急性心肌梗塞溶栓再通的临床标准与冠脉造影的对比研究

我院对四年来收入的７８例急性心肌梗塞（ＡＭＩ）患者进行静脉溶栓治疗。作者以冠状动脉造影结果为标准，对ＡＭＩ溶栓治疗再通临床标准（参考方案）进行了验证。结果：参考方案的灵敏度为７０．２％，特异性６７．７％，阳性预测值７６．７％，阴性预测值６０．０％，临床准确度６９．２％。提示：参考方案与冠状动脉造影结果有较好的相关性，判定再通的准确性较高。     

急性心肌梗死患者冠状动脉再通的临床判定（摘要）

急性心肌梗死患者冠状动脉再通的临床判定（摘要）首都医科大学附属北京友谊医院心内科南方，顾复生，沈潞华，杨家声，那开宪，王榭应用间接指征判断急性心肌梗死（ＡＭＩ）患者溶栓后冠状动脉是否再通已为临床普遍接受。我们以冠状动脉造影为对照，观察了冠状动脉再通患...     

超早期急性心肌梗死溶栓治疗的冠状动脉造影结果分析

目的　评价急性心肌梗死 (AMI)超早期诊断的临床价值 ,进一步探讨超早期溶栓治疗的临床意义。方法　对 3 4例符合溶栓标准的 AMI超早期患者溶栓治疗。应用重组链激酶 (r SK) :15 0万 U用 10 ml生理盐水溶解 ,再加入 10 0 ml 5 %葡萄糖液体中 ,60 min内静脉滴入。冠状动脉再通的临床指征执行 1996年中华心血管病杂志编委会制定的急性心肌梗死溶栓疗法参考方案。溶栓后 90 min及溶栓治疗 3周后进行冠状动脉造影 ,比较相关闭塞血管开通情况。结果　在 3 4例溶栓治疗患者中 ,2 7例达临床再通指标 ,其余 7例在 2 4h内延迟再通。 2 7例再通者中 ,2 1例做冠状动脉造影 ,其中 19例显示急性心肌梗死溶栓治疗试验 (TIMI)血流 3级以上。结论　对急性心肌梗死超早期患者及时做出诊断 ,尽早开始溶栓治疗 ,可明显提高相关闭塞血管的开通率     

胸痛缓解对于判断急性心肌梗死溶栓治疗后冠脉再通的意义

目的研究胸痛缓解对于判断急性心梗溶栓治疗后冠脉再通的意义。方法选择我院AN／患者76例，采用静脉尿激酶溶栓治疗后90min行冠状动脉造影，判断冠脉罪犯血管是否再通，分析胸痛缓解对于判定冠脉再通的敏感性及特异性。结果胸痛缓解对于判断急性心梗．溶栓治疗后冠脉再通的敏感性为71．4％，特异性为92．5％，准确性78．9％，阳性预测值94、5％。结论胸痛缓解是一种简便的判定急性心梗溶栓治疗后冠脉再通的临床指标，虽然敏感性不高，但特异性强，阳性预测值高。     

冠状动脉再通临床标准与冠状动脉造影的对比研究

目的：了解溶栓治疗后冠状动脉再通的临床标准的准确性。方法：以冠状动脉造影为标准，对冠状动脉再通的临床标准进行双盲诊断试验研究。７３例急性心肌梗死患者在静脉溶栓治疗后２小时内接受冠状动脉造影检查。结果：以《中华心血管病杂志》编委会推荐的参考方案的标准判断４０例再通，３３例未通；以冠状动脉造影判断４４例再通，２９例未通。参考方案标准的敏感度为６８．２％，特异度为６５．５％，临床准确度为６７．１％。结论：目前临床沿用的参考方案的标准是较好的判断标准。试图改变其中某些标准的方法不能增加其敏感度和准确度。在对假阳性及假阴性患者进行分析时发现：ＳＴ段在溶栓治疗后２小时内不能迅速下降是影响其临床准确度的原因；不同类型心律失常预报临床再通的价值不同，且与心肌梗死部位有关。     

急性心肌梗塞溶栓治疗后冠状动脉再通临床与造影的对比研究

41例AMI患者在溶栓过程中行冠状动脉造影，其中冠状动脉内溶栓14例，静脉溶栓27例。对冠脉再通与否进行了冠脉造影TIMI血流与临床指标的对比研究，临床四项指标为：溶栓开始后2小时内胸痛缓解，升高的ST段回降、出现再灌注心律失常及CK峰值的提前，旨在探讨临床指标评价血管再通的意义。本文分析了单项临床指标、两项、三项指标的不同组合及四项指标与血管再通与否的关系。结果表明：两项指标或以上评定血管再通的敏感性为96．9％，特异性87．5％，准确性95．1％。结论：临床无创指标评定血管再通与否是简便和可行的。     

