ST段抬高型急性心肌梗死溶栓治疗后不同抗凝治疗的临床观察

目的观察比较ST段抬高型急性心肌梗死溶栓治疗后普通肝素(UFH)和parnaparin(商品名新复先) 两种不同抗凝辅助治疗方法的疗效和安全性。方法186名入院后接受溶栓治疗的ST段抬高型急性心肌梗死患者随机分为2组,UFH组及parnaparin组。UFH组在溶栓治疗后12 h给予肝素100 U/kg·b.w.静脉推注,续1 000 U/h静脉滴注,维持活化的部分凝血活酶时间为正常对照的1.5~2.0倍,连续3 d后改为皮下注射7 500 U每12 h 1次,连续注射4 d。parna-parin组在溶栓治疗后12 h给予parnaparin 0.4 ml皮下注射,每12 h 1次,连续注射7 d。主要观察终点:治疗2、7、14、30 d内发生心脏性或非心脏性死亡、再梗死、药物治疗疗效差而必须行急诊血运重建的三联终点事件(死亡、心肌再梗死、紧急血运重建术)。所有入选患者住院14 d以上,随访至治疗后45 d。结果随访45 d内复合三联终点事件在par-naparin组明显下降(42.22% vs37.08%,P=0.03),出血事件(10.00% vs3.13%,P=0.06)及血小板减少(3.33% vs0,P=0.07)亦少于UFH组。结论做为ST段抬高型急性心肌梗死溶栓治疗后的辅助抗凝治疗,parnaparin较UFH至少在45 d内更能减少心脏事件的再发生,更少发生出血事件和血小板减少。     

Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial

Context  Enoxaparin has demonstrated advantages over unfractionated heparin in low- to moderate-risk patients with non–ST-segment elevation acute coronary syndromes (ACS) treated with a conservative strategy. Objectives  To compare the outcomes of patients treated with enoxaparin vs unfractionated heparin and to define the role of enoxaparin in patients with non–ST-segment elevation ACS at high risk for ischemic cardiac complications managed with an early invasive approach. Design, Setting, and Participants  The Superior Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors (SYNERGY) trial was a prospective, randomized, open-label, multicenter, international trial conducted between August 2001 and December 2003. A total of 10 027 high-risk patients with non–ST-segment elevation ACS to be treated with an intended early invasive strategy were recruited. Interventions  Subcutaneous enoxaparin (n = 4993) or intravenous unfractionated heparin (n = 4985) was to be administered immediately after enrollment and continued until the patient required no further anticoagulation, as judged by the treating physician. Main Outcome Measures  The primary efficacy outcome was the composite clinical end point of all-cause death or nonfatal myocardial infarction during the first 30 days after randomization. The primary safety outcome was major bleeding or stroke. Results  The primary end point occurred in 14.0% (696/4993) of patients assigned to enoxaparin and 14.5% (722/4985) of patients assigned to unfractionated heparin (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.86-1.06). No differences in ischemic events during percutaneous coronary intervention (PCI) were observed between enoxaparin and unfractionated heparin groups, respectively, including similar rates of abrupt closure (31/2321 [1.3%] vs 40/2364 [1.7%]), threatened abrupt closure (25/2321 [1.1%] vs 24/2363 [1.0%]), unsuccessful PCI (81/2281 [3.6%] vs 79/2328 [3.4%]), or emergency coronary artery bypass graft surgery (6/2323 [0.3%] vs 8/2363 [0.3%]). More bleeding was observed with enoxaparin, with a statistically significant increase in TIMI (Thrombolysis in Myocardial Infarction) major bleeding (9.1% vs 7.6%, P = .008) but nonsignificant excess in GUSTO (Global Utilization of Streptokinase and t-PA for Occluded Arteries) severe bleeding (2.7% vs 2.2%, P = .08) and transfusions (17.0% vs 16.0%, P = .16). Conclusions  Enoxaparin was not superior to unfractionated heparin but was noninferior for the treatment of high-risk patients with non–ST-segment elevation ACS. Enoxaparin is a safe and effective alternative to unfractionated heparin and the advantages of convenience should be balanced with the modest excess of major bleeding.      

