急性心肌梗死直接经皮冠状动脉介入术心肌缺血再灌注损伤的发病因素分析

目的探讨急性心肌梗死（AMI）直接经皮冠状动脉介入术（PCI）心肌缺血再灌注损伤（MIRI）发生的影响因素。方法回顾性分析2001年1月至2004年12月在我院接受直接PCI且成功开通梗死相关血管（IRA）的AMI患者228例。MIRI判断标准为AMI直接PCI开通IRA后数分钟内急性发生的严重心动过缓和低血压,或需电复律的严重室性心律失常,或IRA前向血流≤TIMI2级且除外因造影可见的血栓、栓塞、夹层或痉挛等所致急性闭塞。应用多因素logistic回归模型对18个临床和冠状动脉造影因素进行分析。结果logistic回归分析显示,AMI发病时间≤6h（P=0.014）、下壁梗死（P=0．006）和PCI前IRA前向血流≤TIMI 1级（P=0．028）是MIRI发生的独立危险因子,多支血管病变（P=0．063）和肾功能不全（P=0．067）也是危险因子;而梗死前心绞痛是独立保护因子（P=0．005）。结论AMI发病时间短、下壁梗死、PCI前IRA前向血流≤TIMI1级、多支血管病变和肾功能不全增加直接PCI术MIRI发生的危险性,而梗死前心绞痛则可减少MIRI的发生。     

急诊冠状动脉支架术联合国产替罗非班治疗急性ST段抬高性心肌梗死的临床疗效和安全性

目的前瞻性评价急性ST段抬高性心肌梗死（STEMI）患者急诊经皮冠状动脉介入治疗（PCI）联合应用国产替罗非班治疗的临床疗效及安全性。方法入选连续160例接受急诊PCI治疗的急性STEMI患者,随机分为替罗非班组（80例）和对照组（80例）。比较两组基础临床情况、介入治疗结果、术后即刻疗效、术后30天和180天主要心脏不良事件（MACE,包括死亡、再梗死、再次靶血管重建）发生率及左室射血分数（LVEF）。结果两组基础临床情况、介入治疗结果差异均无统计学意义。与对照组相比,替罗非班组术后即刻心肌梗死溶栓试验（TIMI）3级复流血流差异无统计学意义（95．0％比87．5％,P〉0．05）,但即刻心肌组织灌注（TMP）3级（75．0％比56．3％,P〈0．05）、校正TIMI帧数[（23．56±5．19）帧比（31．05±6．92）帧,P〈0．01）]、ST段抬高总和回落[（6．51±3．56）mm比（4．53±2．47）mm,P〈0．01]、肌酸激酶同工酶（CK—MB）峰值[（225．02±105．81）μg／L比（269．20±110．88）μg／L,P〈0．05）、肌钙蛋白Ⅰ（TnⅠ）峰值[（45．25±33．00）μg／L比（56．46±29．48）μg／L,P〈0．05]及平均住院天数[（11．38±4．63）天比（14．68±6．90）天,P〈0．01]均显著优于对照组。替罗非班组术后MACE发生率30天（5．0％比16．3％,P〈0．05）和180天（7．5％比18．8％,P〈0．05）明显降低,LVEF（术后30天：53％±7％比49％±9％,P〈0．01;术后180天：59％±8％比53％±9％,P〈0．01）显著提高。多因素logistic回归分析表明,年龄〉65岁[比值比（OR）=3．42,P〈0．01]、替罗非班治疗（OR=0．56,P〈0．05）、住院期LVEF〈0．5（OR=2．56,P〈0．01）是术后180天MACE发生率的主要决定因素。替罗非班组术后出血并发症发生率高于对照组（16．3％和7．5％）,但差异无统计学意义（P〉0．05）。结论急诊冠状动脉支架术联合应用国产替罗非班治疗STEMI能显著提高相关梗死区域再灌注水平,明显改善术后即刻、术后30天及180天临床预后和左心室收缩功能。     

