析。结果:到达心导管室时,溶栓加PCI组(联合治疗组)在溶栓后血管开通率为88%(TIMIⅡ级占26%,TIMIⅢ级占62%)。而单纯PCI组为36%(未溶栓,自然开通,TIMIⅡ级占20%,TIMIⅢ级占16%),前者血管开通率明显高于后者(P<0.05)。两组总的PCI血管再通率相似,分别为96%,94%。两组TIMIⅢ级患者相同,分别为84%,82%。左室射血分数(LVEF):两周后:联合治疗组的优于单纯PCI组,分别为65.4%,54.6%(P<0.05);两年后:联合治疗组的(60.6%)亦显著优于单纯PCI组(48.23%),P<0.01。结论:联合治疗组(溶栓加PCI)和单纯PCI组相比,早期血管再通率较高,住院2周和远期(术后2年)左心功能恢复较好,值得推广。     

应用小剂量溶栓剂联合经皮冠状动脉介入治疗急性心肌梗死的临床研究

目的评价急性心肌梗死(AMI)患者应用小剂量溶栓剂重组组织型纤溶酶原激活剂(rt-PA)联合经皮冠状动脉介入治疗(PCI)的疗效和安全性。方法2005年4月至2006年4月,首都医科大学附属北京安贞医院116例首次AMI患者随机分为接受小剂量溶栓联合PCI治疗(小剂量易化PCI)组和直接PCI治疗组,69例患者接受静脉rt-PA50mg溶栓加PCI治疗,47例患者行直接PCI治疗。比较两组患者PCI前后梗死相关血管(IRA)开通率、出院前左室射血分数(LVEF)、住院期间出血事件、主要心脏不良事件(MACE)发生率。结果两组患者自入院至PCI时间比较差异无统计学意义;首次冠状动脉造影显示小剂量溶栓易化PCI治疗组PCI术前IRA开通率和血管床灌注评分(TIMI)3级血流率明显高于直接PCI组(44.7%对21.7%,P<0.05;34.0%对10.1%,P<0.05);小剂量易化PCI组术后TIMI3级血流率和出院前LVEF明显高于直接PCI治疗组[95.9%对85.9%,P<0.05;(65.2±7.6)%对(50.4±14.3)%,P<0.05];两组患者MACE发生率和住院期间主要出血事件发生率比较差异无统计学意义(P>0.05)。结论小剂量易化PCI治疗AMI安全有效,早期再通率高,有利于保护心室功能,且不增加MACE和出血并发症。     

区域救治体系中急性ST段抬高型心肌梗死溶栓后早期介入与直接介入的疗效比较

目的比较急性ST段抬高型心肌梗死(STEMI)溶栓后早期经皮冠状动脉介入治疗(PCI)与直接PCI的疗效。方法 STEMI患者89例根据治疗方法分为溶栓后早期PCI组41例和直接PCI组48例,分别对两组梗死相关动脉(IRA)的再通率、并发症发生率、支架植入术、住院期间死亡率及1个月后患者左室射血分数(LVEF)等指标进行比较。结果 PCI术前,溶栓后早期PCI组血管开通率85.4%(19.5%TIMI 2级,65.9%TIMI 3级血流),明显高于直接PCI组(18.7%,10.4%为TIMI 2级血流,8.3%TIMI 3级血流,P<0.001)。两组PCI术后TIMI血流分级无统计学差异(P=0.653),但溶栓后早期PCI组所用支架数更少。两组住院期间不良事件发生率(大出血、再梗死、急性左心衰竭和住院天数)无显著差异(P>0.05)。1个月后随访LVEF、左室舒张末期内径(LVEDd)、心源性死亡、再梗死、脑卒中等无显著差异(P>0.05)。结论溶栓后早期PCI治疗是一种有效、安全的替代再灌注策略。     

溶栓和直接经皮冠状动脉腔内成形术治疗青年人急性心肌梗塞的研究(摘要)

