冠心病猝死者心肌细胞凋亡与Bcl-2和Bax 基因蛋白表达及其临床意义

目的：探讨Bcl-2和Bax基因蛋白在冠心病心脏性猝死者心肌细胞凋亡中的作用，为冠心病生物治疗提供理论依据。方法；用凋亡原位末端标记检测（TUNEL）法检测16例冠心病心性猝死者和10例心脏正常其他原因死亡者心肌细胞凋亡，用免疫组化法检测Bcl-2和Bax基因蛋白在心肌细胞中表达水平，并探讨其相互关系。结果：（1）冠心病心性猝死者梗死区心肌细胞凋亡数与Bax蛋白表达阳性细胞数均明显高于正常对照组（P〈0．05）；且于梗死区心肌细胞凋亡数及冠状动脉病变支数成明显正相关性。Bcl-2基因蛋白表达则与之相反，梗死区心肌细胞Bcl-2基因蛋白表达明显低于对照组（P〈0．05），且与梗死心区肌细胞凋亡数、冠状动脉病变支数成明显的负相关性。结论：冠心病心性猝死者梗死心肌细胞存在明显的凋亡现象，且受Bax蛋白与Bcl-2基因蛋白下调影响，Bax蛋白与Bcl-2蛋白共同调节心肌细胞凋亡，诱导心肌细胞表达Bcl-2将可能成为探索心肌生物治疗措施的新途径。     

心脏性猝死前动态心电图分析

目的：探讨老年心脏性猝死患者的动态心电图特征。方法：分析20例老年患者心脏性猝死前的动态心电图，并与19例存活的老年患者进行比较。结果：（1）心脏性猝死组冠心病发病率高，动态心电图显示心脏性猝死组Lown3级以上室性心律失常的发生率明显高于存活组（P〈0．05）。（2）心脏性猝死组缺血性ST段压低的总发生率、最大压低幅度和全程呈持续性压低的发生率均明显高于存活组（P〈0．05）。结论：在老年患者中，冠心病伴严重心肌缺血和复杂室性心律失常是老年心脏性猝死的危险因子。     

外伤性脑梗塞16例临床分析

我院自1993年以来共诊治经CT、MRI证实的外伤性脑梗塞16例，结合病例对其临床特点、CT、MRI表现及发病机制进行讨论。1临床资料1．1一般资料男11例，女5例，年龄8－67岁，平均32岁，均无高血压及心脏病史，其中儿童4例，50岁以上3例。致伤原因：车祸7例，打架6例，跌伤3例。伤后意识情况：11例有一过性昏迷，3例浅昏迷，2例中度昏迷；GCS13－15分12例，9－12分2例，8分2例；偏瘫10例，癫病2例，失语2例，面瘫3例，头痛头晕13例；肌力0级2例，Ⅰ－Ⅱ级7例，Ⅲ－Ⅳ级5例。1．2CT及MRI检查结果本组均行CT检查，4例在伤后24h内CT扫描未…     

老年人急性心力衰竭用Isoket与西地兰静脉注射后改善时间的比较

1资料和方法（1）资料：老年男性、女性各30例，年龄在60－86岁。按纽约心脏协会（NYHA）心力衰竭分级标难，心功能均在Ⅳ级。Isoket组冠心病20例，高血压心脏病6例，肺冠心2例，心肌病2例。西地兰组，冠心病20例，高血压性心脏病7例，肺冠心1例，心肌病2例。心率范围：Isoket组112-148次／min，26例窦性心律，4倒房颤心律；西地兰组110－160次／min，24例窦性心律，6例房颤心律。血压范围：Isoket组，16－26／10－13．5kPa，西地兰组，16．5－25／10．5－13．5kPa。（2）方法：全部病人为留院观察病人，一经诊断心功能Ⅳ级后（NYHA）…     