三种术式切除子宫肌瘤对患者卵巢功能的影响

子宫肌瘤患者87例,15例行子宫肌瘤剔除术（A组）,34例行保留附件子宫次全切除术（B组）,38例行保留附件子宫全切术（C组）。观察三组患者手术前后围绝经期综合征的发生情况,并用放免法检测患者血清卵巢泡刺激素（FSH）、雌二醇（E）水平,结果A、B、C组患者术前发生围绝经期综合征2、3、4例,组间比较,P均〉0．05;术后分别为1、5、10例,发生率C组〉A组〉B组,P均〈0．05。术后2周E2水平B、C两组分别为（81．3±22．6）ng／L、（84．4±46．2）ng／L,明显低于术前的（122．5±28．3）ng／L、（143．8±55．7）ng／L,P均〈0．05。FSH水平B、C组术后2周分别为（15．1±4．8）IU／L、（14．9±5．9）IU／L,明显高于术前的（11．2±3．2）IU／L、（11．5±4．1）IU／L,P均〈0．05。A组手术前后血清E2、FSH水平比较P均〉0．05。术后6个月三组FSH、E2水平与术前相比．P均〉0．05。认为子宫肌瘤剔除术对患者卵巢功能无明显影响。保留附件的子宫全切和次全切均可影响患者卵巢功能．但术后6个月可恢复。     

血栓抽吸在高血栓负荷患者急诊冠脉介入治疗中的应用

目的：探讨血栓抽吸在急性ST段抬高型心肌梗死（STEMI）患者急诊冠状动脉介入治疗（PCI）中对梗死相关动脉（IRA）高血栓负荷患者的临床效果。方法：71例STEMI患者急诊PCI时冠脉造影提示IRA高血栓负荷,其中40例应用Diver CE抽吸导管对IRA内血栓进行抽吸治疗为抽吸组,31例行标准PCI为PCI对照组;观察两组无复流现象、术后1h心电图ST段回落、肌酸激酶（CK）和肌酸激酶同工酶（CK-MB）的峰值、术后1周左心室射血分数（LVEF）及左心室舒张末期内径（LVEDd）、住院期间主要心脏不良事件（MACE）及出血并发症情况,并进行比较。结果：抽吸组无复流发生率明显低于PCI组（5.0%比22.6%,P〈0.05）,ST段回落率及LVEF明显高于PCI组[60.0%比32.3%、（58.0±6.4）%比（53.3±9.2）%,P均〈0.05];CK、CK-MB及LVEDd明显低于PCI组[（1692.9±394.5）U/L比（1995.1±571.5）U/L、（174.5±38.0）U/L比（203.7±65.2）U/L、（51.7±4.1）mm比（54.2±5.2）mm,P均〈0.05],两组住院期间MACE发生率差异无显著性（P〉0.05）。结论：在高血栓负荷的急性ST段抬高型心肌梗死患者急诊PCI中,应用Diver CE抽吸导管能有效减少梗死相关血管内血栓负荷,改善术后即刻心肌灌注,减少无复流现象的发生。     

老年高血压病患者血浆神经肽Y、神经降压素水平变化与心肾功能损害的相关分析

目的观察老年高血压病患者血浆神经肽Y（NPY）、神经降压素（NT）水平变化与心肾功能损害的关系。方法选择符合高血压病诊断标准的解放军总医院第一附属医院住院的老年患者57（男性36，女性21）例，年龄60～88（71．3±6．8）岁，选择23（男16，女7）例老年健康查体者或健康志愿者作为对照组，年龄60～76（65．5±6．6）岁。用彩色超声心动图检查患者心脏结构和功能。测定内生肌酐清除率（Ccr）评价患者肾功能。用放射免疫分析法检测血浆NPY、NT浓度。结果（1）老年高血压病患者血浆NPY水平（159±56）pg／ml高于老年对照组（123±54）pg／ml（t=-2．585，P〈0．05），而NT水平（66±31）pg／ml明显低于对照组（101±19）pg／ml（t=2．617，P〈0．01）。（2）将老年高血压病患者按左室射血分数（LVEF）分为3组（1组：LVEF≥55％，2组：LVEF=41％～54％，3组：LVEF≤40％）。3组间NPY、NT浓度均差异明显（F=12．36，P〈0．01，F=4．92，P〈0．05），随心功能恶化，NPY水平升高，而NT水平降低。伴有左室肥厚[室间隔≥11mm和（或）左室后壁≥11mm为左室肥厚]组血浆NPY水平（177±52）pg／ml高于室间隔和左室后壁正常组（135±47）pg／ml（t=-2．84，P〈0．01），而NT水平则肥厚组（56±25）pg／ml低于正常组（94±31）pg／ml（t=4．74，P〈0．01）。（3）将患者按其肾功能，Ccr≥50ml／min和Ccr≤49ml／min分为两组，Ccr≤49ml／min组血浆NPY水平（187±53）pg／ml高于Ccr≥50ml／min组（148±55）pg／ml（t=-1．978，P〈0．05）。NT水平二组分别为（61±29）pg／ml和（69±33）pg／ml，比较未显示出明显差异（t=0．991，P〉0．05）。结论老年高血压病患者血浆NPY、NT水平变化与患者心肾功能损害程度相关，观察血浆NPY、NT水平变化有助于判断老年高血压病患者的病情和预后。     

