心尖球形综合征1例报告

急诊就诊的心电图示ST段上抬胸痛患者可诊断为急性心肌梗死,按照2004年美国心脏病学会（ACC）和美国心脏协会（AHA）联合发布的关于ST段：抬高型急性心肌梗死治疗指南推荐意见,应该尽快进行再灌注治疗,根据条件选择溶栓或者急诊经皮冠脉成形术。有时,为了争取再灌注时间,不等待心肌损伤标志物的结果,这样误诊难以避免,心尖球形综合征（apical ballooningsyndrome）就是其中一种,其临床表现可以酷似急性ST段抬高的心肌梗死。     

62例急性冠脉综合征患者心电血压监护分析

急性冠状动脉综合征(acute coronary syndrome，ACS)患者的治疗主要取决于ST。对ST段抬高的患者尽早实施冠状动脉血流的再灌注，即溶栓疗法、经皮冠状动脉腔内成形术(PTCA)或冠状动脉旁路移植术；对ST段不抬高的患者，应在住院观察和充分抗血栓、抗缺血治疗基础上，进一步进行危险分层。     

ST段抬高型心肌梗死患者溶栓再灌注后的心电图分析

目的:对ST段抬高型心肌梗死溶栓后再灌注心电图进行临床分析.方法:对116例心肌梗死患者均给以尿激酶溶栓治疗,按有无再灌注,分为再灌注组和未再灌注组,观察再通率以及两组心电图ST段再抬高、心律失常和心肌梗死后心绞痛的情况,并比较两组心律失常的类型.结果:ST段抬高型心肌梗死溶栓后的再灌注率为65.5%,再灌注组与未再灌注组在ST段再抬高、心律失常和梗死后心绞痛发生率上比较,差异有显著统计学意义(P<0.01).再灌注组在频发室性早搏上与未再灌注组比较,差异有统计学意义(P<0.05),在加速性室性自主心律上,差异有显著统计学意义(P<0.01),而在其他心律失常类型(房性早搏、室性心动过速、窦性心动过缓、窦性阻滞和心室颤动等)差异均无统计学意义(P>0.05).结论:急性心肌梗死溶拴后出现短暂的ST段反常抬高与心律失常,可作为心肌再灌注与心肌再灌注损伤参考指标.     

ST段抬高的鉴别诊断

ST段抬高的心肌梗死强调早期再灌注，特别是简便易行的溶栓治疗已普及到基层医院，再灌注越早，预后越好。但是除了急性心肌梗死外，很多疾病甚至正常变异，都可以引起ST段抬高，本文对ST段抬高的鉴别诊断总结如下。     

基层医院救治急性冠状动脉综合征68例临床体会

目的总结基层医院药物救治急性冠脉综合征（ACS）的经验,提高救治效果,使患者获益提高。方法对68例ACS患者类型、治疗方法、并发症、转归及治疗进行回顾性分析,以总结经验,提高药物救治成功率。结果 40例非ST段抬高型ACS患者通过强化抗栓、抗凝、调脂、抗缺血等治疗,病情好转34例（有效率85%）,转上级医院行经皮冠状动脉介入（PCI）6例;28例ST段抬高型急性心肌梗死患者,静脉溶栓治疗12例,再通9例（再通率75%）,转上级医院行PCI 5例。溶栓治疗组有1例再灌注心律失常、1例消化道出血并发症。结论基层医院在不能开展PCI的情况下,对ACS患者进行严格的风险评分,对适合介入治疗的患者及时转院,转院前ST段抬高型急性心肌梗死患者尽早行静脉溶栓治疗是安全的。对未转院者积极强化抗栓、抗凝、调脂、抗缺血、再灌注等治疗,可使患者获益提高。     

