老年急性心肌梗死患者住院死亡危险因素分析

目的探讨入院时影响老年急性心肌梗死(AMI)患者住院病死率的危险因素。方法选取因AMI收住的356例老年患者为研究对象。分析病死组(45例)与存活组(311例)患者的临床特征、实验室化验指标、心血管并发症(心源性休克、心力衰竭、室速/室颤),以Logistic多因素逐步回归分析影响老年AMI患者住院病死率的相关因素。结果单因素分析显示:年龄、糖尿病史、陈旧性MI病史、脑卒中病史、肾功能不全、贫血、首发症状呼吸困难、并发心源性休克、心力衰竭、室速/室颤,入院时血清肌酐升高、肾小球滤过率(eGFR)及血红蛋白减低、肌酸激酶及其同工酶峰值水平与老年AMI患者住院病死率相关(均P0.05)。多因素分析显示:年龄、糖尿病史、陈旧性MI病史,并发心源性休克、心力衰竭、室速/室颤,入院时eGFR水平是影响老年AMI患者住院病死率的独立危险因素(均P0.05)。结论年龄、糖尿病及陈旧性MI病史、发生心血管并发症、入院时eGFR水平是影响老年AMI患者住院病死率的独立危险因素。     

In-hospital mortality after acute myocardial infarction in patients with diabetes mellitus.

OBJECTIVES: To examine in-hospital mortality after acute myocardial infarction in patients with diabetes mellitus. METHODS: All patients in an 800-bed teaching hospital who had a discharge diagnosis of myocardial infarction, verified by creatine kinase levels at admission, between 1991 and 1993 made up the study population. All 118 such patients who died during this period made up the case group. Two control subjects (n = 236), survivors of the hospitalization, matched by sex, age, and length of hospitalization, were selected randomly for each case. Information on the presence of diabetes mellitus, medical history, and data related to myocardial infarction were obtained through retrospective chart review. RESULTS: The mean age of all subjects in the study was 76 years. Thirty-three percent of the patients in the case group and 31% of the control subjects had a history of diabetes mellitus (odds ratio = 1.04; 95% CI, 0.64-1.70), indicating that diabetes mellitus was not associated with an increased risk of in-hospital death. The adjusted odds ratio was 1.10 (95% CI, 0.48-2.51) in patients with non-insulin-treated diabetes mellitus and 0.80 (95% CI, 0.34-1.86) in insulin-treated patients. Multivariate analysis, with conditional logistic regression, confirmed that known prognostic factors for myocardial infarction, rather than diabetic status, are predictive of in-hospital mortality. CONCLUSIONS: Once the effects of age are accounted for, the risk of in-hospital mortality is not greater in patients with diabetes mellitus than in patients without diabetes; however, diabetes mellitus may be an important factor for long-term survival.     

Insulin worsens ischemia-induced myocardial contracture in the isolated rat heart

We used a modification of Langendorff's isolated perfused nonworking rat-heart model to study the effects of diabetes, insulin-treated diabetes, and hyperinsulinemia on left ventricular pressure, force of ventricular contraction, and myocardial contracture, before, during, and after 20 min of complete normothermic global ischemia. Untreated diabetic rat hearts behaved the same as normal hearts, but insulin-treated diabetic hearts had more ischemic and postischemic contracture (p less than .01), and less return of left ventricular function. Chronic insulin treatment potentiated ischemic contracture in diabetic and nondiabetic rat hearts. These results support the hypotheses that insulin can increase Ca++ actin-myosin ATPase activity, and increase the affinity of myofibrillar receptors for calcium, which may lead to increased ischemic contracture. Insulin as a risk factor in myocardial ischemia, cardiothoracic surgery and cardiac resuscitation, and other pathogenetic factors of "stone heart" development, deserve further investigation.     