急性心肌梗死直接介入治疗与静脉溶栓及补救介入治疗的临床疗效

目的探讨急性心肌梗死(AMI)静脉溶栓与时间限定性补救经皮冠状动脉腔内介入(PCI)顺序疗法的合理性、安全性及有效性.方法 1999年1月至2002年10月入院的102例AMI患者中,44例接受直接PCI治疗,58例首先接受尿激酶静脉溶栓,限定自溶栓开始90 min内仍未再通者立即行补救性PCI,溶栓再通者则行择期冠状动脉造影,选择治疗方案.对以上两种方法的再通率、并发症、第4周左室射血分数(LVEF)等临床资料进行分析,对静脉溶栓与时间限定性补救PCI顺序疗法的可行性、安全性、有效性进行评价.结果直接PCI组再通率95.45%(42/44),静脉溶栓+拟行时间限定性补救PCI组90 min内溶栓再通率32.76%(19/58),补救PCI再通率97.43%(38/39);直接PCI组2例于支架置入后出现无或缓再流现象,静脉溶栓未通+时间限定性补救PCI者1例出现缓再流现象,静脉溶栓再通者至择期介入诊疗前无梗死相关血管(IRA)再闭塞;直接PCI组消化道出血2例,溶栓未通+补救PCI组1例出现血尿,无其它出血及穿刺部位血肿发生;第4周超声心动图检查结果直接PCI组平均LVEF为59.5%,静脉溶栓未通+补救PCI组为58.8%,溶栓再通+延迟PCI组为60.4%(P>0.05),6 h以内再通者LVEF为62.7%,6 h以后再通者LVEF为56.8%(P<0.05).结论静脉溶栓与时间限定性补救PCI顺序疗法是AMI获得早期再灌注安全合理有效的方法.     

冠状动脉造影评估国产尿激酶静脉溶栓治疗AMI疗效分析

本文对41例经静脉溶栓后的患者，于溶栓开始后90分钟行急诊冠状动脉造影检查，旨在探讨国产尿激酶（天普-洛欣）的血管再通率，并观察各项临床再通指标与冠状动脉造影的符合率。结果发现，国产尿激酶（天普洛欣）静脉溶栓冠脉开通率为75．6％。判断梗塞血管再通的无创指标中以心肌酶峰值前移最为准确，其次为心电图ST段下移，胸痛缓解及再灌注的心律失常不能作为判断再通的独立指标。     

急性心肌梗死患者血清肌钙蛋白Ⅰ浓度的释放特点及其对静脉溶栓再通的判定价值

目的观察急性心肌梗死(AMI)接受静脉溶栓治疗患者血清肌钙蛋白Ⅰ(cTnⅠ)的浓度变化情况及其评价溶栓再通的价值. 方法 66例AMI者均接受静脉溶栓治疗,应用ELISA法测定cTnⅠ值. 结果溶栓再通组52例,溶栓未通组14例,两组的cTnⅠ释放大部分存在双峰,溶栓再通组第一峰时(11.34小时±3.30小时)、第二峰时(23.80小时±12.43小时)比未通组相对应的时间明显提前(P＜0.05),cTnⅠ第一峰时比CK-MB峰时提前.以cTnⅠ第一峰值到达时间≤14小时判定溶栓再通的敏感性、特异性及准确性分别为92.31%、64.29%及66.5%. 结论在大多数AMI者血清cTnⅠ释放呈双峰,其第一、二峰值到达时间在溶栓再通组前移,血清cTnⅠ≤14小时作为评价溶栓再通与否,有一定的判定价值.     

