初发急性心肌梗死患者二尖瓣返流的发生率及预后——单中心6年回顾性研究

目的:探讨初发急性心肌梗死(AMI)患者缺血性二尖瓣返流的发生率及其对患者住院期间死亡及出院患者远期预后的影响. 方法:回顾性入选2000年1月至2006年1月间入院治疗的初发AMI患者,根据住院期间心脏超声检查结果,将患者分为二尖瓣无返流组、轻度、轻-中度、中-重度返流组,随访患者的远期预后.结果:在448例AMI患者中,急性期院内死亡者24例.住院期间心超结果发现二尖瓣返流发生率为67.2%,其中轻度返流为51.1%、轻-中度为9.4%、中一重度为6.7%.门诊或电话随访到患者268例(59.8%),平均随访(33.8±19.6)月,共发生死亡37例(13.8%),其中心源性死亡19例(7.1%),非心源性死亡18例(6.8%).经多因素回归分析,死亡与二尖瓣返流的严重程度呈正相关(RR=1.504,95%CI:1.002～2.256,P=0.049),心源性死亡与缺血性二尖瓣返流显著正相关(RR=3.088,95%CI:1.767～5.395,P<0.001),均独立于入院时心功能分级(NYHA)、左室射血分数及有无靶血管重建. 结论:缺血性二尖瓣返流在初发AMI患者中有较高的发生率,其对预测AMI患者的远期死亡有意义,建议纳入AMI预后的危险分层,指导今后的临床治疗.     

急性心肌梗死后二尖瓣返流与心房纤颤的关系

目的:探讨急性心肌梗死（AMI）后缺血性二尖瓣返流与初发心房纤颤（atrial fibrillation,AF）的关系。方法: 回顾性分析269例AMI患者的临床资料,排除既往有AF和原发瓣膜病的病例,根据二尖瓣返流程度分为2组:无返流组（n=165）和返流组(n=104)。AF通过住院期间心电图或心电监护诊断。结果: 无返流组和返流组新发AF分别为15例(9.1%)和22例(21.2%)(P<0.01)。结论: AMI后二尖瓣返流与AF发生有密切的关系。     

急性心肌梗死并缺血性二尖瓣返流的临床特征分析

目的：探讨初发急性心肌梗死并缺血性二尖瓣返流（IMR）的临床特征。方法：对初发AMI363例患者的临床资料进行回顾性分析,根据心脏超声检查和二尖瓣返流情况分为2组,二尖瓣返流组119例,无二尖瓣返流组244例,比较2组临床特征、左房直径、左室舒张末期直径、左室收缩末期直径、左室射血分数和心血管事件发生率。结果：单因素分析结果显示年龄、性别、吸烟、Killip分级、下壁心肌梗死、β受体阻滞剂和ACEI/ARB应用、直接冠状动脉介入治疗、主动脉内球囊反搏应用、左房直径、左室舒张末期直径、左室收缩末期直径、左室射血分数、房颤发生率及住院病死率2组资料比较差异有统计学意义。多因素分析显示二尖瓣返流与年龄（P〈0.01）、左室舒张末期直径、左室收缩末期直径（P〈0.05）及早使用β受体阻滞剂和ACEI/ARB、直接冠状动脉介入治疗密切相关（P〈0.01）。结论：AMI并IMR多见于老年患者,与左室直径大小密切相关,及早应用β受体阻滞剂和ACEI/ARB,直接冠脉介入治疗可能会减少二尖瓣返流的发生。     

二尖瓣成形环瓣环环缩术在缺血性二尖瓣返流中的应用

目的 研究应用二尖瓣成形环行瓣环环缩术治疗缺血性二尖瓣返流的手术效果。方法 选择2000年1月~2015年12月在我院行二尖瓣成形术的缺血性二尖瓣返流并发室壁瘤的患者72例,根据二尖瓣病变部位及性质选择成形方案,其中33例使用二尖瓣成形环进行瓣环环缩术。回顾性分析手术的近期、远期治疗效果。结果 围手术期死亡4例（6%）。术后二尖瓣返流程度较术前明显改善,中度及中度以上二尖瓣返流1例（1%）。术后随访(5±3)年,随访期死亡11例（16%）,出现中度及中度以上二尖瓣返流12例（18%）。是否使用成形环进行瓣环环缩术后早期二尖瓣返流程度无统计学差异,但远期成形环环缩组较对照组二尖瓣返流程度有显著改善（P<0.05）。结论 缺血性二尖瓣返流并发室壁瘤的患者中,二尖瓣成形术可安全、有效地重建二尖瓣功能。使用成形环进行瓣环环缩可改善远期效果。     

