溶栓后抬高的ST段早期恢复对急性心肌梗死预后的影响

溶栓治疗已被证明可显著改善急性心肌梗死（AMI）的临床预后，已成为AMI再灌注治疗的标准方法之一。目前临床判断溶栓血管再通常以胸痛消失，血清肌酸激酶（CK）峰值前移、再灌注心律失常及心电图抬高的ST段回降为指标，但只有后者可能是反映心肌组织水平再灌注的临床指标。本文旨在探讨抬高的ST段早期回降与否对AMI住院期间临床预后的影响。     

急性心肌梗死溶栓治疗后ST段再抬高的临床意义

目的 观察急性心肌梗死（AMI）静脉溶栓治疗后ST段再抬高的临床特点。方法 对142例AMI者,根据溶栓后有无ST段再抬高分为ST段再抬高组（A组）和未再抬高组（B组）,测定血清肌酸激酶（CK）及左心室射血分数（LVEF）。观察住院期间梗死相关血管再通率、充血性心衰、严重心律失常的发生情况。结果 A组血管再通率较B组低,A组CK峰值较B组高,而其LVEF低于B组（P〈0．05）;A组充血性心衰发生率、严重心律失常发生率高于B组（P〈0．05）。结论 溶栓治疗后ST段再抬高者血管再通率低,易并发充血性心衰、严重心律失常、较无ST段再抬高者临床预后差。     

急性心肌梗死溶栓治疗中ST段再抬高的意义

目的 探讨急性心肌梗死静脉溶栓治疗中ST段再抬高产生的原因和意义。方法 通过回顾性分析31例首发急性心肌梗死病人，按静脉溶栓治疗中有无ST段再抬高分为A、B两组，比较两组间伴发疾病、再通率、并发症发生情况、CK峰值水平、梗死后心绞痛，结合冠脉造影结果进行分析。结论 静脉溶栓治疗时ST段再抬高与病人合并糖尿病、高血压病、高脂血症及再灌注损伤有关；根本原因是冠状动脉存在多支病变及梗死血管狭窄程度重所致。这类病人心肌受损较重，血管再通率低，常发生梗死后心绞痛。单纯溶栓治疗难以获得满意的效果，应重视再灌注损伤的处理，并可作为补救性PTCA的手术指征。     

211例急性ST段抬高心肌梗死不同治疗方法临床结果分析

目的：分析急性ST段抬高心肌梗死患接受不同再灌注治疗的临床疗效。方法：来自国内12家医院的211例急性ST段抬高心肌梗死患分别接受了经皮冠状动脉介入治疗（PCI）、溶栓治疗、溶栓＋PCI治疗及未接受任何形式的再灌注治疗，分析各种治疗方法的分布、患的临床特征、未接受再灌注治疗的预测因素以及患住院期间不良心血管事件发生率及出院转归情况。结果：接受PCI、溶栓、溶栓＋PCI治疗的例数分别为98、27及27例，59例未接受任何形式的再灌注治疗。未接受再灌注治疗的患中女性占40％，远远高于另外三组中女性患所占的比例（P＜0．001）。合并糖尿病的患在未接受再灌注治疗组约占30％，与其他三组比较，统计学上有显性差异（P＜0．01）。各组在年龄上虽然未显示统计学上的差异，但未接受再灌注治疗组的平均年龄明显大于另外三组。伴有充血性心力衰竭的患则更多地接受了溶栓治疗（11．1％），下壁心肌梗死患也较多地接受了溶栓治疗（55．6％）。多因素逻辑回归分析结果显示，高龄、糖尿病病史及无胸痛症状是未能接受再灌注治疗的预测因子（OR值分别为1．061、2．122、2．310）。未接受再灌注治疗组的住院期间不良事件（再发心肌梗死、再发心绞痛、充血性心力衰竭、心原性休克、肺水肿以及急性肾功能衰竭）发生率明显高于另外三组（P＜0．01）。溶栓组再发心肌梗死、再发心绞痛及充血性心力衰竭等不良事件的发生率高于PCI组。接受再灌注治疗的死亡率明显低于未接受再灌注治疗（P＜0．01）。结论：再灌注治疗可以降低急性ST段抬高心肌梗死患的住院死亡率，减少住院期间不良心血管事件的发生。急性ST段抬高心肌梗死患接受PCI的住院期间效果要优于接受溶栓治疗。目前近1／3的急性ST段抬高心肌梗死患未接受再灌注治疗，与患的年龄，是否合并糖尿病以及发作时有无胸痛症状有关。本组ST段抬高急性心肌梗死患接受PCI治疗较多，与患就诊医院均有导管室有关。     