糖尿病对急性ST段抬高心肌梗死急诊经皮冠状动脉介入治疗心肌灌注的影响

目的采用心电图ST段回落指数（STR）和冠状动脉造影心肌呈色分级（MBG）评价糖尿病对急性心肌梗死（AMI）直接PCI后心肌灌注以及患者预后影响的价值。方法287例AMI并行急诊PCI的患者依据病史以及入院前是否接受药物和非药物降糖治疗的情况分为糖尿病组（n=95例）和非糖尿病组（n=192例）。所有患者分析心电图STR和MBG,并进行临床随诊。结果与非糖尿病组比较,糖尿病组年龄较大[（65±12）岁比（57±11）岁,P〈0．05]。两组PCI术后TIMIⅢ级血流的患者数差异无统计学意义（P〉0．05）。糖尿病组心肌微循环灌注不良多于非糖尿病组（MBG 0／156．0％比41．1％,P=0．019）,ST段回落不全也多于非糖尿病组（43．2％比30．7％,P=0．038）。糖尿病组患者在随诊期间联合终点事件的发生率明显多于非糖尿病组（27．4％比16．1％,P=0．025）。多因素回归分析显示糖尿病是患者预后不良的独立危险因素（RR=1．83,95％CI：1．04～3．36,P=0．01）。患者接受再灌注的时间（RR=3．63,95％CI：1．27～10．42,P=0．03）、ST段回落不全（RR=11．71,95％CI：1．53～38．70,P=0．03）以及MBG0／1（RR=1．16,95％CI：1．03～1．38,P=0．01）与患者预后不良相关。结论糖尿病是AMI患者在成功接受介入治疗术后预后不良的独立危险因素,这可能与糖尿病患者出现心肌微循环灌注不良有关。     

急性心肌梗死患者内源性促红细胞生成素与梗死面积的关系

目的 探讨急性ST抬高型心肌梗死（STEMI）患者,直接经皮冠状动脉介入（PCI）治疗后,内源性促红细胞生成素（EPO）对心肌梗死面积的预测价值。方法 选取发病12h内的STEMI患者163例,根据入院时血清EPO中位数19.6 IU/L进行分组,高EPO组83例,低EPO组80例,测定两组患者生化指标及CK峰值、CK总累积量,并进行统计分析。结果 低EPO组患者CK峰值为（3.63±1.87）×103 U/L、CK总累积量为（107.5±82.3）×103 U?h/L、梗死前心绞痛发生率为22.9%（19/83）,高EPO组患者CK峰值为（2.15±1.23）×103 U/L、CK总累积量为（68.1±50.4）×103 U?h/L、梗死前心绞痛发生率为40.0%（32/80）,两组比较差异均有统计学意义（P＜0.05）。血清EPO与CK总累积量（r=-0.503,P＜0.001）和CK峰值（r=-0.441,P＜0.001）均呈显著负相关;二元Logistic回归分析的结果显示,血清EPO（OR=0.750,95% CI：0.606-0.928,P=0.008）是侧枝循环不良的独立预测因子;多元逐步回归分析显示EPO（β=-0.504,P=0.001）和梗死前心绞痛（β=0.269,P=0.030）是CK总累积量的独立预测因子。结论 血清EPO水平与STEMI患者冠状动脉侧枝循环和心肌梗死面积密切相关,内源性EPO具有一定的心脏保护作用。     

经皮冠状动脉介入术引起再灌注损伤的死因分析

目的 探讨直接经皮冠状动脉介入术（percutaneous coronary intervention,PCI）治疗急性心肌梗死引起心肌缺血再灌注损伤（myocardial ischemical reperfusion injury,MIRI）的病死率及其影响因素。方法 分析直接PCI且成功开通梗死相关血管的急性心肌梗死患者228例。根据MIRI的临床表现分为抑制型：直接PCI开通梗死相关血管后数分钟内急性发生的严重心动过缓和低血压;激惹型：需电复律的严重室性心律失常;和无复流型：梗死相关血管血流等于或小于TIMI 2级且除外急性闭塞。调查性别、发病时间、梗死部位、MIRI类型对住院病死率的影响。结果 MIRI组119例的住院病死率13.4%,显著高于无MIRI组109例的4.6%（P=0.021）;激惹型MIRI的病死率27.6%,显著高于抑制型9.3%和无复流型8.3%（P=0.037）;女性MIRI病死率29.0%,显著高于男性8.0%（P=0.003）;AMI发病时间6小时或以下病人的MIRI病死率14.3%,发病时间6小时以上为10.7%,差异无统计学意义（P=0.628）;前壁梗死MIRI病死率17.0%,下壁梗死病死率11.1%,差异无统计学意义（P=0.356）。结论 激惹型MIRI和女性是AMI直接PCI术MIRI病死率高的重要因素,AMI发病时间和梗死部位不影响MIRI住院病死率。     