注射用重组瑞替普酶治疗急性心肌梗死的疗效评价

目的对比观察瑞替普酶(reteplase rPA)与重组组织型纤溶酶原激活剂(rt-PA)用于急性心肌梗死(AMI)溶栓治疗的效果及安全性。方法自2001年11月~2002年5月,共26例AMI患者随机接受rPA或rt-PA溶栓治疗,观察溶栓再通率、急性期死亡率、并发症及不良反应发生率。结果溶栓后2h再通率rPA为92.86%,rt-PA组为75%(P>0.05),90min rPA组3例行冠状动脉造影显示全部再通,rt-PA组3例冠状动造影显示仅1例再通,35d rPA组病死率为14.29%,rt-PA组病死率8.33%(P>0.05),两组各有1例患者发生冠状动脉再闭塞,rt-PA组1例患者发生心力衰竭(P>0.05)。结论rPA为国人治疗AMI安全、有效的溶栓药物。     

Prediction of infarct coronary artery recanalization after intravenous thrombolytic therapy

Clinical assessment of patients with evolving acute myocardial infarction may suggest recanalization of the infarct coronary artery if chest pain, electrocardiographic ST-segment elevation and reperfusion arrhythmia are diminished. These 3 criteria, however, have not been correlated with immediate coronary angiography. Determination of which patients will achieve myocardial reperfusion after intravenous fibrinolytic therapy would allow for appropriate triage; those in whom it fails may be considered for mechanical or surgical recanalization. Fifty-six patients were studied: 28 received intravenous streptokinase and 28 intravenous recombinant tissue-type plasminogen activator. None of these clinical criteria, considered separately, was predictive of infarct artery recanalization status. Using the presence or absence of all 3 criteria, the specificity and predictive value increased to 100%. However, only 9% of patients in the series had all 3 criteria present (all had a patent infarct artery) and 34% had no criteria present (all had an occluded vessel). Noninvasive clinical markers are simple and practical, but only concordance of all 3 major criteria, when present, accurately predicts results of thrombolytic therapy.     

Integration of clinical and imaging data to predict the presence of coronary artery disease with the use of neural networks

AIM: To establish proof of the principle that a computer-based neural network method can be employed that will enhance diagnostic accuracy vis-a-vis image analysis alone in the interpretation of treadmill exercise tests performed in conjunction with myocardial perfusion imaging. MATERIALS AND METHODS: One-hundred-and-two patients underwent myocardial perfusion imaging in association with the standard Bruce protocol. Twenty objective parameters describing each patient's exercise physiology, general clinical status and image appearance were used to train an artificial neural network. Classification accuracy of the neural network and clinical interpretation was determined by coronary angiography. We evaluated the ability of the neural network to integrate clinical, exercise and imaging data to determine the likelihood of coronary artery disease and compared these results with an optimized method of clinical image interpretation, which made use of all available clinical, angiographic and stress test data. RESULTS: The artificial neural network had a sensitivity of 88% and a specificity of 65% for detection of ischemic heart disease and was comparable to that of the optimized clinical method (sensitivity 80%, specificity 69%). Incorporation of clinical and exercise data significantly improved the predictive accuracy of the network compared to a network based on image data alone (P<0.05). CONCLUSION: The results show a computer-based neural network can perform as well as expert readers working under optimal conditions including full knowledge of the patient's clinical, prior angiographic and stress test data. Thus, the method is promising as a diagnostic aid to the recognition of ischemic heart disease in the clinical setting of treadmill exercise testing in conjunction with myocardial perfusion imaging.     

320排螺旋CT冠状动脉成像与冠脉造影对冠心病诊断的的对比研究（英文）

目的：探讨320排螺旋CT冠状动脉成像对冠心病诊断的临床应用价值。方法：85例病人先后进行320排螺旋CT冠状动脉成像（SCTCA）和选择性冠状动脉造影（CAG）。以CAG为诊断冠心病（CHD）的＂金标准＂,比较320排螺旋CT检出CHD的敏感度,特异度,阳性预测值,阴性预测值和准确度。结果：320排螺旋CT诊断CHD的敏感性,特异性,阳性预测值,阴性预测值,准确度分别是：95.65%（44/46）、74.36%（29/39）、81.48%（44/54）、93.55%（29/31）、85.9%（73/85）。结论：320排螺旋CT冠状动脉成像是一种简单易行、安全可靠的无创性检查,可作为冠心病的筛选及术后复查的方法。     

Detection of coronary artery disease by free-breathing, whole heart coronary magnetic resonance angiography: our initial experience