18例老年病人非心脏手术后并发心肌梗塞的护理

老年人在冠心病人群中发病率较高，在施行大中型外科手术后，极易发生心肌梗塞，是外科手本意外死亡的重要因素之一。我院自1991年1月～1998年1月收治病人中有18例非心脏手术术后并发心肌梗塞的病人，护理体会如下：1临床资料18例病人中，年龄最小62岁，最大73岁，平均对岁；男11例，女7例；其中原发病的分布为食道癌7例，贲门癌3例，胃癌4例，结肠癌1例，化脓性胆管炎2例，坏死性胰腺炎1例；既往病史：冠心病13例，高血压2例，糖尿病2例，无明显异常1例。本组死亡3例，术中出现低血压10例，心功能不全3例，房早2例，室早1例，无异常2例；术…     

硝酸甘油静脉注射治疗急慢性心衰61例临床观察

1995年6月-1996年5月，我院用硝酸甘油注射液经微调泵静注治疗各种病因引起的急慢性心力衰竭61例，取得满意效果，现分析如下。1临床资料（1）一般资料：本组61例，男32例，女29例；年龄38-87岁，60岁以上46例，80岁以上5例。其中冠心病17例，高血压合并冠心病14例，原发性扩张型心肌病9例，风心病9例，急性心肌梗死6例，肺心病合并冠心病4例，高血压心脏病2例。按美国纽约心脏协会的心功能标准：Ⅲ级19例，Ⅳ级42例。病程1－30年。（2）治疗方法：均为住院病人，慢性心衰者经洋地黄及／或利尿剂等常现抗心衰治疗，心衰未能控制后加用硝酸甘…     

中老年心脏性猝死的诱因

目的：探讨中老年心脏性猝死的诱因。方法：收集我院自1996-2003年急诊及住院的20例心脏性猝死的患者临床资料进行回顾性分析。结果：其中猝死诱因情绪激动8例，占40％，劳累5例，占25％，用力排尿便后4例，占20％，饮酒后2例，占10％，睡眠中1例，占5％。结论：中老年心脏性猝死发病急，病情凶，掌握其发病诱因、规律、临床先兆，避免诱因，积极采取避免措施，是降低猝死的关键。     

病毒性心肌炎猝死相关机制研究进展

猝死(sudden death)是指貌似健康或症状不明或病情稳定的人，由于体内潜在的器质性病变或器官功能突然改变而发生意料不到的突然自然死亡，是临床及法医尸检中常见的现象，心脏性猝死为其中重要的一种。据新近统计，美国35岁以上因心脏病死亡的患者中约有63％属于心脏性猝死。在英国一项全国调查中，16～64岁成人因心脏及某些不明原因猝死发生率已达11／10万。在澳大利亚，35岁以下的青壮年心脏性猝死约占总死亡率的6．5％。     

冠心病患者306例室性心律失常分析

心脏性猝死最多见于冠心病，辞死的发生与严重的心律失常有关。现就我院1989年6月～1996年6月动态心电图检出的冠心病患者室性心律失常306例进行分析，旨在为协助临床诊断及进行相应的治疗和预防心脏性摔死提供理论依据。1资料和方法1．1对象冠心病组306例，均符合WHO诊断标准[1]。男177例，女129例，平均年龄61．4岁。对照组102例，均经血清心肌酶谱、超声心动图、常规心电图、血生化、肝功能、血沉、抗“O”、T3、T4等检查；临床除室性心律失常外，上述各项检查均在正常范围内的非器质性心脏病者102例，其中男37例，女65例，平均年龄38…     

心脏性猝死与预测

猝死近年有增长的趋势,据报导美国每年约有45万人猝死。据美国纽约等六个城市的统计,心脏性猝死占全部猝死的44.9～66.3％。北京每百万人口中每周不到1.5人猝死 我国孙氏报告心脏性 猝占猝死的67.9％、江氏报告占71％。 心脏性猝死多发于男性,约为女性3～4倍,随年龄增加这种差异缩小,Malora报告40～49岁组男与女之比为2.5∶1,70～79岁组为1.25∶1、心脏性猝死多发生于壮老年人,45岁以下女性罕见。 心脏性猝死的病因很多,1975年Silber曾综合有十种以上。其中以冠心病最多,约占42～75％。一组病死于12小时以内猝死者463例,尸检发现冠心病422例,占91％,据379例心脏性猝死分析,冠心病占54.4％,心肌炎占12.9％,依次为梅心病,风心病、先心病、主动脉窦破裂。Kuler报告猝死     