ST段抬高的急性心肌梗死溶栓治疗后早期ST段下降对心功能的影响

再灌注治疗后心肌是否得到真正的再灌注，一直是临床关注的话题，溶栓治疗后心电图抬高ST段的恢复情况和介入TMA血流恢复情况是临床最常用来判断心肌再灌注的手段，但溶栓后体表心电图的变化与心功能恢复的关系研究尚少，本研究回顾分析了我院急性ST段抬高心肌梗死静脉溶栓治疗早期ST段抬高振幅总和（∑STE）的下降情况。结合患者的心功能恢复情况。用于判断体表心电图ST段情况与心功能的关系。     

急性心肌梗死溶栓后血管性再灌注损伤的临床研究

梗塞相关动脉（ＩＲＡ）早期开通仍然是急性心肌梗死（ＡＭＩ）最有效的治疗措施。但由于缺血再灌注损伤的存在,ＩＲＡ血流的恢复并不能保证心肌组织的再灌注。溶栓治疗后,抬高的ＳＴ段早期恢复和ＣＫ峰值提前,被认为是成功再灌注的指标。ＩＲＡ再通导致ＣＫ峰值提前,我们假设此二项指标的不一致,反映了血管再通与心肌再灌注的差异。为了证实此假设,我们比较了心肌梗死溶栓后ＣＫ峰值提前,有或无ＳＴ段早期恢复患者的临床结果的差异及意义。 方法 １．研究对象：选自１９９０年～２００１年根据临床症状、心电图、心肌酶谱确诊 １８…     

静脉溶栓联合替罗非班治疗急性ST段抬高型心肌梗死的效果

目的: 观察急性ST段抬高型心肌梗死(STEAMI)早期尿激酶静脉溶栓联合国产替罗非班治疗的疗效及安全性。方法: 2007年6月~2008年7月收治STEAMI患者60例，均符合WHO的诊断标准且≤3 h能接受溶栓治疗并在1周内完成冠状动脉造影（CAG），分成常规组(24例)和联合组(36例)。常规组用尿激酶150万U 30 min内静脉滴入。联合组在溶栓同时应用替罗非班。两组均配合低分子肝素皮下注射，记录心电图、超声心动图、心肌酶谱、活化部分凝血酶时间(APTT)、CAG，观察间接和直接冠脉再通指标、院内心脏事件、药物不良反应，评价近期疗效和安全性。结果: 联合组在冠状动脉间接指标再通率、直接指标再通率、溶栓后胸痛缓解时间、CK-MB峰值、CK-MB达峰值时间、1周后左心室收缩末期直径(LVESD)、1周后左心室舒张末期直径(LVEDD)、平均住院天数、院内紧急血运重建、院内再发心肌梗死和常规组比较两组无统计学意义，但在心电图ST段回落≥50%、1周后梗死相关血管（IRA）血流≥TIMIⅡ级、1周后后心肌TMPⅢ级、1周后左室射血分数(LVEF)值、院内发生不稳定型心绞痛、院内心脏事件方面两组有统计学意义（P<0.05）。不良反应方面联合组溶栓24 h后凝血酶原时间延长有统计学意义（P<0.05），在血小板计数和出血事件方面两组无统计学意义。结论: ≤3 h的STEAMI在早期静脉溶栓的同时联合应用国产盐酸替罗非班在改善梗死相关血管TIMI血流和心肌灌注方面优于常规溶栓组，并未增加出血风险。     