急性心肌梗塞(AMI)时,静脉溶栓和经皮冠状动脉腔内成形术(PTCA)均能使梗塞相关血管再通。本文报告我院应用这两种方法治疗46例40岁以下青年人AMI经验。1　资料与方法　　1995年～1999年我院住院的46例AMI患者,男45例,女1例,年龄35.2(22～40)岁。其中前壁38例,下壁8例。均在发病后6小时内入院,心功能Killip级36例、级10例。随机抽选30例按AMI溶栓方案治疗(溶栓组),并于溶栓后60～90分内行冠状动脉造影术,16例直接PTCA治疗(直接PTCA组)。心肌梗塞溶栓治疗临床试验(TIMI)血流3级为溶栓和PTCA成功,溶栓组溶栓后TIMI血流3级以下者…     

急性ST段抬高型心肌梗死尿激酶原溶栓后早期介入与直接介入治疗的研究

目的：比较急性ST段抬高心肌梗死(STEMI)重组人尿激酶原溶栓后早期经皮冠状动脉介入治疗( PCI) 与直接PCI的疗效。方法：2014年1月－2015年6月就诊于我院STEMI患者69例,根据治疗方法将患者分为尿激酶原溶栓后早期PCI组和直接PCI组,分别对两组患者梗死相关动脉( IRA) 的再通率、并发症发生率、支架植入术、住院期间死亡率及1 个月后患者左室射血分数( LVEF) 等指标进行比较分析。结果：溶栓后早期PCI组共纳入32例患者,直接PCI组共纳入37例患者。术前溶栓后早期介入组血管开通率87.5%(18.7%TIMI Ⅱ级, 68.8%TIMI Ⅲ 级血流), 直接PCI组为18.9%(10.8%为TIMI Ⅱ级血流, 8.1%TIMI Ⅲ 级血流)(P <0.001)。两组PCI术后血流再通率相似, 分别为90.6%、89.8 %(P=0.653),但尿激酶原溶栓早期PCI组所用支架数更少。两组住院期间不良事件发生率(大出血、在闭塞、急性型左心衰和住院天数)无显著差异。1月后随访LVEF、LVEDd、心源性死亡、再梗、脑卒中等无显著差异。结论：尿激酶原溶栓后早期PCI治疗是一种有效、安全的替代再灌注策略。     

紧急经皮冠状动脉腔内成形术与溶栓治疗急性心肌梗死的比较

目的　比较紧急经皮冠状动脉腔内成形术 (PTCA)治疗急性心肌梗死 (AMI)与尿激酶静脉溶栓治疗AMI的临床疗效及安全性。方法　在 77例AMI患者中 ,2 8例患者接受紧急PT CA治疗 ,49例患者接受尿激酶静脉溶栓治疗。结果　紧急PTCA组中梗塞相关血管开通 2 6例 ,开通率为 92 .9% ,尿激酶静脉溶栓组中梗塞相关血管再通 2 8例 ,再通率为 5 7.1% ,两组比较差异有显著性 (P <0 .0 5 )。紧急PTCA组住院期间心脏事件发生率为 7.1% ,尿激酶静脉溶栓组为2 0 .4% ,两组比较差异有显著性 (P <0 .0 5 )。紧急PTCA组住院时间为 (11.5± 4.2 )天 ,尿激酶静脉溶栓组为 (19.7± 5 .6)天 ,两组比较差异有显著性 (P <0 .0 5 )。结论　紧急PTCA与尿激酶静脉溶栓治疗AMI时 ,前者的开通梗塞相关血管及降低住院期间心脏事件发生率优于后者 ,而且住院时间明显缩短。     

Surgery for myocardial salvage in acute myocardial infarction and acute coronary syndromes

This article addresses the pathophysiology, the treatment options, and their rationale in the setting of life-threatening acute myocardial infarction and acute on chronic ischemia. Although biases may exist between cardiologists and surgeons, with this review, we hope to provide the reader with information that will shed light on the options that best suit the individual patient in a given set of circumstances.     