ST段抬高型急性心肌梗死溶栓治疗后不同抗凝治疗的临床观察

OBJECTIVE: To compare the efficacy and safety of unfractionated heparin with a low-molecular-weight heparin (parnaparin) in the management of anticoagulation following thrombolytic therapy for acute ST-segment elevation myocardial infarction. METHODS: One hundred and eighty-six patients with acute ST-segment elevation myocardial infarction undergoing thrombolytic therapy were randomly assigned to receive either unfractionated heparin (100 U/kg x b.w. intravenous bolus, 1,000 U/h continuous infusion for 3 days just 12 h after thrombolysis to maintain the activated partial thromboplastin time at 1.5 to 2.0 times as normal, then subcutaneous 7500 U every 12 h for 4 days, n=90) or parnaparin (0.4 ml subcutaneously every 12 h for 7 days 12 h after thrombolysis, n=96) in conjunction with routine therapy. The patients enrolled stayed in hospital for at least 14 days and were followed for 45 days after admission into the hospital. RESULTS: The composite triple end-point (death, recurrent myocardial infarction, emergency revascularization assessed at 2, 7, 14, 45 days) was significantly reduced in patients receiving parnaparin 42.22% vs 37.08%, P=0.03 . Compared with unfractionated heparin group, the incidences of hemorrhage 10.00% vs 3.13%, P=0.06 and heparin-induced thrombocytopenia (3.33% vs 0, P=0.07) were also lower in parnaparin group. CONCLUSION: Parnaprin is more effective in reducing composite cardiac events, hemorrhage and heparin-induced thrombocytopenia at least in 45 days as compared with unfractionated heparin during anticoagulation following thrombolytic therapy for acute ST-segment elevation myocardial infarction.     

Long term clinical outcome and bleeding complications among hospital survivors with acute coronary syndromes

Objective

To examine the 21 month clinical outcome and bleeding complications in hospital survivors with non‐ST segment elevation acute coronary syndromes (NSTEACS) who were discharged with combined clopidogrel and aspirin anti‐thrombotic therapy, and compare with those having ST segment elevation myocardial infarction (STEMI) who were discharged with aspirin alone.

Design

Observational study.

Setting

A large university hospital.

Patients

224 patients were admitted to hospital with either NSTEACS or STEMI, and survived to discharge between 1 October 2001 and 31 December 2002.

Main outcome measures

Cardiovascular death, total death, new myocardial infarction, unstable angina requiring hospitalisation, stroke or transient ischaemic attack, coronary revascularisation; and fatal, life threatening, major and minor bleeding over 21 months after discharge.

Results

Despite having no or small infarct (median maximum creatine kinase 155 v 1295 u/l; p<0.001) and taking more antianginal drugs, patients with NSTEACS had similar rates of cardiovascular death (9.5% v 8.3%; p = NS), new myocardial infarction (9.5% v 6.5%; p = NS) or unstable angina requiring hospitalisation (15.5% v 10.2%; p = NS) when compared with STEMI. Fatal, life threatening or major bleeding were <1% in both groups (p = NS); and minor bleeding occurred in 4.3% NSTEACS and 2.8% STEMI patients respectively (p = NS).

Conclusions

Patients with NSTEACS had a similar and unfavourable long term outcome when compared with STEMI. There was no difference in serious bleeding complications between both groups.     

Comparison of tirofiban combined with dalteparin or unfractionated heparin in primary percutaneous coronary intervention of acute ST-segment elevation myocardial infarction patients

Background  Primary percutaneous coronary intervention (PCI) is the best treatment of choice for acute ST segment elevation myocardial infarction (STEMI). This study aimed to determine the clinical outcomes of tirofiban combined with the low molecular weight heparin (LMWH), dalteparin, in primary PCI patients with acute STEMI.

Methods  From February 2006 to July 2006, a total of 120 patients with STEMI treated with primary PCI were randomised to 2 groups: unfractionated heparin (UFH) with tirofiban (group I: 60 patients, (61.2±9.5) years), and dalteparin with tirofiban (group II: 60 patients, (60.5±10.1) years). Major adverse cardiac events (MACE) during hospitalization and at 4 years after PCI were examined. Bleeding complications during hospitalization were also examined.

