急性心肌梗塞经桡动脉腔内冠状动脉成形术

目的 近年来随着心导管器械的小型化,经桡动脉冠状动脉造影术及经皮腔内冠状动脉成形术(PTCA)已逐渐成为一种有益的替代途径.本文观察了其在急性心肌梗塞患者中的应用价值.方法和结果 对我院6例急性心肌梗塞患者行直接PT-CA,全部采用经桡动脉途径.其中男性4人,女性2人,平均年龄(62±5.8)岁.对6例梗塞相关血管行直接PTCA均获成功,其中4例各植入支架一枚.所有患者术后即拔导管鞘,局部弹性绷带固定、压迫4～6小时,无出血、假性动脉瘤、动静脉瘘等并发症发生.一例患者桡动脉搏动较术前减弱,无手缺血症状.结论 本研究初步显示,经桡动脉直接PTCA可安全有效应用于急性心肌梗塞患者.采用经桡动脉途径具有快速简便、穿刺中位出血并发症少、患者可尽早离床等优点.     

Management of multivessel coronary disease after ST elevation myocardial infarction treated by primary angioplasty

BACKGROUND: Optimal treatment strategy of patients with ST elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD) undergoing primary angioplasty is still unclear. Percutaneous coronary intervention (PCI) of non-culprit vessels simultaneously or soon after primary angioplasty is feasible and safe, but available data failed to consistently show a benefit in long-term clinical outcomes. METHODS: We retrospectively compared in-hospital and long-term outcomes for patients with STEMI and multivessel CAD treated by primary angioplasty with (Group 1, n=64) or without (Group 2, n=46) early, staged PCI of other angiographically significant coronary lesions. In-hospital major adverse cardiovascular events (MACE) were defined as a composite of death, periprocedural myocardial infarction after staged, elective PCI, stroke, stent thrombosis, major bleeding, and vascular complications. MACE at follow-up were defined as a composite of death, stroke, stent thrombosis, any coronary revascularization, and re-hospitalization for acute coronary syndrome. RESULTS: Group 1 patients underwent staged PCI 5.9 +/- 3.5 days after primary angioplasty. The mean length of follow-up was 13 months (392 +/- 236 days). The incidence of in-hospital MACE was 20.3% in Group 1 and 10.8% in Group 2 (P=0.186); the incidence of out of hospital MACE was 9.3% in Group 1 and 23.9% in Group 2 (P=0.037). In Group 1 in-hospital MACE were driven by periprocedural myocardial infarction after the elective procedure, which occurred in 15.6% of patients. CONCLUSIONS: Our data show that multivessel, staged PCI in STEMI patients is associated with a low incidence of adverse events at follow-up but with a higher incidence of in-hospital MACE, mainly driven by periprocedural myocardial infarction during the elective procedure.     

Multivessel percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction

Background

The optimal percutaneous interventional strategy for dealing with significant non-culprit lesions in patients with multivessel disease (MVD) with acute myocardial infarction (AMI) at presentation remains controversial.

Methods

A total of 820 patients treated with primary angioplasty for AMI between 1998 and 2002 were classified in groups of patients with single vessel disease (SVD) or MVD (≥70% stenosis of ≥2 coronary arteries). Patients with MVD were subdivided in 3 groups on the basis of the revascularization strategy: 1) patients undergoing percutaneous coronary intervention (PCI) of the infarct-related artery (IRA) only; 2) patients undergoing PCI of both the IRA and non-IRA(s) during the initial procedure; and 3) patients undergoing PCI of the IRA followed by staged, in-hospital PCI of the non-IRA(s). Procedural, 30-day, and 1-year outcomes are reported.

