青年和老年急性心肌梗死临床及冠状动脉病变特点的差异研究

目的：比较青年和老年急性心肌梗死（AMI）患者临床及冠状动脉病变特点。方法：入选我院10年的≤40岁AMI患者83例,≥60岁AMI患者463例,比较两组患者病史、临床特点及冠状动脉病变特点。结果：与老年组比较,青年AMI患者男性更多见,具有吸烟史、饮酒史的患者比例更高,更多患者具有冠心病家族史,TC、LDL-C水平明显高于老年患者,而高血压病史、糖尿病史、既往心绞痛发作史患者比例均低于老年患者（P〈0.05）;青年AMI组造影正常或单支病变比例明显高于老年AMI组,而双支/多支病变比例低于老年组,差异具有统计学意义（P〈0.05）;老年AMI患者累及RCA和LCX的比例明显高于青年组,差异具有统计学意义（P〈0.05）。结论：吸烟、饮酒、代谢紊乱和家族史是≤40岁AMI的主要危险因素;青年AMI患者冠脉病变程度显著低于老年组患者。     

Acute myocardial infarction in a young woman with normal coronary arteries and myocardial bridging

Myocardial bridging (MB) is defined as an intramural segment of a coronary artery that normally courses epicardially. MB is usually a benign condition; however, some cases resulting in myocardial ischaemia, infarction and sudden death have been reported. We describe a case of myocardial infarction related to MB in a young healthy woman with no risk factors for coronary artery disease. The bridge was demonstrated in detail by coronary CT angiography using multiplanar reconstruction and three-dimensional volume-rendered techniques.     

ECG-gated multi-detector row spiral CT in the assessment of myocardial infarction: correlation with non-invasive angiographic findings

Our objective was to retrospectively evaluate the ability of multidetector-row computed tomography (MDCT) to detect previous myocardial infarctions (MIs) and to correlate necrosis with the status of coronary arteries supplying the infarcted territory. After having clinically evaluated 187 patients referred for ECG-gated MDCT of the coronary arteries, 30 previous MIs were identified in 29 patients (9 recent and 21 chronic). MDCT data were evaluated qualitatively and quantitatively by measuring attenuation values and wall thickness within the infarcted region and normal adjacent myocardium. Each MI was also assigned to the distribution territory of a coronary vessel, and morphological data were combined with MDCT angiographic findings. MDCT was able to detect 25/30 MIs showing an overall sensitivity and specificity of 83 and 91%, respectively. Quantitative analysis revealed a statistically significant difference in attenuation values between normal and infarcted regions (38.9±14 HU vs. 104.0±16 HU). Regional wall thinning was observed in chronic MIs (4.1±2 mm vs. 10.5±3.8 mm), and not in patients with recent event (7.9±1.6 mm vs 9.1±4 mm). In 22/25 cases, MDCT angiographic findings showed the presence of suspicious critical lumen narrowing (n=3), previous coronary stenting (n=14) and surgical revascularization (n=5) in the infarct-related coronary. During a single examination, MDCT might provide comprehensive imaging of MI offering a combined morphological and angiographic assessment.     

放射性核素心肌灌注显像在急性冠状动脉综合征中的临床应用

近年来,急性冠状动脉综合征(ACS)在临床上越来越受到重视。应用放射性核素心肌灌注显像(MPI)可以对常规方法不能明确诊断的急性胸痛患者排除或确诊ACS作出迅速、准确判断,其诊断的灵敏度和阴性预测值均很高。MPI还有助于评价心肌缺血和梗死灶的范围和程度,对ACS患者进行危险分层,为ACS的预后判断和疗效评估提供重要信息。     

Acute myocardial infarction demonstrated by multidetector CT scanning

A 55-year-old man was brought to the emergency room complaining of left-sided chest pain. His electrocardiogram was indeterminate, and a multidetector computed tomogram (MDCT) was performed to exclude aortic dissection. The patients aorta was normal, but an area of hypoperfusion was evident in the lateral ventricular myocardial wall. The ability to diagnose myocardial ischemia and infarcts on nongated MDCT is of particular clinical interest. As more imaging technology is devoted to imaging the heart, the greater expectations of radiologists ability to diagnose cardiac disease in the emergency room will become.     

