Dobutamine-induced ST segment elevation in a patient with angina at rest and critical coronary lesions.

A case of dobutamine-induced ST-segment elevation in a patient with angina at rest and severe two-vessel disease is described. Coronary angiography performed during the ischaemic episode showed patency of coronary arteries; ST-segment elevation and chest pain regressed after propranolol administration. This case suggests that in the presence of severe coronary lesions dobutamine may produce transmural myocardial ischaemia by increasing myocardial oxygen demand and inducing myocardial blood flow maldistribution.     

优化急性ST段抬高型心肌梗死的直接经皮冠状动脉介入治疗

对ST段抬高型心肌梗死实施直接经皮冠状动脉介入治疗不应只是为获得TIMI 3级血流,而应是良好的心肌灌注。可通过上游使用血小板膜糖蛋白Ⅱb/Ⅲa受体拮抗剂、他汀类调脂药,个体化正确使用血栓抽吸装置,必要时延迟支架植入等手段,优化直接经皮冠状动脉介入治疗术的效果。     

Antiplatelet therapy for postdischarge medical management of acute coronary syndrome

Postdischarge management of patients with acute coronary syndrome is often suboptimal, despite their high risk of a subsequent event. Updated American College of Cardiology/American Heart Association guidelines emphasize the need for aggressive modification of risk factors and treatment with antiplatelet, antihypertensive, and lipid-lowering agents commenced in-hospital and continued long-term. Antiplatelet therapy involving aspirin and clopidogrel is the mainstay of secondary risk reduction. Increased adherence to medication and risk factor modification at discharge has been demonstrated with acute care quality improvement initiatives. Extension of these initiatives to postdischarge care will provide data on medication adherence post acute coronary syndrome and functional outcomes in the community setting. Successful secondary prevention of cardiovascular events requires implementation of evidence-based guidelines by physicians, and adherence to pharmacotherapy and lifestyle modifications by patients. Primary care physicians are well placed to influence adherence through their ongoing relationships with patients and can save lives by implementing secondary risk reduction measures after discharge.     

多层螺旋CT评价急性冠状动脉综合征及稳定性心绞痛患者斑块特征的作用

目的利用多层螺旋CT评价急性冠状动脉综合征(ACS)及稳定性心绞痛(SAP)患者冠状动脉病变的差异。方法连续性入选诊断为ACS及SAP、并于介入治疗前72h内行多层螺旋CT检查的患者45例,将诊断为ACS的31例作为ACS组,诊断为SAP的14例作为SAP组,将ACS组的病变分为罪犯病变和非罪犯病变,SAP组的病变定义为稳定病变;比较冠状动脉病变性质。结果 2组共有60处病变,ACS组40处,SAP组20处;ACS组罪犯病变非钙化斑块和脂质斑块比例明显高于同组非罪犯病变及SAP组的稳定病变(96.8%vs 55.6%vs 20.0%,83.3%vs 40.0%vs 25.0%,P<0.01);ACS组罪犯病变的血管截面积、斑块面积、重构指数、斑块的偏心指数明显高于同组的非罪犯病变及SAP组的稳定病变(P<0.05)。结论多层螺旋CT作为无创的影像学工具,可识别ACS与SAP患者冠状动脉斑块病变的差异。     

不同类型急性冠状动脉综合征患者罪犯病变的形态学特点

目的 比较急性ST段抬高型心肌梗死(STEMI)和非ST段抬高型急性冠状动脉综合征(NSTEACS)患者罪犯病变的形态学特点.方法 入选2018年1月至2019年12月在河南省人民医院接受冠状动脉造影的急性冠状动脉综合征患者93例,对其临床资料进行回顾性分析.根据诊断类型,将患者分为STEMI组(45例)和NSTEAC...     

Quantitative T-wave analysis predicts 1 year prognosis and benefit from early invasive treatment in the FRISC II study population.

AIMS: To investigate the prognostic value of T-wave abnormalities in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), and whether such ECG changes may predict benefit from an early coronary angiography. Although ST-segment changes are considered the most important ECG feature in NSTE-ACS, T-wave abnormalities are the most common ECG finding. We hypothesize that a new quantitative approach to T-wave analysis could improve the prognostic value of this ECG abnormality. METHODS AND RESULTS: Quantitative T-wave analysis was performed on the admission ECG in 1609 patients with NSTE-ACS. Nine different categories of T-wave abnormality were analysed for their prognostic value concerning clinical outcome in patients not randomized to early coronary angiography. Also, the presence of one category (i.e. T-wave abnormality in > or =6 leads) was analysed for its predictive value concerning benefit from early coronary angiography. The combined study endpoint was death or myocardial infarction at 1 year follow-up. Patients with > or =6 leads with abnormal T-waves and concomitant ST-segment depression had a higher risk when not receiving early coronary angiography (24 vs. 12%, respectively; P=0.003), but could be brought to the same level of risk as the remaining patients with this treatment. For non-invasively treated patients five different categories of T-wave abnormality were significantly associated with an adverse outcome. CONCLUSION: New quantitative T-wave analysis of the admission ECG gives additional predictive information concerning clinical outcome and identifies patients who benefit from early coronary angiography.     