Results

At 1 year, compared with patients with SVD, patients with MVD had a higher incidence of re-infarction (5.9% vs 1.6%, P = .003), revascularization (18% vs 9.6%, P <.001), mortality (12% vs 3.2%, P <.001), and major adverse cardiac events (MACEs; 31% vs 13%, P <.001). In patients with MVD, compared with PCI restricted to the IRA only, multivessel PCI was associated with higher rates of re-infarction (13.0% vs 2.8%, P <.001), revascularization (25% vs 15%, P = .007), and MACEs (40% vs 28%, P = .006). Multivessel PCI was an independent predictor of MACEs at 1 year (odds ratio = 1.67, P = .01).

Conclusions

These data suggest that in patients with MVD, PCI should be directed at the IRA only, with decisions about PCI of non-culprit lesions guided by objective evidence of residual ischemia at late follow-up. Further studies are needed to confirm these findings.     

Value of the initial electrocardiogram in patients with inferior-wall acute myocardial infarction for prediction of multivessel coronary artery disease

BACKGROUND: Patients with inferior-wall acute myocardial infarction (AMI) who have ST-segment depression in the left precordial leads (LSTD+) on the initial electrocardiogram were reported to have more diffuse coronary artery disease (CAD) than had those without this finding (LSTD-). This suggests that LSTD+ patients may need extensive revascularization interventions more often than do LSTD- patients. However, this has not yet been confirmed. OBJECTIVE: To compare the coronary angiographic findings and treatment strategies for patients with inferior-wall AMI according to the LSTD pattern. METHODS: The clinical outcomes and the angiographic findings for 238 consecutive patients aged < or = 75 years who had been admitted to our hospital between 1 February 1995 and 1 February 1997 with inferior-wall AMI were retrospectively analyzed. The patients were divided into two groups according to the pattern of precordial ST-segment depression: LSTD+, ST-segment depression in leads V4-V6; and LSTD-, absence of this finding. All patients were treated according to current practice guidelines including with thrombolysis and revascularization interventions. RESULTS: The final study population included 217 patients; 83 were LSTD+ and 134 were LSTD-. All underwent coronary angiography within 30 days of the infarction. Compared with LSTD- patients, LSTD+ patients tended to be older (mean age 62.7 +/- 11.7 versus 58.3 +/- 9.6 years, P = 0.004), and had higher incidences of hypertension (39.8 versus 24.6%, P = 0.019) previous myocardial infarction (45.8 versus 20.1%, P = 0.0001) and congestive heart failure (21.7 versus 3.7%, P = 0.00008). Three-vessel CAD was much more common, and single-vessel CAD much less common, in the LSTD+ than in LSTD- group (62.7 versus 13.4% and 8.4 versus 50.7%, P < 0.00001 for both). Coronary-artery-bypass surgery and multivessel percutaneous coronary interventions (PCI) were used in treating 65.1% of the LSTD+ versus only 6.0% of the LSTD- patients (P < 0.00001), whereas single-vessel PCI was used in treating 71.6% of the LSTD- patients versus only 24.1% of the LSTD+ patients (P < 0.00001). Thus, the LSTD- pattern predicted single-vessel disease and single-vessel PCI only, whereas the LSTD+ pattern was predictive of multivessel CAD and of use of coronary-artery-bypass surgery or multivessel PCI (predictive values of 94.0 and 65.1%, respectively). CONCLUSIONS: Among patients with inferior-wall AMI, left precordial ST-segment depression predicts a very high prevalence of multivessel CAD and use of extensive revascularization interventions. The absence of this finding predicts nondiffuse CAD and lack of a need for extensive revascularization.     

Outcome of urgent percutaneous transluminal coronary angioplasty in acute myocardial infarction: comparison of single-vessel versus multivessel coronary artery disease.