飞行员冠状动脉痉挛致急性心肌梗死一例并文献复习

目的 探讨飞行员冠状动脉痉挛(coronary artery spasm,CAS)致急性心肌梗死(acute myocardial infarction,AMI)的临床特征、诱发因素、诊断、治疗及医学鉴定. 方法 分析1例直升机飞行员冠状动脉痉挛致急性心肌梗死的病史、临床诊断、治疗过程及医学鉴定结论,并进行相关文献复习. 结果 本例飞行员有大量饮酒、吸烟、高血脂、疲劳等多种诱发因素;临床表现为心前区疼痛,胸闷,左肩及左臂发麻,出汗;心电图及心肌酶谱符合急性心肌梗死演变过程;冠状动脉造影未见粥样硬化狭窄,造影过程中发生左冠状动脉全程僵硬,左前降支中段95％狭窄,右冠状动脉僵硬;左、右冠状动脉内推注硝酸甘油后僵硬及狭窄缓解,考虑为冠状动脉痉挛,痉挛血管与心肌梗死部位吻合,证实心肌梗死由CAS所致.该飞行员病后无明显并发症,心电图大致正常,超声心动图正常.经积极控制诱发因素,其病情稳定,未再出现心前区不适等症状,能正常参加体能训练,地面观察半年后复查心电图正常,心功能等指标良好,最后结论:飞行合格.安全飞行1年余无任何不适. 结论 CAS可发生于冠状动脉无粥样硬化狭窄基础上,可引起心绞痛、心律失常、急性心肌梗北等;CAS与冠状动脉内皮功能受损有关,其发作往往有饮酒、吸烟、疲劳等诱因,对高危人群应采取积极预防措施.     

维拉帕米治疗急性心肌梗死直接经皮冠状动脉介入术中无复流疗效的观察

 目的 探讨冠状动脉内给予维拉帕米治疗AMI直接PCI 术中无复流现象的疗效.方法 常规方法 进行AMI直接PCI术,对发生无复流现象的患者,冠状动脉内给予维拉帕米100～200 μg/次,总量不超过600 μg,造影评价给药前后冠状动脉血流TIMI分级和校正的心肌梗死溶栓治疗临床试验帧数(CTFC).对比分析术后 30 d时梗死相关血管同为前降支发生无复流组和未发生无复流组的临床及超声心动图资料. 结果 33例AMI直接PCI术中发生无复流的患者,冠状动脉内给予维拉帕米后冠状动脉血流明显改善.TIMI血流:(0.85±0.64)级vs (2.24±0.75)级(P<0.01) ;CTFC:(76.43±13.85)帧vs(37.53±9.81)帧(P<0.01).术后30 d时梗死相关血管同为前降支者,发生无复流组较未发生无复流组左心室射血分数明显减低(46.56%±5 .6%) vs (50.34%±4.76%)(P<0.05).结论 维拉帕米冠状动脉内给药治疗AMI直接PCI术中无复流现象有显著疗效.     

A case of neurofibromatosis associated with a coronary artery aneurysm and myocardial infarction

A case of myocardial infarction secondary to thrombosis of a coronary artery aneurysm in a patient with neurofibromatosis is presented. The vascular manifestations of neurofibromatosis, and the associated clinical sequelae, are reviewed.     

Acute and chronic myocardial infarction in a pig model: utility of multi-slice cardiac computed tomography in assessing myocardial viability and infarct parameters

Objectives

The aim of this study was to determine the feasibility of multi-slice computed tomography (MSCT) biphasic imaging in assessing myocardial viability and infarct parameters in both acutely and chronically infarcted pig models.

Materials and methods

Seven pigs underwent ligation of the distal left anterior descending artery. Imaging was performed on the day of infarction and 3 months post-infarct, with contrast infusion followed by MSCT scan acquisition at different time-points. Left ventricular ejection fractions (LVEFs) were obtained by left ventriculography (LVG) after 3 months. Infarcted locations found using MSCT were compared with those obtained using SPECT. Infarcted areas were also analysed histopathologically and compared with the findings from MSCT.

Results

Chronic phase images had perfusion defects with lower CT values relative to normal myocardium (43 ± 10 HU vs. 156 ± 13 HU, p = 0.001) on the early images but no residual defects on delayed images. However, we found hyperenhancing regions on delayed images (244 ± 20 HU vs. 121 ± 25 HU, p = 0.001), and good correlation between MSCT- and LVG-derived LVEFs (60.56 ± 7.56%). The areas identified by MSCT corresponded to the location of ²⁰¹Tl SPECT-/pathologic staining-derived regions in all models. Infarct size was in good agreement with MSCT and pathological analyses of chronic phase models.