再发心肌梗死的危险因素及对短期预后的影响

目的探讨再发急性心肌梗死（AMI）的危险因素及对短期预后的影响。方法连续入选2006年1月至2010年12）1在北京大学人民医院住院治疗的AMI患者1447例。根据病史分为初发AMI组（n=1268）和再发AMI组（n=179）。记录患者性别、年龄、心血管相关危险因素、人院时心功能、心肌梗死类型、冠状动脉造影结果、住院期间死亡率、入院24h内的血脂、空腹血糖、血清肌酐等,并用logisticN归模型探寻再发AMI的危险因素。结果与初发AMI患者相比,再发AMI患者年龄较大,合并糖尿病的比例高。同时患者人院时心功能差,冠状动脉病变程度重。Logistic回归分析结果显示,年龄（OR1．03,95％CI：1．01～1．04,P〈0．01）、糖尿病（OR2．10,95％CI：1．51～2．91,P〈0．01）、吸烟（0R1．76,95％CI：1．20～2．57,P〈0．01）、血清肌酐水平（OR1．003,95％CI：1．001～1．004,P〈0．01）是再发AMI的独立危险因素。与初发AMI患者相比,再发AMI患者住院期间全因死亡率及心源性死亡率有升高趋势,但差异无统计学意义。结论年龄、糖尿病、吸烟、血清肌酐水平是再发AMI的独立危险因素。再发AMI患者住院期间短期死亡率并不明显增加。     

进口与国产药物洗脱支架治疗急性ST段抬高心肌梗死的预后分析

目的 进口和国产药物洗脱支架（DES）治疗急性ST段抬高心肌梗死（STEMI）的住院期间与远期预后比较.方法 连续入选2009年1月至2010年8月的197例确诊急性STEMI并行冠状动脉介入治疗的患者,按照支架的类型分为国产DES组和进口DES组,比较两组住院期间和长期心脑血管事件发生率.结果 国产DES组共113例（57.4％）,进口DES组84例（42.6％）,两组住院期间全因死亡率（2.7％比4.8％,P=0.515）、严重心力衰竭发生率（2.7％比0,P=0.053）、恶性心律失常发生率（10.6％比3.6％,P=0.098）差异均无统计学意义;两组患者随访中位数41个月,随访期内两组的无事件生存率分别为91.5％和90.9％ （P=0.885）.多因素分析显示,高龄（HR=1.872,95％ CI：1.008～2.118,P=0.023）、高血压史（HR=6.018,95％ CI：1.307～21.716,P=0.021）、脑血管病史（HR=4.995,95％ CI：1.536～16.242,P=0.008）、心功能Killip分级（HR=3.947,95％ CI：1.809～8.612,P=0.001）、高尿酸血症（HR=1.006,95％ CI：1.003～1.010,P＜0.001）是患者远期发生全因死亡、非致死性心肌梗死、再次血运重建、严重心力衰竭、脑血管病的独立危险因素.结论 急性STEMI患者,应用国产与进口DES住院期间及远期预后差异无统计学意义.     

二尖瓣成形和置换术治疗室壁瘤合并缺血性二尖瓣返流的对比研究

目的比较二尖瓣成形术或二尖瓣置换术治疗合并室壁瘤的缺血性二尖瓣返流的围手术期及远期疗效。方法纳入2009年7月~2015年12月于中国医学科学院阜外医院因缺血性二尖瓣返流合并室壁瘤患者行二尖瓣手术者49例。按手术方式分为二尖瓣置换组9例,二尖瓣成形组40例。对上述病例的资料进行回顾性分析,并随访(3.1±2.0)年。结果两组围手术期死亡无统计学差异(P=0.569)。两组出院前二尖瓣返流情况、左室射血分数(LVEF)、左室舒张末径(LVEDD)均较术前显著改善。二尖瓣成形组LVEF高于置换组(P=0.016)。随访期死亡3例。成形组远期二尖瓣返流高于置换组(P=0.020)。末次随访时,两组LVEF、LVEDD均无统计学差异(P=0.981、0.596)。结论在合并室壁瘤的缺血性二尖瓣返流患者中,二尖瓣置换术与成形术手术风险相似。二尖瓣成形存在远期返流复发的风险,但远期生存及心功能无显著差异。     