Despite recent clinical trials of percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction, specific groups of patients that may benefit from adjunctive or alternative therapy have yet to be adequately characterized. The in-hospital outcome of 151 consecutive patients treated for acute myocardial infarction with urgent PTCA of the infarct-related artery was studied to identify a subgroup of patients at high risk. Patients were divided into two groups based on the angiographic presence of either single-vessel (n = 86) or multivessel (n = 65) coronary artery disease. Despite PTCA of only the infarct-related artery and similar baseline clinical characteristics such as age, peak serum creatine kinase concentration, left ventricular ejection fraction, and time from the onset of chest pain to arrival at the hospital, the group with multivessel disease had a lower rate of successful angioplasty (75% vs 92%, p < 0.005), with higher incidences of persistent total occlusion of the infarct-related artery (14% vs 3%, p < 0.02) and procedural complications during PTCA (28% vs 13%, p < or = 0.02), and were more likely to have multiple complications (12% vs 1%, p < 0.004). In addition, the group with multivessel disease had a higher rate of urgent (< or = 24 hours) coronary artery bypass graft surgery (13% vs 2%, p < 0.05) and a trend toward a higher in-hospital mortality rate (6% vs 1%, p < or = 0.17). By stepwise logistic regression, only the presence of single-vessel versus multivessel disease was predictive of PTCA success (p < 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)     

Hospital transfer for primary coronary angioplasty in high risk patients with acute myocardial infarction

OBJECTIVE—To investigate the feasibility, safety, and associated time delays of interhospital transfer in patients with acute myocardial infarction for primary percutaneous transluminal coronary angioplasty (PTCA).
DESIGN AND PATIENTS—Prospective observational study with group comparison in a single centre. 68 consecutive patients with acute myocardial infarction transferred for primary PTCA from other hospitals (group A) were compared with 78 patients admitted directly to the referral centre (group B).
MAIN OUTCOME MEASURES—Patient groups were analysed with regard to baseline characteristics, time intervals from onset of chest pain to balloon angioplasty, hospital stay, and follow up outcome.
RESULTS—Patients in group A presented with a higher rate of cardiogenic shock initially than patients in group B (25% v 6%, p = 0.01) and had been resuscitated more frequently before PTCA (22% v 5%, p = 0.01). No deaths or other serious complications occurred during interhospital transfer. Median transfer time was 63 (range 40-115) minutes for helicopter transport (median 42 (28-122) km, n = 14), and 50 (18-110) minutes by ground ambulance (median 8 (5-68) km, n = 54). The median time interval from the decision to perform coronary arteriography to balloon inflation was 96 (45-243) minutes in group A and 52 (17-214) minutes in group B (p = 0.0001). In transferred patients (group A) the transportation associated delay and the longer in-hospital median decision time (50 (10-1120) minutes in group A v 15 (0-210) minutes in group B, p = 0.002) concurred with a longer total period of ischaemia (239 (114-1307) minutes in group A v 182 (75-1025) minutes in group B, p = 0.02) since the beginning of chest pain. Success of PTCA (TIMI 3 flow in 95% of all patients), in-hospital mortality (7% v 9%, mortality for patients not in cardiogenic shock 0% v 4%), and follow up after median 235 days was similarly favourable in groups A and B, respectively. Only one hospital survivor (group A) died during follow up.
CONCLUSION—Interhospital transport for primary PTCA in high risk patients with acute myocardial infarction is safe and feasible within a reasonable period of time. Short and medium term outcome is favourable. Optimising the decision process and transport logistics may further improve outcome by reducing the total time of ischaemia.


Keywords: acute myocardial infarction; primary percutaneous transluminal coronary angioplasty; hospital transfer; time delay     