院内发生器官功能衰竭对老年急性心肌梗死患者预后的影响——附2 535例病例分析

目的 比较不同年龄老年急性心肌梗死(AMI)患者住院发生心、肺、肾器官功能衰竭等严重并发症情况及其对近期预后的影响.方法 对2 535例老年AMI住院患者按年龄、住院期间预后分别分组,回顾分析各组并发症的发生率.结果 ①与60～79岁组(老年组)AMI患者相比,≥80岁组(高龄组)住院病死率显著升高(22.75%(326/422)比12.26%(1 854/2 113),X2=42.15,P<0.01].②老年死亡组(259例)并发心源性休克(44.0%)、心功能Killp Ⅱ～Ⅲ级(28.2%)、呼吸衰竭(14.3%)、脑卒中(11.2%)、肾衰竭(11.2%)、心律失常(49.8%)、贫血(14.7%)的发生率均高于存活组(1 854例,分别为27.1%、17.4%、7.5%、4.5%、4.5%、40.3%、9.1%,均P<0.01);两组间消化道出血(5.8%比3.9%)和肺感染(24.7%比20.2%)发生率差异无统计学意义(均P>0.05).高龄死亡组(96例)并发心源性休克(28.1%)、心功能KillpⅡ～Ⅲ级(32.3%)、呼吸衰竭(17.7%)、肾衰竭(16.7%)、消化道出血(10.4%)、心律失常(49.O%)、贫血(21.9%)的发生率均高于存活组(326例,分别为12.9%、21.2%、9.2%、5.2%、2.1%、35.OH、10.1%,P<0.05或P<0.01);两组间脑卒中(11.4%比5.8%)和肺感染(32.3%比23.3%)发生率差异均无统计学意义(均P>0.05).③老年死亡组和存活组患者住院并发症种类前4位均为心律失常、心源性休克、心功能KillpⅡ～Ⅲ级、肺感染;而高龄死亡组和存活组患者住院并发症种类前4位依次为心律失常、肺感染、心功能KillpⅡ～Ⅲ级、心源性休克.高龄死亡组患者住院期间心源性休克发生率低于老年死亡组(28.1%比44.0%,P<0.01),但猝死率显著高于老年死亡组(22.92%比7.34%,P<0.01).结论 高龄AMI患者住院病死率升高,器官功能衰竭发生率明显增多;其中心律失常是老年和高龄AMI患者首要的并发症.对于老年患者,应高度重视心源性休克的发生和救治,而对于高龄AMI患者,更需警惕和预防猝死的发生.     

The Effect of Age on the Electrophysiological and Autonomic Correlates of Sudden Death After Acute Myocardial Infarction

To examine the influence of age on the autonomic and electrophysiological correlates of sudden death after myocardial infarction, 223 patients aged <60 and 195 patients aged ≥60 were followed up for a mean of 790 days. The patients had Holter monitoring and a signal-averaged EGG 5–11 days after infarction. A mean ventricular ectopic beat frequency >10 beats/ hour (VE10) was present in 17.0% of young versus 28.2% of old patients (P < 0.01); a low heart heart variability index in 17.9% of young but in 32.3% of old patients (P < 0.001) and late potentials in 17.5% but 32% of young and old patients, respectively (P < 0.01). There was no difference in the incidence of sudden death between young and old patients (3.6% vs 3.1%). However, sudden death accounted for 50%, compared with 24% of all deaths in the young and old groups, respectively (P < 0.01). Sudden death was more closely associated with low heart rate variability and VE10 in the young than in the older group. The predictive values of a heart rate variability index <20 units with VE10 in younger patients were a sensitivity of 50%, a positive predictive accuracy (PPA) of 33% and risk ratio (RR) of 18 (P < 0.001); these values did not reach significance in older patients (16.7%, 4.3% and 1.4%, respectively.) Late potentials had a sensitivity of 50%, a PPA of 12.1%, and an RR of 4.7 in young patients (P < 0.05): the corresponding values in the older group were 80%, 8.9, and 8.4 (P < 0.02). It is concluded that sudden death is a more predominant mode of death and is more strongly associated with lower heart rate variability and with the VE10 incidence in young than in older postinfarction patients. Age should be taken into account when assessing the risk of sudden death after myocardial infarction.     