急性心肌梗死再灌注治疗后ST段下降程度与心功能恢复的关系

目的：探讨急性心肌梗死再灌注治疗后ST段下降程度与慢性期左心功能的关系。方法：将再灌注治疗后30分钟的ST段高度持续下降超过或等于再灌注治疗前最大ST段高度50％的病例作为ST段下降组（31例），未达到50％的病例作为ST段抬高组（30例），根据左室造影对两组间急性期和慢性期梗死局部室壁运动，左室舒张末期容积及左室射血分数（LVEF）进行比较，结果：两组再灌注治疗前ST段高度，侧支循环形成及梗死前有无心绞痛未见明显差异。发病到开始再灌注治疗的时间ST段下降组明显短于ST段抬高组，梗死局部室壁运动指数（SD／chord)在急性期和慢性期有明显改善（P＜0．01），左室舒张末期容积急性期与慢性期比较无扩大，左室射血分数急性期与慢性期比较明显增加（P＜0．01），ST段抬高组，SD/chord在急性期和慢性期未见明显改善，左室舒张末期容积急性期与慢性期比较，呈现显著扩大（P＜0．01），左室射血分数急性期与慢性期比较，无明显改善，CK最高值，ST段抬高组明显高于ST 段下降组（P＜0．01），再灌注治疗过程中ST段再度抬高的出现率，ST段抬高组明显高于ST段下降组（P＜0．05），结论：急性心肌梗死再灌注治疗后ST段下降程度可以作为判断晚期功能改善的指标。     

急性ST段抬高心肌梗死患者溶栓治疗后D-二聚体水平及其与冠状动脉再灌注相关性研究

目的探讨急性ST段抬高心肌梗死患者溶栓治疗后再灌注损伤与纤溶活性之间是否存在一定关系。方法选取2011年1月至2013年12月间收治的172例ST段抬高心肌梗死患者为研究对象,溶栓治疗后纤溶活性通过血浆D-二聚体水平反映。172例患者在急性心肌梗死发病后静脉给予组织纤溶酶原激活物(t PA)100 mg或链激酶(SKZ)1 500 000 U,6 h内分别在治疗前和治疗后采集患者的静脉血液。比较溶栓治疗前后患者间血浆D-二聚体水平差异,分析冠状动脉再灌注组与未灌注组血浆总D-二聚体水平差异,并分析其与冠状动脉灌注的相关性。结果溶栓治疗后再灌注组患者及未灌注组患者血浆总D-二聚体水平较治疗前显著升高(P0.05),但再灌注组与未灌注组患者治疗后其血浆总D-二聚体水平则无显著差异(P0.05);Logistic回归分析显示急性ST段抬高心肌梗死患者溶栓治疗后血浆总D-二聚体水平不是反映冠状动脉的再灌注的因素(P0.05)。结论急性ST段抬高心肌梗死患者溶栓治疗后血浆总D-二聚体水平显著升高,但其不是影响冠状动脉再灌注的重要因素。     

一过性ST段抬高的急性冠状动脉综合征初步分析

急性冠状动脉综合征（ACS）主要临床表现为胸痛，心电图常有ST段和T波的改变。根据患者发病时心电图ST段抬高与否，可将ACS分为ST段抬高的ACS和非ST段抬高的ACS两类。而ST段抬高ACS又分为ST段持续抬高和一过性ST段抬高的ACS。持续ST段抬高是指ST段抬高（肢体导联≥1mm，胸部导联≥2mm）持续时间大于30分钟，此类患者绝大部分发展为ST段抬高的心肌梗死（STEMI），临床上多见。     