Free-breathing, whole heart coronary magnetic resonance angiography (MRA) has gained great attention as a totally noninvasive diagnostic modality for the detection of coronary artery disease. We examined the accuracy of coronary MRA to identify the presence or absence of coronary artery stenosis in comparison with conventional coronary angiography. Free-breathing, whole heart coronary MRA was performed in 43 consecutive patients undergoing conventional coronary angiography. A total of 172 coronary arteries and 344 coronary artery segments were analyzed. In the coronary artery segment-based analysis, the sensitivity to detect coronary stenosis ≥50% was 82% and specificity was 100%. The accuracy, positive predictive value, and negative predictive value was 97%, 98%, and 96%, respectively. In the vessel-based analysis the sensitivity was 86%, specificity 99%, accuracy 95%, positive predictive value 98%, and negative predictive value 94%. In the patient-based analysis, the sensitivity to detect coronary stenosis <50% was 97% and the specificity to define luminal narrowing <50% was 90%. The accuracy, positive predictive value, and negative predictive value was 95%, 97%, and 90%, respectively. Free-breathing, whole heart coronary MRA yields excellent diagnostic accuracy to detect significant coronary artery disease and has the potential to become the routine diagnostic modality for patients with suspected coronary artery disease.     

Diagnostic work-up of unselected patients with suspected coronary artery disease: complementary role of multidetector computed tomography, symptoms and electrocardiogram stress test

AIM: We evaluated the accuracy of multidetector computed tomography in detecting coronary artery disease and how it could change the indication to coronary angiography in patients with suspected cardiac chest pain. METHODS AND RESULTS: We enrolled 142 consecutive patients who had already performed an exercise electrocardiogram test referred to our hospital and scheduled for coronary angiography for chest pain. According to the characteristics of chest pain and the results of exercise electrocardiogram, patients were divided into four groups: atypical chest pain and negative exercise electrocardiogram (group 1); typical chest pain and negative exercise electrocardiogram (group 2); atypical chest pain and positive exercise electrocardiogram (group 3); and typical chest pain with positive exercise electrocardiogram (group 4). We evaluated the accuracy of multidetector computed tomography and whether it could reduce the number of unnecessary coronary angiography in the study groups. Of 1801 segments larger than 1.5 mm, 1696 (94%) were assessable. In a segment based-model, sensitivity, specificity, negative predictive value, positive predictive value and accuracy were 81% (95% confidence interval 75-89%), 94% (95% confidence interval 90-98%), 96% (95% confidence interval 93-98%), 75% (95% confidence interval 69-82%) and 91% (95% confidence interval 89-93%), respectively. In a patient-based model, sensitivity, specificity, negative predictive value, positive predictive value and accuracy were 95% (95% confidence interval 91-99%), 78% (95% confidence interval 67-89%), 88% (95% confidence interval 79-97%), 89% (95% confidence interval 83-95%) and 89% (95% confidence interval 84-94%). Unnecessary coronary angiography may be avoided by multidetector computed tomography results particularly in group 2 (16%) and group 3 (24%), whereas in groups 1 and 4 the role of multidetector computed tomography in facilitating the correct indication to coronary angiography was less relevant. CONCLUSIONS: Multidetector computed tomography is a particularly helpful technique in patients with discordance between the clinical features of chest pain and stress-test results. This technique may be introduced in the diagnostic work-up of patients with suspected coronary artery disease and may potentially reduce the number of unnecessary coronary angiography.     

64层螺旋CT对老年冠状动脉疾病患者的诊断价值评价

目的探讨64层螺旋CT对老年冠状动脉疾病患者的诊断价值。方法对61例疑为冠心病的老年患者进行冠状动脉64层螺旋CT扫描,并于1周之内进行冠状动脉造影检查。以冠状动脉造影为“金标准”,评价冠状动脉64层螺旋CT诊断老年冠状动脉疾病患者的敏感性、特异性、阳性预测值、阴性预测值及准确度。结果61例患者总计915个冠状动脉节段,64层螺旋CT能够评价其中882个节段(96．4％),其检测中度以上冠状动脉狭窄的敏感性75．6％,特异性88．1％,阳性预测值64．0％,阴性预测值92．8％,准确度85．4％。结论64层螺旋CT对老年冠状动脉疾病患者具有较高的诊断价值,有可能成为筛查老年人冠心病的一个较为可靠的无创检测手段     

DCG联合TET检查在早期复极综合征合并冠心病诊断中的应用

目的探讨动态心电图(DCG)联合平板运动试验(TET)检查在早期复极综合征(ERS)合并冠心病诊断中的应用效果。 方法选取2016年8月至2017年6月聊城市人民医院疑似ERS合并冠心病患者106例,以冠状动脉造影(CAG)结果作为金标准,均进行DCG与TET检查,对比分析DCG＋TET诊断符合率、灵敏度、特异度、阴性预测值及阳性预测值。 结果DCG＋TET检查符合率、灵敏度、阴性预测值高于DCG、TET单独检查(P<0.05);DCG＋TET联合检查特异度、阳性预测值与DCG、TET单独检查对比,差异无统计学意义(P>0.05)。 结论DCG联合TET检查ESR合并冠心病,可提高诊断准确性,为临床制定治疗方案提供参考依据。     