Conclusions

Necrotic myocardium in different stages after infarction could be qualitatively and quantitatively assessed using MSCT biphasic imaging, as could the status of microcirculation formation. MSCT-measured LVEFs matched well with other modalities, and hence MSCT is a useful tool in assessing post-infarct cardiac function.     

冠状动脉解剖变异对急性下壁心肌梗死经皮冠状动脉介入治疗后心功能的影响

目的应用平衡法核素心室显像(ERNA)与静息心肌灌注显像(MPI)判断冠状动脉解剖变异对急性下壁心肌梗死(AIMI)患者经皮冠状动脉介入治疗(PCI)后心室功能的影响。方法将47例经 PCI 的 AIMI 患者分为左优势型组(含均势型血液供应)12例和右优势型组35例。结合 ERNA和 MPI 结果,比较不同冠状动脉分布类型对 AIMI 患者 PCI 后双心室血流动力学和心肌供血,及3个月的短期预后影响。结果右、左优势冠状动脉供血类型患者出院前左室射血分数(LVEF)分别为(63.03±5.64)%和(57.67±7.35)%,P=0.012;高峰射血率(PER)为(3.52±0.66)和(2.93±0.73)舒张末期容积(EDV)/s,P=0.011;高峰充盈率(PFR)为(2.71±0.88)和(2.11±0.45)EDV/s,P=0.004;左心室游离壁局部射血分数(rEF)为(81.94±20.75)%和(67.25±16.54)%,P=0.032;右室射血分数(RVEF)为(37.89±3.86)%和(41.67±4.81)%,P=0.009;右心室游离壁 rEF 为(57.86±11.77)%和(67.83±10.38)%,P=0.012。PCI 后急性期左心室心肌血流灌注评分差异无显著性(P=0.357)。出院后3个月对比,仅 RVEF[(44.60±5.29)%和(48.00±3.30)%,P=0.043]差异有显著性。左心室心肌血流灌注评分差异无显著性(P=0.754)。2组自身配对研究显示各自均有多项功能参数改善。结论急性期,右优势型 AIMI 右心室功能损害更严重;恢复期,大部分患者右心室功能恢复,ERNA 可显示部分患者的持续右心室功能障碍。     

心肌灌注MRI和MR电影在急性冠状动脉综合征中的应用

目的　评估心肌灌注MRI和MR电影在急性冠状动脉 (简称冠脉 )综合征中的应用价值。方法　急性冠状动脉综合征患者 5 5例 ,再灌注治疗 3～ 6个月后 ,进行心脏MR影像检查。真正快速稳态梯度序列 (FIESTA)用于观察心肌运动 ;快速梯度回波序列 (FGREET)用于观察首过时相心肌灌注的MRI特征 ;反转恢复梯度回波序列 (MDE)用于观察延迟时相心肌灌注MRI特征。结果5 5例中 38例患者可见位于心内膜下心肌的首过灌注缺损 ,其信号强度相对值显著低于周围心肌。心肌灌注延迟时相MRI示 5 1例患者心室壁内存在不同范围的强化灶 ,其信号强度值是周围心肌的4 36倍 (t=1.6 9,P <0 .0 5 )。心室壁内所存在的延迟强化灶范围和信号均匀程度与心室壁运动能力显著相关 (非标准相关系数分别为 - 4 2 195、- 10 1 75 0 ,标准相关系数分别为 - 0 377、0 4 2 5 ;t分别为- 5 735、- 5 4 4 5 ,P值均 <0 .0 0 1)。结论　梗死心肌于MR心肌灌注延迟时相呈现显著强化。通过综合分析延迟强化 ,运动能力显著降低和可能存在的首过灌注缺损 ,可以更有效地识别梗死 (或瘢痕 )心肌     

社区干预对心肌梗死合并代谢综合征的影响

目的对冠心病心肌梗死合并代谢综合征患者进行随访,并进行社区干预。方法符合国际糖尿病联盟颁布的代谢综合征诊断标准,同时确诊心肌梗死者人选本研究。入选对象共207例,其中有195例完成了2年随访,随访率为94．2％。对所有患者采取群体教育与个体指导,包括健康教育、运动锻炼、控制饮食、戒烟限酒等。部分确诊高血压、2型糖尿病患者给予降压、降糖药物治疗。所有人选患者均给予他汀类药物,同时进行冠心病的相应治疗。随访采用门诊、电话随访或住院随访诊治的形式,随访1年、2年,分别测定患者的血压、甘油三酯、体重指数、腰围、空腹血糖等指标的变化。随访终止于进入调查后的2年。计数资料用,检验,计量资料用t检验,采用SPSS13．0统计软件进行数据处理。结果随访2年后,SBP、DBP、甘油三酯、体重指数、体重、腰围较随访前明显降低,但SBP、DBP、腰围、甘油三酯等指标总体上未达标;完成随访的195例,吸烟人数较前明显下降,但有131例仍在吸烟。结论对冠心病心肌梗死合并代谢综合征患者实施的行为干预,在改善患者行为生活方式、控制血压、血糖、降低体重等方面有积极作用,但仍不达标。     