Risk factors and triggers of sudden death in the working generation: an autopsy proven case-control study

In Japan, studies on the risk factors of sudden death in the working generation have been rarely carried out, especially among extremely rare cases of causative disease. Thus, the present study aimed to identify the risk factors and triggers of sudden death in cases whose causes of death were definitely proven by autopsy. We investigated the legal medical records for four years from May 1994 to February 1998. Out of 271 cases, 176 patients 20 to 59 years were enrolled as cases of sudden death in the working generation. Among these, 91 cases, 52%, could be analyzed by telephone interviews from close family members. Only one examiner undertook all phone questions to the case subjects. As control subjects, 1167 persons who consulted us for a health check were employed. Of the sudden death cases, the final diagnosis in 29 cases was coronary artery disease (31.9%), 18, acute cardiac dysfunction (19.8%), 6, other cardiac diseases (6.6%), 4, acute aortic dissection (4.4%), 4, cerebrovascular disease (4.4%) and 30, other diseases (32.9%). Through conditional logistic analysis, the following risk factors emerged as candidates: Long-term stress, history of heart disease, hypertension, chest symptoms, autonomic disturbance, short-term stress and a smoking habit. Short-term stress, autonomic disturbance and a smoking habit increased the risk of sudden death due to coronary artery disease. Long-term stress was associated with an increased risk of sudden death due to acute cardiac dysfunction. It was also demonstrated that autonomic disturbance and stress were closely related to the occurrence of sudden death. Therefore, to prevent sudden death, it would be helpful to identify subjective symptoms to relieve such stress in some way.     

209例中青年院前猝死及复苏状况回顾分析

目的分析广西南宁市中青年院外猝死度现场复苏成败的原因,以进一步提高现场复苏成功率。方法收集1999年1月至2004年12月经本院急诊科外出急救的209例猝死病历,参照Utstein模式进行资料收集并进行回顾性研究。结果猝死前有心血管病史者占首位,为93例,占44．49％;猝死高发年龄40～49岁,占37．32％,男性多于女性;家中猝死者约占50％;先由目击者进行心肺复苏（CPR）的18例中5例复苏有效,有效率27．78％,呼叫至到迭现场平均间期分别为16．4分钟;总复苏成功率为3．82％（8例）。结论南宁市中青年猝死者以心源性为主,现场复苏成功率低,亟待强化院外猝死发生率的急救干预,特别是在人群中普度以CPR为主的初级救护知识和努力缩短急救反应时间。     

Long-term Survival After Resuscitation From Ventricular Fibrillation Occurring Before Hospital Admission

Factors related to long-term (post-discharge) outcome followingsuccessful resuscitation from pre-hospital ventricular fibrillationby a physician-manned mobile coronary care unit were studied.Between 1 January 1966 and 31 December 1987, 190 patients wereresuscitated from pre-hospital ventricular fibrillation (158male; mean age 56 years). The aetiology of ventricular fibrillationwas acute myocardial infarction in 131 patients (69 per cent),ischaemic heart disease without infarction in 48 (25 per cent)and other or unknown in 11 (6 per cent). Predicted actuarialsurvival rates at 1, 2, 5, 10 and 20 years were 76 per cent,66 per cent, 41 per cent, 27 per cent and 12 per cent respectively.Of 128 recorded deaths over 20 years, 85 per cent were cardiacand 48 per cent were defined as sudden death outside hospital.Factors significantly associated with increased long-term mortality(p<0.05), based on analysis of 10 year actuarial life tablesusing the Lee–Desu statistic were ventricular fibrillationdue to ischaemic heart disease without infarction rather thanacute myocardial infarction, a history of previous myocardialinfarction, a history of hypertension, digoxin and diuretictherapy before ventricular fibrillation and digoxin as dischargemedication, and failure to stop smoking after discharge fromhospital by patients who had been smoking prior to ventricularfibrillation. In addition, Cox's regression analysis showedthat patient age     