二维超声心动图诊断首次急性心肌梗死后室壁运动情况的价值探讨

目的 探讨首次急性心肌梗死(AMI)患者出院前二维超声心动图检查对长期预后危险度分层的价值.方法 281例首次AMI患者出院前常规进行二维彩色超声心动图检查,并对患者进行2～10年随访,平均随访5.5年.结果 281例患者有室壁运动异常者152例(54.1%),其中室壁瘤49例,无室壁瘤的室壁运动异常者103例.室壁运动正常者为127例.患者出院后发生再梗死78例,充血性心衰64例,心源性死亡31例.室壁瘤组患者长期预后发生再梗死26例,充血性心衰23例,心源性死亡9例.该组患者的预后明显较有无室壁瘤的室壁运动异常组和室壁运动正常者组更差,差异具有统计学意义.结论 严重室壁运动异常(室壁瘤)是影响AMI长期预后主要因素.出院前二维超声心动图检查对AMI长期预后危险分层具有实际意义.     

The impact of comorbidities on stroke prophylaxis strategies in atrial fibrillation patients

Arial fibrillation (AF) is the most commonly occurring sustained arrhythmia in the United States and is associated with increased mortality. AF is a risk factor for ischemic stroke, and risk factors for AF include comorbid conditions such as congestive heart failure, diabetes mellitus, older age, hypertension, diabetes, pulmonary disease, and history of stroke, transient ischemic attack, or heart failure. Risk stratification for ischemic stroke in AF patients is based on scoring a group of risk factors that allows for the appropriate tailoring of antithrombotic therapy. The vitamin K antagonists are effective at reducing ischemic stroke rates in medium-risk to high-risk patients and are therefore generally recommended for this group. However, a large proportion of these patients are not treated with vitamin K antagonists because of the potential for adverse outcomes, particularly in elderly patients. New direct thrombin inhibitors and direct Factor Xa inhibitors in development offer the possibility of simplifying treatment and management although offering similar or better efficacy and safety profiles to warfarin. In light of these potential new treatments, the importance and improvement of risk stratification methods and the resulting recommendations in thromboprophylaxis become even more paramount as they make it more likely that medium-risk to high-risk patients can be treated safely.     

利多卡因导致老年急性心肌梗死患者精神障碍相关因素分析

目的 探讨治疗量利多卡因导致急性心肌梗死老年人精神障碍的相关因素。方法 对使用治疗量利多卡因用于预防及治疗急性心肌梗死后室性心律失常老年患者128例进行回顾性调查分析,分为精神障碍组和非精神障碍组,对临床资料进行观察比较。结果 精神障碍组年龄明显高于非精神障碍组,且梗死范围、无痛性心梗发作次数、心功能及并发急性左心衰的发生率与非精神障碍组比较,有显著性差异(P<0.05或<0.01)。结论 精神障碍的发生与老年急性心肌梗死患者的年龄、病情严重程度及预后有关,精神障碍会使急性心肌梗死病情加重,提示在护理过程中要做好预见性护理,在预防室性心律失常的同时要注意预防利多卡因导致精神障碍的发生。     

Prospective evaluation of pulmonary edema

OBJECTIVES: To describe the clinical profile and hospital outcome of successive unselected patients with pulmonary edema hospitalized in an internal medicine department. DESIGN: Prospective, consecutive, unsolicited patients diagnosed with pulmonary edema. SETTING: An internal medicine department in a 900 tertiary care center. PATIENTS: A total of 150 consecutive unselected patients (90 males, 60 females; median age, 75 yrs). RESULTS: Ischemic heart disease, hypertension, various valvular lesions and diabetes mellitus were present in 85%, 70%, 53%, and 52% of patients, respectively. Acute myocardial infarction at admission was observed in 15% of patients. The most common precipitating factors associated with the development of pulmonary edema included: high blood pressure (29%), rapid atrial fibrillation (29%,) unstable angina pectoris (25%), infection (18%), and acute myocardial infarction (15%). Twenty-two patients (15%) were mechanically ventilated. Eighteen patients (12%) died while in the hospital, and the cause of death was cardiac pump failure in 82%. The median hospital stay was 10 days. Predictors for increase rate of in-hospital mortality included: diabetes (p<.05), orthopnea (p<.05), echocardiographic finding of moderate-to-severely depressed global left ventricular systolic function (p<.001), acute myocardial infarction during hospital stay (p<.001), hypotension/shock (p<.05), and the need for mechanical ventilation (p<.001). CONCLUSIONS: Most patients with pulmonary edema in the internal medicine department are elderly, having ischemic heart disease, hypertension, diabetes, and a previous history of pulmonary edema. The overall mortality is high (in-hospital, 12%) and the predictors associated with high in-hospital mortality are related to left ventricular myocardial function. The long median hospital stay (10 days) and the need for many cardiovascular drugs, impose a considerable cost in the management and health care of these patients.     