Balloon coronary angioplasty in patients with acute myocardial infarction

After successful thrombolysis, approximately 75% of all patients will have significant coronary stenosis, which can be dilated by means of percutaneous transluminal balloon angioplasty (PTCA). In a randomized control study, 95 of our patients (Group I) had thrombolysis alone, whereas 95 others (Group II) had thrombolysis and PTCA. Both groups were comparable with respect to age, sex, infarct location, and maximal creatine kinase (CK) value. The clinical outcome during the hospital phase was better in Group II, which had a reocclusion rate of 13%, a reinfarction rate of 5%, a lethal reinfarction rate of 2%, and a cardiac death rate of 7%, compared with respective rates of 20%, 13%, 7%, and 13% in Group I. Furthermore, in Group I, residual coronary stenosis immediately after thrombolysis (75% +/- 20%) did not improve significantly until the end of the hospital phase, when it decreased to 69% +/- 21%. In Group II, stenosis (78% +/- 16%) was improved by PTCA to 33% +/- 21%, and this improvement remained constant during the hospital phase (30% +/- 26%). In Group-II patients who had an unsuccessful PTCA, stenosis was approximately the same before dilatation (83% +/- 12%), after dilatation (80% +/- 17%), and at the control study (83% +/- 17%). The end-diastolic, end-systolic, and stroke volume indices, as well as the ejection fraction, also remained unchanged. In Group I, the number of pathologic wall segments (12.2 +/- 5.0) did not improve during the hospital phase (12.2 +/- 7.9), but in Group II, the improvement was significant (14.0 +/- 5.7 vs. 10.9 +/- 8.2) (p < 0.05). PTCA seems to improve the clinical outcome, reduce the infarction and mortality rates, and enhance myocardial perfusion and performance.     

Heart rate variability in patients with acute myocardial infarction undergoing primary coronary angioplasty

Depressed heart rate variability (HRV) has been associated with adverse outcome during and after acute myocardial infarction (AMI). The effects of reperfusion in AMI on the course of HRV have not been well characterized as yet. We analyzed 123 consecutive patients with a first AMI who underwent successful reperfusion (Thrombolysis In Myocardial Infarction grades 2 and 3) by primary percutaneous transluminal coronary angioplasty (PTCA). Time- and frequency-domain HRV was measured from 24-hour Holter monitoring, which began at hospital admission. Mean RR interval increased significantly after successful PTCA. Reperfusion immediately caused an immediate transient depression of HRV, which was followed by a significant increase of HRV. Quantitative markers of sympathetic activity and sympathovagal balance, such as SD of the averages of NN intervals in all 5-minute segments, and low- and/or high-frequency ratio continuously decreased within the observation period. Patients with anterior AMI exhibited the same pattern of temporal changes of HRV, with, however, lower absolute values for HRV and mean RR interval than patients with non-anterior AMI. Subgroup analysis in 21 patients with reperfusion > 12 hours after onset of pain showed that the biphasic profile of HRV and the marked increase of mean RR interval was absent. Furthermore, in patients with late reperfusion, HRV was significantly lower compared with those with early reperfusion. Thus, timely reperfusion in AMI leads to a biphasic effect on autonomic tone, characterized by a transient suppression, followed by a significant activation of the vagal tone, as well as an attenuation of sympathetic activity. Recovery of HRV may contribute to the benefits of early reperfusion in AMI.     

Meta-analysis of multivessel coronary artery revascularization versus culprit-only revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease

American College of Cardiology/American Heart Association guidelines for management of patients with ST-segment elevation myocardial infarction (STEMI) recommend culprit artery-only revascularization (CULPRIT) based on safety concerns during noninfarct-related artery intervention. However, the data to support this safety concern are scant. Searches were performed in PubMed/EMBASE/CENTRAL for studies evaluating multivessel revascularization versus CULPRIT in patients with STEMI and multivessel disease (MVD). A multivessel revascularization strategy had to be performed at the time of CULPRIT or during the same hospitalization. Early (≤30-day) and long-term outcomes were evaluated. Among 19 studies (23 arms) that evaluated 61,764 subjects with STEMI and MVD, multivessel revascularization was performed in a minority of patients (16%). For early outcomes, there was no significant difference for outcomes of mortality, MI, stroke, and target vessel revascularization, with a 44% decrease in risk of repeat percutaneous coronary intervention and major adverse cardiovascular events (odds ratio 0.68, 95% confidence interval 0.57 to 0.81) with multivessel revascularization compared to CULPRIT. Similarly, for long-term outcomes (follow-up 2.0 ± 1.1 years), there was no difference for outcomes of MI, target vessel revascularization, and stent thrombosis, with 33%, 43%, and 53% decreases in risk of mortality, repeat percutaneous coronary intervention, coronary artery bypass grafting, respectively, and major adverse cardiovascular events (odds ratio 0.60, 95% confidence interval 0.50 to 0.72) with multivessel revascularization compared to CULPRIT. In conclusion, in patients with STEMI and MVD, multivessel revascularization appears to be safe compared to culprit artery-only revascularization. These findings support the need for a large-scale randomized trial to evaluate revascularization strategies in patients with STEMI and MVD.     

