Effect of ambulance 12-lead ECG recording on times to hospital reperfusion in acute myocardial infarction

OBJECTIVE: To review the evidence that recording a prehospital 12-lead electrocardiogram (ECG) reduces time from hospital arrival to initiation of reperfusion therapy for acute myocardial infarction (AMI). DATA SOURCES: Medline search from 1966 to the present (articles in all languages) and examination of bibliographies. STUDY SELECTION: Published studies of prehospital 12-lead ECG recording that included control groups and reported time intervals from hospital arrival to start of reperfusion therapy. DATA EXTRACTION: Eight articles satisfied selection criteria (two randomised controlled trials, four non-randomised interventional studies and two prospective observational studies). DATA SYNTHESIS: Widely varying study methodologies precluded meta-analysis. All studies had methodological problems, but hospital delays were consistently reduced. Such improvements appear to be small in hospitals where delays are already minimal. CONCLUSIONS: Little evidence is available to support routine prehospital 12-lead ECG recording if the median hospital time to reperfusion is already less than 30 minutes. Improvement of in-hospital treatment times may be a better initial strategy than prehospital 12-lead ECG recording, as this will benefit more patients and allow ambulance services to better allocate their available resources.     

Acute myocardial infarction in Fukushima area of Japan

Although acute myocardial infarction (AMI) is the most serious coronary disease, the background of its onset and the mortality are not fully understood, especially in Japan. From June 1999 to May 2005, we mailed an annual questionnaire to eighteen hospitals in which emergency cardiac catheterization and percutaneous coronary intervention (PCI) were available in the Fukushima area of Japan. A total of 1,590 patients were included. The onset time of AMI had two peaks, i.e., from 9:00 AM to 10:00 AM and 9:00 PM to 10:00 PM. As for reperfusion therapy, four groups were analyzed, the non-reperfusion therapy group (Group N, n = 233), thrombolysis alone group (Group T, n = 80), PCI without thrombolysis group (Group P, n = 1106), and PCI with thrombolysis group (Group TP, n = 151). The in-hospital mortality rate was significantly reduced in Group P (8.4%) compared with that in Group N (33.0%, p < 0.01) and Group T (18.8%, p < 0.01). However, the in-hospital mortality in Group P did not differ from that in Group TP (9.9%). The in-hospital mortality was analyzed by the logistic regression analysis among age, arrival time after onset, peak creatine kinase (CK) values, coronary risk factors, reperfusion therapy, PCI, and thrombolysis. There were significant differences in age (P < 0.01), peak CK values (p < 0.01), hypertension (p < 0.05), and diabetes mellitus (p < 0.01). These results suggest that the onset of AMI may be partly related to human biorhythms, and that PCI would be effective in reducing the in-hospital mortality.     

Safety outcomes in meta-analyses of phase 2 vs phase 3 randomized trials: Intracranial hemorrhage in trials of bolus thrombolytic therapy

CONTEXT: Recent studies have reported disagreement between meta-analysis of small trials and subsequent large trials addressing the same question. However, disagreement for uncommon but serious adverse safety outcomes has not been examined. OBJECTIVE: To explore disagreement for serious adverse safety (intracranial hemorrhage [ICH]) and efficacy outcomes between meta-analysis of phase 2 (small) vs meta-analysis of phase 3 (large) randomized controlled trials comparing the efficacy of bolus thrombolytic therapy with infusion for acute myocardial infarction (AMI). DATA SOURCES: Electronic databases (MEDLINE, Cochrane Database of Clinical Trials) between January 1980 and December 1999 using the search terms thrombolysis, thrombolytic therapy, and myocardial infarction; conference proceedings; and reference lists. STUDY SELECTION: Fifteen randomized trials comparing thrombolytic agents administered by bolus injection with standard infusion therapy in patients with AMI. DATA EXTRACTION: Data on ICH, other causes of stroke, total mortality, and reinfarction were independently extracted from each study by 2 observers. DATA SYNTHESIS: Meta-analysis of 9 phase 2 trials (n = 3956) revealed a lower risk of ICH with bolus thrombolytic therapy (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.27-1.01), which was not statistically significant. Meta-analysis of 6 phase 3 trials (n = 62 673) indicated a significant increase in risk of ICH (OR, 1.25; 95% CI, 1.06-1.49). These results were significantly different (P =.01). There was no disagreement for efficacy outcomes. Phase 2 trials included younger and heavier patients with lower baseline blood pressures, and were more often open-label. Subgroup analyses suggested that each of these factors was associated with a lower estimate of risk of ICH with bolus agents. CONCLUSIONS: Our results suggest that when therapeutic interventions are associated with a potential for uncommon but serious adverse safety outcomes, there may be differences between small phase 2 and large phase 3 trials that result in their disagreement for safety but not necessarily efficacy outcomes. Further investigation of the frequency and causes of disagreement between small and large trials for safety outcomes is warranted.     