冠心病延迟增强MRI与心脏事件相关性研究

目的 探讨延迟增强MRI (DE-MRI)检测心肌梗死积分与近期心脏事件的相关性.方法 40例经完整资料确诊的冠心病患者行DE-MRI心肌梗死积分评价、超声心动图射血分数(EF)测量、每周硝酸甘油次数、每周心绞痛发作次数及最近1年心功能不全发作次数、6 min步行距离评价及西雅图心绞痛健康状况(SAQ)评分.结果行Spearman秩相关分析、完全随机设计多个样本比较及两两比较.结果 DE-MRI心肌梗死积分[12分(四分位数间距:6.0～ 19.8分)]与6min步行距离(378.93±100.53)、SAQ(74.55±11.40)呈轻至中度负相关(r值分别为0.66、0.54,P＜0.05)；每周硝酸甘油次数[1次(四分位数间距:0～2.8次)]、每周心绞痛发作次数[3次(四分位数间距:1.0 ～6.5次)]及最近1年心功能不全发作次数[0次(四分位数间距:0～2次)]呈高度正相关(r值分别为0.87、0.85、0.89,P值均＜0.05),高于EF值[(49.2±13.72)％]与相应心脏事件的相关系数.结论 DE-MRI检测的心肌梗死积分可用于近期心脏事件发生的预测,相对于传统的EF评价,其对于冠心病近期心脏事件发生的预测有更高的价值.     

冠状动脉造影正常的心肌梗死患者~(99)Tc~m-MIBI心肌灌注显像

目的　探讨99Tcm 甲氧基异丁基异腈 (MIBI)心肌灌注断层显像 (MPI)对冠状动脉造影(CAG)正常的心肌梗死 (MI)患者的临床应用价值。方法　 5例患者中 4例为急性MI,1例为异常Q波原因待查 ,均经CAG证实冠状动脉正常。于CAG后 7～ 10d行运动 静息99Tcm MIBIMPI。结果　 5例患者中 4例MPI异常 (均为固定放射性缺损 ) ,1例正常。 1例异常Q波待诊患者经MPI确诊为MI。4例MPI显示的MI部位较ECG大 ;1例ECG示透壁性MI者MPI正常。随访期间 ,1例因心功能不全行室壁瘤切除术。结论　99Tcm MIBIMPI对CAG正常的MI诊断及梗死部位、程度和预后的判断有较高价值     

静息心肌灌注显像判断梗塞相关动脉的作用

目的　评价静息心肌显像的缺血缺损部位对于判断梗塞相关动脉 (IRA)的价值。方法对 44例心肌梗死患者进行99Tcm 甲氧基异丁基异腈 (MIBI)静息心肌断层显像和冠状动脉造影(CAG)。结果　CAG提示IRA 44支 ,其中左前降支 (LAD) 2 7支 ,左旋支 (LCX) 9支 ,右冠脉 (RCA) 8支。当IRA是LAD时出现间壁受累 ,IRA是LCX时出现侧壁受累和IRA是RCA时表现下后壁受累的意义较大 (χ2 =8.98和 8.96 ,P均 <0 .0 5 ;χ2 =43.82 ,P <0 .0 0 5 )。前壁、心尖部、间壁和广泛前壁稀疏缺损对于判断IRA LAD的灵敏度较高 ,分别是 89% ,86 % ,80 %和 89% ;特异性以间壁最高 ,达 80 % ;侧壁和后侧壁判断IRA LCX的灵敏度和特异性分别是 75 % ,6 7%和 85 % ,83% ;下后壁病变判断IRA RCA的灵敏度和特异性分别是 71%和 91%。结论　心肌灌注显像对于判断心肌梗死的IRA有一定价值     