Results  There were no significant differences in sex, mean age, risk factors, past history, inflammatory marker, or echocardiography between the 2 groups. In terms of the target vessel and vascular complexity, there were no significant differences between the 2 groups. During the first 7 days, emergent revascularization occurred only in 1 patient (1.7%) in group I. Acute myocardial infarction (AMI) occurred in 1 (1.7%) patient in group I and in 1 (1.7%) in group II. Three (5.0%) patients in group I and 1 (1.7%) in group II died. Total in-hospital MACE during the first 7 days was 4 (6.7%) in group I and 2 (3.3%) in group II. Bleeding complications were observed in 10 patients (16.7%) in group I and in 4 patients (6.7%) in group II, however, the difference was not statistically significant. No significant intracranial bleeding was observed in either group. Four years after PCI, death occurred in 5 (8.3%) patients in group I and in 4 (6.7%) in group II. MACE occurred in 12 (20.0%) patients in group I and in 10 (16.7%) patients in group II.

Conclusions  Dalteparin was effective and safe in primary PCI of STEMI patients and combined dalteparin with tirofiban was effective and safe without significant bleeding complications compared with UFH. Although there was no statistically significant difference, LMWH decreased the bleeding complications compared with UFH.

     

High-risk patients with acute coronary syndromes treated with low-molecular-weight or unfractionated heparin: outcomes at 6 months and 1 year in the SYNERGY trial

Context  The SYNERGY trial comparing enoxaparin and unfractionated heparin in high-risk patients with acute coronary syndromes (ACS) showed that enoxaparin was not inferior to unfractionated heparin in reducing death or nonfatal myocardial infarction (MI) at 30 days. Objective  To evaluate continued risk in this patient cohort through 6-month and 1-year follow-up. Design, Setting, and Patients  Overall, 9978 patients were randomized from August 2001 through December 2003 in 487 hospitals in 12 countries. Patients were followed up for 6 months and for 1 year. Main Outcome Measures  Six-month outcomes were death, nonfatal MI, revascularization procedures, stroke, and site-investigator–reported need for rehospitalization; 1-year outcome was all-cause death. Results  Six-month and 1-year follow-up data were available for 9957 (99.8%) and 9608 (96.3%) of 9978 patients, respectively; 541 patients (5.4%) had died at 6 months and 739 (7.4%) at 1 year. Death or nonfatal MI at 6 months occurred in 872 patients receiving enoxaparin (17.6%) vs 884 receiving unfractionated heparin (17.8%) (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.89-1.07; P = .65). In the subgroup of patients receiving consistent therapy, ie, only enoxaparin or unfractionated heparin during the index hospitalization (n = 6138), a reduction in death or nonfatal MI with enoxaparin was maintained at 180 days (HR, 0.85; 95% CI, 0.75-0.95; P = .006). Rehospitalization within 180 days occurred in 858 patients receiving enoxaparin (17.9%) and 911 receiving unfractionated heparin (19.0%) (HR, 0.94; 95% CI, 0.85-1.03; P = .17). One-year all-cause death rates were similar in the 2 treatment groups (380/4974 [7.6%] for enoxaparin vs 359/4948 [7.3%] for unfractionated heparin; HR, 1.06; 95% CI, 0.92-1.22; P = .44). One-year death rates in patients receiving consistent therapy were also similar (251/3386 [7.4%] for enoxaparin vs 213/2720 [7.8%] for unfractionated heparin; HR, 0.95; 95% CI, 0.79-1.14; P = .55). Conclusions  In the SYNERGY trial, patients continued to experience adverse cardiac events through long-term follow-up. The effect of enoxaparin on death or MI compared with that of unfractionated heparin at 6 months was similar to that observed at 30 days in the overall trial and in the consistent-therapy group. One-year death rates were also similar in both groups. High-risk patients with ACS remain susceptible to continued cardiac events despite aggressive therapies. ClinicalTrials.gov Identifier:  NCT00043784.      

普通肝素和低分子肝素在急性ST段抬高型心肌梗死患者溶栓中的应用效果比较

目的:比较普通肝素和低分子肝素在急性ST段抬高型心肌梗死患者溶栓中的应用效果。方法:选取102例急性ST段抬高型心肌梗死患者为研究对象,按随机数字表法分为研究组和对照组各51例,对照组在常规用药基础上应用瑞替普酶联合肝素钠治疗,研究组在常规用药基础上给予瑞替普酶联合低分子肝素钙治疗,比较两组临床疗效、临床指标水平和不良反应发生率。结果:研究组治疗总有效率为100.00%,明显高于对照组的82.35%,差异有统计学意义(P<0.05);研究组ST段下降50%以上时间及胸痛缓解时间均明显短于对照组,差异有统计学意义(P<0.05);研究组不良反应发生率为7.84%,明显低于对照组的27.45%,差异有统计学意义(P<0.05)。结论:瑞替普酶联合低分子肝素钙治疗急性ST段抬高型心肌梗死效果显著,可改善临床指标水平,安全性高。     

Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acute coronary syndromes

Context  Effective medical care assumes delivery of evidence-based medicines to appropriate patients with doses comparable to those studied. Objective  To investigate dosing of unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), and glycoprotein IIb/IIIa inhibitors, and the association between dosing and major outcomes. Design, Setting, and Participants  A prospective observational analysis in 387 US academic and nonacademic hospitals of 30 136 patients from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative Registry who had non–ST-segment elevation acute coronary syndromes (NSTE ACS) with chest pain and either positive electrocardiograms or cardiac biomarkers between January 1 and September 30, 2004. Main Outcome Measures  Excessive dosing of UFH, LMWH, and glycoprotein IIb/IIIa inhibitors and major clinical outcomes, including bleeding, in-hospital mortality, and length of stay. Results  A total of 3354 patients (42%) with NSTE ACS who were administered antithrombotic agents received at least 1 initial dose outside the recommended range. An excess dose was administered to 2934 patients (32.8%) treated with UFH, 1378 (13.8%) treated with LMWH, and 2784 (26.8%) treated with glycoprotein IIb/IIIa inhibitors. Factors associated with excess dosing included older age, as well as female sex, renal insufficiency, low body weight, diabetes mellitus, and congestive heart failure. Relative to those patients not administered excess dosages, patients with excess dosages of UFH, LMWH, and glycoprotein IIb/IIIa inhibitors either tended toward or had higher risks for major bleeding (adjusted odds ratio [OR], 1.08; 95% confidence interval [CI], 0.94-1.26; OR, 1.39; 95% CI, 1.11-1.74; and OR, 1.36; 95% CI, 1.10-1.68; respectively). Bleeding increased relative to the degree of excess dose and to the number of agents administered in excess (6.6% [237/3590] if neither heparin nor glycoprotein IIb/IIIa excess vs 22.2% [93/419] if both excess). Mortality and length of stay were also higher among those patients administered excess dosing. We estimated that 15% (400/2766) of major bleeding in this population may be attributable to excess dosing. Conclusions  Patients with NSTE ACS treated in the community often receive excess doses of antithrombotic therapy. Dosing errors occur more often in vulnerable populations and predict an increased risk of major bleeding.      

急性冠状动脉综合征非介入患者强化阿托伐他汀治疗疗效观察

目的 评估对于未行血运重建的非ST段抬高的急性冠状动脉综合征（NSTE-ACS）患者强化阿托伐他汀治疗的效果和安全性。方法 选取未行血运重建的NSTE-ACS患者68例,均在常规二级预防治疗的基础上,其中34例（强化组）予阿托伐他汀40mg/d,1个月后20mg/d维持;另34例（对照组）予阿托伐他汀10mg/d,疗程至少6个月。分别于服药前及服药后6个月行血脂、肝功能、高敏C反应蛋白（hs-CRP）的检测,同时记录两组患者心绞痛发作次数、发作时间及严重心血管事件。结果 两组患者治疗后6个月TC、LDL-C、hs-CRP均较治疗前明显改善（P＜0.05或0.01）;与对照组比较,强化组治疗后6个月TC、LDL-C、hs-CRP均明显改善（P＜0.05）。住院期间强化组死亡2例,对照组死亡3例,病死率差异无统计学意义（P ＞0.05）;出院后强化组心脏不良事件发生率显著低于对照组（P＜0.01）。两组患者治疗后心绞痛发作次数及持续时间均较治疗前明显减少（P＜0.05）,而且强化组治疗后心绞痛发作次数、持续时间较对照组亦明显减少（P＜0.05）。结论 对于未行血运重建的NSTE-ACS患者,早期强化阿托伐他汀治疗,能明显改善临床症状,减少并发症和心脏不良事件的发生,其安全性和低剂量相当。     

Effect of recombinant ApoA-I Milano on coronary atherosclerosis in patients with acute coronary syndromes: a randomized controlled trial