冠心病合并2型糖尿病患者脂代谢与冠脉病变相关性研究

目的探讨2型糖尿病合并冠心病患者脂代谢异常与冠状动脉病变的特点。方法将253例行冠脉造影的冠心病患者,分为糖尿病组和非糖尿病组,并进行心血管危险因素(性别、年龄、空腹血糖、血脂水平)的比较。其中97例型冠心病合并2糖尿病组患者,分为脂代谢异常和正常组,比较两组间的冠状动脉造影资料。结果糖尿病合并冠心病组TG值为2.7±20 mmol/L、LDL-C值为214±019 mmol/L,较非糖尿病冠心病组明显升高;HDL-C值为019±012 mmol/L,较非糖尿病冠心病组水平下降。血脂异常组多支病变(包括二支、三支病变)为27例(21.4%),较血脂正常组比例明显增高。Gensini积分为66.8±16.1,高于血脂正常组患者。结论糖尿病伴血脂异常与冠心病的关系密切,其中血脂异常和血脂正常者相比,血管病变的程度更重,范围更弥漫。     

国产替罗非班对糖尿病并急性ST段抬高心肌梗死经皮冠状动脉介入治疗后临床预后的影响

目的：探讨急诊经皮冠状动脉介入治疗术（PCI）中应用国产血小板糖蛋白Ⅱb／Ⅲa受体拮抗利替罗非班对糖尿病并ST段抬高急性心肌梗死（AMI）患者预后的影响。方法：97例首发ST段抬高AMI且有糖尿病病史并接受急诊PCI治疗成功的患者,按术中应用替罗非班与否,分为替罗非班治疗组（观察组,n=-47）;常规治疗组（对照组,n=50）。测量2组术后左心室舒张期末容积指数（LVEDVI）、左心室收缩期求容积指数（LVESVI）、左心室射血分数（LVEF）;观察术后梗死后心绞痛、心力衰竭、心源性休克及住院期间病死率发生情况。结果：与对照组比较,观察组术后3个月左心室容积减小,LVEDVI[（65．2±5．4）ml／m^2;（68．3±5．7）ml／m^2,P〈0．05．LVESVI[（31．5±4．2）ml／m^2：（35．6±3．7）ml／m^2,P〈0．05],LVEF升高[（0．52±0．04）％：（0．48±0．03）％．P〈0．05];梗死后心绞痛、心力衰竭、心源性休克发生率及住院期间病死率明显减低,比较差异有统计学意义（P〈0．05）。结论：急诊经皮冠状动脉介入治疗术中应用替罗非班可改善糖尿病并ST段抬高急性心肌梗死患者临床及预后。     

Is insulin an endogenous cardioprotector?

Stress hyperglycemia and diabetes mellitus with myocardial infarction are associated with increased risk for in-hospital mortality, congestive heart failure, or cardiogenic shock. Hyperglycemia triggers free radical generation and suppresses endothelial nitric oxide generation, and thus initiates and perpetuates inflammation. Conversely, insulin suppresses production of tumor necrosis factor-α and free radicals, enhances endothelial nitric oxide generation, and improves myocardial function. It is proposed that the balance between insulin and plasma glucose levels is critical to recovery and/or complications that occur following acute myocardial infarction and in the critically ill. Adequate attention should be given to maintaining euglycemia (plasma glucose ≤ 110 mg/dl) in order to reduce infarct size and improve cardiac function while using a glucose–insulin–potassium cocktail.     