What are appropriate rates of invasive procedures following acute myocardial infarction? A systematic review

OBJECTIVE: To assess the evidence that higher rates of coronary angiography (CA) and revascularisation (RV) in the subacute phase of acute myocardial infarction (AMI) improve patient outcomes. DATA SOURCES: MEDLINE 1990 - December 1999, Current Contents 1990-1999, Cochrane Library (Issue 4, 1999), HealthSTAR 1990-1999, selected websites and bibliographies of retrieved articles. STUDY SELECTION AND DATA EXTRACTION: Studies selected were (1) randomised trials comparing outcomes of "invasive" versus "conservative" use of CA and RV following AMI; (2) observational studies with formal methods comparing outcomes of high versus low rates of use of these procedures; and (3) clinical practice guidelines (CPGs), expert panel statements and decision analyses which met critical appraisal criteria, and which specified procedural indications. Outcome measures were rates of mortality, re-infarction and limiting or unstable angina. DATA SYNTHESIS: 56 articles were identified; 24 met inclusion criteria. Pooled data from nine RCTs of "invasive" (CA rate 96%; RV rate 66%) versus "conservative" (CA rate 28%; RV rate 19%) strategies showed no significant differences in mortality or re-infarction rates. Pooled results from 12 observational studies showed no mortality differences, but an excess reinfarction rate (8.0% vs 6.4%; P<0.001) in high- versus low-rate populations. Evidence of survival benefit from procedural intervention was strongest for patients with recurrent ischaemia combined with left ventricular dysfunction. CONCLUSIONS: In the subacute phase of AMI, rates of CA and RV in excess of 30% and 20%, respectively, may not confer additional benefit in preventing death or re-infarction. However, variability between studies in design, patient selection, and extent of cross-over from medical to procedural groups, as well as limited data on symptom status, limits generalisability of results.     

老年性急性心肌梗塞临床分析（附97例报告）

目的：研究老年性急性心肌梗塞（AMI）的临床经过及预后。方法。将我院1990－1999年中的133例AMI病人分为老年组（97例）和非老年组（36例）,分析两组的临床症状,主要并发症,住院病死率及死亡原因,结果：老年组中不典型或无明显我痛者多,泵衰竭或心律失常的发展率及住院病死率高,死亡原因依次为泵衰竭,休克及恶性心律失常,结论：老年性AMI症状不典型,并发症多,死亡率高,泵衰竭是老年AMI的主要死亡原因。     

Primary coronary angioplasty vs thrombolysis for the management of acute myocardial infarction in elderly patients.