急性冠状动脉综合征患者经皮冠状动脉介入治疗围术期死亡原因分析

目的：探讨急性冠状动脉综合征（ACS）患者经皮冠状动脉介入治疗（PCI）围术期死亡原因。方法：2002年1月—2006年3月在复旦大学附属中山医院接受PCI的3 806例冠心病患者中36例ACS患者发生围术期死亡。其中男性23例,女性13例;年龄24~85岁（平均年龄69±23岁）,包括急性心肌梗死（AMI）29例、不稳定心绞痛7例,其中既往有陈旧性心肌梗死史者7例、PCI治疗史者4例、冠状动脉旁路移植术（CABG）史者1例、脑卒中史者4例,合并有高血压病者20例、脂代谢紊乱者11例、糖尿病者6例、慢性阻塞性肺病者4例。结果：36例ACS患者中,因AMI行急诊PCI者24例,ACS行择期PCI者12例（包括AMI5例、不稳定心绞痛7例）。冠状动脉造影显示,26例有2支及以上多支血管病变,10例为单支血管病变。36例ACS患者PCI围术期死亡原因为心力衰竭或（和）心源性休克16例（44.4%）,室颤和（或）心脏骤停8例（22.2%）,多脏器功能衰竭4例（11.1%）,心脏破裂4例（11.1%）,急性或亚急性支架内血栓形成3例（8.3%）,消化道大出血1例（2.8%）。急诊PCI因泵衰竭死亡的12例患者中,广泛前壁AMI7例、下壁＋后壁AMI3例,下壁＋右室AMI2例。结论：ACS患者PCI围术期死亡的主要原因为泵衰竭、室颤和（或）心脏骤停、多脏器功能衰竭、心脏破裂及支架内血栓形成。     

Diabetes Does Not Affect Ventricular Repolarization and Sudden Cardiac Death Risk in Patients with Dilated Cardiomyopathy

Background: We studied the effects of diabetes on ventricular repolarization parameters and sudden cardiac death in patients with dilated cardiomyopathy (DCM).
Methods: We enrolled 132 consecutive patients in New York Heart Association (NYHA) heart failure functional classes II or III and left ventricular ejection fraction <40% without evidence of coronary artery disease. In 45 patients (34%), diabetes was diagnosed according to standard criteria (study group), and the remaining 87 (66%) had no diabetes (controls). All patients underwent a 5-minute high-resolution electrocardiogram recording for determination of QT variability (QTV) index and were followed for 1 year thereafter.
Results: At baseline, the two groups did not differ in age, gender, left ventricular ejection fraction, NYHA functional class, or plasma brain natriuretic peptide levels. Similarly, QTV index did not differ between the study group (−0.51 ± 0.55) and controls (−0.48 ± 0.51; P = 0.48). During follow-up, 18 patients (14%) died of cardiac causes. Of the 18 deaths, eight were attributed to heart failure, and 10 to sudden cardiac death. Mortality was higher in the study group (10/45, 20%) than in controls (8/87, 10%) (P = 0.03). The same was true of the heart failure mortality (6/45 [13%] vs 2/87 [2%], P = 0.01), but not of the sudden cardiac death rate (3/45 [7%] vs 7/87 [8%], P = 0.78). By multiple variable analyses, diabetes predicted total and heart failure mortality, and a high QTV predicted sudden cardiac death.
Conclusions: Diabetes appears to increase the risk of heart failure in patients with DCM without affecting ventricular repolarization parameters and sudden cardiac death risk.     

Comparison of conventional autopsy and magnetic resonance imaging in determining the cause of sudden death in the young

Background

Sudden death in the young is a tragic complication of a number of medical diseases. There is limited data regarding the utility of post-mortem Magnetic Resonance (MR) imaging and Computer Tomography (CT) scanning in determining the cause of sudden death. This study sought to compare the accuracy of post-mortem cross-sectional imaging (MR and CT) with the conventional autopsy in determining the cause of sudden death in the young.

Methods

Consecutive patients from 2010 to 2012 (aged 1–35 years) who had sudden death were included. Patients were scanned by CT and 1.5 T MR imaging prior to the conventional autopsy being performed. The primary outcome was diagnostic congruence between imaging and conventional autopsy.