髓过氧化物酶与急性冠状动脉综合征相关性及其临床意义

目的研究髓过氧化物酶（MPO）与急性冠状动脉综合征（ACS）的相关性及其临床意义。方法将176例行冠状动脉造影患者按MPO的值四分位法分组,观察各组之间临床事件、理化指标等差异;用多元逐步回归法计算MPO与多因素的相关性;以MPO水平四分位中位数62．9AUU／L为界限（n=176）,MPO水平≥62．9AUU／L和MPO水平〈62．9AUU／L两组数据中,用卡卜兰．迈尔图方法比较6个月随访终点事件的累计发生率。结果（1）MPO血清水平最高四分位数（MPO水平≥82．5AUU／L）组中ACS患者为36．2％（42／116）,是最低四分位数（MPO水平〈48．1AUU／L）组[5．2％（6／116）]的7倍（P〈0．01）。（2）MPO血清水平最高四分位数组中Gensini积分（65．6±30．3）明显高于最低四分位数组（17．3±10．2,P〈0．01）;最高四分位组中白细胞计数为（7．7±1．6）×10^9／L,明显高于最低四分位组的（6．6±1．8）×10^9／L,P〈0．05。（3）TnI≤0．05ng／ml时,血清中MPO活性水平和Gensini积分呈正相关（r=0．321,P=0．002）;与白细胞数呈正相关（r=0．230,P=0．025）。（4）卡卜兰-迈尔图显示,MPO水平≥62．9AUU／L和MPO水平〈62．9AUU／L两组数据中,比较6个月随访终点事件如死亡、非致死急性心肌梗死、再次血管重建和冠状动脉搭桥的累计发生率,差异有统计学意义（x^2=13．5,P=0．01）。结论MPO的活性水平对于ACS危险性评估及初步诊断,是一个很好的指标,尤其是对急性胸痛患者6个月内患心肌梗死或再梗死等严重心血管疾病的危险性有一定的辅助预测作用。     

不同类型心绞痛患者低密度脂蛋白及氧化型低密度脂蛋白的比较研究

目的探讨血浆低密度脂蛋白胆固醇（LDL-C）和氧化型低密度脂蛋白（ox-LDL）与冠状动脉粥样硬化病变严重程度的关系。方法病例选择：冠状动脉痉挛组（CAS,n=31）,临床上具有胸痛表现、冠状动脉造影无显著狭窄并经过乙酰胆碱试验确诊的患者,根据痉挛血管形态分为节段性痉挛组和弥漫性痉挛组;稳定性心绞痛组（SAP,n=35）,为稳定的劳力型心绞痛患者,根据冠状动脉造影结果分为单支病变组和多支病变组;对照组（n=24）,为健康体检患者。各组于清晨空腹采取静脉血,采用全自动生化分析仪测定血浆LDL-C,用ELISA法检测血浆ox-LDL含量,分组比较其LDL．C及ox-LDL水平。结果血浆LDL-C水平SAP亚组[单支病变组（2．6±0．9）mmol／L,多支病变组（2．8±0．9）mmol／L]和CAS亚组[弥漫性痉挛组（3．2±0．5）mmol／L,节段性痉挛组（2．9±0．8）mmol／L]间差异无统计学意义,但均高于对照组[（2．2±0．5）mmol／L,P〈0．05];SAP组血浆ox-LDL含量[（575±219）μg/L]高于对照组[（218±35）μg/L,P〈0．01]和CAS组[（299±117）μg/L,P〈0．01],CAS组与对照组比较,差异无统计学意义（P〉0．05）;弥漫性痉挛组[（225±63）μg／L]、节段性痉挛组[（328±123）μg／L]、单支血管病组[（462±72）μg／L]、多支血管病变组[（672±92）μg／L]的血浆ox—LDL浓度逐步上升,各组间差异有统计学意义（P〈0．05）,与冠状动脉硬化程度呈一致趋势,而血浆LDL水平组间差异无统计学意义。结论血浆ox-LDL比LDL—C更能准确地预测冠状动脉粥样硬化的严重程度,调脂治疗应该更为重视降低ox-LDL,而不应单纯控制LDL水平。     

Endothelin-1 and acute myocardial infarction: a no-reflow mediator after successful percutaneous myocardial revascularization.

