二级医院急性冠脉综合征住院治疗现状

目的:了解二级医院不同年代急性冠脉综合征(ACS)住院治疗现状及与指南的差距。方法:回顾性分析ACS 119例病人的治疗情况,其中64例为ST段抬高型心肌梗死(STEMI)。结果:①再灌注治疗:在64例STEMI中,18例行尿激酶溶栓治疗。46例未溶栓患者中,35例入院时超溶栓时间窗;23例住院稳定后转院择期冠状动脉介入性治疗(PCI),占35.9%。②药物使用情况:阿司匹林(ASA)98.3%,氯吡格雷80.7%,ACEI/ARB 78.2%,他汀类调脂药95.8%,β受体阻滞剂68.9%,低分子量肝素84.0%,硝酸酯类药88.2%,钙离子拮抗剂7.6%及中成药86.6%。逐年相比,除ASA及转运PCI逐年升高外(P<0.05),其他治疗无明显变化。结论:基层医院能较好的执行指南,但因条件限制,再灌注率尚不理想。     

小剂量利尿剂治疗慢性心力衰竭患者预后分析

目的 评价在《慢性心力衰竭诊断治疗指南》(简称指南)指导下小剂量利尿剂对慢性心力衰竭患者治疗的可行性和有效性,探讨小剂量利尿剂对改善心力衰竭预后的临床意义.方法 选择2005年1月至2011年6月165例左心室射血分数＜50％的住院患者,并建立门诊日志,给予小剂量利尿剂,遵循指南联合血管紧张素转换酶抑制剂(ACEI)/血管紧张素Ⅱ受体阻滞剂(ARB)和β受体阻滞剂,随访至2011年12月31日.计算人群的再住院率及病死率,评价治疗前后患者心脏结构、功能及运动耐量.结果 总病死率为11.0％(17/154).随访期间再住院38例(24.6％,38/154).治疗后左心室舒张末期内径显著缩小[(55.8±4.4) mm比(64.2±4.1) mm](P＜ 0.01),恢复正常大小者占44.5％(61/137).治疗后左心室射血分数、6 min步行试验距离与治疗前比较差异均有统计学意义[(45.5±11.5)％比(30.2±6.8)％、(519.7±59.2)m比(317.5±102.6)m,P＜O.01].结论 遵循指南小剂量利尿剂联合ACEI/ARB和β受体阻滞剂可显著改善慢性心力衰竭患者的心脏结构及功能,提高运动耐量,降低病死率.     

β受体阻滞剂治疗心力衰竭新进展

一、β受体阻滞剂的应用历史及分类 β受体阻滞剂多年来用于治疗急性心肌梗死(AMI)、心律失常、高血压和心力衰竭并取得了显著疗效.我国充血性心力衰竭的患病率是0.9%,因缺血或非缺血性心肌病导致的稳定、轻度、中度及重度慢性心力衰竭并存在左室射血分数减低的患者(NYHAⅡ～Ⅵ级),均需要接受β受体阻滞剂的治疗,除非存在禁忌证(Ⅰ级,证据级别A).AMI后左室收缩功能不全的患者,即使无心力衰竭的症状,为了降低病死率,在血管紧张素转换酶抑制剂(ACEI)治疗基础上建议长期使用β受体阻滞剂(Ⅰ级,证据级别A).欧洲心脏学会专家共识中指出,在左室功能正常的慢性心力衰竭患者中也建议使用β受体阻滞剂(Ⅱa级,证据级别C)[1].     

β受体阻滞剂治疗心力衰竭新进展

一、β受体阻滞剂的应用历史及分类 β受体阻滞剂多年来用于治疗急性心肌梗死（AMI）、心律失常、高血压和心力衰竭并取得了显著疗效。我国充血性心力衰竭的患病率是0．9％，因缺血或非缺血性心肌病导致的稳定、轻度、中度及重度慢性心力衰竭并存在左室射血分数减低的患者（NYHAⅡ～Ⅵ级），均需要接受β受体阻滞剂的治疗，除非存在禁忌证（Ⅰ级，证据级别A）。AMI后左室收缩功能不全的患者，即使无心力衰竭的症状，     