Results

In 17 patients studied, the mean age at death was 23 ± 11 years, with a male predominance (n = 12; 71%). The most common cause of death was a primary cardiac pathology (n = 8; 47%), including ARVC (24%) and ischemic heart disease (12%). Non-cardiac causes identified included pulmonary embolism (6%), and aortic dissection (6%). MR imaging correctly identified the diagnosis in 12 patients who subsequently had positive findings at conventional autopsy, while the diagnosis in the remaining 5 cases remained unexplained. MR imaging was found to be highly sensitive (100%) with a high negative (100%) and positive (80%) predictive value.

Conclusions

Dedicated post-mortem MR imaging of the heart and brain is a useful modality in determining the cause of sudden death in children and young adults, particularly in situations where a conventional autopsy cannot be performed for logistic, cultural or personal reasons.     

Clinical Outcome Following ICD Removal

The Bilitch ICD Registry includes 1,869 patients from 13 medical centers enrolled between March 1982 and April 1992. of these, 95 patients had their units removed and not immediately replaced (77 maIes/18 females mean age 54.9 ± 13.0 years, range 10–76). The mean duration of implanted ICD was 19.5 ± 18.2 months, mean ejection fraction 30.1 ± 11.7%. Coronary artery disease was present in 55 patients, absent in 30, and unknown in 10. The presenting clinical event was sudden death in 35 patients, symptomatic ventricular tachycardia in 34, other causes in 6, and unknown in 20. Reasons for ICD removal were: infection in 33 patients, cardiac transplant in 32, elective in 20, following battery depletion in 7, lead system failure in 2, and inappropriate shock in 1. Of all groups who had their ICD removed, the patients who had removal for cardiac transplantation had the highest incidence of appropriate ICD discharges while the device was implanted (43.8%). Of the 63 nontransplanted patients seven were lost to follow-up while alive. Of the 56 remaining, 17 died (1 cause unknown, 6 noncardiac, 3 sudden, 1 arrhythmic, 6 nonsudden nonarrhythmic cardiac death), 7 had an ICD reimplanted, and 32 are alive and well without an ICD. Follow-up for the 32 cardiac transplant patients: 2 were lost to follow-up while alive, 2 died of nonsudden nonarrhythmic death, and 28 are alive and well. The survival of patients who had their ICD removed and not reimplanted was not different from that of patients who never had their ICD removed up to 2 years. Thereafter, the survival without a device fell below that of those who never had their device removed. Summary: There is a high incidence of ICD discharges in the group undergoing ICD removal for cardiac transplantation. The most common cause of ICD removal was infection. The need for device reimplantation increases at 2 years following device removal. The “elective” device reimplantation does not compromise overall survival.     

Adverse cardiovascular events temporally associated with ma huang, an herbal source of ephedrine.

OBJECTIVE: To evaluate possible cardiovascular toxic effects associated with use of dietary supplements containing ma huang, an herbal source of ephedrine. METHODS: We reviewed the comprehensive database Adverse Reaction Monitoring System of the Food and Drug Administration, which included clinical records, investigative reports, and autopsy reports related to ma huang use. The main outcome measurements were stroke, myocardial infarction, and sudden death. RESULTS: From 1995 to 1997, 926 cases of possible ma huang toxicity were reported to the Food and Drug Administration. In 37 patients (23 women and 14 men with a mean +/- SD age of 43 +/- 13 years), use of ma huang was temporally related to stroke (in 16), myocardial infarction (in 10), or sudden death (in 11). Autopsies performed in 7 of the 11 patients who experienced sudden death showed a normal heart in 1, coronary atherosclerosis in 3, and cardiomyopathies in 3. In 36 of the 37 patients, use of ma huang was reported to be within the manufacturers' dosing guidelines. CONCLUSIONS: Analysis of the 37 patients indicates the following findings: (1) ma huang use is temporally related to stroke, myocardial infarction, and sudden death; (2) underlying heart or vascular disease is not a prerequisite for ma huang-related adverse events; and (3) the cardiovascular toxic effects associated with ma huang were not limited to massive doses. Although the pathogenesis of the cardiac toxic effects of ma huang remains incompletely defined, available observational and circumstantial evidence indicates that use of the substance may be associated with serious medical complications.