老年急性心肌梗死患者红细胞分布宽度与预后的关系

目的研究老年急性心肌梗死（AMI）患者红细胞分布宽度（RDW）与预后的相关性。方法选取老年AMI患者204例,按RDW≥13．8％和〈13．7％分组。住院期间检测N-末端脑钠肽前体（NT-proBNP）浓度,测量左心室射血分数（LVEF）,观察Killip分级、主要不良心血管事件（MACE）发生率和住院心源性死亡率。结果RDW升高组的NT—proBNP显著升高,心力衰竭（HF）（Killip分级2～4级）、MACE发生率及心源性死亡率明显高于RDW正常组（P〈0．05）,而LVEF显著降低（P〈0．05）。结论老年AMI患者RDW升高,预后差,HF、MACE、心源性死亡率高。     

血清肌酐水平对急性心肌梗死患者预后的影响

目的评估血清肌酐增高对急性心肌梗死（AMI）患者临床及预后的影响。方法分析因AMI住院患者共340例,分为肌酐正常组269例,高肌酐组71例,随诊1年,观察并比较两组患者心源性休克、心力衰竭、心室颤动、Ⅲ度房室传导阻滞及30d病死率、住院病死率、随诊1年病死率的差异。结果高肌酐组患者年龄大、心肌梗死病史多;心源性休克、心力衰竭、心室颤动、Ⅲ度房室传导阻滞的发生率明显增加（P值分别为0．003、0．031、0．000、0．001）,30d病死率（32．39％比4．83％,P=0．000）、住院病死率（35．21％比5．20％,P=0．000）、1年病死率（43．66％比11．15％,P=0．000）都明显增高。Cox回归分析结果提示血清肌酐是30d死亡的独立危险因素（OR=4．591,95％CI2．149～9．808,P=0．000）,也是AMI1年死亡的独立危险因素（OR=3．936,95％CI2．264～6．845,P=0．000）。结论AMI患者血清肌酐水平增高30d病死率、住院病死率及1年病死率均明显增加;高血清肌酐是AMI预后的独立危险因素。     

动态心电图在心力衰竭患者预后中的预测价值

目的探讨动态心电图（AECG）在心力衰竭患者预后中的价值。方法本研究回顾性分析了心功能不全患者78例，每例患者都有完整的临床资料和AECG资料并进行了随访。采用多元Logistic回归模型建立回归方程进行危险因素的筛选。结果在132例患者中，死亡21人。在多元Logistic回归模型中，心力衰竭的危险因素包括年龄（RR：1．02；95％CI：1．01～1．03）、低射血分数（RR：0．963；95％CI：0．948～0．982）、心率过快（RR：1．05；95％CI：1．04～1．07）、心率范围较小（RR：0．973；95％CI：0．961～0．984）、阵发性房颤（RR：1．21；95％CI：1．15～1．28）和非持续性室速（RR：1．31；95％CI：1．22～1．37）。结论AECG所监测的心率范围、阵发性房颤以及非持续性室速是心力衰竭患者死亡的危险因素。因此，AECG在心力衰竭患者的预后中有参考价值。     

Ischemic mitral regurgitation and risk of heart failure after myocardial infarction

