早期静脉溶栓联合阿托伐他汀对急性心肌梗死的干预效果

目的 观察早期静脉溶栓联合阿托伐他汀治疗急性心肌梗死的临床疗效.方法 选取201 1年3月至2012年3月收治的急性心肌梗死患者72例作为研究对象.采用随机数字表法分为试验组和对照组,每组36例,试验组给予早期静脉溶栓联合阿托伐他汀治疗,对照组给予阿托伐他汀治疗.观察两组治疗效果.结果 试验组血管再通率明显高于对照组[80.6％（29/36）比52.8％（19/36）],梗死后心绞痛、心力衰竭以及再灌注心律失常的发生率明显低于对照组[11.1％（4/36）比27.8％ （10/36）,8.3％ （3/36）比25.0％（9/36）,44.4％ （16/36）比72.2％（26/36）],差异均有统计学意义（P＜0.05）.两组患者治疗前白细胞配体分化抗原、基质金属蛋白酶9以及C反应蛋白比较差异无统计学意义（P＞0.05）,治疗后均较治疗前明显改善,且试验组改善情况优于对照组,差异有统计学意义（P＜0.05）.试验组与对照组治疗前美国国立卫生研究院卒中量表（NIHSS）评分比较差异无统计学意义（P＞0.05）,试验组治疗后NIHSS评分显著优于对照组[（4.2±3.7）分比（7.9±4.1）分],差异有统计学意义（P＜0.05）.试验组治疗后3个月改良Rankin量表（mRS）评分0～1分比例明显高于对照组[52.8％（19/36）比33.3％（12/36）],2～6分比例明显低于对照组[47.2％（17/36）比66.7％（24/36）],差异均有统计学意义（P＜0.05）.结论 早期静脉溶栓联合阿托伐他汀治疗急性心肌梗死疗效显著,具有一定的临床应用价值.     

三维磁共振血管成像技术在下肢深静脉血栓成像中应用价值——与DSA对比研究

目的探讨三维磁共振血管成像（3D—CEMRA）技术在下肢深静脉血栓形成中的应用价值。、方法选择100洲趟声检查初诊为单侧下肢深静脉血栓形成患者,其中男性54例．女性46例：年龄20～85岁,平均年龄52岁。,均行3D—CEMRA检查．利用弥散加权成像（DWI）序列对血栓信号进行判断,分为急性期、亚急性期、慢性期。所有病例于48h内行数字减影血管造影（DSA）介入溶栓治疗．对比3D—CEMRA与DSA对血管狭窄程度的评估及分析血栓分期与DSA溶栓效果．、结果100例中,MRA评估I级血管狭窄42支．Ⅳ级血管狭窄23支,与DSA基本吻合,灵敏度为100％;Ⅱ级血管狭窄53支．灵敏度为96.23％：Ⅲ级血管狭窄39支,灵敏度为92.31％。3D—CEMRA对Ⅱ、Ⅲ级血管狭窄的评价仔在岛估现象。MRI血栓分期：急性期47例,介入溶栓术后完全再通率为100％;业急性期35例,介入溶栓术后完全复通率为9l.43％;慢性期18例．介入溶术后栓完全复通率仅为61．11％。MRI血栓分型与DSA溶栓疗效有相关,3期溶柃率比较,差异在统计学意义（P〈0．05）。结论3D—CEMRA技术是下肢深静脉血栓形成介入溶栓治疗前有效的量化指标。对临床治疗办案的选择有十分重要的指导意义。     

Recurrence of myocardial infarction related to different vessels in a patient with diffuse coronary artery spasm without underlying severe organic stenosis

A 59-year-old man had a first myocardial infarction in the right coronary artery, followed by an another infarction in the left anterior descending coronary artery. Coronary thrombolysis for both occasions of acute myocardial infarction was successfully performed without severe residual stenosis. In the chronic phase after the second myocardial infarction, ergonovine test showed diffuse coronary artery spasm. The etiology of myocardial infarction is briefly discussed.     