AIMS: No-reflow after a primary percutaneous coronary intervention (PCI) is associated with a high incidence of left ventricular (LV) failure and a poor prognosis. Endothelin-1 (ET-1) is a potent endothelium-derived vasoconstrictor peptide and an important modulator of neutrophil function. Elevated systemic ET-1 levels have recently been reported to predict a poor prognosis in patients with acute myocardial infarction (AMI) treated by primary PCI. We aimed to investigate the relationship between systemic ET-1 plasma levels and no-reflow in a group of AMI patients treated by primary PCI. METHODS AND RESULTS: A group of 51 patients (age 59+/-9.9 years, 44 males) with a first AMI, undergoing successful primary or rescue PCI, were included in the study. Angiographic no-reflow was defined as coronary TIMI flow grade < or =2 or TIMI flow 3 with a final myocardial blush grade < or =2. Blood samples were obtained from all patients on admission for ET-1 levels measurement. No reflow was observed in 31 patients (61%). Variables associated with no-reflow at univariate analysis included culprit lesion of the left anterior coronary descending artery (LAD) (67 vs. 29%, P=0.006) and ET-1 plasma levels (3.95+/-0.7 vs. 3.3+/-0.8 pg/mL, P=0.004). At multivariable logistic regression analysis, ET-1 was the only significant predictor of no-reflow (P=0.03) together with LAD as the culprit vessel (P=0.04). CONCLUSION: ET-1 plasma levels predict angiographic no-reflow after successful primary or rescue PCI. These findings suggest that ET-1 antagonists might be beneficial in the management of no-reflow.     

急性心肌梗死急诊介入治疗无再流发生的独立预测因素及对长期预后的影响

目的探讨急性心肌梗死(AMI)患者接受急诊经皮冠状动脉介入治疗(PCI)术中发生无再流的相关因素,并评估无再流对于该类患者的长期预后意义。方法930例行急诊PCI的AMI患者依其是否发生无再流分为两组,分析无再流发生的危险因素及两组患者院内和长期随访中主要不良心脏事件(MACE)。结果930例患者中共82例发生无再流(8.8%)。与正常血流组相比,无再流组患者的入院血糖水平[(9.8±4.3)mmol/L比(8.5±3.5)mmol/L,P<0.01]、肌酸激酶同工酶(CK-MB)峰值[(369.4±167.8)U/L比(282.3±161.7)U/L,P<0.01]、PCI术前0级血流(69.5%比54.5%,P=0.009)发生率较高,AMI前心绞痛发生率较低(19.5%比48.1%,P<0.01)。Logistic回归分析显示入院血糖水平、缺乏AMI前心绞痛、PCI术前0级血流及严重心力衰竭是无再流发生的独立预测因素。无再流患者院内MACE(37.8%比11.3%,P<0.01)和院后(2.5±1.2)年随访MACE发生率(37.5%比17.4%,P<0.01)均显著高于正常血流患者,Kaplan-Meier生存分析提示无再流组患者心因性病死率明显高于正常血流组患者(29.9%比11.7%;logrank检验,P<0.001)。Cox回归分析显示无再流是AMI患者长期心因性病死率的独立预测因素(相对危险度3.83,95%可信区间1.71~5.57)。结论入院血糖水平、缺乏AMI前心绞痛、PCI术前0级血流及严重心力衰竭是无再流发生的独立预测因素。与正常血流组相比,无再流组患者院内及长期随访MACE发生率分别增高3.3和2.2倍。     