左卡尼汀对糖尿病合并心力衰竭老年患者的临床疗效观察

目的观察左卡尼汀对糖尿病合并心力衰竭老年患者的临床疗效。方法选取糖尿病合并心力衰竭老年患者48例,随机分为两组。对照组采取常规抗心力衰竭治疗14 d,治疗组在此基础上静脉滴注左卡尼汀3.0 g,每日1次,共14 d。治疗前及治疗后分别检查两组患者的6 min步行试验、心脏超声心动图及血浆钠尿肽(BNP)、血糖、血脂、胰岛素水平。结果治疗后,两组患者的心功能指标6 min步行试验、左室舒张末期内径(LVEDD)、左室收缩末期内径(LVESD)、左室射血分数(LVEF)、左室缩短分数(FS)和舒张功能指标E峰与A峰的比值(E/A)均较治疗前显著改善(P0.05)。且治疗组6 min步行试验、LVEF、E/A改善程度较对照组更为明显(P0.05)。对照组治疗后BNP、空腹血糖(FBG)、胰岛素抵抗指数(HOMA-IR)较治疗前有改善(P0.05),治疗组治疗后BNP、FBG、三酰甘油(TG)、总胆固醇(TC)、高密度脂蛋白(HDL)、HOMA-IR较治疗前有显著改善(P0.05),且治疗组BNP、FBG、TC及HOMA-IR改善程度较对照组更为显著,差异有统计学意义(P0.05)。治疗组治疗后临床疗效总有效率明显高于对照组(P0.05)。结论左卡尼汀可明显纠正糖尿病合并心力衰竭老年患者的心肌能量代谢障碍,调节心肌的舒张及收缩功能,改善胰岛素抵抗,从而改善患者的临床症状和预后,延缓心力衰竭的进展。     

自体外周血单个核细胞移植老年急性心肌梗死：5年心功能评价

背景：心肌梗死患者出现心室重构及心功能不全是其常见的并发症,老年患者因其自身生理特点上述情况发生可能性更高。近年来干细胞移植治疗急性心肌梗死及心力衰竭成为研究热点,其可行性及安全性已得到证实,但其对于老年患者长期效果尚未明确。 目的：评价自体外周血单个核细胞移植对老年急性心肌梗死患者左室重构和心功能的长期影响。 方法：自2003年8月至2006年8月共入选老年急性心肌梗死患者（年龄≥60岁）30例,分为2组,移植组在常规治疗（药物与介入）基础上经冠状动脉输注自体外周血单个核细胞;对照组经常规方法（药物与介入）治疗。在外周血单个核细胞动员、采集及经冠状动脉回输过程中观察其不良反应。在治疗前及治疗后6,12,24,60个月应用超声心动图评价左室形态及心功能变化。 结果与结论：治疗前两组左室容量及心功能指标比较差异无显著性意义。与治疗前比较,治疗后6,12,24,60个月移植组左室舒张末容积、左室收缩末容积显著降低,左室射血分数显著增高。与治疗前比较,治疗后6,12,24,60个月对照组左室舒张末容积、左室收缩末容积、左室射血分数差异均无显著性意义。与对照组相比较,各个时间点移植组左室舒张末容积、左室收缩末容积均显著降低,左室射血分数增高。随访期间均未发现移植相关不良反应及心血管事件。结果可见自体外周血单个核细胞移植可显著、长期改善老年急性心肌梗死患者的左室重构及心功能情况,且安全性良好。     

急诊超声心动评价心脏功能的意义

目的：评价超声心动在急诊心功能不全和急性心肌梗死的意义和可行性，方法：选择急诊以重症心功能不全和第一次急性心肌梗死就诊入住ICU的患者，在就诊即刻至24h内进行超声心动评价心脏左室收缩，舒张功能以及左室局部收缩功能。结果：急诊就诊的心力衰竭的大多数病因是高心病，肺心病和冠心病，分别占41．3％，24．7％，22．2％，单纯舒张性心力衰竭占18％，超声心动可检测急性心肌梗死的左室局部收缩功能异常，但是在溶栓的最佳6h内不能增强诊断及溶栓治疗的信心。结论：急诊超声心动对于急重症心力衰竭和急性心肌梗死的诊治具有重要作用，特别是诊断单纯舒张功能不全具有不可替代的价值，超声心动在急诊科用于心功能和急性心肌梗死的评价也是可行的。     

Usefulness of the resting electrocardiogram in the elderly.