Context  Although low levels of high-density lipoprotein cholesterol (HDL-C) increase risk for coronary disease, no data exist regarding potential benefits of administration of HDL-C or an HDL mimetic. ApoA-I Milano is a variant of apolipoprotein A-I identified in individuals in rural Italy who exhibit very low levels of HDL. Infusion of recombinant ApoA-I Milano–phospholipid complexes produces rapid regression of atherosclerosis in animal models. Objective  We assessed the effect of intravenous recombinant ApoA-I Milano/phospholipid complexes (ETC-216) on atheroma burden in patients with acute coronary syndromes (ACS). Design  The study was a double-blind, randomized, placebo-controlled multicenter pilot trial comparing the effect of ETC-216 or placebo on coronary atheroma burden measured by intravascular ultrasound (IVUS). Setting  Ten community and tertiary care hospitals in the United States. Patients  Between November 2001 and March 2003, 123 patients aged 38 to 82 years consented, 57 were randomly assigned, and 47 completed the protocol. Interventions  In a ratio of 1:2:2, patients received 5 weekly infusions of placebo or ETC-216 at 15 mg/kg or 45 mg/kg. Intravascular ultrasound was performed within 2 weeks following ACS and repeated after 5 weekly treatments. Main Outcome Measures  The primary efficacy parameter was the change in percent atheroma volume (follow-up minus baseline) in the combined ETC-216 cohort. Prespecified secondary efficacy measures included the change in total atheroma volume and average maximal atheroma thickness. Results  The mean (SD) percent atheroma volume decreased by -1.06% (3.17%) in the combined ETC-216 group (median, -0.81%; 95% confidence interval [CI], -1.53% to -0.34%; P = .02 compared with baseline). In the placebo group, mean (SD) percent atheroma volume increased by 0.14% (3.09%; median, 0.03%; 95% CI, -1.11% to 1.43%; P = .97 compared with baseline). The absolute reduction in atheroma volume in the combined treatment groups was -14.1 mm³ or a 4.2% decrease from baseline (P<.001). Conclusions  A recombinant ApoA-I Milano/phospholipid complex (ETC-216) administered intravenously for 5 doses at weekly intervals produced significant regression of coronary atherosclerosis as measured by IVUS. Although promising, these results require confirmation in larger clinical trials with morbidity and mortality end points.      

替格瑞洛用于急性冠脉综合征患者经皮冠状动脉介入治疗的疗效及安全性

【摘要】 目的 研究替格瑞洛对急性冠脉综合征（ACS）患者血小板抑制率及主要心脏不良事件的影响。方法 将2014年9月～2015年12月期间的51例经皮冠状动脉介入治疗（PCI）术后使用替格瑞洛治疗的ACS病人作为观察组,同时期使用氯吡格雷治疗的行PCI手术的ACS患者51例作为对照组,比较两组治疗后二磷酸腺苷（ADP）诱导的血小板抑制率、主要心脏不良事件发生率以及出血、呼吸困难发生率。结果 治疗后1周及1个月,观察组的血小板抑制率明显高于对照组,组间差异有显著性（P＜005）;观察组主要心脏不良事件发生率明显低于对照组,组间差异亦有显著性（P＜005）。结论 替格瑞洛用于行PCI术的ACS病人中,抗血小板效果显著,且能降低主要心脏不良事件的发生率,安全性良好。     

Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials

Context  Patients with unstable angina or non–ST-segment elevation myocardial infarction (NSTEMI) can be cared for with a routine invasive strategy involving coronary angiography and revascularization or more conservatively with a selective invasive strategy in which only those with recurrent or inducible ischemia are referred for acute intervention. Objective  To conduct a meta-analysis that compares benefits and risks of routine invasive vs selective invasive strategies. Data Sources  Randomized controlled trials identified through search of MEDLINE and the Cochrane databases (1970 through June 2004) and hand searching of cross-references from original articles and reviews. Study Selection  Trials were included that involved patients with unstable angina or NSTEMI who received a routine invasive or a selective invasive strategy. Data Extraction  Major outcomes of death and myocardial infarction (MI) occurring from initial hospitalization to the end of follow-up were extracted from published results of eligible trials. Data Synthesis  A total of 7 trials (N = 9212 patients) were eligible. Overall, death or MI was reduced from 663 (14.4%) of 4604 patients in the selective invasive group to 561 (12.2%) of 4608 patients in the routine invasive group (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.72-0.93; P = .001). There was a nonsignificant trend toward fewer deaths (6.0% vs 5.5%; OR, 0.92; 95% CI, 0.77-1.09; P = .33) and a significant reduction in MI alone (9.4% vs 7.3%; OR, 0.75; 95% CI, 0.65-0.88; P<.001). Higher-risk patients with elevated cardiac biomarker levels at baseline benefited more from routine intervention, with no significant benefit observed in lower-risk patients with negative baseline marker levels. During the initial hospitalization, a routine invasive strategy was associated with a significantly higher early mortality (1.1% vs 1.8% for selective vs routine, respectively; OR, 1.60; 95% CI, 1.14-2.25; P = .007) and the composite of death or MI (3.8% vs 5.2%; OR, 1.36; 95% CI, 1.12-1.66; P = .002). But after discharge, the routine invasive strategy was associated with fewer subsequent deaths (4.9% vs 3.8%; OR, 0.76; 95% CI, 0.62-0.94; P = .01) and the composite of death or MI (11.0% vs 7.4%; OR, 0.64; 95% CI, 0.56-0.75; P<.001). At the end of follow-up, there was a 33% reduction in severe angina (14.0% vs 11.2%; OR, 0.77; 95% CI, 0.68-0.87; P<.001) and a 34% reduction in rehospitalization (41.3% vs 32.5%; OR, 0.66; 95% CI, 0.60-0.72; P<.001) with a routine invasive strategy. Conclusions  A routine invasive strategy exceeded a selective invasive strategy in reducing MI, severe angina, and rehospitalization over a mean follow-up of 17 months. But routine intervention was associated with a higher early mortality hazard and a trend toward a mortality reduction at follow-up. Future strategies should explore ways to minimize the early hazard and enhance later benefits by focusing on higher-risk patients and optimizing timing of intervention and use of proven therapies.      