急性冠状动脉综合征非ST段抬高患者心血管危险因素及其影像学特征

目的：分析比较非ST段抬高的急性冠状动脉综合征与ST段抬高的急性心肌梗死患者的心血管危险因素和影像学特征.方法：选择2003-01/2004-04在南方医科大学南方医院心内科住院并接受冠脉造影的冠心病患者,按照2002年美国心脏病学学院/美国心脏协会不稳定型心绞痛和非ST段抬高心肌梗死治疗指南及2000年中华医学会心血管病学分会的不稳定性心绞痛诊断和治疗建议进行诊断分类.非ST段抬高的急性冠状动脉综合征患者33例（非ST段抬高组）,男30例,女3例.ST段抬高的急性心肌梗死患者33例（ST段抬高组）,男27例,女6例.对两组患者的心血管危险因素和影像学特征进行对比统计分析.结果：进入结果分析非ST段抬高急性冠状动脉综合征患者33例,ST段抬高急性心肌梗死患者33例.非ST段抬高组与ST段抬高组具有相同程度的冠心病危险因素年龄、血脂紊乱、高血压、肥胖、合并糖尿病、有吸烟史、有早发冠心病家族史（P＞0.05）.非ST段抬高组患者具有2个以上心血管危险因素,其病变血管数与ST段抬高组相似;冠状动脉狭窄程度重于ST段抬高组[狭窄程度＜50%：8,3例;50%～74%：9,9例;75%～99%：53,43例;100%：1,20例,Z=3.45,P=0.001],但＞75%以上严重的狭窄病变占总病变的76%.严重狭窄病变形态差于ST段抬高组（Z=3.23,P=0.001）.结论：非ST段抬高的急性冠状动脉综合征与ST段抬高的心肌梗死患者具有相似的危险因素;ST段抬高的急性心肌梗死患者冠状动脉狭窄更严重,而且较严重的病变形态多于非ST段抬高的急性冠脉综合征患者.     

临床护理路径在急性ST段抬高型心肌梗死再灌注治疗中的应用

目的 探讨临床护理路径应用于急性ST段抬高型心肌梗死急诊再灌注治疗中的应用效果.方法 选取因急性ST段抬高型心肌梗死在我院行急诊再灌注治疗（急诊PCI）的病人60例,随机分为两组,每组各30例,实验组按设计好的急性ST段抬高型心肌梗死急诊再灌注治疗护理路径表进行治疗与护理,对照组采取传统急诊治疗及护理.结果 实验组急诊PCI的时间少于对照组（P〈0.05）,治疗成功率较对照组高,住院总费用、西药费、住院天数低于对照组,健康教育有效性及满意度高于对照组（P〈0.05）.结论 在急性ST段抬高型心肌梗死再灌注中应用临床护理路径,可为病人赢得宝贵治疗时机,减少医疗费用,提高护理质量,符合我国目前卫生体制改革的需求,值得推广.     

The medical management of acute coronary syndromes and potential roles for new antithrombotic agents

Antithrombic therapy is recommended to prevent ischemic complications in patients with high-risk non-ST-segment elevation acute coronary syndromes, including patients with unstable angina/non-ST-segment elevation myocardial infarction and patients with ST-segment elevation myocardial infarction undergoing fibrinolysis with fibrin-specific agents. Ischemic benefit from these agents must be balanced against an increased risk of bleeding, which may itself carry adverse long-term consequences. Recent trials suggest that the low-molecular-weight heparin enoxaparin may be superior to unfractionated heparin for preventing ischemic complications, although it also may be associated with an increase in bleeding risk. In two other contemporary trials, the Factor Xa inhibitor fondaparinux improved mortality and morbidity in patients with unstable angina/non-ST-segment elevation myocardial infarction and in patients with ST-segment elevation myocardial infarction undergoing fibrinolytic reperfusion, without increasing bleeding risk. These data underscore the promise of new antithrombotic agents to improve outcomes in acute coronary syndrome (ACS) patients being medically managed.     

Management of ST-segment elevation myocardial infarction in EDs

Emergency department (ED) physicians are critical in the accurate diagnosis, efficient management, and treatment of patients with ST-segment elevation myocardial infarction. The initial reperfusion strategy involves the choice between mechanical reperfusion using primary percutaneous coronary intervention and pharmacologic treatment with fibrinolytics. The benefits of these approaches are time dependent, and practices vary according to institutional resources and local guidelines. Nevertheless, the need for early intervention and the use of certain therapies are well recognized. Therefore, ED physicians must be aware of all treatment options available, including the use of adjunctive therapies. Initial treatment should include beta-blockers, aspirin (or clopidogrel if aspirin is contraindicated), nitroglycerin, and analgesia, regardless of reperfusion strategy. Clopidogrel is now approved as an adjunctive therapy for patients undergoing fibrinolysis as their reperfusion therapy. Both unfractionated heparin and low-molecular-weight heparin are feasible adjunctives in patients with ST-segment elevation myocardial infarction undergoing reperfusion therapy. In addition, multiple new antithrombin agents are being investigated. The choice adjunctive treatments should be based on specific patient populations and on the initial reperfusion strategy.     