The ECG is useful in diagnosing acute myocardial infarction and unrecognized Q-wave myocardial infarction in the elderly. Unrecognized myocardial infarction and myocardial infarction associated with clinical symptoms have a similar incidence of new coronary events. Ischemic ST-segment depression on the resting ECG is associated with an increased incidence of new coronary events. The ECG is useful in the diagnosis of LV hypertrophy but is less sensitive and less specific than echocardiography in diagnosing LV hypertrophy. ECG LV hypertrophy is associated with an increased incidence of cardiovascular events in the elderly. However, echocardiographic LV hypertrophy is more sensitive in predicting new coronary events, atherothrombotic brain infarction, and congestive heart failure than is ECG LV hypertrophy. The ECG is also useful in diagnosing conduction defects and arrhythmias in the elderly. In the elderly, left bundle branch block, intraventricular conduction defect, Type II second-degree atrioventricular block, and pacer rhythm are associated with an increased incidence of new cardiac events, whereas right bundle branch block, left anterior fascicular block, and first-degree atrioventricular block are not. In the elderly, atrial fibrillation is associated with an increased incidence of thromboembolic stroke and new cardiac events. Premature atrial complexes and paroxysmal supraventricular tachycardia are not associated with an increased cardiac risk. Complex ventricular arrhythmias on the resting ECG are associated with an increased incidence of cardiac events in elderly patients with heart disease but not in elderly patients without heart disease.(ABSTRACT TRUNCATED AT 250 WORDS)     

罗格列酮对2型糖尿病及糖尿病前期患者大血管事件影响的系统评价

目的讨论罗格列酮对2型糖尿病及糖尿病前期患者大血管事件的影响。方法按照国际Cochrane协作网的系统评价方法 ,检索关于罗格列酮对2型糖尿病或糖尿病前期患者大血管系统影响的临床随机对照试验,对照治疗包括安慰剂或阳性对照药物,其随访时间至少1年以上。由两位研究者独立地对符合纳入标准的试验进行质量评价和资料提取。采用下列指标对罗格列酮对2型糖尿病及糖尿病前期患者大血管系统的影响进行Meta分析:全因死亡、全部心血管事件、心肌梗死事件、心力衰竭事件、心血管死亡事件、脑卒中事件、周围血管事件。结果 5个试验符合纳入标准,包括11871例2型糖尿病及糖尿病前期患者。长期罗格列酮治疗与其它对照治疗比较,可能增加其心力衰竭事件(P<0.01)的发生率,但是对其全因死亡事件(P=0.42)、全部心血管事件(P=0.11)、心肌梗死事件(P=0.09)、心血管死亡事件(P=0.80)、脑卒中事件(P=0.18)及周围血管事件(P=0.32)发生率的影响差异无统计学意义。结论罗格列酮治疗糖尿病及糖尿病前期患者可能增加心力衰竭事件的发生,对于全因死亡事件、全部心血管事件、心血管死亡事件、脑卒中事件、周围血管事件等影响不大;而对于心肌梗死事件则有一定的增加其风险的趋势,但差异并不显著。     

Left main coronary artery disease.

Eighteen patients with significant stenosis of the left main coronary artery are reported and compared with 1,040 patients described in the ten largest published series. In comparison to previous reports, our patients have a higher incidence of congestive heart failure, previous myocardial infarction (especially inferior wall), poorer left ventricular function, and more advanced coronary artery disease. Despite this, there was no increased risk during catheterization and bypass surgery. This small group of patients reflects the modern experience that, with increasing awareness of this lesion, there need not necessarily be a higher risk during diagnostic studies and therapeutic intervention.     