老年冠心病患者不同临床类型血脂水平的观察

目的　探讨老年冠心病患者不同临床类型血脂水平的差异。方法　将确诊为冠心病的 70岁以上老年患者6 4 7例 ,分为急性心肌梗死 (AMI)组、稳定性心绞痛 (SAP)组、不稳定性心绞痛 (UAP)组 ,另选无冠心病的老年患者 70例作为对照组 ,比较各组间的血脂水平。结果　AMI组和UAP组血清胆固醇水平与对照组及SAP组比较 ,差异有显著性意义 ;血清甘油三酯水平随着冠心病病情程度加重 ,呈逐渐升高的趋势 ;SAP组、UAP组和AMI组低密度脂蛋白胆固醇 (LDL C)水平高于对照组 ,高密度脂蛋白胆固醇 (HDL C)水平低于对照组 ,差异有显著性意义 ;SAP组、UAP组和AMI组LDL C HDL C比值均高于对照组 ,AMI组LDL C HDL C比值高于UAP组和SAP组 ,差异有显著性意义。结论　在 70岁以上老年冠心病患者中 ,LDL C HDL C比值与AMI的发生关系密切     

急性ST段抬高型心肌梗死患者溶栓后经皮冠状动脉介入治疗时机的选择

目的:探讨急性心肌梗死静脉溶栓后紧急转诊经皮冠状动脉介入治疗(PCI)模式的科学性、有效性及安全性。方法:5例急性ST段抬高型心肌梗死(STEMI)患者在外院行静脉溶栓后经绿色通道直接送至我院心导管室行紧急PCI术,观察转运途中的安全性、术中及术后的并发症,术后即刻疗效及出院后短期随访效果。结果:溶栓后立即转诊至我院并紧急PCI的5例患者均顺利完成PCI术,住院期间未见再发缺血事件,也未见明显出血并发症,缩短了患者的住院时间,术后短期随访未见明显不良事件发生。结论:在具备抢救设备及医护人员陪同的条件下,外院STEMI患者溶栓后立即转诊实施紧急PCI术是安全的,且对患者有益,手术时间应在溶栓3h之后,根据术中情况决定术后抗血小板聚集和抗凝治疗。     

冠脉内小剂量替罗非班在急性STEMI急诊介入时应用观察

目的:探讨急性ST段抬高型心肌梗死(STEMI)患者行急诊经皮冠状动脉介入治疗(PCI)时冠脉内小剂量应用替罗非班对介入治疗安全性和有效性。方法:入选77例STEMI急诊介入治疗患者,全部患者入院后立即给予阿司匹林300 mg嚼服,氯吡格雷300 mg口服,随机分为替罗非班组(试药组,39例)和对照组(38例,未用替罗非班)。PCI术后梗死相关血管的心肌梗死溶栓(TIMI)血流分级、术后24 h ST段完全回落率、术后1周左心室射血分数(LVEF)、术后30 d主要心血管事件(死亡、再发心肌梗死、靶血管血运重建、反复心绞痛发作)及TIMI出血事件作为评价指标。结果:术前两组患者基线资料(年龄、性别、危险因素)差异无统计学意义。术后即刻TIMIⅢ级血流获得率试药组明显高于对照组(P0.05)。术后24h ST段完全回落率及1周时LVEF试药组明显高于对照组(均P0.05,P0.01)。术后30 d随访两组主要心血管事件和主要出血事件的发生率差异均无统计学意义。结论:对急性STEMI患者急诊介入治疗时,冠脉内应用小剂量替罗非班可以获得较好的即刻造影结果,且安全、有效。     

Effects of intracoronary injection of acetylcholine on coronary collateral circulation