普乐林对急性心肌梗死溶栓后再灌注损伤的影响

目的：探讨普乐林对急性心肌梗死溶栓后再灌注损伤的影响。方法：60例AMI患者被随机分为两组，治疗组与对照组，两组溶栓、抗凝治疗方式相同，治疗组另加普乐林（葛根素）注射液500ml/d静脉滴入，10－15日。结果：治疗组胸痛缓解，ST段下移、心肌酶峰值时间提前，血管再通优于对照组（P＜0．05）。治疗组心力衰竭、休克、心梗后心绞痛、再灌注心率失常发生率均低于对照组（P＜0．05）。结论：普乐林注射液（葛根素）具有扩张冠状动脉，促进心梗侧枝循环建立，降低心梗溶栓后心肌再灌注损伤的作用。     

急性心肌梗死溶栓后早期T波倒置与血管再通

目的探讨急性心肌梗死(AM I)溶栓再灌注治疗24h内早期T波倒置的意义及其与血管再通的关系。方法42例急性心肌梗死患者溶栓24h内据T波是否倒置分组,根据ST段、血清CK峰值及其时间变化等血管再通间接指征判断血管是否再通及其与T波倒置的关系。结果42例患者经溶栓治疗后,冠状动脉再通27例(64.3%);早期T波倒置组28例(66.7%),其中溶栓再通24例(85.7%),未通4例(14.3%);T波未倒置组14例(33.3%),其中再通3例(21.4%),未通11例(78.6%)。两组相比T波倒置组血管再通率明显高于T波未倒置组(P<0.01)。结论早期T波倒置对预测冠脉再灌注与ST段具有近似的敏感度(66.7%)、特异度(85.7%)及诊断价值,它与ST段一样可以作为临床判断再灌注的间接指征,且较ST段更易识别,值得临床应用。     

急性心肌梗死溶栓治疗中ST段再抬高的意义

目的探讨急性心肌梗死静脉溶栓治疗中ST段再抬高产生的原因和意义.方法通过回顾性分析31例首发急性心肌梗死病人,按静脉溶栓治疗中有无ST段再抬高分为A、B两组,比较两组间伴发疾病、再通率、CK峰值水平、梗死后心绞痛,冠脉造影结果.结果A、B两组患者各项指标均有显著性差异(P＜0.05).结论静脉溶栓治疗时ST段再抬高与病人合并糖尿病、高血压病、高脂血症及再灌注损伤有关,原因可能是冠状动脉存在多支病变及梗塞血管狭窄程度严重.     

急性心肌梗塞早期溶栓后心电图ST段改变与预后

目的:探索急性心肌梗塞(AMI)早期溶栓治疗后,心电图抬高的ST段回降的幅度对临床预后的影响。方法: 描记88例AMI早期患者溶栓治疗后1 h、2 h、3 h、1 d、3 d等时段的心电图,根据有、无早期(溶栓后2 h)ST段的恢复分为三组:A组,ST段基本恢复至等电线,即回降的幅度≥90％;B组,ST段回降的幅度在50％～90％之间; C组,ST段回降的幅度不到50％。比较三组心肌酶、左心功能及住院病死率。结果:血清肌酸激酶(CK)峰值、左室射血分数(LVEF)及病死率,A组与B组、C组相比较有显著差异(P<0．05,或<0．01):A组CK峰值低、LVEF 高、预后好;C组则相反。结论:AMI早期溶栓后的心电图ST段变化,有助于对临床预后的评估。     

The distinction between coronary and myocardial reperfusion after thrombolytic therapy by clinical markers of reperfusion