CONTEXT: Despite evidence from randomized trials that, compared with early thrombolysis, primary percutaneous transluminal coronary angioplasty (PTCA) after acute myocardial infarction (AMI) reduces mortality in middle-aged adults, whether elderly patients with AMI are more likely to benefit from PTCA or early thrombolysis is not known. OBJECTIVE: To determine survival after primary PTCA vs thrombolysis in elderly patients. DESIGN: The Cooperative Cardiovascular Project, a retrospective cohort study using data from medical charts and administrative files. SETTING: Acute care hospitals in the United States. PATIENTS: A total of 20683 Medicare beneficiaries, who arrived within 12 hours of the onset of symptoms, were admitted between January 1994 and February 1996 with a principal discharge diagnosis of AMI, and were eligible for reperfusion therapy. MAIN OUTCOME MEASURES: Thirty-day and 1-year survival. RESULTS: A total of 80356 eligible patients had an AMI at hospital arrival and met the inclusion criteria, of whom 23.2% received thrombolysis and 2.5% underwent primary PTCA within 6 hours of hospital arrival. Patients undergoing primary PTCA had lower 30-day (8.7% vs 11.9%, P=.001) and 1-year mortality (14.4% vs 17.6%, P=.001). After adjusting for baseline cardiac risk factors and admission and hospital characteristics, primary PTCA was associated with improved 30-day (hazard ratio [HR] of death, 0.74; 95% confidence interval [CI], 0.63-0.88) and 1-year (HR, 0.88; 95% CI, 0.73-0.94) survival. The benefits of primary coronary angioplasty persisted when stratified by hospitals' AMI volume and the presence of on-site angiography. In patients classified as ideal for reperfusion therapy, the mortality benefit of primary PTCA was not significant at 1-year follow-up (HR, 0.92; 95% CI, 0.78-1.08). CONCLUSION: In elderly patients who present with AMI, primary PTCA is associated with modestly lower short- and long-term mortality rates. In the subgroup of patients who were classified as ideal for reperfusion therapy, the observed benefit of primary PTCA was no longer significant.     

急性心肌梗死患者行经皮冠状动脉介入术后住院期间死亡的危险因素分析

目的 探讨影响急性心肌梗死(AMI)患者行经皮冠状动脉介入术(PCI)后住院期间死亡的危险因素.方法 回顾性分析2009年1月至2011年9月因AMI入住我院并行PCI的275例患者的一般情况、既往史、入院情况、术中及术后情况、并发症等资料,对可能影响术后死亡的危险因素通过logistic回归模型进行分析.结果 多因素logistic回归分析表明,女性( P=0.047,OR=2.91)、广泛前壁心肌梗死(P=0.044,OR=3.07)、肾功能不全史(P=0.021,OR=7.98)、发生心源性休克(P=0.008,OR=15.71)、术后心肌梗死溶栓(TIMI)血流＜3级(P=0.016,OR=5.61)、置入主动脉内球囊反搏(IABP;P=0.043,OR=3.49).结论 影响AMI患者行PCI术后院内死亡的危险因素为女性、广泛前壁心肌梗死、置入IABP、术后TIMI血流＜3级、肾功能不全史和发生心源性休克.     

急性心肌梗死伴心衰、心源性休克病人经皮冠状动脉介入治疗近中期疗效

OBJECTIVE: To observe the short- and mid-term effects of percutaneous coronary intervention (PCI) in patients with ST-segment elevation acute myocardial infarction (AMI) complicated by heart failure and/or cardiogenic shock . METHODS: Altogether 90 patients with AMI were recruited, of whom 58 were treated by PCI, 20 by thrombolytic therapy, and the other received general treatment without reperfusion therapy. The length of hospital stay, major adverse cardiac events (MACE) and left ventricular ejection fraction (LVEF) were compared between PCI and thrombolysis groups. The relationship between the patency time of the infarct-related artery (IRA), thrombolysis in myocardial infarction (TIMI) grade after PCI and prognosis were analyzed in PCI group. RESULTS: The patency rate of IRA was significantly improved in patients receiving PCI therapy in comparison by those with thrombolytic therapy (98.3% vs 65.0%, P<0.01), and the LVEF was also higher in PCI group with lower mortality (6.9% vs 25.0%, P<0.05) during in-hospital and follow-up period. CONCLUSION: PCI can be a more effective therapy than thrombolytic therapy in the treatment of ST-segment elevation AMI accompanied with heart failure and/or cardiogenic shock.     

Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis

CONTEXT: Establishing relative benefit or harm from specific antihypertensive agents is limited by the complex array of studies that compare treatments. Network meta-analysis combines direct and indirect evidence to better define risk or benefit. OBJECTIVE: To summarize the available clinical trial evidence concerning the safety and efficacy of various antihypertensive therapies used as first-line agents and evaluated in terms of major cardiovascular disease end points and all-cause mortality. DATA SOURCES AND STUDY SELECTION: We used previous meta-analyses, MEDLINE searches, and journal reviews from January 1995 through December 2002. We identified long-term randomized controlled trials that assessed major cardiovascular disease end points as an outcome. Eligible studies included both those with placebo-treated or untreated controls and those with actively treated controls. DATA EXTRACTION: Network meta-analysis was used to combine direct within-trial between-drug comparisons with indirect evidence from the other trials. The indirect comparisons, which preserve the within-trial randomized findings, were constructed from trials that had one treatment in common. DATA SYNTHESIS: Data were combined from 42 clinical trials that included 192 478 patients randomized to 7 major treatment strategies, including placebo. For all outcomes, low-dose diuretics were superior to placebo: coronary heart disease (CHD; RR, 0.79; 95% confidence interval [CI], 0.69-0.92); congestive heart failure (CHF; RR, 0.51; 95% CI, 0.42-0.62); stroke (RR, 0.71; 0.63-0.81); cardiovascular disease events (RR, 0.76; 95% CI, 0.69-0.83); cardiovascular disease mortality (RR, 0.81; 95% CI, 0.73-0.92); and total mortality (RR, 0.90; 95% CI, 0.84-0.96). None of the first-line treatment strategies-beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers (CCBs), alpha-blockers, and angiotensin receptor blockers-was significantly better than low-dose diuretics for any outcome. Compared with CCBs, low-dose diuretics were associated with reduced risks of cardiovascular disease events (RR, 0.94; 95% CI, 0.89-1.00) and CHF (RR, 0.74; 95% CI, 0.67-0.81). Compared with ACE inhibitors, low-dose diuretics were associated with reduced risks of CHF (RR, 0.88; 95% CI, 0.80-0.96), cardiovascular disease events (RR, 0.94; 95% CI, 0.89-1.00), and stroke (RR, 0.86; 0.77-0.97). Compared with beta-blockers, low-dose diuretics were associated with a reduced risk of cardiovascular disease events (RR, 0.89; 95% CI, 0.80-0.98). Compared with alpha-blockers, low-dose diuretics were associated with reduced risks of CHF (RR, 0.51; 95% CI, 0.43-0.60) and cardiovascular disease events (RR, 0.84; 95% CI, 0.75-0.93). Blood pressure changes were similar between comparison treatments. CONCLUSIONS: Low-dose diuretics are the most effective first-line treatment for preventing the occurrence of cardiovascular disease morbidity and mortality. Clinical practice and treatment guidelines should reflect this evidence, and future trials should use low-dose diuretics as the standard for clinically useful comparisons.     

Early statin treatment following acute myocardial infarction and 1-year survival

CONTEXT: Randomized trials have established statin treatment as secondary prevention in coronary artery disease, but it is unclear whether early treatment with statins following acute myocardial infarction (AMI) influences survival. OBJECTIVE: To evaluate the association between statin treatment initiated before or at the time of hospital discharge and 1-year mortality after AMI. DESIGN AND SETTING: Prospective cohort study using data from the Swedish Register of Cardiac Intensive Care on patients admitted to the coronary care units of 58 Swedish hospitals in 1995-1998. One-year mortality data were obtained from the Swedish National Cause of Death Register. PATIENTS: Patients with first registry-recorded AMI who were younger than 80 years and who were discharged alive from the hospital, including 5528 who received statins at or before discharge and 14 071 who did not. MAIN OUTCOME MEASURE: Relative risk of 1-year mortality according to statin treatment. RESULTS: At 1 year, unadjusted mortality was 9.3% (1307 deaths) in the no-statin group and 4.0% (219 deaths) in the statin treatment group. In regression analysis adjusting for confounding factors and propensity score for statin use, early statin treatment was associated with a reduction in 1-year mortality (relative risk, 0.75; 95% confidence interval, 0.63-0.89; P =.001) in hospital survivors of AMI. This reduction in mortality was similar among all subgroups based on age, sex, baseline characteristics, previous disease manifestations, and medications. CONCLUSIONS: Early initiation of statin treatment in patients with AMI is associated with reduced 1-year mortality. These results emphasize the importance of implementing the results of randomized statin trials in unselected AMI patients.     