To clarify the effect of intracoronary injection of acetylcholine on coronary collateral circulation, acetylcholine (20 and 50 μg) was injected directly into the donor artery of 5 patients with rest angina who had angiographically demonstrable collateral channels. Coronary spasm was defined as severe vasoconstriction (≥ 90% of luminal diameter) with chest pain and/or ischemic ST-segment changes. The intracoronary injection of acetylcholine induced spasm in all the 5 patients. The site of spasm was collateral vessels in 3, and the recipient coronary artery in 2 of the 5 patients. The spasm resolved spontaneously without administration of nitroglycerin. The contralateral intracoronary injection of acetylcholine also induced diffuse coronary spasm in 4 patients. These findings indicate that collateral vessels and recipient coronary arteries of the collateral circulation are susceptible to acetylcholine. Impaired relaxation and vasospastic responses to acetylcholine presumably due to endothelial dysfunction in the collateral and recipient coronary vessels may explain, at least in part, myocardial ischemia in patients with a well-developed collateral circulation. © 1993 Wiley-Liss, Inc.     

Precordial ST-segment elevation in acute occlusion of the proximal right coronary artery

Isolated right ventricular myocardial infarction (RVMI) rarely occurs and accounts for only 3% of all myocardial infarction cases. In the literature, there are several reported isolated RVMI cases with precordial ST-segment elevation. We describe a 45-year-old man with marked ST-segment elevations in leads V1 through V4 accompanied by slight ST-segment elevations in the inferior leads (III, aVF) caused by acute occlusion of a nondominant small right coronary artery proximal to the conus branch causing isolated RVMI.     

急性ST段抬高型心肌梗死直接冠脉成形术ST段变化的临床价值

目的探讨急性ST段抬高型心肌梗死患者行直接冠脉成形术,术前和术后ST段变化对远期心血管事件的临床预测价值。方法对54例ST段抬高型心肌梗死患者行直接冠脉成形术,观察术前和术后1h心电图ST段变化,计算ST段回落指数。对所有患者随访12个月,观察12个月内心血管事件（猝死、心肌梗死、再狭窄、再次血管重建、慢性心衰）发生情况。对ST段回落指数和随访心血管事件行ROC分析,并通过COX比例风险模型多因素回归分析ST段回落指数对12个月终点事件的独立预测价值。结果在12个月的随访中,发生心源性死亡2例,再发心绞痛4例,慢性心衰7例。ST段回落指数临界点取63％时,对目标心脏事件预测的ROC曲线下面积0．843,灵敏度76．9％,特异度78．0％。COX比例风险模型多因素回归分析显示ST段回落指数对目标终点事件具有独立预测价值。结论急性ST段抬高型心肌梗死患者行直接PCI术,术前和术后ST段的变化即ST段回落指数对术后12个月预后具有独立预测价值。     

Safety and efficacy of antiplatelet and antithrombotic therapy in acute coronary syndrome patients with chronic kidney disease

Chronic kidney disease (CKD) is prevalent and affects an ever-increasing proportion of patients presenting with acute coronary syndrome (ACS). Patients with CKD have a higher risk of ACS and significantly higher mortality, and are also predisposed to increased bleeding complications. Antiplatelet and antithrombotic drugs form the bedrock of management of patients with ACS. Most randomized trials of these drugs exclude patients with CKD, and current guidelines for management of these patients are largely based on these trials. We aim to review the safety and efficacy of these drugs in patients with CKD presenting with ACS.     

急性ST段抬高心肌梗死患者急诊经皮冠状动脉介入治疗无复流现象相关因素分析

目的探讨急性ST段抬高心肌梗死（STEMI）患者急诊经皮冠状动脉介入治疗（PCI）中出现无复流的相关危险因素。方法选取发病在12h内的1059例STEMI患者给予急诊PCI,收集患者的临床、造影和介入治疗资料。PCI术后,根据心肌梗死溶栓（TIMI）分级和校正TIMI帧数将患者分为正常血流组和无复流组。比较两组患者的基本临床资料、造影结果和手术相关资料的差异,分析STEMI患者急诊PCI术中出现无复流的原因。结果急诊PCI术中无复流组患者118例。正常血流组941例,无复流发生率为11．14％。研究共纳入63个指标,通过单变量分析发现,年龄、症状至PCI时间、谷草转氨酶、氯吡格雷使用情况、干预病变数、狭窄程度及血栓负荷与急诊PCI术中发生无复流具有相关性（P〈0．05）。多变量Logistic回归模型认为,年龄（OR=1．04,95％CI：1．02—1．06）与血栓负荷（OR=1．72,95％CI：1．07～2．76）可作为预测急诊PCI术中无复流发生的独立危险因素。结论年龄与血栓负荷可作为预测急性STEMI患者急诊PCI术中发生无复流的独立危险因素,而糖尿病、高血压、高血脂、吸烟等冠心病的传统危险因素与无复流未见相关性。     

