微导管溶栓在处理急诊PTCA术后无复流现象中的初步应用

目的：探讨微导管溶栓在治疗急性心肌梗塞急诊PTCA及支架术后无复流现象中的应用。方法：对我院76例急性心梗病人施行急诊PTCA及支架术,对8例术后出现无复流现象的病人给予冠脉内推注药物,并对其中的5例病人采用梗塞相关冠状动脉内留置微导管滴注溶栓药治疗,并于10h后复查冠脉造影及定期随访。结果：5例轻微导管溶栓治疗者较药物治疗者血流改善,心功能改善。结论：微导管溶栓对于急诊PTCA及支架术后无复流的急性心梗病人能较有效地恢复血流,改善心功能,可作为临床处理无复流的一种方法手段。     

急性心肌梗塞溶栓治疗后血清超氧化物歧化酶活性和丙二醛的变化

为探讨溶栓治疗急性心肌梗塞(AMI)对血清超氧化物歧化酯(SOD)活性和丙二醛(MDA)的影响。将61例AMI患者分成溶栓再通组(37例)、溶栓未通组(24例)进行治疗观察。结果溶栓再通组,不同时问测定的血浆SOD和浓度高于对照组(P<0.01)。而MDA的浓度是下降的。结论提示只有使梗塞相关血管(IRA)再通,才能通过增加心肌细胞内SOD活性,降低MDA,对抗氧自由基对心肌细胞的损害作用。     

Improving the efficacy and stability of coronary reperfusion following thrombolysis: Exploring the thrombin hypothesis

A major assumption in the treatment of patients with acute myocardial infarction (MI) implies that the speed of coronary arterial reperfusion correlates directly with the overall extent of myocardial salvage, and that the extent of myocardial salvage, in turn, determines the absolute reduction in patient mortality. While a growing experience has made it clear that myocardial salvage-independent (time-independent) mechanisms of benefit also exist, few would argue with the hypothesis that the greatest benefit derived from coronary thrombolysis occurs with early (time-dependent) treatment. Thus, improvements in the efficacy of reperfusion and the stability of reperfusion are likely to have considerable impact on patient outcome.     

用酶峰时间聚类分析法判断急性心肌梗塞再灌注

目的：为解决急性心肌梗塞溶栓治疗中再灌注与未再灌注者酶峰重叠问题;方法：将多种血清酶达峰时间用模糊数学的方法（等混合聚类分析）进行综合分类。结果：将２８例急性心肌梗塞患者区分为再灌注与未灌注组,与临床情况基本符合;结论：用酶峰时间聚类分析法判断急性心肌梗塞再灌注,效果满意,且有广泛应用前景。     

The influence of baseline prognostic variables on outcome after thrombolysis

Thrombolysis increases case fatality but reduces the proportion of disabled survivors in recent trials in acute ischaemic stroke, although some trials show much higher mortality rates than others. One possible explanation for the different outcomes between trials is that the treatment effect with thrombolysis varies with baseline prognostic factors such as stroke severity. We examined the interaction between baseline risk and thrombolysis on outcome using individual patient data from the Multicentre Acute Stroke Trial–Italy (MAST-I). A multiple logistic regression of the MAST-I data was performed to identify which factors, identifiable at randomisation, most strongly predict a poor functional outcome. We then stratified the patients into those with severe strokes and those with mild strokes and examined the effect of thrombolysis on (a) case fatality and (b) dependency at 6 months after the stroke in the 157 patients who received streptokinase alone and the 156 controls. Streptokinase was found to cause an absolute increase of about 3% in case fatality in both “severe” and “mild” strokes; however, there was a 12% reduction in the number of dead or dependent “mild” strokes but a 6% increase in “severe” strokes. The number of patients was small, and therefore neither finding was statistically significant. In this exploratory analysis, the hazard with streptokinase appears similar in “severe” and “mild” strokes, but the benefit may be greater in “mild” strokes. Thrombolysis may be more effective in patients with “mild” strokes, but more information is required to confirm this hypothesis. Received: 29 January 1999 Received in revised form: 13 April 1999 Accepted: 5 May 1999     

lschaemic heart disease: Non-invasive prediction of reperfusion and coronary artery patency by continuous ST segment monitoring in the GUSTO-I trial

In the GUSTO-I ECG ischaemia monitoring substudy, 1067 patientsunderwent continuous ST segment monitoring, using vector-derived12-lead (406 patients), 12-lead (373 patients) and 3-lead Holter(288 patients) ECG recording systems. Simultaneous angiogramsat 90 or 180 min following thrombolytic therapy were performedas a part of the prospective study in 302 patients. Infarct vessel patency was established as TIMI perfusion grades2 or 3 and occlusion as TIMI perfusion grades 0 or 1. Coronaryartery patency was predicted from ST trends up to the time ofangiography. Predictive values at 90 and 180 min after the startof thrombolysis were 70% and 82% for patency and 58% and 64%for occlusion, respectively. In retrospect, accuracy appearedgreatest (79–100%) in patients with extensive ST segmentelevation (400 µV), if both speed of ST recovery and extentof ST segment: elevation were taken into account. Although thethree recording systems differed considerably in signal processing,no significant difference in accuracy was demonstrated amongthese systems. We conclude that continuous ECG monitoring may help select highrisk patients without apparent reperfusion who may benefit fromadditional reperfusion therapy. As ST recovery may occur earlyafter the start of thrombolytics and accuracy of the test isrelated to peak ST levels, the use of on-line ECG monitoringdevices on emergency wards and cardiac care units is recommended.(Eur Heart J 1996; 17: 689–698)     