Correlation between clinical course and quantitative analysis of the ischemia related artery in patients with unstable angina pectoris, refractory to medical treatment

Patients with unstable angina, refractory to intensive medical therapy, are at high risk for developing thrombotic complications, such as recurrent ischemia, myocardial infarction and coronary occlusion during coronary angioplasty. As both platelet aggregation and/or thrombus formation play an important role in this ongoing ischemic process, a monoclonal platelet GPIIb/IIIa receptor antibody (c7E3) or thrombolytic therapy (alteplase) might be able to modify the clinical course and underlying coronary lesion morphology. To evaluate whether alteplase or c7E3 could influence the incidence of complications, we randomized 36 and 60 patients, respectively to alteplase or placebo, or c7E3 or placebo. All patients exhibited dynamic ECG changes and recurrent pain attacks, despite maximal tolerated medical therapy. Patients were randomized in both studies after initial angiography had demonstrated a culprit lesion amenable for angioplasty. After study drug infusion quantitative angiography was repeated and angioplasty performed. Recurrent ischemia during study drug infusion occured in 5, 6, 9 and 16 patients from the alteplase, placebo, c7E3 and placebo group, respectively. Major events defined as death, myocardial infarction or urgent intervention occurred in 7, 3, 1 and 7 patients, respectively. Two patients died: one in the alteplase group and one in the placebo group from the c7E3 study. The first patient due to retroperitoneal hemorrhage, the second as a result of recurrent infarction. Qualitative angiography showed resolution of clots in the c7E3 group only, while the same group of patients showed in 20% an improvement in TIMI flow grade, without deterioration in any patient from this group. Quantitative angiography showed a significant improvement in percentage diameter stenosis in the c7E3 group, which was not observed in all three other groups, although differences between groups were not significant. Alteplase infusion in patients with refractory unstable angina did not change the clinical course, nor the coronary morphology, c7E3 on the other hand, both improved the clinical course and the coronary lesion morphology and rheology in the same category of patients.     

Low molecular weight heparin as an adjunct to thrombolysis for acute myocardial infarction: the FATIMA study

Objective—To investigate the feasibility of fixed dose, weight adjusted subcutaneous low molecular weight heparin (LMWH), with monitoring of anti-Xa levels and assessment of coronary patency rates after three to five days, thereby giving an initial indication of its safety and efficacy.
Design—In 30 patients with acute myocardial infarction, LMWH (nadroparine) was given as a body weight adjusted intravenous bolus with thrombolysis (rt-PA infusion) and in weight adjusted subcutaneous doses at six hours, and every 12 hours thereafter for 72 hours. The target range was defined prospectively as 0.35-0.70 anti-factor Xa activity (aXa) units. The aXa level was measured every six hours. Coronary angiography was performed in all patients within five days after the start of thrombolytic treatment to determine patency (TIMI 2 and 3 flow) of the infarct related artery.
Results—The mean (SEM) aXa level over 72 hours was 0.52 (0.08) U/ml; from 12 hours onwards 88% of all aXa measurements were within the target range. At angiography, a patent infarct related artery was present in 24 of the 30 patients. No major bleeding complications occurred, though minor bleeding complications were observed in two patients.
Conclusions—This small study indicates that LMWH is feasible as an adjunct to thrombolysis in patients with acute myocardial infarction. The aXa levels were within the target range and patency rates at three to five days were around 80%, with no major bleeding complications.

Keywords: acute myocardial infarction;  thrombolysis;  low molecular weight heparin;  FATIMA study     

Hospital protocols and policies that may delay early identification and thrombolytic therapy of acute myocardial infarction patients