BACKGROUND: The development of ischemic mitral regurgitation (MR) after myocardial infarction may impose hemodynamic load during a period of active left ventricular remodeling and promote heart failure (HF). However, few data are available on the relationship between ischemic MR and the long-term risk for HF. METHODS: We prospectively studied 1190 patients admitted for acute myocardial infarction. Mitral regurgitation was assessed by echocardiography and was considered mild, moderate, and severe when the regurgitant jet area occupied less than 20%, 20% to 40%, and greater than 40% of the left atrial area, respectively. The median duration of follow-up was 24 months (range, 6-48 months). RESULTS: Mild and moderate or severe ischemic MR was present in 39.7% and 6.3% of patients, respectively. After adjusting for ejection fraction and clinical variables (age, sex, Killip class, previous infarction, hypertension, diabetes mellitus, anterior infarction, ST-elevation infarction, and coronary revascularization), compared with patients without MR, the hazard ratios for HF were 2.8 (95% confidence interval [CI], 1.8-4.2; P<.001) and 3.6 (95% CI, 2.0-6.4; P<.001) in patients with mild and moderate or severe ischemic MR, respectively. The adjusted hazard ratios for death were 1.2 (95% CI, 0.8-1.8; P = .43) and 2.0 (95% CI, 1.2-3.4; P = .02) in patients with mild and moderate or severe MR, respectively. CONCLUSIONS: There is a graded independent association between the severity of ischemic MR and the development of HF after myocardial infarction. Even mild ischemic MR is associated with an increase in the risk of HF.     

Prognostic significance of mild mitral regurgitation by color Doppler echocardiography in acute myocardial infarction

Mitral regurgitation (MR) complicating acute myocardial infarction (AMI) is associated with increased mortality. The prognostic significance of only mild MR detected by echocardiography in patients with AMI is unknown. This study assessed the long-term risk associated with mild MR detected by color Doppler echocardiography within the first 48 hours of admission in 417 consecutive patients with AMI. No MR was detected in 271 patients (65%), mild MR was seen in 121 patients (29%), and moderate or severe MR was noted in 25 patients (6%). One-year mortality rates were 4.8%, 12.4%, and 24%, respectively (p<0.001). Multivariate analysis revealed that mild MR was independently associated with increased 1-year mortality (p<0.05) after adjustment for age, gender, previous myocardial infarction, diabetes mellitus, systemic hypertension, Killip grade > or =2 on admission, and left ventricular ejection fraction < or =40%. The hazard ratio for 1-year mortality was 2.31 (95% confidence interval 1.03 to 5.20) for mild MR and 2.85 (95% confidence interval 0.95 to 8.51) for moderate or severe MR. Thus, mild MR detected by color Doppler echocardiography within the first 2 days of admission in patients with AMI is a significant independent risk predictor for 1-year all-cause mortality.     

二尖瓣反流对急性心肌梗死预后的意义

目的　探讨二尖瓣反流 (MR)对急性心肌梗死 (AMI)患者预后的意义。方法　对 142例 AMI患者住院早期(7天内 )进行超声心动图检查 ,以彩色多普勒定量测定其 MR。并对 MR组及无 MR组的临床资料、超声心动图指标及预后进行对比分析。结果　 142例 AMI患者无 MR90例 (6 3.38%) ,轻度 MR43例 (30 .2 8%) ,中、重度 MR9例 (6 .34 %)。 MR组较无 MR组患者年龄更大、既往心肌梗死患病率及高血压患病率更高 (P均 <0 .0 5 )。 MR组脉冲多普勒 E峰、E/A显著高于无 MR组 (P均 <0 .0 5 )。 MR组 30天及 1年死亡率均显著高于无 MR组 (P<0 .0 5和 P<0 .0 1)。结论　超声心动图证实的 MR对 AMI患者的预后具有预测价值。     

The prognostic role of mitral regurgitation after primary percutaneous coronary intervention for acute ST-Elevation myocardial infarction