半剂量替罗非班联合PCI对早期肾功能不全急性心肌梗死患者的疗效及安全性

目的：观察半剂量替罗非班联合经皮冠脉介入治疗（PCI）对合并早期肾功能不全急性心肌梗死（AMI）患者的疗效及安全性。方法：选择合并早期肾功能不全的AMI患者55例作为肾功能不全组,56例肾功能正常的AMI患者作为AMI对照组,两组均应用常规抗凝、抗血小板治疗,肾功能不全组于穿刺成功后开始应用半剂量替罗非班,AMI对照组全量应用替罗非班。比较两组间住院期主要不良心血管事件（MACE）,出血、血小板减少发生率及对比剂肾病发生率的差异。结果：与AMI对照组比较,肾功能不全组3支病变比例（21．1％比43．60）、术后肌酸激酶峰值浓度[（1863．1±86．7）IU／L比（2371．5±126．3）IU／L]明显升高（P均〈0．05）;两组术后TIMI3级血流率、校正的TIMI计帧数和Blush3级率未见显著性差异（P〉0．05）,术后2h心电图相关导联ST段下降幅度及住院期间的MACE发生率亦无显著性差异（P〉0．05）,出血事件发生率和血小板减少发生率亦无显著差异（P〉0．05）。对比剂肾病：AMI对照组无发生,肾功能不全组有3例发生（0％比5．45％,P〈0．05）。结论：合并早期。肾功能不全的急性心肌梗死患者三支病变比例高,半剂量替罗非班联合PCI能有效再灌注心肌,降低住院心血管事件发生,未见明显出血及血小板减少发生率增加,但需警惕对比剂肾病的发生,术后应加强监测与干预。     

急性心肌梗死患者血B-型尿钠肽水平的变化特点

目的观察急性心肌梗死(AMI)后血B-型尿钠肽(BNP)水平升高的特点,探讨AMI后BNP水平升高的意义。方法连续入选住院AMI患者230例及正常对照111例进行BNP测定。按照首次或再发AMI后ST段抬高型或非ST段抬高型AMI(STEMI或NSTEMI)、不同部位AMI、不同冠状动脉病变、不同梗死相关血管(IRA)、IRA不同TIMI血流和是否急诊经皮冠状动脉介入治疗(PCI)进行分组,采用Student-t检验和ANOVA分析对比各组间BNP水平和心功能相关指标的差异。结果AMI后2~7天,患者BNP水平显著升高(P<0.01),平均为(553.7±735.1)ng/L,是对照组的21倍;与首次AMI组对比,再发组左室射血分数(LVEF)显著降低(P<0.01),左室舒张末径(LVEDd)、BNP水平和LnBNP均显著升高(P均<0.01);与无显著狭窄病变AMI患者对比,单支、三支血管狭窄组的BNP水平显著为高(P均<0.05);IRA的TIMI血流0~1、2级组BNP水平均显著高于TIMI血流3级组(P均<0.01);与未急诊PCI组对比,急诊PCI组血肌酸激酶同工酶(CK-MB)、肌钙蛋白T(TnT)虽显著升高(P<0.05~0.01),然BNP水平显著降低(P<0.05)。结论AMI后,血BNP水平显著升高。以再发AMI、未行急诊PCI治疗和IRA血流TIMI0~2级者更高。急诊PCI可出现心肌酶升高,而BNP降低的矛盾现象。     

Decreased no-reflow in patients with anterior myocardial infarction and pre-infarction angina.

AIMS: Pre-infarction angina is associated with better outcome after myocardial infarction. The aim of this study was to assess whether pre-infarction angina is associated with decreased no-reflow after coronary recanalization. METHODS AND RESULTS: Twenty-three patients underwent intracoronary myocardial contrast echocardiography during the acute phase of anterior myocardial infarction after successful recanalization, and before hospital discharge. Myocardial perfusion was graded semi-quantitatively in the area at risk (dyssynergic segments). Global left ventricular function was assessed by radionuclide angiography on days 8 and 42 and regional wall motion was assessed by 2D echocardiography on days 0 and 42. Fourteen patients had pre-infarction angina (angina less than 7 days before myocardial infarction) and nine did not. Baseline characteristics were similar in the two groups. The myocardial contrast echocardiography perfusion score in the area at risk after recanalization was higher in the patients with pre-infarction angina than in those without (0.72 +/- 0.19 vs 0.53 +/- 0.22, P=0.04), and the incidence of no-reflow (myocardial contrast echocardiography perfusion score < or =0.5) was lower (14% vs 56%, P=0.04). This difference persisted 8 +/- 2 days after myocardial infarction (0. 87 +/- 0.11 vs 0.69 +/- 0.26, P=0.04), and was associated with greater mid-term (day 42) improvement in left ventricular function in patients with pre-infarction angina than in those without, as assessed by changes in radionuclide left ventricular ejection fraction (+5.8 +/- 8.1% vs -3.3 +/- 4.6%, respectively;P=0.01) and by changes in regional wall motion score on 2D echocardiography (-0. 61 +/- 0.39 vs -0.24 +/- 0.17, respectively;P=0.04). CONCLUSION: Pre-infarction angina is associated with preservation of the microvasculature, reflected by reduced no-reflow. This may be a mechanism underlying greater recovery of left ventricular function in patients with pre-infarction angina.     