双源CT对冠状动脉支架靶血管再狭窄的诊断价值

目的:探讨双源CT（DSCT）对冠状动脉支架置入靶血管再狭窄的诊断价值。方法:对我院69例冠状动脉支架置入患者（共111枚支架）进行DSCT,评价支架图像质量得分与靶血管级别的相关性;并对部分患者同期进行冠状动脉造影（CAG）检查,对比分析DSCT对冠状动脉支架置入靶血管病变的真实性。结果:DSCT支架图像质量得分与靶血管级别正相关;DSCT对支架靶血管再狭窄诊断的灵敏度82%、特异度98%、和准确度95%;DSCT与CAG对不同直径支架的靶血管再狭窄检出率差异无统计学意义,但DSCT对直径≥3.0 mm支架靶血管再狭窄检出的特异度和准确度明显高于直径＜3.0 mm支架靶血管的相应指标（均P＜0.05）,而灵敏度的差异未达到显著水平。结论:DSCT可清晰的显示冠状动脉支架靶血管的病变情况,能较准确地评价冠状动脉支架靶血管再狭窄的发生,具有临床应用价值。     

Improved detection of coronary artery disease by stress perfusion cardiovascular magnetic resonance with the use of delayed enhancement infarction imaging.

OBJECTIVES: We tested a pre-defined visual interpretation algorithm that combines cardiovascular magnetic resonance (CMR) data from perfusion and infarction imaging for the diagnosis of coronary artery disease (CAD). BACKGROUND: Cardiovascular magnetic resonance can assess both myocardial perfusion and infarction with independent techniques in a single session. METHODS: We prospectively enrolled 100 consecutive patients with suspected CAD scheduled for X-ray coronary angiography. Patients had comprehensive clinical evaluation, including Rose angina questionnaire, 12-lead electrocardiography, C-reactive protein, and calculation of Framingham risk. Cardiovascular magnetic resonance included cine, adenosine-stress and rest perfusion-CMR, and delayed enhancement-CMR (DE-CMR) for infarction imaging. Matched stress-rest perfusion defects in the absence of infarction by DE-CMR were considered artifactual. All patients underwent X-ray angiography within 24 h of CMR. RESULTS: Ninety-two patients had complete CMR examinations. Significant CAD (> or =70% stenosis) was found in 37 patients (40%). The combination of perfusion and DE-CMR had a sensitivity, specificity, and accuracy of 89%, 87%, and 88%, respectively, for CAD diagnosis, compared with 84%, 58%, and 68%, respectively, for perfusion-CMR alone. The combination had higher specificity and accuracy (p < 0.0001), owing to incorporating the exceptionally high specificity (98%) of DE-CMR. Receiver operating characteristic curve analysis demonstrated the combination provided better performance than cine, perfusion, or DE-CMR alone. The accuracy was high in single-vessel and multivessel disease and independent of CAD location. Multivariable analysis including standard clinical parameters demonstrated the combination was the strongest independent CAD predictor. CONCLUSIONS: A combined perfusion and infarction CMR examination with a visual interpretation algorithm can accurately diagnose CAD in the clinical setting. The combination is superior to perfusion-CMR alone.     

64排螺旋CT冠脉成像与冠脉造影对冠心病诊断的比较

目的：探讨64排螺旋CT冠脉成像对冠心病的诊断价值。方法：以冠脉造影（CAG）结果为金指标，采用64排螺旋CT对100例疑诊冠心病患者的冠脉主干及主要分支400节段进行重建和分析，评价其诊断冠心病的灵敏性和特异性。结果：64排螺旋CT能清晰显示冠脉主干及分支狭窄、钙化、开口起源异常及桥血管病变，对冠脉狭窄性病变的诊断准确性高，诊断冠脉病变的灵敏度96.37％，特异度96．14％，阳性预测值95．88％，阴性预测值96．6％。但对慢性闭塞性病变诊断性的准确率稍差，灵敏度50％，特异度96．77％，阳性预测值62．5％，阴性预测值94．73％。结论：64排螺旋CT冠脉成像对冠脉狭窄病变、桥血管、心肌桥、支架管腔均显影良好，对钙化病变诊断率优于冠脉造影，可以作为冠心病高危人群无创性筛选检查及冠脉支架、搭桥术后随访手段。