尿激酶溶栓治疗急性心肌梗死成功后相关冠状动脉形态动态观察

目的:观察急性心肌梗死(AMI)尿激酶溶栓成功后相关冠状动脉(冠脉)形态动态改变。方法:以溶栓成功的42例患者为观察对象,溶栓后90min和6个月时分别对其进行冠脉造影,然后用计算机辅助定量冠脉造影系统对溶栓后的冠脉病变处进行测量。结果:溶栓后90min42例患者中5例残余狭窄为90%～95%,32例残余狭窄为70%～90%,4例残余狭窄<50%,1例无明显狭窄;与溶栓后90min相比较,溶栓后6个月时34例患者残余狭窄无明显改变(P>0.05),7例残余狭窄明显改善(P<0.05)。结论:AMI静脉溶栓虽可挽救一部分濒临坏死的心肌,但大部分相关冠脉仍留有明显的残余狭窄,仍需行经皮冠脉介入术来解决残余狭窄问题。     

Release of chemoattractants and neutrophil activation in acute myocardial infarction immediately after successful recanalization of the infarct-related vessel by angioplasty

The study investigated inflamatory responses in evolving myocardialinfarction. Fifteen patients with acute myocardial infarction,who had undergone balloon recanalization of the infarct-relatedcoronary artery within 4 h after onset of symptoms, were examined.Blood samples were obtained through the guiding catheter andfrom the pulmonary artery before and immediately after successfulrecanalization. After recanalization, plas from the pulmonaryartery was 47% (quartiles: l9%, 78; P =0·001) more chemotacticto neutrophils from normal donors than before recanalization.Furthermore, significant changes in neutrophil function werefound in the pulmonary artery. Compared to the values beforerecanalization, the nitroblue tetrazolium score rose by 31%(quartiles: 4%, 37% P=0·003), FMLP-stimulated superoxideanion production by 10% (quartiles: 0%, 39% P=0·020),and chemotaxis by 46% (quartiles: 0%, 81%, P=0·011),while neutrophil filterability decreased by 28% (quartiles:15%, 47%; P=0·010). No significant changes in neutrophilparameters were found in the arterial blood The study indicatesthat chemoattractants are released in the early reperfusionperiod of evolving myocardial infarction. These chemoattractantsmay act as inflammatory mediators causing neutrophil activation.     

Long-term clinical outcomes after rescue angioplasty are not different from those of successful thrombolysis for acute myocardial infarction.

AIMS: The long-term value of rescue percutaneous transluminal coronary angioplasty (PTCA) in patients with ST-segment elevation myocardial infarction who received thrombolytic therapy but failed to achieve early recanalization of the artery is still debated. This study aimed to compare long-term outcomes after successful thrombolysis vs. systematic attempted rescue PTCA. METHODS AND RESULTS: A total of 362 consecutive patients with STEMI hospitalized within 6 h of symptom onset and treated with intravenous thrombolytic therapy were studied. Of these, 345 underwent coronary angiography within 90 min. Sixty per cent of patients achieved TIMI 3 flow and were treated medically; the in-hospital death rate in this group was 4%. Nine per cent of patients had TIMI 2 flow and 31% TIMI 0-1 flow. In this latter group, rescue PTCA was attempted in 85.8% with a hospital death rate of 5.5% (20% with failed vs. 4% with successful rescue PTCA, P=0.03). Eight year actuarial survival without recurrent myocardial infarction was no different in patients who had successful thrombolytic therapy and in patients with attempted rescue PTCA [78 and 95% CI (71-85) vs. 78 and 95% CI (68-87), respectively, hazard ratio: 0.93 (0.52-1.65), P=0.80]. Total mortality, cardiac mortality, and other composite endpoints also did not differ between groups. CONCLUSION: Routine attempted rescue PTCA 90 min after thrombolytic therapy in patients with persistent occlusion of the infarct-related vessels achieves long-term clinical outcomes which do not differ from those obtained by successful thrombolysis.     