再灌注治疗早期单导联ST段抬高峰值与T波倒置时间共同预测急性心肌梗死患者近期预后

目的 评价再灌注治疗后ST段恢复的不同测量方法及早期T波倒置对急性ST段抬高心肌梗死(STEMI)患者近期临床的预测价值．以期更简便快速识别高危患者。方法 268例STEMI患者，行直接经皮冠状动脉成形术开通梗死相关血管，观察术前、术后即刻、术后1h单导联ST段抬高峰值及ST段抬高总和以及与术前比较ST段恢复百分比，动态观察心电图，记录T波倒置的时间点，观察住院期间死亡及复合终点事件(包括死亡、再梗死、心衰、反复缺血发作、严重室性心律失常)。结果 术后1h单导联ST段抬高峰值是住院期间复合终点事件最强的预测因子，术后1hST段抬高总和对预测住院期间死亡有较高价值。T波倒置时间及发病至球囊开通时间均是预测死亡独立的因素。进一步强调尽快开通血管的重要性。结论 术后1h单导联ST段抬高峰值简单且直观，不需计算，结合T波倒置时间，共同预测临床预后，有助于识别高危患者。     

Reperfusion strategies in the emergency treatment of ST-segment elevation myocardial infarction

Prompt restoration of blood flow is the primary treatment goal in ST-segment elevation myocardial infarction to optimize clinical outcomes. The ED plays a critical role in rapid triage, diagnosis, and management of ST-elevation myocardial infarction, and in the decision about which of the 2 recommended reperfusion options, that is, pharmacologic and mechanical (catheter-based) strategies, to undertake. Guidelines recommend percutaneous coronary intervention (PCI) if the medical contact-to-balloon time can be kept under 90 minutes, and timely administration of fibrinolytics if greater than 90 minutes. Most US hospitals do not have PCI facilities, which means the decision becomes whether to treat with a fibrinolytic agent, transfer, or both, followed by PCI if needed. Whichever reperfusion approach is used, successful treatment depends on the ED having an integrated and efficient protocol that is followed with haste. Protocols should be regularly reviewed to accommodate changes in clinical practice arising from ongoing clinical trials.     

Prognostic value of minimal blood flow restoration in patients with acute myocardial infarction after reperfusion therapy

Purpose  

The prognostic impact of low-flow reperfusion after percutaneous coronary intervention (PCI) in patients with ST-segment elevation acute myocardial infarction (STEMI) is unknown. The aim of the study was to investigate the impact of low-flow reperfusion after PCI in patients with STEMI.     

Right ventricular infarction: specific requirements of management.

The principal cause of right ventricular infarction is atherosclerotic proximal occlusion of the right coronary artery. Proximal occlusion of this artery leads to electrocardiographically identifiable right-heart ischemia and an increased risk of death in the presence of acute inferior infarction. Clinical recognition begins with the ventricular electrocardiographic manifestations: inferior left ventricular ischemia (ST segment elevation in leads II, III and aVF), with or without accompanying abnormal Q waves and right ventricular ischemia (ST segment elevation in right chest leads V3R through V6R and ST segment depression in anterior leads V2 through V4). Associated findings may include atrial infarction (PR segment displacement, elevation or depression in leads II, III and aVF), symptomatic sinus bradycardia, atrioventricular node block and atrial fibrillation. Hemodynamic effects of right ventricular dysfunction may include failure of the right ventricle to pump sufficient blood through the pulmonary circuit to the left ventricle, with consequent systemic hypotension. Management is directed toward recognition of right ventricular infarction, reperfusion, volume loading, rate and rhythm control, and inotropic support.     