急性冠状动脉综合征介入治疗4670例近期疗效的评价

目的分析过去15年经皮冠状动脉介入(PCI)治疗急性冠状动脉综合征(ACS)患者的近期临床疗效。方法1989年8月至2004年10月沈阳军区总医院心血管内科对4670例住院的ACS患者行PCI治疗,其中发病30d内的急性心肌梗死(AMI)患者1750例(37.5%),不稳定心绞痛患者2920例(62.5%)。评价PCI的成功率、合并症及住院期间近期临床疗效。结果PCI总的病例成功率为98.1%(4579/4670),AMI行急诊PCI者梗死相关动脉开通率98.2%(825/840)。住院期间共死亡52例(总病死率1.1%),其中术中死亡2例(术中病死率0.04%)。总的PCI相关并发症发生率为6.5%(304/4670)。从入院至PCI时间为3.5d±2.1d,平均住院12d±8d。结论PCI治疗ACS成功率高,术中、术后死亡率和手术相关并发症发生率低,近期疗效好。     

急性心肌梗死患者心肺复苏后静脉溶栓临床疗效观察

目的观察急性心肌梗死患者心肺复苏后静脉溶栓的临床疗效。方法回顾分析我院2002年1月至2010年12月就诊的60例急性心肌梗死患者心肺复苏术后行静脉溶栓（观察组）治疗和同期60例急性心肌梗死患者心肺复苏后未行静脉溶栓（对照组）治疗的临床疗效,比较两组再通率、死亡率及30d内两组临床特征的变化情况。结果两组比较,观察组再通18例,再通率为26.67%;对照组再通3例,再通率为5.00%,观察组再通率明显高于对照组（P〈0.05）,治疗后30d内临床特征变化情况观察组治疗后情况比对照组佳,观察组总有效率为58.33%,高于对照组的30.00%,两组比较差异有统计学意义（P〈0.05）。结论急性心肌梗死患者心肺复苏后行静脉溶栓治疗安全有效,临床疗效明显优于急性心肌梗死心肺复苏后不行静脉溶栓治疗的患者,值得临床推广。     

急性心肌梗死溶栓后24小时内T波倒置的临床观察

目的 :探讨急性心肌梗死溶栓后 2 4h内T波倒置与冠脉再通的关系及临床意义。方法 :根据溶栓后2 4h内T波倒置与否 ,将 5 6例接受溶栓治疗的患者分为A组 (倒置组 )和B组 (未倒置组 ) ,根据临床间接血管再通标准观察两组冠脉再通情况及临床意义。结果 :两组冠脉再通率分别为 72 4%和 3 3 3 % (P <0 .0 1) ;住院期间室射血分数分别为 ( 5 7 5± 11 6) %和 ( 4 6 2± 13 2 ) % (P <0 .0 1) ;住院期间冠脉事件发生率分别为 13 7%和 3 7 0 % (P <0 .0 5 )。结论 :急性心肌梗死溶栓后 2 4h内T波倒置可作为冠脉再通的临床间接指标 ,同时提示更好的临床预后。     

急性ST段抬高型心肌梗死合并急性肾损伤的危险因素及其对预后的影响

目的：探讨急性ST段抬高型心肌梗死(STEMI)患者并发急性肾损伤(AKI)的危险因素及其对预后影响。方法选择我院2009年7月至2014年6月急性STEMI住院患者302例,根据是否发生AKI将患者分成AKI组和非AKI组。分析AKI发生的相关危险因素,观察住院期间主要不良心血管事件(充血性心力衰竭、恶性心律失常、心源性休克)发生率及死亡率。随访观察出院后1年全因死亡率。结果 STEMI患者并发AKI 75例,发病率为24.83%。多因素Logistic回归分析结果显示,左心室射血分数(LVEF)降低(OR=0.013,95%CI：0.000~0.327)、KillipⅣ级(OR=20.050,95%CI：6.520~61.654)、利尿剂(OR=3.102,95%CI：1.250~7.697)是AKI发生的独立危险因素;与非AKI组患者比较,AKI组患者住院期间主要不良心血管事件发生率及住院死亡率(5.28%vs 13.33%)显著升高,两组间比较差异均有统计学意义(P<0.05)。两组患者随访1年的生存曲线结果显示,AKI组患者全因死亡率明显高于非AKI组,两组间比较差异有统计学意义(P=0.003)。结论 LVEF降低、KillipⅣ级及利尿剂应用是STEMI患者并发AKI的独立危险因素;STEMI患者并发AKI增加住院不良心血管事件发生率及死亡率,降低患者1年生存率。     