Relationship of admission haematological indices with infarct-related artery patency in patients with acute ST-segment elevation myocardial infarction treated with primary angioplasty

OBJECTIVE: Mean platelet volume (MPV), a marker for platelet reactivity, and white blood cell count (WBC-C), a marker for inflammation, have been shown to be predictive of unfavourable outcomes among survivors of ST elevation myocardial infarction (STEMI). The relationship of admission MPV and WBC-C with infarct-related artery (IRA) patency is not clear. We aimed to evaluate the value of admission MPV and WBC-C for the prediction of IRA patency, in patients with acute STEMI treated with primary percutaneous coronary intervention. METHODS: Blood samples were obtained on admission in 351 STEMI patients. The patients who had thrombolysis in myocardial infarction (TIMI) 3 flow in initial angiography constituted the IRA patent group and others having less than TIMI 3 flow constituted the IRA occluded group. RESULTS: In 16% of the patients, IRAs were found to be patent on initial angiography. Patients in the IRA occluded group had higher admission MPVs (9.3+/-1.2 vs. 8.6+/-1.3 fl, P<0.001) and higher WBC-C (13.3+/-4.8 vs. 11.0+/-2.9, P=0.002) compared with patients in the patent IRA group. In regression analysis, WBC-Cs [beta, 0.131; odds ratio (OR), 1.140; 95% confidence interval (CI), 1.043-1.245, P=0.004)] and MPV (beta, 0.519; OR, 1.680; 95% CI, 1.206-2.339, P=0.002) were found to be independent predictors of occluded IRA. The best cutoff value of MPV for predicting an occluded IRA was determined to be 8.55 fl with a sensitivity of 74% and a specificity of 60%. CONCLUSION: MPV and WBC-C at admission might be valuable in the prediction of IRA patency and in planning the need for adjunctive therapy to improve outcomes in patients with STEMI undergoing percutaneous coronary intervention.     

静脉溶栓冠脉再通对急性心肌梗死生存率的影响

目的：探讨静脉溶栓对急性心肌梗死存活率的影响。方法：对64例经静脉溶栓治疗的患,以临床血管再通为标准,对比分析再通组与未通组的存活率。结果：血管再通组存活率为97．6％,死亡率2．4％,未通组存活率为73％,死亡率27％,结论：急性心肌梗死静脉溶栓治疗是提高生存率的关键。     

Comparison of left ventricular function and contractile reserve after successful recanalization by thrombolysis versus rescue percutaneous transluminal coronary angioplasty for acute myocardial infarction

To determine how coronary reperfusion affects rest and exercise ventricular function after acute myocardial infarction (AMI), 63 patients with a patent infarct artery after intravenous thrombolytic therapy (lysis) were compared with 27 patients who failed thrombolysis but had successful acute recanalization by percutaneous transluminal coronary angioplasty (PTCA) as a "rescue" procedure. Contrast ventriculography was performed acutely and on day 7. Resting radionuclide ventriculography was performed at 24 hours and repeated with exercise on day 30. There were no differences in global ejection fraction (EF) between the 2 groups during acute contrast ventriculography. However, by 24 hours, the EF had deteriorated in the rescue group (40 +/- 17 vs 49 +/- 11% in the lysis group, p less than or equal to 0.05). No improvement occurred in either group on day 7. By day 30, an improvement in resting radionuclide EF 5.9 +/- 1.9% occurred in rescue patients and the difference between rescue and lysis groups was no longer significant (46 +/- 14 vs 50 +/- 11%, p = 0.12). A normal (greater than or equal to 5%) increase in EF with exercise occurred in 64%, with either normal or exercise-enhanced regional wall motion present in 67% of patients. A significant increase in EF occurred within the rescue group, from 46 +/- 14% at rest to 50 +/- 15% at peak exercise (p less than or equal to 0.0005). The EF increased with exercise from 50 +/- 11 to 58 +/- 15% in the lysis group (p less than or equal to 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)     

A randomized trial of coronary stenting versus balloon angioplasty as a rescue intervention after failed thrombolysis in patients with acute myocardial infarction

OBJECTIVES: This study was conducted to assess whether coronary stenting produces better results compared with balloon angioplasty in patients with acute myocardial infarction (AMI) after failed thrombolysis. BACKGROUND: Little evidence exists on the value of rescue mechanical reperfusion after failed thrombolysis. METHODS: This open-label, randomized study enrolled 181 patients with AMI referred for failed thrombolysis performed within the previous 24 h. The patients had to have a Thrombolysis In Myocardial Infarction (TIMI) flow grade of 相似文献   

Functional role of microvascular integrity in patients with infarct-related artery patency after acute myocardial infarction