Effects of direct stenting on epicardial and myocardial perfusion in patients with acute ST segment elevation myocardial infarction

BACKGROUND: Results of studies comparing direct stenting (DS) with conventional stenting (CS) after balloon predilatation in patients with acute myocardial infarction (MI) have been reported in the past, however they are conflicting. There are only few randomised studies that aim to answer whether DS improves epicardial and myocardial patency. AIM: To assess the effects of DS on epicardial and myocardial patency in patients with acute MI. METHODS: Consecutive patients with acute MI were randomised either to DS or CS strategy. Clinical exclusion criteria were as follows: clinical and electrocardiographic features of reperfusion, pulmonary oedema, cardiogenic shock, contradictions to coronarography, allergy to aspirin, ticlopidine, clopidogrel, heparin and stainless steel. Angiographic exclusion criteria were as follows: lesion <50% with correct patency in the infarct-related artery (IRA), lesion in the left main coronary artery, previously performed percutaneous coronary intervention in the target vessel, diameter of the IRA <2 mm or >4 mm. We assessed epicardial patency according to the TIMI (thrombolysis in myocardial infarction) scale and myocardial patency according to the TMPG (TIMI myocardial perfusion grade) scale. In addition, we analysed ST segment resolution in 12-lead electrocardiography (ECG). The ECG was performed before and 30 minutes after PCI. RESULTS: We analysed 300 consecutive patients with acute ST segment elevation MI. After exclusion of patients not suitable for the study design, the DS group comprised 110 patients and the CS group - 107 patients. Clinical and angiographic results were similar in both groups. Initial TIMI 0 (48.2% vs. 43.0%), initial TIMI 3 (31.8% vs. 28.0%), initial TMPG 0-1 (77.3% vs. 78.5%), final TIMI 3 (95.5% vs. 93.5%) and final TMPG 2-3 (68.2% vs. 60.8%) were similar in the DS and CS groups, respectively (p=NS). The incidence of no-reflow phenomenon was comparable in both groups (4.5% vs. 6.5%, NS). The inclusive rate of no-reflow phenomenon plus worsening patency in the IRA were 6.4% vs. 10.3% in the DS and CS groups respectively. The ST segment resolution > or = 50% was 58.1% in the DS group and 56.1% in the CS group (NS). CONCLUSIONS: Direct stenting does not significantly improve epicardial and myocardial patency in an unselected group of patients with acute ST segment elevation MI.     

冠状动脉内应用山莨菪碱对急性心肌梗死介入治疗后无再流及心室功能和收缩同步性的影响

目的探讨冠状动脉内应用山莨菪碱对急性心肌梗死介入治疗（AMI-PCI）后无再流患者的逆转作用并评价其对患者局部、整体心室功能和收缩同步性的影响。方法自2003年1月至2006年2月首发急性前壁心肌梗死并于12h内行急诊PCI的患者136例,根据心肌灌注分级方法（myocardial blush grade,MBG）确认无再流患者（MBG0-1级）47例（男36例,女11例）,平均年龄（63．23±11．24）岁,随机分为两组：A组（山莨菪碱组,24例）和B组（对照组23例）,A组于PCI后即刻由指引导管冠状动脉内注射山莨菪碱1000斗g／次,余治疗同B组。于PCI后即行左心室造影,测定心室容积、压力参数和室壁运动积分（wall motion score,WMS）;AMI后1周时行平衡法核素心室造影,测定左室整体和局部收缩功能、舒张功能和收缩同步性参数;AMI后6个月随访时重复行心室造影和核素心室造影检查测定上述参数,同时随访并记录术后6个月内主要不良心脏事件（MACE）的发生率。结果（I）A组患者在冠状动脉内应用山莨菪碱1000μg／次,平均（2．53±0．34）次后MBG由（0．74±0．32）级增加到用药后的（2．33±0．28）级。（2）AMI-PCI后6个月随访时,A组左室收缩末容积指数、左心室舒张末期容积指数、WMS和左室舒张末期压均较B组明显降低[（40．53±8．12）mL／m^2比（50．32±8．26）mL／m^2,（80．13±9．74）ml／m^2比（87．17±10．25）mL／m^2,（8．24±1．31）比（10．23±1．82）,（13．36±4．21）mmHg（1mmHg=0．133kPa）比（16．38±3．21）mmHg,P均〈0．05];核素心室造影参数比较,A组左室射血分数、峰射血率和峰充盈率等参数均较B组明显增加I（44．02±5．86）％比（38．52±5．18）％,（1．86±0．09）EDV／s比（1.61±0．09）EDV／s,（2．19±0．32）EDV／s比（1.78±0．17）EDV／s,P均〈0．05]。（3）A组AMI-PCI后6个月左室局部射血分数（LrEF）2-LrEF8均分别较B组增加13．96％、25．02％、30．36％、22．86％、27．67％、22．07％和18．71％（P均〈0．05）.（4）相位分析示A组左室收缩同步性参数相角程、半高宽和峰相位标准差亦均低于B组[（46．04±8．93）°比（53．19±16．62）°,P〈0．05;（23．02±6．27）°比（25．02±5．31）°,P〉0．05;（7．92±4．12）°比（11．76±4．11）°,P〈0．05]。（5）在6个月随访期内,A组MACE发生率明显低于B组。结论冠状动脉内注射山莨菪碱可明显逆转AMI-PCI后无再流现象,改善无再流患者的心室功能和收缩同步性,降低MACE发生率。     