老年糖尿病病人合并心力衰竭的预见性护理

目的 :探讨老年糖尿病(DM )突发左心衰竭预见性护理。方法 :将 10 0例老年DM病人根据其合并症的不同分为DM合并冠心病组(CHD组 )和DM合并心肌梗死组 (AMI组 ) ,分析病人是否使用胰岛素在发生心力衰竭时及治疗后血糖、血压、水肿情况及心力衰竭的诱发因素。结果 :老年DM发生左心衰竭主要诱发因素是感染、高血脂症。且心力衰竭时可能出现血糖降低 ;注射胰岛素者在心力衰竭治疗过程中水肿较明显。结论 :通过针对危险因素进行预见性护理 ,监测及控制血糖 ,可减少心力衰竭病人合并症的发生率     

Successful resuscitation of a patient with electrical storm

A 41 year old woman with type 2 diabetes, hypertension, and hyperlipidaemia but no known heart disease received 130 DC shocks for repeated cardiac arrests due to ventricular tachyarrhythmias over 48 hours. She was stabilised by intravenous amiodarone and had a defibrillator implanted. Serial ECGs did not change, but raised troponin I confirmed myocardial infarction as the underlying cause. Electrical storm is an uncommon and dramatic but usually treatable syndrome of recurrent ventricular arrhythmias. Frequent precipitants of electrical storm include recent worsening heart failure, hypokalaemia, hypomagnesaemia and myocardial ischaemia. Amiodarone is the antiarrhythmic agent of choice and implantable cardioverter defibrillator improves long term outcome.     

急性心肌梗死并糖尿病患者窦性心率震荡的临床观察

目的:观察糖尿病对急性心肌梗死(AMI)病人窦性心率震荡(HRT)的影响。方法:将2004年1月~2006年1月收治的56例急性AMI病人按是否合并糖尿病分为两组,合并糖尿病组26例,无糖尿病组30例,另入选30例正常对照组。三组病人入院1周内行24小时动态心电图(Holter)检查,计算HRT的两个参数震荡初始(TO)和震荡斜率(TS),并进行统计学分析。结果:与正常对照组比较,急性AMI合并糖尿病组和无糖尿病组心率震荡现象均减弱,存在统计学差异(P<0.05);合并糖尿病组和无糖尿病组比较,心率震荡现象无统计学差异。结论:急性AMI病人窦性心率震荡现象较非冠心病人群减弱,是否合并糖尿病对急性AMI病人的窦性心率震荡似乎无明显影响。     

Prevention of coronary heart disease in type 2 diabetes

Patients with diabetes without a prior myocardial infarction are at a similar risk of coronary heart disease (CHD) events as non-diabetic subjects with a prior myocardial infarction. Furthermore, prognosis after the first myocardial infarction is worse in diabetic compared to non-diabetic patients. Therefore, management of cardiovascular risk factors in subjects with diabetes should be as vigorous as in patients with known CHD who have had a myocardial infarction. Randomised controlled trials have shown that efficacy of cholesterol lowering and antihypertensive therapy in type 2 diabetes is at least as effective as in non-diabetic subjects in preventing macrovascular disease. Antiplatelet therapy with aspirin reduces the risk of CHD events in high-risk patients and the benefit is similar in subjects with and without diabetes. Improved glycaemic control has a modest beneficial effect on CHD risk. There is residual excess risk of CHD in type 2 diabetes, which is not explained by traditional cardiovascular risk factors. Insulin resistance may partly mediate this. Prediabetic subjects who are insulin resistant have more adverse levels of triglycerides, high density lipoprotein (HDL)-cholesterol and blood pressure than those who are insulin sensitive. Moreover, factors associated with insulin resistance are significant predictors of CHD events in subjects with diabetes, in addition to conventional risk factors. The thiazolidinedione, pioglitazone, improves glycaemia and insulin sensitivity in hyperglycaemic patients. It also improves insulin and triglyceride levels and lowers blood pressure. Thiazolidinediones have been found to have vasculo-protective effects in both acute and chronic vascular injury in animal models. For prevention of CHD in type 2 diabetes a multi-factorial approach should be considered, including improved glycaemic control, aggressive management of dyslipidaemia and hypertension, anti-platelet therapy, reduction of insulin resistance and use of agents that improve insulin sensitivity.