AIMS: The study was set up to evaluate the functional role of post-infarctpreserved microvascular integrity. Low dose dobutamine echocardiographyand myocardial contrast echocardiography were used to studypatients before hospital discharge who had suffered a recentmyocardial infarction and had a patent infarct-related artery(TIMI flow grade 3). METHOD: In the dysfunctioning infarct area, the wall motion score indexwas calculated at baseline, during the dobutamine infusion andat the 3 month follow-up echocardiogram; contrast echocardiographywas performed at the time of coronary angiography, before hospitaldischarge. RESULTS: In patients with more than 50% of the dysfunctioning infarctarea opacified at contrast echocardiography (group A), regionalwall motion score index decreased, compared to baseline, duringthe dobutamine infusion (1·97 ± 0·78 vs2·5 ± 0·35 at baseline; P<0·001)and at follow-up echocardiography (1·83 ± 0·63vs 2·5 ± 0·35 at baseline; P<0·001).In patients with less extensive microvascular integrity as revealedby contrast echocardiography (group B), regional wall motionscore index did not decrease from baseline during either thedobutamine infusion (2·73 ± 0·21 vs 2·81± 0·20 at baseline; P=ns) or at follow-up (2·81± 0·20 vs 2·81 ± 0·20 atbaseline; P=ns). CONCLUSION: In patients with post-infarct dysfunctioning myocardium buta patent infarct-related artery, microvascular integrity, asassessed by myocardial contrast echocardiography, is an indicatorof myocardial viability in terms of preserved contractile reserve,as demonstrated by dobutamine infusion and functional recoveryat follow-up.     

Bleeding risks with abciximab after full-dose thrombolysis in rescue or urgent angioplasty for acute myocardial infarction

BACKGROUND: The bleeding risk associated with platelet glycoprotein IIb/IIIa inhibition in patients undergoing percutaneous transluminal coronary angioplasty (PTCA) after full-dose thrombolysis for acute myocardial infarction (AMI) is unclear. We examined the risk and predictors of bleeding complications in patients with AMI who received abciximab during rescue or urgent PTCA after full-dose thrombolytic therapy. METHODS: A multicenter retrospective cohort of 147 consecutive patients who underwent PTCA within 48 hours after full-dose thrombolysis for AMI was studied. Bleeding events (major, minor, nuisance) from the onset of AMI to discharge were compared between those who received abciximab (n = 57) and those who did not (n = 90). RESULTS: Baseline clinical characteristics were similar between the two groups. Despite lower doses of procedural heparin, the incidence of non-coronary artery bypass graft-related major and minor bleeding was higher in the abciximab group than in controls (63% vs 39%, P =.004). Although the risk of major bleeding was 4-fold with abciximab (12% vs 3%, P =.04), only one intracranial and one fatal bleeding event occurred. Multivariable regression identified abciximab therapy as the most powerful independent predictor of combined major and minor bleeding, with a hazard risk ratio of 1.9 (P =.04). CONCLUSIONS: In the setting of rescue or urgent PTCA within 48 hours after full-dose thrombolytic therapy after AMI, major and particularly minor bleeding were frequently encountered. The adjunctive use of abciximab increased these bleeding risks by approximately 2-fold.     

Late angiographic follow-up after successful coronary arterial thrombolysis and angioplasty during acute myocardial infarction

Emergency percutaneous transluminal coronary angioplasty (PTCA) is accepted as an important reperfusion intervention for acute myocardial infarction (AMI). Although its primary success rate is well documented, the frequency of restenosis after this procedure is unclear. The frequency of restenosis was determined in patients undergoing emergency PTCA at least 6 months after PTCA was performed during AMI. Of 66 consecutive patients undergoing emergency PTCA, 25 had a second, elective catheterization at an average of 22 months after AMI and 6 underwent repeat catheterization because of recurrent chest pain. Restenosis of the PTCA site was found in 10 of the 31 patients (32%) restudied. Also, 14 (45%) of these 31 patients showed progression of narrowing in the non-infarct-related coronary arteries. In summary, patients in whom AMI is treated by PTCA are at risk for restenosis and for progressive narrowing of the non-infarct artery.     

Primary angioplasty versus systemic thrombolysis in anterior myocardial infarction

OBJECTIVES: This study compares the efficacy of primary angioplasty and systemic thrombolysis with t-PA in reducing the in-hospital mortality of patients with anterior AMI. BACKGROUND: Controversy still exists about the relative benefit of primary angioplasty over thrombolysis as treatment for AMI. METHODS: Two-hundred and twenty patients with anterior AMI were randomly assigned in our institution to primary angioplasty (109 patients) or systemic thrombolysis with accelerated t-PA (111 patients) within the first five hours from the onset of symptoms. RESULTS: Baseline characteristics were similar in both groups. Primary angioplasty was independently associated with a lower in-hospital mortality (2.8% vs. 10.8%, p = 0.02, adjusted odds ratio 0.23, 95% confidence interval 0.06 to 0.85). During hospitalization, patients treated by angioplasty had a lower frequency of postinfarction angina or positive stress test (11.9% vs. 25.2%, p = 0.01) and less frequently underwent percutaneous or surgical revascularization after the initial treatment (22.0% vs. 47.7%, p < 0.001) than did patients treated by t-PA. At six month follow-up, patients treated by angioplasty had a lower cumulative rate of death (4.6% vs. 11.7%, p = 0.05) and revascularization (31.2% vs. 55.9%, p < 0.001) than those treated by t-PA. CONCLUSIONS: In centers with an experienced and readily available interventional team, primary angioplasty is superior to t-PA for the treatment of anterior AMI.     