Despite the compelling relationship between early treatment and outcome from reperfusion therapy in patients with acute myocardial infarction, significant delays in early treatment are imposed by the patient, prehospital systems, and hospital processes and protocols used in the identification and treatment of patients with myocardial infarction. A survey instrument designed to determine the prevalence of hospital policies and protocols that might delay or expedite treatment with thrombolytic therapy in patients with acute myocardial infarction was completed by 524 hospitals participating in the National Registry for Myocardial Infarction (NRMI). Participating hospitals had treated 17,646 patients with tissue plasminogen activator. The door to drug time for the entire population of patients treated at each hospital was available. Door to drug times were compared between those hospitals that had a positive response to a policy and those that had a negative response to that policy. Among respondent hospitals, thrombolysis was excluded by protocol in 34.4% for age above 75 and in 55% for presentation after 6 hours of chest pain onset. Furthermore, 29.4% of hospitals required routine laboratory testing other than electrocardiography (ECG), including chest x-ray, prior to determination of eligibility for thrombolysis. Door to drug times were shorter in those hospitals with prehospital 12-lead ECG availability, assessment of the 12-lead ECG by the emergency department nurse and physician as soon as it was available, and initiation of thrombolysis by the emergency physician (in patients with clear-cut ST elevation myocardial infarction) without bedside cardiology consultation. Door to drug times were longer in those hospitals in which predecision laboratory results were required, written informed consent was mandated, and drug was initiated in the cardiac intensive care unit rather than in the emergency department itself. Door to drug times were not significantly different in those hospitals with a designated chest pain center compared with those operating under a focused patient care protocol. We conclude that the earliest possible hospital treatment of acute myocardial infarction patients may be precluded by multiple components of emergency department policies and process, many of them inappropriate for safe, efficient, and effective identification and management of these patients.This research was presented in part at the Annual Scientific Session, American College of Cardiology, Atlanta, Georgia, March 1994     

置管溶栓与系统溶栓治疗下肢深静脉血栓形成的临床分析

目的探讨2种不同的溶栓方法治疗下肢深静脉血栓形成的临床效果。方法将青岛市中心医院血管外科2012年3月至2013年4月收治的65例混合型急性下肢深静脉血栓形成患者随机分成置管溶栓组与系统溶栓组,置管溶栓组患者采用下腔静脉滤器置入、抗凝、患肢深静脉置管溶栓等方法治疗,系统溶栓组采用抗凝、经患肢足背静脉静滴溶栓等方法治疗,在治疗过程中测量并记录患者治疗前及治疗后3d时、7d时、14d时（出院时）、出院1个月时患侧、健侧3个不同部位的周径,通过观察患肢周径及患肢皮肤张力变化情况来判断治疗效果。结果在相同时间段将2组患者治疗前后患肢周径差进行比较,差异较大,有统计学意义。在治疗3d时置管溶栓组患者踝关节处、膝关节下15cm处、膝关节上15cm处患侧治疗前后的周径差以M（P225,P75）表示分别为0．0（0．0,0．0）、1．0（0．5,1．2）、1．0（0．5,1．2）cm,与系统溶栓组相比[其相应部位周径差分别为0．0（0．0,0．0）、0．5（0．0,0．5）、0．5（0．0,0．5）cm]差异有统计学意义;在治疗7d时置管溶栓组患者踝关节处、膝关节下15cm处、膝关节上15cm处患侧治疗前后的周径差分别为1．0（0．0,1．5）、3．5（2．8,4．5）、2．5（1．5,5．8）am,与系统溶栓组相比[其相应部位周径差分别为：0．0（0．0,0．5）、1．0（0．5,1．0）、1．0（0．0,1．0）cm]差异有统计学意义;在治疗14d时置管溶栓组患者踝关节处、膝关节下15cm处、膝关节上15cm处患侧治疗前后的周径差分别为1．0（0．0,2．0）、4．0（2．8,5．5）、3．0（1．8,7．8）cm,与系统溶栓组相比[其相应部位周径差分别为0．5（0．0,1．0）、2．0（1．0,2．5）、2．0（0．6,3．0）cm]差异有统计学意义;出院1个月时置管溶栓组患者踝关节处、膝关节下15cm处、膝关节上15cm处患侧治疗前后的周径差分别为1．0（0．0,2．0）、4．0（3．0,6．0）、3．5（2．0,7．8）cm,与系统溶栓组相比[其相应部位周径差分别为1．0（0．0,1．5）、3．2（1．1,5．4）、3．2（1．0,5．4）cm]差异无统计学意义。与系统溶栓组相比,置管溶栓组患者在治疗7d时患肢周径缩减幅度最大;出院后随访1个月,发现2组患者患肢周径与健侧相比差异均无统计学意义,但复查深静脉彩色多普勒超声发现置管溶栓组通畅率远大于系统溶栓组。结论深静脉置管溶栓治疗急性下肢深静脉血栓形成患者具有见效快、治愈率高等特点,经患肢深静脉置管溶栓时尿激酶直接注入血栓处,局部浓度高,使血栓清除快,效果显著,症状缓解明显,能够迅速恢复深静脉血流,在无Cockett综合症的前提下,深静脉通畅率远远大于系统溶栓者。     