Angiographic no-reflow phenomenon and plaque characteristics by virtual histology intravascular ultrasound in patients with acute myocardial infarction

OBJECTIVE: This study aimed to evaluate the relationship between the occurrence of the angiographic no-reflow phenomenon in patients with acute myocardial infarction (AMI) and the preintervention plaque composition as assessed by virtual histology intravascular ultrasound (VH-IVUS). BACKGROUND: The angiographic no-reflow phenomenon is an adverse prognostic factor in patients with AMI. METHOD: We enrolled consecutive 50 patients with ST-elevation AMI was treated by primary stent implantation. All culprit lesions were imaged by VH-IVUS before stent implantation. The angiographic no-reflow phenomenon was defined as a decrease in final TIMI flow grade compared with TIMI flow grade before stent implantation. RESULTS: Eight of 50 patients developed angiographic no-reflow after stent implantation. Gray-scale intravascular ultrasound (IVUS) showed significantly larger external elastic membrane volume and plaque burden in the no-reflow group. VH-IVUS showed a trend toward larger percentage of fibro-fatty plaque volume in the no-reflow group than in the reflow group (23.1 +/- 3.5 vs. 17.0 +/- 1.1%, P = 0.05). The presence of "marble"-like image, mainly consisting of fibro-fatty and fibrous plaque (plaque volume of fibro-fatty + fibrous >80% and containing fibro-fatty plaque volume >10%) was associated with angiographic no-reflow (P = 0.02). Corrected TIMI frame counts of the cases with "marble"-like image were significantly larger than the cases without it (46.8 +/- 5.6 vs. 27.4 +/- 2.3, P = 0.01). CONCLUSION: The culprit lesions with large plaque burden, or with "marble"-like image by VH-IVUS, are associated with the angiographic no-reflow phenomenon in patients with AMI.     

急性心肌梗死直接介入治疗中Diver CE血栓抽吸术的应用

目的探讨和评价急性心肌梗死（AMI）急诊冠状动脉介入治疗（PCI）中联合应用Div-erCE血栓抽吸术的疗效及安全性。方法选择符合急诊PCI的AMI并经冠状动脉造影明确梗死相关冠状动脉（IRA）内高负荷血栓性病变的56例患者,随机分为两组,Diver CE组（n=28）用DiverCE血栓抽吸导管抽吸血栓后再行PCI治疗,对照组（n=28）直接行PCI治疗。结果Diver CE血栓抽吸术后的PCI术后ST段回落（STR）（〉70%）明显优于对照组（71.4%比39.3%,P〈0.05） 术后冠状动脉TIMI血流（2.8±0.4比2.0±0.6,P〈0.05）、血栓积分（TS）（0.1±0.2比1.5±1.0,P〈0.05）、左室舒张末期容积（left ventricular end-diastolic volume,LVEDV）（50±12mL比60±14mL,P〈0.05）、左室射血分数（LVEF）（0.58±0.18比0.46±0.14,P〈0.05）较对照组明显改善,慢血流/无复流发生率低（3.6%比14.3%,P〈0.05） 30d时主要不良心脏事件（MACE）包括死亡、心肌梗死和靶血管再成形术和缺血性卒中的发生率两组未见明显差异（0比3.6%,P〉0.05）。未见与Diver CE血栓抽吸相关的血管并发症。结论Diver CE血栓抽吸术能促进AMI急诊PCI术后STR,改善TIMI血流、TS和左心室功能 该方法操作简单,安全性高 对AMI患者,若其冠状动脉内以血栓性病变为主,应考虑应用Diver CE血栓抽吸术。