Objectives : The aim of this study was to elucidate the prognostic significance of mitral regurgitation (MR) after primary percutaneous coronary intervention (PCI) for acute ST‐elevation myocardial infarction (STEMI). Background : MR has prognostic implications after myocardial infarction (MI). However, for STEMI patients receiving primary PCI, the influence of MR on long‐term (3–5 years) outcome is unknown. Methods : We examined 888 STEMI patients receiving primary PCI enrolled in a prospective database at a regional STEMI center, who had an echocardiogram within 72 hr following successful primary PCI. MR was graded by color Doppler as none/trace vs. mild vs. moderate/severe. Mean ± SD follow‐up was 3.1 ± 1.4 years. Results : For patients with none/trace (n = 469), mild (n = 325), and moderate/severe (n = 94) MR, mortality at 3 years was 8.1%, 13.6%, and 25.7% and at 5 years was 12.7%, 18.3%, and 33.5%, respectively (P < 0.0001, log‐rank test). Patients with moderate/severe MR tended to be older (P < 0.0001) with lower ejection fraction (P < 0.0001) and were less likely to have had an anterior MI (P < 0.001). Independent predictors of mortality included age, creatinine, and heart rate. Conclusions : Following primary PCI for STEMI, echocardiographic detected MR in the first 72 hr following PCI stratifies mortality risk. However, when accounting for age, MR is not an independent predictor of mortality. © 2011 Wiley Periodicals, Inc.     

急性心肌梗死早期伴发二尖瓣关闭不全对患者预后影响

目的:探讨急性心肌梗死(AMI)患者伴发二尖瓣关闭不全(MR)的临床意义及预后。方法:将2年来我院收治的AMI患者145例分为MR组与no-MR组;根据梗死部位分为前壁AMI组与下壁AMI组,前、下壁各组又根据是否伴发MR分为:前壁MR组与前壁no-MR,下壁MR组与下壁no-MR组4个亚组。观察各组的临床情况与心血管事件。结果:MR组63例,占43.4%,与no-MR组相比,其年龄、左心室射血分数、终点心血管事件及随访期间心血管事件均差异具有统计学意义(P<0.05)。亚组间相比,前壁AMI-MR组与下壁AMI-MR组与相应的no-MR组比较终点心血管事件差异具有统计学意义,且该2组间随访期间临床心血管事件差异具有统计学意义(P<0.05);下壁AMI-MR组与no-MR组2组间的终点心血管事件差异具有统计学意义(P<0.05)。结论:AMI患者伴发MR提示预后不良,AMI患者伴有MR与梗死部位有关,且其部位与预后密切相关。     

Long-term outcomes of patients with mitral regurgitation undergoing percutaneous coronary intervention

The most appropriate treatment for patients with ischemic mitral regurgitation (MR) remains controversial. MR has prognostic importance in patients after myocardial infarction and those undergoing coronary artery bypass surgery, but the long-term outcomes after percutaneous coronary intervention (PCI) are less well defined. We evaluated patients who underwent PCI and had assessment of MR by left ventriculography and/or echocardiography in the year 2000. We determined effects of MR on 30-day and 5-year survival. The cohort included 711 patients (67% men) with an average age of 64.5 +/- 12.4 years. MR severity was divided into 3 strata: none (n = 420, 59%), mild (n = 209, 29%), and moderate to severe (n = 82, 12%). Patients with more severe MR differed from patients with mild or no MR in that they were older (p <0.001), more frequently women (p <0.001), and more likely to have a coronary artery bypass graft (p <0.001), myocardial infarction (p <0.001), and lower ejection fraction (p <0.001). Decreased survival rates were associated with increasing MR severity (none vs mild vs moderate to severe) at 30 days (100%, 98.7%, and 96.6%, respectively; p <0.0025) and 5 years (97%, 83.3%, and 57.5%; p <0.0001). MR was an important independent predictor of survival (hazard ratio 1.57, p <0.0009). In conclusion, patients with ischemic MR undergoing PCI have significantly decreased survival rates at 5 years, and severity of MR is an independent predictor of survival.     

Significance of a mitral regurgitation systolic murmur complicating a first acute myocardial infarction in the coronary care unit--assessment by colour Doppler flow imaging.