Early administration of captopril and nitroglycerin in combination after acute myocardial infarction: an invasive haemodynamic study

The combination of captopril and nitroglycerin early after acutemyocardial infarction (AMI) could lead to a dangerous decreasein blood pressure coronary perfusion. To evaluate the safetyaspects and haemodynamic effects of this combination, we studied36 first ‘Q wave’ thrombolysed anterior wall AMIpatients during the 24 h following the onset of symptoms. Afterwards, thrombolysis patients received a continuous infusionof nitroglycerin and were submitted to pulmonary artery catheterization.Those patients with mean arterial pressure (MAP) 70 mmHg, cardiacindex 2.21. min^–1.m^–2, and wedge pressure 10 mmHgwere included and randomized to receive 6.25 mg of captoprilevery 6 h on the first day and 12.5 mg qid on the second f MAP 70mmHg (group 1). A second group (group 2) received a placebo.Haemodynamic parameters were determined after 1, 6 and thenevery 6 h up to 48 h after basal measurements. Significant differenceswere observed only for the MAP and the rate-pressure product(reduction in group 1 values, P <0.05). However, MAP wasmaintained within acceptable limits. Our data support the factthat the combination of captopril and nitroglycerin in the earlyhours of a non-complicated anterior wall AMI is safe, and couldguarantee its use in large clinical trials to determine theeffects on left ventricle remodelling and survival after AMI.     

护理干预在动脉溶栓联合自体骨髓间充质干细胞治疗股骨头缺血性坏死中的应用

目的:探讨护理干预在动脉溶栓联合自体骨髓间充质干细胞治疗股骨头缺血性坏死中的应用效果.方法:将64例患者随机分为观察组30例和对照组34例.对照组给予常规干预护理,观察组在此基础上给予护理干预.比较两组患者治疗后股骨头颈区域数字减影血管造影结果、关节活动度改变、髋部疼痛改变、治愈率.结果:治疗后两组股骨头颈区域数字减影血管造影显示狭窄闭塞血管再通或明显出现侧支循环血管,同区域血管明显增多、增粗并延长,静脉回流通畅,股骨头血管染色区域明显增大,且观察组优于对照组(P<0.05).观察组关节活动度、对髋部疼痛的治疗总有效率、股骨头缺血性坏死的治愈率优于对照组(P<0.01,P<0.05).结论:护理干预可提高股骨头缺血性坏死患者治疗效果,促进患者康复.     

重组人组织型纤溶酶原激活剂溶栓脑梗死患者卒中评分与血压测量结果分析

目的对脑梗死患者施行静脉溶栓治疗前后的相关状况和指标进行评价分析。方法2003年1月一2010年11月对神经内科收治的29例脑梗死患者予以静脉溶栓治疗及护理,并就治疗前后各相关时间点血压监测及美国国立卫生研究院卒中量表（National Institute of Health stroke scale,NIHSS）评分情况进行分析。结果溶栓前后血压对比显示：溶栓后2h收缩压相对于溶栓前和溶栓后24h升高（P〈O．05）;溶栓前后NIHSS评分差异有统计学意义（P〈O．05）。结论溶栓后患者收缩压出现升高,护理上应该加强血压监控,为临床治疗提供支持。