Emergency myocardial revascularization in acute evolving myocardial infarct

Immediate coronary artery bypass for acute evolving myocardial infarction could be the elective therapy if provided on useful time, because myocardial salvage can be achieved by early reperfusion. Thirty eight patients had emergency coronary artery by-pass graft for acute evolving myocardial infarction during the early phase: 35 were male, the mean age was 51 years (34 to 74). The mean interval between the onset of symptoms and surgery in this series of patients was two hours and a half. This interval seems to be also the time limit in our experience to get a partial or complete recovery of ischemic area. Four patients died in hospital, but they were in severe cardiogenic shock before emergency surgery. Twenty nine cases were free of symptoms at a mean follow-up of 18 months (6 to 36) and two suffered for residual angina. Three patients died after discharge few months later: two during redo emergency vein grafts operations, one in deep left ventricular failure, while he was waiting for heart transplant. All these patients operated on as emergency developed acute myocardial infarction during their stay in hospital waiting for catheter study, surgical operation or during percutaneous transluminal coronary angioplasty. Saphenous vein grafts, were used in twenty nine patients, left internal mammary artery in nine cases, single in four and associated to saphenous vein in five, with an average number of anastomoses of 2.6 (1 to 6) for patient. ECG was found to be normal in 76% of the patients operated on within two hours and a half from the beginning of symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)     

Neuroleptanalgesia in acute myocardial infarction

Neuroleptanalgesia describes a state of sedated analgesia produced by the administration of the tranquilizer, droperidol, and the potent narcotic, fentanyl, in combination. This combination of drugs was administered intravenously to effect neuroleptanalgesia in the early treatment of eight patients with acute anterior transmural myocardial infarction. Criteria for inclusion in the study were (1) persistent ischemic pain, (2) ST segment elevation of 0.3 or more mV in at least two standard precordial leads, (3) a heart rate of 80 or more beats per minute, (4) a mean arterial pressure of 75 or more mm Hg, and (5) a cardiac index of 2.0 L/min/m(2). Within 30 minutes of the administration of the drugs, all patients were relieved of pain and emotional stress. The sum of ST segment elevation from leads V(1) through V(6) (sigmaST(6)) and the average ST elevation over the precordium (ST) decreased significantly by 57% and 56%, respectively. At the same time, there was a significant reduction in heart rate (from 112 +/- 17 to 86 +/- 8 beats per minute), mean arterial pressure (from 100 +/- 7 to 82 +/- 4 mm Hg), and pulmonary arterial wedge pressure (from 17 +/- 7 to 12 +/- 2 mm Hg). The cardiac index increased from 2.25 +/- 0.22 to 2.40 +/- 0.07 L/min/m(2). Two hours later the hemodynamic parameters had returned to control levels, but the beneficial effect on myocardial injury persisted. Thus neuroleptanalgesia in the early hours of myocardial infarction can reduce preload, afterload, oxygen demand, and eventually the infarct size without depressing myocardial function.     

Echocardiography in acute myocardial infarction

Echocardiography has recently gained increasing popularity as a noninvasive technique to assess left ventricular function and regional wall motion in acute myocardial infarction. Detection of regional dyssynergy is possible in over 90 per cent of patients with acute infarction, allowing assessment of site and extent of involvement. Estimates of severity of left ventricular dysfunction on admission into the coronary care unit allow stratification of patients into risk categories in terms of acute and long-term prognosis. Complications of myocardial infarction such as right ventricular infarction, ventricular septal rupture, papillary muscle rupture, papillary muscle dysfunction, formation of mural thrombi, ventricular aneurysms, and pericardial effusion can be diagnosed echocardiographically at the bedside. This article discusses these applications as well as some of the limitations of echocardiography in the setting of acute myocardial infarction.