Objectives. We sought to examine the hypothesis that rapid resolution of ST-segment elevation in acute myocardial infarction (AMI) patients with early peak creatine kinase (CK) after thrombolytic therapy differentiates among patients with early recanalization between those with and those without adequate tissue (myocardial) reperfusion.Background. Early recanalization of the epicardial infarct-related artery (IRA) during AMI does not ensure adequate reperfusion on the myocardial level. While early peak CK after thrombolysis results from early and abrupt restoration of the coronary flow to the infarcted area, rapid ST-segment resolution, which is another clinical marker of successful reperfusion, reflects changes of the myocardial tissue itself.Methods. We compared the clinical and the angiographic results of 162 AMI patients with early peak CK (≤12 h) after thrombolytic therapy with (group A) and without (group B) concomitant rapid resolution of ST-segment elevation.Results. Patients in groups A and B had similar patency rates of the IRA on angiography (anterior infarction: 93% vs. 93%; inferior infarction: 89% vs. 77%). Nevertheless, group A versus B patients had lower peak CK (anterior infarction: 1,083 ± 585 IU/ml vs. 1,950 ± 1,216, p < 0.01; and inferior infarction: 940 ± 750 IU/ml vs. 1,350 ± 820, p = 0.18) and better left ventricular ejection fraction (anterior infarction: 49 ± 8, vs. 44 ± 8, p < 0.01; inferior infarction: 56 ± 12 vs. 51 ± 10, p = 0.1). In a 2-year follow-up, group A as compared with group B patients had a lower rate of congestive heart failure (1% vs. 13%, p < 0.01) and mortality (2% vs. 13%, p < 0.01).Conclusions. Among patients in whom reperfusion appears to have taken place using an early peak CK as a marker, the coexistence of rapid resolution of ST-segment elevation further differentiates among patients with an opened culprit artery between the ones with and without adequate myocardial reperfusion.     

The effect of preinfarction angina on clinical reperfusion time in patients with acute myocardial infarction receiving successful thrombolytic therapy

BACKGROUND: Preinfarction angina (PA) and early reperfusion of infarct-related arteries have been shown to reduce infarct size in patients with acute myocardial infarction (AMI). The beneficial effects of PA on infarct size have been attributed to the development of ischemic preconditioning and faster coronary recanalization in patients treated with thrombolytic therapy (TT). OBJECTIVE: To evaluate the effect of PA on clinical coronary reperfusion time in patients with AMI receiving successful TT. METHODS: Seventy-five patients presenting with AMI (within 6 h after the initial onset of symptoms) were studied. All patients received TT and were evaluated with coronary angiography (CA) at predischarge. The patients were divided into two groups: group 1 (PA-positive) comprised those who experienced a new onset of prodromal angina within 72 h before the onset of AMI. Group 2 (PA-negative) comprised those who had a sudden onset of AMI without the preceding angina. The successful myocardial reperfusion criteria after TT were ST segment resolution of 50% or greater, the appearance of reperfusion arrhythmias and the resolution of chest pain. The time of reperfusion criteria was recorded after TT. CA was performed in all patients at predischarge. Patients with no patent infarct-related arteries on CA and clinical failure of reperfusion were excluded from the study. RESULTS: Clinical characteristics, risk factors and angiographic findings did not differ significantly between the groups. The time interval from the start of continuous chest pain to TT was also similar between the groups. The left ventricular ejection fraction was higher and there were less frequent ventricular arrhythmias in patients with PA than in those without PA (47.9+/-7.4 versus 44.4+/-8.1, P=0.041, and 17.1% versus 37.5%, P=0.043, respectively). The clinical reperfusion time was significantly shorter in the patients with PA than in those without PA (68.2+/-24.5 min versus 81.4+/-19.3, P=0.012). The clinical reperfusion time was positively correlated with age and the time interval from the start of continuous chest pain to TT but inversely related to the presence of PA. CONCLUSIONS: In patients with AMI preceded by PA, TT resulted in more rapid clinical reperfusion than in patients without PA. Thus, earlier myocardial reperfusion may account for smaller infarct size and better prognosis in patients with PA.     

急性心肌梗死急诊介入治疗与溶栓治疗的疗效比较

目的比较急性ST段抬高性心肌梗死(STEMI)患者分别接受直接经皮冠状动脉介入(PCI)治疗和溶栓治疗住院及随访期间的临床疗效差别。方法108例STEMI患者,66例行直接PCI治疗(PCI组),42例行溶栓治疗(UK组)。比较2组梗死相关动脉(IRA)再通率、左室功能指标、病死率及主要心血管事件发生率的差别。结果PCI组IRA开通率高于UK组(P<0.01),住院病死率低于UK组(P<0.05),左室功能指标优于UK组(左室射血分数更高、左室舒张末径较小、室壁运动障碍率较低,P<0.05)。随访期间比较PCI组再次血运重建率低于UK组(P<0.01),心血管病死率低于UK组(P<0.05)。结论与溶栓治疗相比,PCI治疗能及时有效地开通梗死相关血管,改善左室功能,降低病死率和再次血运重建率。     