Reducing transfer times for coronary angiography in patients with acute coronary syndromes: one solution to a national problem

Backgound

Patients with acute coronary syndrome (ACS) are at high risk of further cardiac events and benefit from early intervention, as reflected by international guidelines recommending early transfer to interventional centres. The current average waiting time of up to 21 days contravenes evidence based early intervention, creates geographical inequity of access, wastes bed days, and is unsatisfactory for patients.

Methods

A regional transfer unit (RTU) was created to expatiate access of ACS patients referred from other centres to the revascularisation service. By redesigning the care pathway patients arriving on the RTU undergo angiography within 24 hours, and then leave the RTU the following day, allowing other ACS patients to be treated.

Results

During the first six months of the RTU, the mean waiting time from referral to procedure decreased from 20 (SD 15) days (range 0–51) to 8 (SD 3) days (range 0–21) for 365 patients transferred from a distict general hopsital. Ninety seven per cent of patients underwent angiography within 24 hours, 61% having undergone percutaneous coronary intervention at the same sitting, and 78% were discharged home within 24 hours.

Conclusions

Delivering standards laid out in the National Service Framework, reducing inequalities of care across the region, and facilitating evidence based strategies of care represents a challenging and complex issue. For high risk patients suffering ACS who need early invasive investigation, a coordinated network wide approach together with the creation of an RTU resulted in a 62% reduction in waiting times for no extra resources. Further improvements can be expected through increased capacity of this verified strategy.     

曲美他嗪联合生脉注射液治疗非ST段抬高性急性冠脉综合征的效果

目的探讨曲美他嗪联合生脉注射液在非ST段抬高性急性冠脉综合征（NSTEACS）中的应用。方法将选择的46例NSTEACS患者随机分为对照组与治疗组,在常规药物治疗的基础上,对照组加用曲美他嗪治疗,治疗组则在对照组治疗的基础上加用生脉注射液进行治疗。观察并比较两组患者治疗总有效率、治疗前后血浆高敏C-反应蛋白（hs-CRP）、一氧化氮（NO）以及内皮素（ET）水平变化。结果治疗组治疗总有效率为91.30%,显著高于对照组的82.61%,差异有统计学意义（P〈0.05）;治疗后两组患者血浆hs-CRP及ET水平均显著降低,NO水平显著升高（P〈0.05）,以治疗组变化更为显著（P〈0.05）。结论曲美他嗪联合生脉注射液治疗NSTEACS疗效肯定,可显著改善内皮功能并抑制炎症,疗效优于单用曲美他嗪。     

Transradial versus transfemoral percutaneous coronary interventionin elderly patients： a systematic overview and meta-analysis

Background Transradial approach （TRA） percutaneous coronary intervention （PCI） has been wildly applied amongunselected patients. However, only very few small studies have compared the outcomes between TRA and transfemoralapproach （TFA） in elderly patients. We aimed to evaluate the efficacy and safety between TRA and TFA in elderly patientsby a pooled analysis.