准分子激光冠脉消融术在急性ST段抬高型心肌梗死直接经皮冠脉介入治疗中的应用

目的评价准分子激光冠脉消融术(ELCA)在富含血栓的急性ST段抬高型心肌梗死(STEMI)直接经皮冠状动脉介入治疗(PCI)中应用的有效性和安全性。方法 2016年11月至2018年2月锦州医科大学北部战区总医院连续纳入25例富含血栓的STEMI患者,分成单纯球囊扩张成形术和(或)支架术(对照组n=13)和辅助的ELCA治疗组(ELCA组n=12),采用冠脉造影或冠状动脉定量测量(QCA)评估TIMI血流、TIMI血栓分级、校正的TIMI帧数(CTFC)、最小血管腔直径(MLD)和直径狭窄程度(DS),主要观察终点为手术即刻成功率和临床成功率。结果与对照组相比,ELCA组左心室射血分数更低[(49.0±11)%比(61.2±7.9)%,P=0.006],其他一般资料包括生活习性、既往史和冠脉造影指标,差异均无统计学意义(P>0.05)。PCI相关指标中,除球囊预扩张指标(P=0.022)外,其余差异均无统计学意义(P>0.05)。ELCA组手术即刻成功率为100%,术中未观察到无复流、夹层、冠脉穿孔等并发症,对照组发生慢血流2例,无复流1例,手术即刻成功率76.9%。采用CTFC评价系统评估术前和术后即刻冠脉灌注血流情况,ELCA组由(67.81±16.5)帧减少至(34.63±14.7)帧,对照组(55.77±12.10)帧减少至(39.54±12.54)帧,二者差异有统计学意义(P<0.05),两组MLD和DS差异无统计学意义(P>0.05)。住院期间及6个月随访期间,ELCA组无MACE事件发生,对照组发生MACE事件2例(因心衰再次住院)。结论 ELCA应用于富含血栓的STEMI直接PCI可提高心外膜血流,改善心肌灌注,减少慢血流或无复流风险,具有较高的即刻成功率和临床成功率,可作为急性心肌梗死直接PCI的辅助治疗手段。     

Temporal Trends in the Clinical Acuity of Patients with ST-Segment Elevation Myocardial Infarction

Background

Despite advances in ST-segment elevation myocardial infarction (STEMI) systems of care over the last decade, studies have shown no improvement in risk-adjusted mortality. It has been hypothesized that the population presenting to the catheterization laboratory has become sicker over time, in ways not accurately captured by current mortality models. The objective of this study was to examine changes in the clinical characteristics and in-hospital case fatality rate of the STEMI population treated with early percutaneous coronary intervention (PCI).

A multicentre retrospective study to understand anti-platelet treatment patterns and outcomes of acute coronary syndrome patients in India (TRACE)

Background

There is limited available information for treatment of acute coronary syndrome (ACS) with respect to outcomes, therapeutic agents and treatment practices. Our retrospective registry study collected and evaluated varying anti-platelet treatment strategies and outcomes of ACS patients who were admitted to 9 different tertiary care hospitals in India. This study was carried out to provide an insight to anti-platelet treatment patterns and analyze outcomes of ACS patients in India.

Methods

All the relevant data, including anti-platelet treatment strategies, outcomes and patient treatment compliance were collected from 500 ACS (defined as STEMI, NSTEMI and unstable angina [UA]) cases from January 2007 to December 2009. These ACS cases were randomly collected from the hospital records and included in the analysis. The patient follow up data was acquired either from the hospital records or via telephonic contact for a period of one year following the event.

Results

Out of 500 ACS patients, 59.8% had UA/NSTEMI and 40.2% had STEMI. On hospital admission, aspirin, clopidogrel, statins, beta-blockers and angiotensin converting enzyme inhibitors (ACE-Is) were used by 83%, 83%, 68%, 43.2% and 31.6% patients, respectively. On discharge, aspirin, clopidogrel, statins and beta-blockers were used by 90.2%, 88%, 80.6%, and 59% patients, respectively. The average patient compliance to statins, clopidogrel and aspirin was recorded as 74.28%, 69.7% and 68.66%, respectively during discharge and follow-up visits. Greater than 50% of ACS patients after discharge were lost to follow-up and as a result there was significant drop in the number of clinical events reported.

Conclusion

This pilot study conducted in tertiary care centers in India showed that patients with ACS were more often diagnosed with UA/NSTEMI as compared to STEMI and reported maximum compliance to statins, clopidogrel and aspirin after discharge over 1 year follow-up. More ACS patients were lost to follow up that resulted in low reporting of clinical outcomes, following discharge upto 1 year.