Relation of corrected thrombolysis in myocardial infarction frame count and ST‐segment resolution to myocardial tissue perfusion after acute myocardial infarction

Objectives : To evaluate myocardial tissue perfusion by corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC) and ST‐segment resolution after successful percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). Background : Early and sustained potency of infarct‐related artery (IRA) has become the main goal of reperfusion therapy in patients with AMI. However, myocardial tissue perfusion may remain impaired even after the achievement of TIMI grade 3 flow of the epicardial artery without residual stenosis. Methods : CTFC was measured after successful PCI in 63 patients with first AMI. The extent of ST‐segment resolution was recorded 1 hr after reperfusion therapy. The wall motion score index (WMSI) was assessed before and 1 month after PCI. Then we studied the correlation between CTFC, ST‐segment resolution, and WMSI. Results : According to CTFC, the patients with TIMI grade 3 flow after PCI were divided into two groups: CTFC fast group and CTFC slow group. CTFC fast group had higher percentage of complete ST resolution (54.1% vs. 25.0%, P < 0.05) and lower percentage of no ST resolution (2.6% vs. 29.2%, P < 0.05). Improvement of WMSI in the CTFC fast group was significantly greater than that of the CTFC slow group (1.30 ± 0.41 vs. 0.64 ± 0.30, P < 0.05). CTFC had a significant negative correlation with the change in WMSI (r = ?0.75, P < 0.01). Conclusions : Combined with ST‐segment resolution, CTFC could predict risk for patients with successful reperfusion therapy after AMI and provide evidence for additional adjunctive treatment. © 2008 Wiley‐Liss, Inc.     

急性心肌梗死冠状动脉再通后ST段回落缓慢的意义

５４例急性心肌梗死患者溶栓或经皮冠状动脉腔内成形术后梗死相关冠状动脉再通，９０分钟时ＳＴ段上移总和回落，≥５０％为乙组。与乙组比较，甲组溶栓距发病时间及肌酸激酶峰值距发病时间延长。住院期间心脏事件发生率甲组显著高于乙组，而且出院前超声心动图检查显示，甲组收缩末期容量较乙组增大，射血分数减低。     

血栓抽吸导管对急性心肌梗死患者心肌灌注水平影响的临床研究

目的分析在血栓负荷较大的急性心肌梗死(AMI)患者行急诊PCI中,应用抽吸导管对心肌再灌注的影响及安全性。方法选择经急诊冠状动脉造影显示血栓负荷较大的AMI患者36例作为血栓抽吸组,另选同期采用常规PCI的AMI患者36例作为对照组,比较2组的血栓负荷、TIMI分级、TIMI心肌灌注(TMP)分级、心肌酶峰值、ST段回落幅度、LVEF、住院期间心血管不良事件。结果血栓抽吸组患者经抽吸后血栓负荷明显降低;血栓抽吸组患者TIMI分级和TMP分级明显优于对照组,差异有统计学意义(P0.01);血栓抽吸组患者较对照组肌酸激酶、肌酸激酶同工酶峰值明显降低,术后1 h ST段回落百分比明显增高,LVEF明显升高,左心室舒张末内径明显下降,差异有统计学意义(P0.01)。结论在血栓负荷较重的AMI患者行急诊PCI时,应用血栓抽吸导管安全可行,可显著改善梗死相关血管前向血流情况,改善心肌再灌注,减少无复流现象和心肌酶的释放。     

Serial analyses of ventricular late potentials in patients with reciprocal ST segment changes during acute myocardial infarction