急性心肌梗死多层螺旋CT心肌灌注和冠状动脉造影的实验研究

目的　应用多层螺旋CT(MSCT)心肌灌注研究急性心肌缺血和梗死的灌注特点 ,探索MSCT冠状动脉造影对冠状动脉阻断的显示情况。方法　健康杂种犬 9只 ,于左冠状动脉前降支结扎前及结扎后 30min、和 1、2、4、6、8h不同时间分别行MSCT心肌灌注扫描 ,分析心肌在不同时期的灌注特点 ,并与病理检查结果对照。同时于左冠状动脉前降支结扎前及结扎后行MSCT冠状动脉造影 ,观察冠状动脉阻断的情况。结果　犬心肌正常灌注量为 (6 9 3± 13 9)ml·10 0 g-1·min-1、达峰值时间为 (12 8± 2 1)s。左冠状动脉前降支结扎 30min后MSCT心肌灌注表现为灌注量减低 ,为(2 5 2± 3 4 )ml·10 0 g -1·min-1,时间 密度曲线低平 ,延迟 10min扫描左冠状动脉前降支供血区心肌密度为 (6 7 1± 11 4 )HU ,与正常心肌密度 (44 9± 2 2 0 )HU比较差异无显著性意义 (P >0 .0 5 )。左冠状动脉前降支结扎 4h后 ,局部心肌呈明显延迟增强 ,为 (82 1± 15 2 )HU。 9只犬MSCT冠状动脉造影均显示结扎处左冠状动脉前降支中断。结论　MSCT心肌灌注结合冠状动脉造影可以判断心肌缺血和梗死 ,同时显示冠状动脉的阻塞状况。     

Methodology and results of intravenous thrombolysis in acute myocardial infarction

For the vast majority of patients with acute myocardial infarction, intravenous thrombolysis is at present the only therapeutic approach aimed at early reperfusion of the ischemic myocardium. Rapid recanalization of the infarct-related coronary artery is achieved in at least 50–60% of the patients by short-term high-dose infusions of streptokinase or urokinase with a low risk of bleeding. A substantial reduction of infarct size, however, can be expected in only a minority of patients, mostly in those who are treated very early. The effects of intravenous thrombolysis on early and late mortality from acute myocardial infarction are still equivocal; more conclusive data may be expected from ongoing randomized trials.     

心肌梗死后不同阶段冠状动脉介入治疗技术难度与即刻疗效观察

目的　观察心肌梗死后不同阶段进行经皮冠状动脉介入治疗 (PCI)的技术难度、即刻造影效果与安全性。方法　 94例心肌梗死患者分成直接、延期及晚期PCI组 ,病例数分别为 38例、2 2例和 34例。术中根据冠状动脉造影评价梗死相关血管特征、PCI技术难度积分、PCI造影成功率及并发症。结果　三组技术难度积分分别为 1.4 7± 1.79、1.82± 1.72和 2 .85± 2 .83(P <0 .0 5 ) ,PCI造影成功率分别为92 .0 %、91.0 %及 76 .5 % (P <0 .0 5 ) ,PCI中严重并发症分别为 5 .3%、0和 5 .9% (P =NS) ,住院期严重并发症分别为 0、9.1%和 0 (P =NS)。结论　心肌梗死后不同阶段进行PCI的技术难度及有效性各不相同 ,晚期PCI总技术难度增加 ,血管开通机会减少     

99Tcm-MIBI静息心肌断层显像对年轻心肌梗死患者心肌损伤的评价

目的　用99Tcm 甲氧基异丁基异腈 (MIBI)静息SPECT显像评价年轻心肌梗死患者的心肌损伤。方法　总结分析了 42例年龄 <40岁的心肌梗死患者99Tcm MIBI静息心肌灌注断层显像 ,并与冠状动脉造影和ECG进行比较。结果　 42例年轻心肌梗死患者 ,90 % (38例 )心肌灌注显像异常 ,10 % (4例 )未见明显异常 ,诊断灵敏度为 90 %。与ECG相比 ,心肌灌注显像对梗死灶定位更准确 ,特别是心尖和后壁梗死。结论　心肌灌注显像显示年轻心肌梗死患者心肌受损较严重。     

急性心肌梗死合并肾梗死1例

临床资料 患者男,45岁.因“持续性胸闷,胸痛2d”于2015年5月17日入院,否认高血压、糖尿病、心脏病病史,有吸烟史30年,约20支/d,少量饮酒,曾有吸毒史.患者于3d前晚19时许无明显诱因突发胸骨下段压榨性疼痛,无放射痛,伴大汗淋漓、恶心、呕吐胃内容物、咳嗽咯痰,持续无缓解,遂来娄底市中心医院心血管内科就诊.