Trials comparing coronary artery bypass grafting with percutaneous transluminal coronary angioplasty and primary stent implantation in patients with multivessel coronary artery disease

With marked improvements in stent technology as adjunct to balloon angioplasty for multivessel coronary disease, several newer trials are currently in progress reviewing the optimal revascularization strategy. This review provides background from older studies and addresses the current progress and design of these newer trials.     

Transfer for primary angioplasty in elderly patients with acute myocardial infarction

A 52‐year‐old asymptomatic man, with cardiac risk factors of hypertension, Type II diabetes, hypertriglyceridemia, low HDL, obesity, and positive family history for early coronary artery disease (CAD), was referred to nuclear stress test. He exercised for 14 minutes, achieved his target heart rate, without any symptoms or ECG changes. Nuclear images were entirely normal. However, the patient was still concerned and anxious so he underwent CT angiography that revealed coronary narrowings. Next, he underwent coronary angiography with similar findings. The lesions were treated with stents. We present a case report to illustrate how newer technology such as CT angiography alters the way in which we diagnose CAD and decide on whether to pursue further invasive therapy.     

Benefit of revascularization in non-infarct-related artery in multivessel disease patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

This study compared the prognosis of ST-elevation myocardial infarction (STEMI) in patients with multivessel disease (MVD) with that of single vessel disease (SVD) and investigated the revascularization benefit of noninfarct-related artery (IRA) in MVD patients undergoing primary percutaneous coronary intervention (PCI). Between 2002 and 2009, 1278 patients with STEMI underwent primary PCI. Of these patients, 717 (56.1%) with SVD (only IRA obstruction) were placed in group A, while 561 (43.9%) with MVD (Group B) were further categorized into group 1 (PCI for IRA) and group 2 (staged PCI for IRA+non-IRA). The results demonstrated a lower degree of successful reperfusion in IRA and higher 30-day and 1-year cumulative mortality rates in group B (P < 0.001). While there was no difference in successful reperfusion in IRA between group 1 and group 2, the 30-day and one-year cumulative mortality rates were higher in group 1. Multivariate analysis identified MVD as an independent predictor of 1-year mortality (P < 0.001). In conclusion, patients with subsequent PCI for MVD had better 30-day and 1-year outcomes than those with conservative treatment.     