Long-term beneficial effect of infarct-related artery patency in acute anterior myocardial infarction in patients with poor myocardial viability in the region-at-risk.

BACKGROUND: Several studies have demonstrated the benefit of the patency of infarct-related artery (IRA) in acute myocardial infarction (AMI). However those studies have not been concerned with myocardial viability in the region-at-risk. In the present study the effect of the patency of IRA was investigated in the setting of anterior AMI with poor viable myocardium in the risk region. METHODS AND RESULTS: From 1993 to 1996 patients with a first time anterior AMI and poor viable myocardium in the region-at-risk at 1 month after onset were identified and enrolled. Patients with a totally occluded IRA were included in the Non-Open group (n=44), and patients with a reperfused IRA were included in the Open group (n=49). At 5 years after onset, left ventricular function was better preserved in the Open group than in the Non-Open group (p<0.05). Kaplan-Meier survival curves for cardiac mortality and event-free survival curves revealed poor prognoses in the Non-Open group over a 5-year period (p<0.05, respectively). The advantages of a patent IRA were further seen in health-related quality-of-life outcomes (p<0.05). CONCLUSIONS: Even in patients with poor myocardial viability after an anterior AMI, the patency of the IRA is strongly associated with improved long-term survival, independent of residual myocardium viability.     

Percutaneous transluminal coronary angioplasty versus thrombolysis in acute myocardial infarction: A meta-analysis

While percutaneous transluminal coronary angioplasty (PTCA) as a primary modality for treating acute myocardial infarction (MI) has been shown to have important advantages over thrombolysis, a survival benefit has not been demonstrated because of the small size of the individual trials. To increase the statistical power to detect a survival benefit, we performed a meta-analysis of trials of PTCA and thrombolysis. We pooled the data for all randomized, controlled trials; randomized, controlled trials stratified according to thrombolytic agent [streptokinase vs. tissue plasminogen activator (TPA)]; and all trials. Pooling was performed by calculating the Mantel-Haenszel odds ratio with the Robins, Greenland, and Breslow estimate of variance. Calculation of the Q statistic was performed to assess heterogeneity. For all four analyses, the odds ratio indicated a significant survival advantage of PTCA over thrombolysis: all randomized controlled trials [0.57,95% confidence index (CI): 0.48,0.68)]; streptokinase trials [0.61,95% CI: 0.43,0.87); TPA trials (0.52,95% CI: 0.36,0.76); all trials (0.51,95% CI: 0.43,0.61). The Q statistic was not significant for any of the analyses. The results of our meta-analysis support the hypothesis that PTCA is associated with a significant reduction in mortality compared with thrombolysis.     

Efficacy of coronary angioplasty following conventional coronary thrombolysis in patients with acute myocardial infarction

The efficacy of combined thrombolysis and angioplasty for the purpose of coronary reperfusion after acute myocardial infarction has been controversial. The present study was conducted, therefore, to evaluate the effects of angioplasty following administration of conventional thrombolytic agents on the long-term prognosis of acute myocardial infarction patients. A total of 409 patients admitted to the hospital within 12 hours of the onset of infarction between January 1990 and May 2001 were studied retrospectively. These included 151 patients treated with thrombolysis alone (group T), 73 patients treated with angioplasty alone (group A), and 35 patients treated with angioplasty after thrombolysis (group T&A). Group T&A had shorter intervals from onset to initial treatment than group A (3.0 hours vs 6.3 hours, p < 0.01), a higher reperfusion success rate than group T (91.4% vs 74.8%, p < 0.01), and more improved left ventricular wall motion than group A. One-year cardiac mortality rates tended to be higher in group T, which had a higher rate of unsuccessful reperfusion than groups T&A or A (8.1% vs 3.4% vs 3.5%). The frequencies of hemorrhagic complications were similar among the 3 groups. From these findings, we conclude that thrombolytic therapy with subsequent angioplasty is an effective strategy for achieving cardiac reperfusion following acute myocardial infarction.     