To determine the prevalence and significance of a systolic mitral murmur heard after a first acute myocardial infarction (MI), we studied 186 consecutive patients in the coronary care unit (CCU) during a one-year period. Fifteen patients had a murmur as a result of mitral regurgitation (MR) (prevalence 8%) documented by colour Doppler flow imaging. It was heard before the third day of hospitalization in 10 (67%) patients, and on the third day itself in the remainder. The severity of MR was graded semi-quantitatively: moderate in 12 (80%) patients, and mild, moderate to severe and severe in three respectively. The direction of the MR jet, determined by colour flow imaging, improved the information obtained by two-dimensional echocardiography (2D echo) that could only diagnose mitral leaflet abnormality in seven (47%) patients. In 10 of 15 (67%) patients, the 2D echo ejection fraction was greater than or equal to 40% and in eight (53%) the wall motion score obtained by analysing 11 left ventricular (LV) segments was less than or equal to 8. Two (13%) patients died in the CCU, four (27%) had LV failure, one angina and eight (53%) remained asymptomatic in the hospital. Of 171 patients without a systolic murmur, 22 (13%) had LV failure, 13 (8%) angina and 25 (15%) died during the in-hospital stay (P-NS for these complications between patients with and without MR murmur). During a follow-up of 12-24 months, one MR patient died, and seven (47%) remained asymptomatic. We conclude that the prevalence of MR systolic murmurs in acute MI patients is low.(ABSTRACT TRUNCATED AT 250 WORDS)     

Mitral regurgitation is an independent predictor of 1-year mortality in ST-elevation myocardial infarction patients presenting in cardiogenic shock on admission.

Abstract

Background: Cardiogenic shock (CS) remains the most serious complication of acute ST-elevation myocardial infarction (STEMI). Mitral regurgitation (MR) is a frequent complication of STEMI and a well-known predictor of mortality in STEMI without CS. The purpose of this study was to determine the prognostic significance of MR in STEMI patients with CS on admission. Methods: Mitral regurgitation was assessed in 147 consecutive STEMI patients with CS on admission and treated by primary percutaneous coronary intervention (PCI). Color Doppler of MR was graded with a 0 to 3 scale (none, n = 26; 1 = mild, n = 62; 2 = moderate, n = 40; 3 = severe, n = 19). Results: Overall one-year mortality in the study cohort was 27%. One-year mortality was 8%, 23%, 30% and 58% for patients with no, mild, moderate and severe MR respectively (P <0.001). For each grade of MR increase, the odds for mortality increased with 71% (OR: 1.71; 95% CI: 1.02–2.87; P = 0.043) when adjusted for age, gender, previous myocardial infarction, left ventricular ejection fraction (LVEF) <40%, multivessel disease and no-reflow. Conclusions: The presence of MR on early echocardiography is an important independent predictor of one-year mortality in STEMI patients with CS on admission treated by primary PCI.     

Importance of mitral regurgitation inpatients undergoing percutaneous coronary intervention for acute myocardial infarction: the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial

OBJECTIVES: We sought to determine the prognostic importance of mitral regurgitation (MR) in patients undergoing percutaneous coronary intervention for acute myocardial infarction (AMI). BACKGROUND: Mitral regurgitation has been associated with a poor prognosis in patients treated with thrombolytic therapy for AMI. The prognostic significance of MR in patients undergoing mechanical reperfusion therapy for AMI is unknown. METHODS: Left ventriculography was performed during the index procedure in 1,976 (95%) of 2,082 non-shock patients enrolled in a prospective, multicenter, randomized trial of mechanical reperfusion strategies in AMI. The severity of operator-assessed MR was divided into four strata: none (n = 1,726), mild (n = 192), and moderate/severe (n = 58). RESULTS: Patients with progressively more severe MR were older (p < 0.0001), were more often women (p < 0.0001), and had higher Killip class (p = 0.0007). More severe grades of MR correlated with triple-vessel disease (p < 0.0001) and lower left ventricular ejection fraction (LVEF) as measured during the index procedure (p = 0.0004). Increasingly severe MR was strongly associated with a higher mortality at 30 days (1.4% vs. 3.7% vs. 8.6%, respectively; p < 0.0001) and at one year (2.9%, 8.5%, 20.8%, respectively; p < 0.0001). By multivariate analysis, the presence of even mild MR was an independent predictor of long-term mortality (mild MR, relative risk [RR] = 2.40, p = 0.005; moderate/severe MR, RR = 2.82, p = 0.006). CONCLUSIONS: Mitral regurgitation of any degree present on the baseline left ventriculogram during the index procedure is a powerful, independent predictor of mortality in patients undergoing mechanical reperfusion therapy for AMI. The presence of MR identifies high-risk patients in whom close out-patient follow-up is warranted, and who may benefit from aggressive adjunctive medical or surgical therapies.