急性ST段抬高型心肌梗死患者直接经皮冠状动脉介入治疗同时处理非梗死相关血管的疗效研究

目的探讨急性ST段抬高型心肌梗死(STEMI)直接经皮冠状动脉介入治疗(PCI)同时处理存在严重狭窄的非梗死相关血管的安全性及1年随访期的疗效。方法将221例多支血管严重狭窄的急性STEMI患者,根据急诊PCI是否处理非梗死相关血管分为常规组(仅处理罪犯血管)179例及处理组(同时处理非梗死相关血管)42例,观察两组的住院时间、术后心绞痛症状、心功能状况、再次手术率、再次住院率、主要不良心血管事件(MACE,包括术后及随访期间心原性死亡、非致死性再次心肌梗死)发生率等的差异。结果两组患者在年龄、性别、体质指数、低密度脂蛋白胆固醇、血糖、血肌酐、吸烟史、糖尿病、高血压、发病至球囊扩张时间等方面,差异均无统计学意义(均为P>0.05)。与常规组比较,术后处理组的心绞痛发生率降低(40.48%比60.34%,χ2=5.46,P=0.02)、再次手术率降低(9.52%比58.10%,χ2=32.13,P=0.00)和再次住院率减低(11.90%比27.93%,χ2=4.68,P=0.03)。处理组心功能状况优于常规组[(1.19±0.59)级比(1.49±0.89)级,t=2.66,P=0.01]。两组MACE发生率差异无统计学意义(4.76%比2.79%,χ2=0.03,P=0.87)。结论急性STEMI直接PCI同时处理存在严重狭窄的非梗死相关血管有助于减少心绞痛发作,降低再次手术率、再次住院率,改善心功能状况,且未增加MACE发生率,在预期成功率高的情况下可作为急性STEMI直接PCI的一种选择。     

Procedural characteristics of primary coronary angioplasty in diabetic patients with acute anterior myocardial infarction

BACKGROUND: Mortality and morbidity rates are higher in diabetics compared to non-diabetics after acute myocardial infarction (AMI). Previous angiographic studies regarding primary angioplasty for the treatment of AMI found that angioplasty was similarly successful in diabetics and non-diabetics. However, it is noteworthy that patients of "real life" are often far from the population randomised in prospective protocols. The aim of this study was to examine the procedural characteristics of consecutive diabetic patients hospitalised for anterior AMI and treated with primary angioplasty as compared to non-diabetics. METHOD: We analysed 28 consecutive diabetics and 74 non-diabetics who underwent primary angioplasty for anterior AMI (< 12 h from the onset of symptoms) during 15 consecutive months between 2000 and 2001 in our institution, depending on the presence or absence of diabetes. RESULTS: Among analysed data, we found that in diabetics compared to non diabetics: (i) the delay before arrival in the cath-lab was significantly longer (5.5 +/- 2.7 vs 4.2 +/- 2.8 h); (ii) there was a less important collateral flow coming from the non-culprit arteries towards the culprit artery; (iii) there was a less important rate of recovery of a normal flow (TIMI 3) in the culprit artery after coronary angioplasty (67% vs 91%). CONCLUSION: Our study demonstrates that several procedural characteristics could explain the poorer prognosis of AMI treated by primary angioplasty in the diabetic population. The longer delay found in diabetics before arrival in hospital could probably be improved.     

Usefulness of coronary artery angioplasty strategies in acute myocardial infarction

The usefulness of percutaneous transluminal coronary angioplasty (PTCA) as an adjunct to thrombolytic therapy for acute myocardial infarction is the focus of intense clinical investigation. With an angiographically significant residual stenosis present in the infarct vessel in at least 70% of cases, PTCA has the potential to resolve residual ischemia of surviving myocardium; provide a route for nutrient influx to promote healing and reorganization by leukocytes and fibroblasts; and maintain ventricular wall integrity. Additionally, the residual lesion may interfere with flow to collateral vessels supplying other diseased vascular territories, or inhibit the delivery of inotropic or antiarrhythmic agents to a problematic peri-infarct region. Various angioplasty strategies have been devised to define the optimal timing of PTCA in several clinical settings. Although the impact on resting left ventricular performance has been disappointing except in cases of cardiogenic shock, an approach involving early angiography with thoughtful triage to PTCA when feasible, has been associated with improved survival at one- to three-year follow-up, compared with a 'thrombolysis only' approach. The results of clinical trials investigating the role of PTCA as a direct method of revascularization; as a 'rescue' procedure following failed thrombolysis; as an empiric, immediate or deferred strategy; or as an elective adjunct to thrombolytic therapy only in the presence of subsequent ischemia are reviewed in detail.