Inducible ventricular arrhythmias and patency of infarct-related artery in survivors of acute myocardial infarction.

BACKGROUND: Patency of infarct-related artery in patients who suffered an acute myocardial infarction (AMI) has been shown to be associated with improved survival. Ventricular tachyarrhythmias induced by programmed electrical stimulation may be predictive of arrhythmic events and sudden death. HYPOTHESIS: The study was undertaken to assess the possible effect of a patent infarct-related coronary artery on induced ventricular tachyarrhythmias during programmed ventricular stimulation in survivors of AMI. METHODS: In this prospective study, programmed electrical stimulation was performed before hospital discharge (14 +/- 2 days) in 79 patients who survived an AMI. Patients were subdivided into two groups: Group I with patent infarct-related coronary artery (n = 64) and Group 2 with occluded infarct-related artery (n = 15) at coronary angiography performed at 14 +/- 2 days. These two groups were comparable in terms of mean left ventricular ejection fraction, location of infarct-related artery, number of diseased vessels, peak creatine kinase value, and infarct location. RESULTS: Ventricular arrhythmias were induced in 21 patients ( 32.6%) of Group I and 4 patients (26.6%) of Group 2. This difference was not statistically significant. CONCLUSION: This study suggests that ventricular arrhythmias induced by programmed ventricular stimulation in survivors of AMI did not differ whether the infarct-related artery was patent or occluded. Other factors may play a role in electrical instability as assessed by programmed ventricular stimulation.     

曲美他嗪对急性心肌梗死溶栓再通患者的心肌保护作用

目的探讨曲美他嗪对急性心肌梗死溶栓再通患者的心肌保护作用.方法68例因急性心肌梗死而行早期静脉溶栓的患者随机分为曲美他嗪组(T组)和对照组(C组),T组在常规治疗的基础上于溶栓前后给予曲美他嗪口服,C组不用曲美他嗪.比较两组再通患者间肌酸激酶(CK)峰值浓度、CK恢复正常的时间、再灌注心律失常及2周后的左室功能.结果(1)T组和C组溶栓再通患者分别为24例和23例,两组临床基线资料无统计学差异.(2)T组CK和CK-MB峰值浓度分别为(1265±728)和(114±67)U/L,显著低于C组的(1739±814)和(159±72)U/L(P＜0.05);T组CK及CKMB峰值时间和恢复正常的时间均显著短于C组(P＜0.05或0.01).(3)T组33%(8例)发生再灌注心律失常,显著低于C组的65%(15例)(P＜0.05).(4)2周后超声心动图检测的左室射血分数T组为(58±10)%,显著高于C组的(51±10)%(P＜0.05);室壁运动指数T组为1.25±0.23,显著低于C组的1.43±0.25(P＜0.05).结论对溶栓再通的急性心肌梗死患者,曲美他嗪可能缩小梗死面积,减轻再灌注损伤,保护心脏功能.     

Primary versus rescue percutaneous coronary intervention in patients with acute myocardial infarction

OBJECTIVE: To compare angiographic and clinical outcomes of patients with acute myocardial infarction (AMI) who underwent primary percutaneous coronary intervention (PCI) versus rescue PCI following failed thrombolysis. BACKGROUND: Patients presenting with AMI are treated either with primary PCI or with thrombolysis. When thrombolysis fails, rescue PCI is performed. METHODS AND RESULTS: We compared the outcome of 105 consecutive patients with AMI who underwent either primary PCI (60 patients) or rescue PCI (45 patients) between January 1997 and January 1999. The patients were followed for up to 6 months. Time delay to reperfusion was significantly longer in the rescue PCI group (354 vs. 189 min; p < 0.001). The majority of patients received a stent (93%). Glycoprotein (GP) IIb/IIIa inhibitors were used in 53% of patients in the primary PCI group and in 22% in the rescue group. TIMI grade 3 flow was achieved in 93.3% of patients in the primary PCI group and in 88.8% in the rescue group (p = 0.08). Post-procedure ejection fraction was 53% in the primary PCI group and 47% in the rescue group (p = 0.014). A composite endpoint of death, recurrent MI, repeat PCI, coronary artery bypass grafting (CABG) and recurrent angina at 6 months occurred in 35% of the patients in the primary PCI group and 26.7% in the rescue group (p = 0.36). CONCLUSION: Despite a significant delay to reperfusion and a lower immediate post-procedure ejection fraction, the clinical outcome of patients treated with rescue PCI following failed thrombolysis appears to be similar to that of patients treated with primary PCI at 6 months.