Raised levels of antistreptokinase antibody and neutralization titres from 4 days to 54 months after administration of streptokinase or anistreplase

Streptokinase and anistreplase are antigenic and their administrationoften leads to antibody formation. These can cause allergicreactions and/or neutralization of streptokinase with resultingsuboptimal treatment. Currently, streptokinase re-administrationis considered appropriate for up to 5 days and from 1 year aftera previous dose. Antistreptokinase antibody and neutralizationtitres (NT) were measured in three groups of patients to determineif this practice is appropriate: 1. (early)—36 patientswhose titres were measured for at least 5 days after thrombolysis;2. (late)—57 patients who received thrombolysis 12–54months previously; 3. (controls)—182 consecutive suspectedmyocardial infarction patients (without previous exposure tothrombolysis). Results were as follows (mean±SEM): 1. (early)—theantibody and/or NT were raised by day 4 in 19.4% of the patients.One patient could have neutralized 1.97 million units (MU) ofstreptokinase by day 4. (Day 4—antibody 1:39±11,NT 0.19±0.05 MU; day 5–1:136±41 and NT 0.7±0.43MU respectively.) 2. (late)—23 patients (40%) had eitherantibody titres 1:160 and/or NT> 1.5 MU. (12–23 months—antibody1:243±43, NT 0.63±0.15 MU; 24–35 months—1:98±31and 0.69±0.22 MU; 36–54 months—1:87±14and 0.54±0.12 MU.) All titres were significantly higherthan the controls (antibody 1:25±3. NT 0.14±0.01MU, P<0.01). After streptokinase or antistreplase, antibodies are raisedfrom 4 days to at least 54 months. It would seem prudent toavoid their re-administration during this time interval.     

急性心肌梗死患者溶栓治疗后心电图早期T波倒置、BNP变化对左室重构的意义

目的观察急性心肌梗死患者接受静脉溶栓治疗后心电图T波倒置、血浆中BNP的水平变化与左室重构之间的关系,探讨T波倒置、BNP对左室重构的预测价值。方法首次急性心肌梗死患者共54例,溶栓治疗后持续24h监测心电图,A组(溶栓治疗后24小时出现T波倒置,n=38)与B组(溶栓治疗后24小时T波仍直立,n=16)于治疗前及治疗后第7天,采用电化学发光法对血浆BNP水平进行检测,并随访复查急性心肌梗死后2~3天及第3个月超声心动图。结果溶栓治疗后BNP水平,A组明显小于B组;A组内治疗前后BNP比较,治疗后明显减小;B组治疗后BNP水平明显增加。A组患者溶栓治疗后2~3天及3个月时LVEDD比较,差异无显著性;B组患者溶栓治疗后3个月时LVEDD明显增大,B组左室重构发生率明显高于A组。结论急性心肌梗死患者溶栓治疗后心电图早期T波倒置和BNP水平降低对于预测左室重构有重要意义。     

北京等15个城市脑卒中患者院前时间及影响因素研究

目的 研究北京等15个城市35家医院脑卒中患者到达医院前时间（院前时间）及其影响因素。方法 通过统一的问卷，对2002年6月30日至2003年4月30日发病一周内的2270例脑卒中患者进行调查。除一般资料外，按是否在脑卒中症状发生后6h内到达医院将患者分为两组，对影响脑卒中院前时间的因素进行单因素和多因素logistic回归分析。结果 （1）患者的平均年龄为64．8岁，男性占60．2％。缺血性脑卒中为78．8％，出血性脑卒中为21．2％。（2）发病后决定马上去医院的占27，8％。使用急救电话和急救车的比例为27．2％；约1／4患者知道脑卒中后需要马上去医院诊治和溶栓治疗；1／4的患者对脑卒中基本无认识，发病后不知道求救而盲目等待。（3）发病后≤6h到达医院的患者占57．5％；首次就诊地点是急诊室的为58．6％；发病后≤6h到达医院的缺血性脑卒中溶栓率为6．7％。（4）影响脑卒中患者院前时间的多因素分析显示：到达医院的方式、首次就诊的地点、发病地点到医院的距离、是否了解疾病的相关知识是影响患者≤6h到达医院的独立因素。结论 42．5％脑卒中患者不能在发病后6h内到达医院，其院前时间延误的主要原因是对脑卒中知识了解不够、使用急救电话／急救车少、患者转运距离超过20km等。加强公众对脑卒中知识的了解是提高患者6h内到达医院的重要因素。     

Ultrasound with Microbubble Contrast Agent and Urokinase for Thrombosis

This study was aimed at assessing the effects of urokinase (UK) in combination with ultrasound and microbubbles in in vitro and in vivo thrombolytic therapy for the treatment of deep vein thrombosis (DVT). Thrombi with formation times of 1, 3, 7, 14 and 21 d were used for thrombolysis. Forty-five adult mongrel dogs were used to evaluate thrombosis in vivo. Both in vitro and in vivo analyses revealed that UK?+?microbubbles had the best effect among the combinations. Thrombolysis <7 d was more effective at a thrombolysis rate of about 50%, but the thrombolytic effect of thrombi >7 d was poor at thrombolysis rates <30%. Ultrasound?+?UK significantly increased the thrombolysis rate of thrombi <7 d. These results suggest that the combination of ultrasound with microbubble contrast agents and UK may have a synergistic effect on thrombolysis.