不同性别急性心肌梗死患者临床对比研究

目的 :探讨男、女性急性心肌梗死 (AMI)患者临床特点的差别。方法 :对 390例急性心肌梗死的患者进行回顾性分析。结果 :在既往病史中 ,女性组糖尿病和高脂血症病史比例高于男性组 (P <0 0 5 ,P <0 0 1) ;男女组梗死部位比较差异无显著性 (P >0 0 5 ) ;女性组血糖、血脂均高于男性组 (P <0 0 1) ;女性组心源性休克、心力衰竭、猝死的发生率及住院病死率均高于男性组 (P <0 0 5 ) ;在接受静脉溶栓治疗的男女患者中 ,男性年龄较女性提前 (P <0 0 1) ,男性溶栓再通率高于女性 (P <0 0 1)。结论 :糖尿病、高脂血症是女性AMI患者的危险因素 ,绝经后女性AMI发病率增高 ,并发症发生率及住院病死率均高于男性 ,静脉溶栓治疗效果较差 ,女性AMI患者近期预后较男性差。     

Automatic external defibrillators: changing the way we manage ventricular fibrillation

OBJECTIVE: To discuss recent developments in automatic defibrillation and to review the evidence that first-responders equipped with automatic external defibrillators (AEDs) improve survival from out-of-hospital cardiac arrest. DATA SOURCES: MEDLINE search from 1966 to 1999 (articles in English only) and examination of bibliographies. STUDY SELECTION: Published studies of out-of-hospital cardiac arrest and first-responders equipped with AEDs. Studies had to have a control group and to report survival to hospital discharge from ventricular fibrillation (VF). DATA EXTRACTION: Six studies met the selection criteria (two prospective randomised trials, two prospective controlled trials, and one cohort study and one retrospective study, both with historical controls). DATA SYNTHESIS: A random effects meta-analysis of odds ratios for survival from VF. CONCLUSIONS: Meta-analysis suggests that equipping first-responders with AEDs increases the probability of survival to hospital discharge after out-of-hospital cardiac arrest (odds ratio, 1.74; 95% CI, 1.27-2.38; P < 0.001). However, most of the studies lacked sufficient power to draw definitive conclusions. Until the impact of wide deployment of AEDs is fully understood, first-responder defibrillation in Australia should only occur as part of coordinated multicentre research studies.     

Reperfusion and revascularization strategies for coronary artery disease in women.

OBJECTIVE--One third of all deaths in women in the United States each year are attributable to coronary heart disease. Gender differences exist in the course and management of patients with coronary heart disease. Few randomized trials have been conducted in women to evaluate effective therapeutic strategies. With the aim of developing rational approaches to women with coronary heart disease, we review gender-related outcomes with coronary revascularization and reperfusion therapies. DATA SOURCE--English-language journal articles and reviews on the subject of women with coronary heart disease or gender-specific responses to coronary heart disease management, from 1970 through 1992, identified through MEDLINE searching. STUDY SELECTION--Selected studies included only randomized controlled trials for topics related to thrombolysis, and articles considered to contribute significantly to the topic of women with coronary artery disease in the case of angioplasty and coronary artery bypass grafting. DATA EXTRACTION--Two reviewers participated in extracting the data with the aim of presenting a balanced and comprehensive review of the subject. DATA SYNTHESIS--Thrombolysis in acute myocardial infarction reduces mortality in men and women, although women may have a reduced mortality benefit compared with men. Angioplasty and the newer interventional devices result in greater procedural morbidity but similar if not better long-term outcomes in women. Women may have a greater mortality rate than men with coronary artery bypass surgery, although studies suggest that outcome after bypass surgery may depend more on coronary size and preoperative risk factors than on gender itself. CONCLUSIONS--The existence of gender differences in the course of coronary heart disease and response to revascularization and reperfusion strategies suggests the need for unique clinical approaches to the female patient with coronary heart disease and stresses the importance of developing randomized trials that enroll adequate numbers of women and that are designed to answer gender-specific questions.     