三维超声评价急性心肌梗死再灌注后左室重构

目的:探讨实时三维超声心动图对急性心肌梗死患者接受再灌注治疗后左室重构的诊断价值。方法:首次急性心肌梗死接受直接经皮冠状动脉介入治疗(P-PCI)或溶栓治疗患者共53例,比较治疗前及P-PCI治疗后1h、溶栓治疗后2h的心电图上ST抬高段的总和。按ST段下降幅度分为两组:ST段下降≥50%(A组n=32);ST段下降<50%(B组n=21)。于治疗后2d、10d、90d时行M型超声心动图和实时三维超声心动图(RT3DE)检查,分别测定左室舒张末期容积(LVEDV)、左室收缩末期容积(LVESV)、左室射血分数(LVEF)、治疗后90d时LVEDV增大率作为反映左室结构和功能变化的指标,并比较M型超声心动图和RT3DE结果。结果:无论是M型超声心动图还是RT3DE,A组治疗后90d时与治疗后2d相比,LV-EDV、LVESV明显减小,LVEF明显增大(P<0.05);10d时变化不明显(P>0.05)。B组治疗后10d、90d与治疗后2d相比,LVEDV、LVESV均明显增大,LVEF均明显减小。M型超声心动图所测数值均大于RT3DE测值(P<0.05);对于B组,治疗后90d时M型超声心动图所测LVEDV增大...     

Severe hypocalcemia simulating ST-elevation myocardial infarction

ST-elevation myocardial infarction (STEMI) is an emergency situation in which immediate measures for myocardial reperfusion are needed. The diagnosis is based on the recognition of ST-segment elevation in the electrocardiogram (ECG). In case of coronary artery occlusion, ST-segment elevation is caused by an injury current from the ischemic myocardium. Rarely, other mechanisms may lead to ECG changes mimicking STEMI. In our case, a 65-year-old man was presented to our institution with ECG abnormalities suggestive of STEMI. However, coronary angiography showed open arteries. Laboratory tests revealed severe hypocalcemia caused by a deficiency of vitamin D. After calcium replacement therapy, the ECG normalized, and the patient was discharged in good condition. Only a few case reports on hypocalcemia-induced ST-segment elevation exist, and the mechanism remains unknown.     

急诊经皮冠状动脉介入治疗ST段抬高心肌梗死的护理

目的研究ST段抬高心肌梗死急诊经皮冠状动脉介入治疗(急诊PCI)的护理要点。方法43例ST段抬高急性心肌梗死行急诊PCI术,观察胸痛、血压、心率、心律失常、再灌注心律失常、出血并发症,密切配合医生做好术前准备,术中监护和术后护理。结果25例术中出现再灌注心律失常,3例出现穿刺部位血肿,所有43例顺利出院。结论快速的术前准备,术中密切监测症状、心电图和血流动力学改变,术后及时发现并发症,做好心理护理与健康指导,有助于手术的安全和成功率。     

小剂量rt-PA与降纤酶联合应用治疗急性心肌梗死临床研究

目的 确定rt-PA与降纤酶合用的临床疗效，寻找溶栓治疗中辅助抗栓治疗的新方法。方法 研究对象为急性ST段抬高型急性心肌梗死(AMI)患者60例，随机分为两组：小剂量rt-PA 降纤酶 低分子肝素组(治疗组)和大剂量rt-PA 低分子肝素组(对照组)，比较两组患者的临床疗效、冠状动脉再通率、心脏事件发生率、并发症及急性期死亡率。结果 小剂量rt-PA与降纤酶联合应用治疗AMI的冠脉再通率可达80％，与对照组相比，患者临床症状改善和冠状动脉再通率均无明显差异；而梗死后心绞痛、再灌注心律失常发生率却明显降低。结论 降纤酶是一种具有溶栓和抗栓双重功效的治疗剂，小剂量rt-PA与降纤酶联合应用治疗AMI，是一种很有应用价值的治疗方法。