The aim of this study was to determine whether successful reperfusion may alter substrate that is responsible for late potentials in the presence or absence of reciprocal ST segment changes (RC). The study population consisted of 50 patients (27 with RC and 23 without RC) with anterior acute myocardial infarction (AMI) undergoing successful thrombolytic therapy (TT). The presence of reciprocal changes was defined as ST-segment depression >1 mm, measured 80 ms after the J point in at least 2 leads other than those reflecting the infarct on admission ECG. All patients were evaluated with coronary angiography at predischarge. Signal averaged ECG (SAECG) recordings were obtained before and 10 days after TT. Baseline characteristics, SAECG findings, and angiographic data were similar between the groups. The only different baseline finding was the time from symptom onset to TT (204 +/- 150 minutes for patients with RC vs 312 +/- 174 minutes for patients without RC. P = 0.021). After TT, RMS values improved in patients with RC (from 35 +/- 17 microV to 43 +/- 14 microV, P = 0.038) and LAS and RMS were significantly better in this group. However, patients without RC did not show any changes in SAECG parameters after TT. LV ejection fraction (10th day) was better in patients with RC (45 +/- 11% vs 39 +/- 6%, P = 0.014). The frequency of ventricular arrhythmias during the hospitalization period was also similar between the groups. Reciprocal ST depression that regresses simultaneously with the infarction related ECG changes after TT in anterior AMI seems to be related to the time that has elapsed since the symptom onset. The improvement in SAECG parameters after TT in these patients is probably the result of earlier reperfusion leading to less myocardial damage.     

Reperfusion arrhythmias during coronary angioplasty for acute myocardial infarction predict ST-segment resolution

BACKGROUND: Despite early recanalization of an occluded infarct-related artery, myocardial reperfusion may remain impaired due to microvascular injury. Reperfusion arrhythmias may indicate successful microvascular reperfusion. METHODS: Microvascular reperfusion was assessed prospectively in 42 consecutive patients with ST-segment elevation acute myocardial infarction (AMI) by evaluation of the resolution of ST-segment elevation (<50% of initial level) immediately after successful coronary angioplasty. Patients were divided into two groups: those with ST resolution (n=24) and those without ST resolution (n=18). The presence of reperfusion arrhythmias immediately after recanalization was recorded. RESULTS: Patients with ST resolution were younger (54+/-12 years compared with 64+/-17 years, P=0.04), their pain-to-recanalization time was shorter (195+/-87 min compared with 294+/-179 min, P=0.05), they were less often diabetic (13% compared with 24%, P=0.05) and were more often given IIb/IIIa inhibitors (58% compared with 22%, P=0.02). Reperfusion arrhythmias were observed in 15 out of 24 patients with ST resolution (62%) but in only one out of 18 without ST resolution (5%) (P<0.01). Reperfusion arrhythmias included accelerated idioventricular rhythm, 13 (81%); multifocal ventricular premature beats, two (13%); and ventricular tachycardia, one (6%). The sensitivity and specificity of reperfusion arrhythmias for ST resolution were 62 and 95%, respectively. In a logistic regression model including age, time to treatment, diabetes, use of IIb/IIIa inhibitors and reperfusion arrhythmias, only the latter was found to be an independent predictor of ST resolution (P<0.01). CONCLUSION: Reperfusion arrhythmias following coronary angioplasty for AMI are a highly specific marker for ST resolution and may indicate successful microvascular reperfusion.     

急性冠状动脉支架成形术后心肌组织灌注的临床研究

目的 观察急性心肌梗死患者冠状动脉介入(PCI)治疗成功后，校正的TIMI帧数(CTFC)与心电图ST段回落联合评价心肌组织水平灌注的可行性。方法 测定PCI治疗后血流达。TIMI3级患者的CTFC，并在术前及术后1个月分别测定室壁运动记分(WMSI)。观察CTFC与WMSI之间的相关性，同时检查术前及术后1小时心电图ST段回落情况。结果 按照CTFC将，TIMI血流3级者分为快、慢两组，快CTFC组患者ST段回落程度明显优于慢CTFC组；1个月后快CTFC组患者的室壁运动记分改善程度明显优于慢CTFC组，CTFC与术前、术后WMSI的差值有明显的负相关；快CTFC组患者从发病到接受PCI治疗的时间明显短于慢CTFC组。结论 CTFC作为一种定量、客观、简单、经济、重复性好的方法评价心肌微循环灌注情况，较低的CTFC及心电图ST段回落完全预示着良好的心功能恢复，可为临床提供是否需要进一步辅助治疗的证据。