Prognostic value of a normal or nonspecific initial electrocardiogram in acute myocardial infarction

CONTEXT: Although previous studies have suggested that normal and nonspecific initial electrocardiograms (ECGs) are associated with a favorable prognosis for patients with acute myocardial infarction (AMI), their independent predictive value for mortality has not been examined. OBJECTIVE: To compare in-hospital mortality among patients with AMI who have normal or nonspecific initial ECGs with that of patients who have diagnostic ECGs. DESIGN, SETTING, AND PATIENTS: Multihospital observational study in which 391 208 patients with AMI met the study criteria between June 1994 and June 2000 and had ECGs that were normal (n = 30 759), nonspecific (n = 137 574), or diagnostic (n = 222 875; defined as ST-segment elevation or depression and/or left bundle-branch block). A logistic regression model was constructed using a propensity score for ECG findings and data on demographics, medical history, diagnostic procedures, and therapy to determine the independent prognostic value of a normal or nonspecific initial ECG. MAIN OUTCOME MEASURES: In-hospital mortality; composite outcome of in-hospital death and life-threatening adverse events. RESULTS: In-hospital mortality rates were 5.7%, 8.7%, and 11.5% while the rates of the composite of mortality and life-threatening adverse events were 19.2%, 27.5%, and 34.9% for the normal, nonspecific, and diagnostic ECG groups, respectively. After adjusting for other predictor variables, the odds of mortality for the normal ECG group was 0.59 (95% confidence interval [CI], 0.56-0.63; P<.001) and for the nonspecific group was 0.70 (95% CI, 0.68-0.72; P<.001), compared with the diagnostic ECG group. CONCLUSION: In this large cohort of patients with AMI, patients presenting with normal or nonspecific ECGs did have lower in-hospital mortality rates than those of patients with diagnostic ECGs, yet the absolute rates were still unexpectedly high.     

Starting thrombolytic therapy for patients with acute myocardial infarction in Accident and Emergency Department: from implementation to evaluation.

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急性心肌梗死患者院内死亡及影响因素的回顾性分析

目的 探讨导致急性心肌梗死(AMI)患者院内死亡的原因并分析可预测院内死亡的因素。方法 回顾性分析2006年12月至2012年1月入院的1 319例AMI患者的一般情况、既往病史及家族史、入院时检查、临床诊断、并发症、治疗情况及院内死亡、死亡原因。结果 (1)近5年AMI院内死亡率为7.4%,其中女性死亡率高于男性(13.2% vs 5.9%,P=0.000),未手术者死亡率高于手术者(31.4% vs 3.4%,P=0.000),急诊手术的患者死亡率高于择期手术的患者(5.0% vs 2.2%,P=0.008)。心源性休克的发生率为10.6%;并发心源性休克患者的死亡率达47.1%,其中未手术的患者死亡率明显高于急诊手术的患者和择期手术的患者(80.4% vs 34.5%、17.6%,P=0.000)。(2)AMI患者院内死亡(控制性别)与年龄、尿酸、尿素、肌酐、胱抑素C、血糖、白细胞、肌钙蛋白峰值、B型钠尿肽(BNP)、并发心律失常、并发心源性休克、并发Killip 3～4级、使用主动脉内球囊反搏(IABP)、未手术治疗呈正相关;与红细胞、血红蛋白、红细胞压积、药物使用率呈负相关。(3)女性、年龄大、高尿素、高血糖、高肌钙蛋白峰值、高BNP、并发心律失常、并发心源性休克、并发Killip 3～4级、未手术治疗、使用IABP、未使用药物是院内死亡的独立危险因素。结论 积极再灌注治疗是改善AMI患者尤其是并发心源性休克者早期预后的最佳治疗措施。应重视年龄、尿素、血糖、肌钙蛋白峰值、BNP对判断预后的价值并提高胱抑素C的检测率。