左旋氨氯地平治疗稳定型心绞痛的临床观察

目的观察左旋氨氯地平治疗稳定型心绞痛的临床疗效。方法将120例稳定型心绞痛患者随机分为治疗组（左旋氨氯地平、β-受体阻滞剂、硝酸酯类、抗血小板聚集药物、低分子肝素、他汀类药物）与对照组（地尔硫卓、β-受体阻滞剂、硝酸酯类、抗血小板聚集药物、低分子肝素、他汀类药物），疗程4周。结果4周后总有效率：治疗组91．67％，对照组78．33％，两组比较，差异有显著性（χ^2=4．18，P〈0．05）。观察20周后治疗组无1例发生心肌梗死，对照组发生心肌梗死2例，严重房室传导阻滞1例。结论左旋氨氯地平能有效地控制心绞痛的发作，减少心肌梗死近期发生率。     

86例老年慢性心力衰竭患者标准药物治疗实施状况的分析

目的 评价慢性收缩性心力衰竭“新的标准药物治疗”在干部病房老年患中的实施状况。方法 以86例住院治疗的老年心力衰竭患为研究对象，对标准药物治疗实施状况作出评价。结果 ①ACEI和β-受体阻滞剂的使用率分别为64．0％和34．9％，高于同期全国平均应用水平。ACEI在Ⅲ、Ⅳ级心功能的患中使用率较高，β-受体阻滞剂在Ⅱ、Ⅲ级心功能的患中使用率较高；②)37．2％的患因心脏传导阻滞、严重过缓性心律失常及低血压等原因而未使用或停用β-受体阻滞剂，13例患因Ⅳ级心功能难以改善而未用或停用p受体阻滞剂；③因医生的因素未使用或停用ACEI26．7％，未使用或停用肛受体阻滞剂12．8％。48．8％的患在作出心力衰竭诊断后仍长期使用钙拮抗剂。结论 在干部病房老年心力衰竭患中，新的标准药物治疗实施状况总体上较好，但老年患合并症多，对实施标准药物治疗带来更多的难题。必须进一步在医师中普及心力衰竭治疗的新理论和新概念。     

β受体阻滞剂和血管紧张素转换酶抑制剂对高血压患者左心室功能的影响

目的 探讨用β受体阻滞剂和血管紧张素转换酶抑制剂(ACEI)治疗对高血压患者左心室功能的影响。方法 对84例高血压患者服用β受体阻滞剂和ACEI，疗程24个月，按服药情况分为β受体阻滞剂组、ACEI组和对照组。结果 长期服用β受体阻滞剂或ACEI不仅能使血压持续稳定较低水平，且随着血压下降，左心室肥厚逆转，心脏舒张功能改善。结论 长期服用β受体阻滞剂或ACEI治疗高血压病，对左心室功能的改善有益。     

胺碘酮防治急性心肌梗死溶栓术后再灌注心律失常研究

目的胺碘酮防治急性心肌梗死（AMI）溶栓术后再灌注心律失常研究。方法80例接受溶栓治疗的AMI患者随机分为胺碘酮治疗组（A组，40例）和常规治疗组（B组，40例），观察两组患者成功溶栓后再灌注心律失常的发生率。结果溶栓后A组再灌注心律失常发生率较B组低（275％vs47．5％，P〈0．05）。结论应用胺碘酮有效减少AMI患者溶栓后再灌注心律失常的发生率。     

胺碘酮联合β受体阻滞剂治疗急性心肌梗死并发快速心律失常的临床疗效分析

目的探索胺碘酮联合β受体阻滞剂治疗急性心肌梗死并发快速心律失常的临床疗效。方法本组收治急性心肌梗死并发快速心律失常患者56例，随机分为两组，对治疗组患者给予β受体阻滞剂阿替洛尔12．5mg，2次／d，加胺碘酮0．2g，1次／d，均需饭后服用；对照组患者给予胺碘酮0．2g，3次／d，饭后服用，5周为1个疗程。治疗前后均需检查血常规、血压、肝和肾功能以及24h动态心电图。结果两者均可降低急性心肌梗死并发快速心律失常的发病率，对照组和治疗组有效率分别为73．1％和948％，两组有效率比较差异有统计学意义（P〈0．01）。结论胺碘酮联合位受体阻滞剂可预防心血管事件的发生，有助于症状缓解，联合用药组比单用胺碘酮组疗效好，且安全、可靠。     

急性心肌梗死药物治疗的影响因素分析

目的对急性心肌梗死(AMI)在药物治疗方面的影响因素作分析评价,为规范AMI的药物治疗提供改进意见。方法抽取我院95份AMI归档病历,按照卫生部颁布的单病种质量管理改进评价指标要求,对影响药物治疗达标的原因进行分析评价,提出改进意见。结果抗血小板药物和他汀类药物应用全部达标,β-受体阻滞剂和ACEI/ARB的使用达标率相对偏低,反映在临床对这两类药物的禁忌证不能严格把握。结论 AMI药物治疗整体合理,临床需进一步对AMI的药物治疗进行规范化管理。     

Diagnosis and treatment of acute myocardial infarction in tertiary and secondary care hospitals in Estonia

AIM: To compare validity of AMI diagnosis and treatment of AMI patients between tertiary and secondary care hospitals in Estonia. METHODS: Two tertiary and seven secondary care hospitals responsible for the treatment of most AMI patients in Estonia were included in the analysis. A random sample of 520 patients admitted to these hospitals with AMI in 2001 was taken from the Estonian Health Insurance Fund database. Medical records were reviewed by trained experts using a standardized data collection form. RESULTS: Forty cases were excluded due to selection errors by the Health Insurance Fund. Of the remaining cases, a diagnosis of AMI was confirmed in 93.3% of cases in tertiary care hospitals and in 83.5% of cases in secondary care hospitals (p < 0.001). A total of 210 cases from tertiary and 213 cases from secondary care hospitals with confirmed AMI diagnoses were included in subsequent analysis. Utilization of beta-blockers, aspirin, and reperfusion therapy was similar in both types of hospitals. In tertiary care hospitals, ACE inhibitors and statins were more frequently used during hospital stay and recommended at discharge compared with secondary care hospitals. In-hospital mortality was similar in both types of hospitals both before and after adjustment. CONCLUSIONS: Tertiary care physicians adhered more strictly to the current definition and guidelines for the management of AMI than did secondary care physicians. However, there is still a need for further improvement in both hospital settings according to international guidelines.     

Quality of Care for Acute Myocardial Infarction in Rural and Urban US Hospitals

CONTEXT: Acute myocardial infarction (AMI) is a common and important cause of admission to US rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care. PURPOSE: To examine the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers. METHODS: This cohort study used data from the Cooperative Cardiovascular Project (CCP), including 4,085 acute care hospitals (408 remote small rural, 893 small rural, 619 large rural, and 2,165 urban) with 135,759 direct admissions of Medicare beneficiaries ages 65 and older for a confirmed AMI between February 1994 and July 1995. Outcomes included use of aspirin, reperfusion, heparin, and intravenous nitroglycerin during hospitalization; use of beta-blockers, aspirin, and angiotensin-converting enzyme (ACE) inhibitors at discharge; avoidance of calcium channel blockers at discharge; and 30-day mortality. FINDINGS: Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive the recommended treatments for AMI. Medicare patients in rural hospitals were less likely than urban hospitals' patients to receive aspirin, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only ACE inhibitors at discharge was used more for patients in rural hospitals than urban hospitals. Medicare patients in rural hospitals had higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals (odds ratio for large rural 1.14 [1.10 to 1.18], small rural 1.24 [1.20 to 1.29], remote small rural 1.32 [1.23 to 1.41]). CONCLUSIONS: Efforts are needed to help hospital medical staffs in both rural and urban areas develop systems to ensure that patients receive recommended treatments for AMI.     

Performance of the '100 top hospitals': what does the report card report?

We examine whether Medicare patients with acute myocardial infarction (AMI) admitted to one of HCIA-Mercer's "100 top hospitals" received better care or had better outcomes than patients treated in other hospitals. Among four hospital peer groups, the top 100 hospitals had similar thirty-day mortality and use of aspirin, beta-blockers, and reperfusion compared with their peers, but lower lengths-of-stay and in-hospital costs, with similar or lower readmission rates. Our findings suggest that the 100 Top Hospitals study may be better suited for identifying hospitals with higher performance on financial and operating measures than superior clinical performance in treating elderly AMI patients. However, there was no evidence that quality was sacrificed for increased financial efficiency among the top 100 hospitals.     

Managing and analysing a large health-care system database for predicting in-hospital mortality among acute myocardial infarction patients.

There is increasing interest in the identification of predictors of risk for in-hospital mortality due to acute myocardial infarction (AMI). This study identified significant predictors of in-hospital mortality among AMI patients using a patient level clinical database. The study population consisted of 4167 cases admitted between October 1999 and April 2001 with a principal diagnosis of AMI to 36 hospitals in three US states. Of the 182 available variables in the clinical data set, 30 variables were used as candidate predictors, and 19 showed significant univariate association with AMI in-hospital mortality. By applying multiple logistic regression and stepwise selection, a final prediction model for AMI in-hospital mortality was developed. Variables included in the final model were age, arrived from cardiac rehabilitation centre, cardiopulmonary resuscitation (CPR) on arrival, Killip class, AMI with co-morbid conditions, AMI with complications, percutaneous transluminal coronary angioplasty (PTCA) performed, beta-blockers given, angiotensin-converting enzyme (ACE) inhibitors given, Plavix given. A 10-variable in-hospital mortality prediction model for AMI patients, which includes both risk factors and beneficial treatment procedures, was developed. chi(2) goodness of fit test suggested a good fit for the model.     

Early management of acute myocardial infarction

Management of acute myocardial infarction (AMI) has changed dramatically since 1962, when the world's first operating coronary care unit opened in our hospital. Recently, thrombolytic agents, aspirin and beta-blockers have been shown to reduce the mortality of patients with AMI if given early. This article reviews management strategies and therapeutic options currently available during the first 24 hours of the hospital phase of AMI.     

急性心肌梗死静脉溶栓327例临床分析

目的观察尿激酶在急性心肌梗死静脉溶栓中的疗效及副作用。方法嚼服阿斯匹林0．3g，尿激酶150万U用100ml生理盐水溶解，30min内滴入，6h后低分子肝素钙5000U，1次／12h，皮下注射。结果治疗后再通229例（70．03％），未通98例（29．97％）。死亡21例（6．42％）。结论急性心肌梗死后应尽早进行静脉溶栓治疗，再通率70％以上，适合在基层医院应用及推广，但同时应注意及时防治各种并发症、合并症。     

JCAHO accreditation and quality of care for acute myocardial infarction

We examined the association between JCAHO accreditation of hospitals, those hospitals' quality of care, and survival among Medicare patients hospitalized for acute myocardial infarction. Hospitals not surveyed by JCAHO had, on average, lower quality (less likely to use aspirin, beta-blockers, and reperfusion therapy) and higher thirty-day mortality rates than did surveyed hospitals. However, there was considerable variation within accreditation categories in quality of care and mortality among surveyed hospitals, which indicates that JCAHO accreditation levels have limited usefulness in distinguishing individual performance among accredited hospitals. These findings support current efforts to incorporate quality of care in accreditation decisions.     

An Australian comparison of specialist care of acute myocardial infarction.

OBJECTIVE: To determine whether patients hospitalized with acute myocardial infarction (AMI) in an Australian setting receive better pharmacological care if managed by cardiologists than by non-cardiologists. DESIGN: Retrospective chart review of patients hospitalized between 1 January 1997 and 30 June 1998, undertaken by abstractors blind to study objectives. SETTING: One tertiary and two community hospitals in south-east Queensland, Australia, in which all patients admitted with AMI were cared for by cardiologists and general physicians, respectively. STUDY PARTICIPANTS: Two cohorts of consecutive patients satisfying diagnostic criteria for AMI: 184 in the tertiary hospital and 207 in the community hospitals. MAIN OUTCOME MEASURES: Frequency of use, in highly eligible patients, of thrombolysis, beta-blockers, aspirin, angiotensin-converting enzyme (ACE) inhibitors, lipid-lowering agents, nitrates, and calcium antagonists. Cohorts were compared for differences in prognostic factors or illness severity. RESULTS: In community hospital patients, there was greater use of thrombolysis [100% versus 83% in the tertiary hospital; difference 17%, 95% confidence interval (CI) 11-26%; P < 0.001] and of ACE inhibitors (84% versus 66%; difference 18%, 95% CI 3-34%; P = 0.02), and lower median length of stay (6.0 days versus 7.0 days; P = 0.001) compared with tertiary hospital patients. Frequency of use of other drugs, and adjusted rates of death and re-infarction were the same for both cohorts. CONCLUSIONS: With respect to pharmacological management of patients hospitalized with AMI, cardiologists and general physicians appear to provide care of similar quality and achieve equivalent outcomes. Further studies are required to confirm the generalizability of these results to Australian practice as a whole.