急性ST段抬高心肌梗死中心脏破裂的认识

目的：研究对急性ST段抬高心肌梗死中心脏破裂的认识。方法选择2010年10月-2011年12月,我院收治的急性ST段抬高心肌梗死患者150例,对患者的心脏破裂进行诊断,并根据诊断结果将150例患者分成12例心脏破裂组,138例无心脏破裂组。观察两组患者的性别,年龄,治疗使用的方法。结果在心脏破裂中,年龄、性别,治疗方法的不同对其均有影响（P〈0.05）。结论心脏破裂是急性ST段抬高心肌梗死中最严重的并发症,了解急性ST段抬高心肌梗死中出现心脏破裂的因素,为临床医生在治疗时提供有利依据,延长患者的生命。     

急性心肌梗死并发心脏破裂19例分析

目的 :探讨急性心肌梗死 (AMI)伴心脏破裂的临床特征、早期诊断及防治措施。方法 :对 AMI院内死亡的 112例患者中经心包穿刺或超声证实为心脏破裂者 19例 ,进行回顾性分析。结果 :年龄≥ 6 0岁者占 89.5 % ,女性发生率多于男性 (P <0 .0 5 ) ,首次发生梗死者 94.7% ,梗死累及广泛前壁者 89.5 % ,心脏破裂时 78.9%患者处于应激状态 ,所有患者均发生在 AMI第 1周内。心脏破裂 6 8.4%的患者表现为心跳骤停、电 -机械分离 ,其余表现为突然血压下降伴心包填塞或心力衰竭。结论 :AMI早期对老年、女性、首次发生的、特别是广泛前壁心肌梗死 ,应积极处理 ,避免增加心脏负担 ,防止心脏破裂。对疑有心脏破裂者 ,尽早行心包穿刺、超声检查 ,争取手术治疗     

急性心肌梗死患者合并心脏破裂的分析

目的:观察急性心肌梗死(AMI)患者发生心脏破裂的特点。方法:连续入选2004年1月至2006年2月收入我院心内科监护室(CCU)确诊为AMI患者共1324例,经超声心动图证实心脏破裂18例。结果:前壁梗死509例,下壁梗死528例,非ST段抬高心肌梗死287例。发生心脏破裂18例(1.36%),其中游离壁破裂9例,室间隔穿孔9例。13例发病72h内破裂,5例在发病4～7d破裂。男性8例(8/973,0.82%),女性10例(10/351,2.85%),女性明显高于男性(P=0.005)。发生心脏破裂患者年龄[(72.6±8.2)岁]明显高于无破裂者[(63.3±12.2)岁,P=0.000]。成功再灌注治疗者心脏破裂发生率(5/575,0.87%)明显少于无再灌注者(13/749,1.74%,P=0.041)。所有合并心脏破裂者全部死亡。前壁梗死合并心脏破裂的发生明显多于下壁和非ST段抬高心肌梗死(2.16%,1.32%,0%,P=0.041)。结论:AMI合并心脏破裂的发生率为1.36%,其预后极差。女性、高龄、前壁梗死患者易于发生心脏破裂。成功再灌注治疗减少心脏破裂的发生。     

急性心肌梗死并发心脏破裂30例临床分析

目的:探讨急性心肌梗死(acute myocardial infarction,AMI)并发心脏破裂(cardiac rupture,CR)的临床特征、早期诊断及防治方法。方法:连续选取我院2002年3月至2010年3月住院确诊为急性心肌梗死的1 526例患者,经超声心动图或心包穿刺证实为心脏破裂的30例患者,结合冠状动脉造影结果进行分组分析。结果:1.发生CR患者年龄明显高于无破裂者(P<0.05);女性高于男性(P<0.05);2.合并高血压、糖尿病、血肌酐异常患者易发生CR;3.急性ST段抬高性前壁AMI并发CR的发生率明显增高(P<0.05);4.左心室舒张末径增大,射血分数(EF)<50%者易发生CR(P<0.05);LAD严重病变尤其是开口病变及LAD合并3支血管病变发生率明显增高(P<0.05);5.早期成功再灌注治疗者CR发生率明显少于无再灌注者(P<0.05)。结论:AMI合并CR预后明显欠佳。女性、高龄、前壁梗死、LAD严重病变及延迟再灌注患者易于发生。床旁超声心动图有助于早期诊断,积极预防及早期成功再灌注治疗可减少CR的发生。     

葛根素注射液对急性心肌梗死患者梗死面积及心功能的影响

目的：评价葛根素注射液对急性心肌梗死患梗死面积及心功能的影响。方法：68例急性前壁心肌梗死患随机分为葛根素治疗组治疗组（n=37)和对照组（n=31)。记录每例患入院即刻和第3、7、14、21d12导联心电图,用Wagner的QRS记分法进行QRS记分,预测梗死面积。于治疗21d后行核素心血池心室造影,判断左室收缩与舒张功能。并测定全部患治疗前后的血浆脂质过氧化物（LPO）、红细胞膜超氧化物歧化酶（SOD）及血管内皮细胞数（CEC）水平。结果：葛根素治疗后14d和21d,QRS记分较对照组显降低,梗死面积缩小。左室射血分数（LVEF）和左室峰充盈率（PFR）明显增高。而且,治疗组的LPO及CEC显降低,SOD显升高。结论：葛根素注射液对防止急性心肌梗死的梗死延展,对保护缺血心肌的损伤及心功能的恢复有一定的作用。     

Time-to-treatment significantly affects the extent of ST-segment resolution and myocardial blush in patients with acute myocardial infarction treated by primary angioplasty.

AIMS: The prognostic role of time-to-treatment in primary angioplasty is still a matter of debate. The aim of our study was to evaluate the relationship between time-to-treatment and myocardial perfusion in patients with ST-segment-elevation myocardial infarction (STEMI) treated by primary angioplasty. METHODS AND RESULTS: Our study population consisted of 1072 patients with STEMI treated by primary angioplasty from 1997 to 2001. Myocardial perfusion was evaluated by using ST-segment resolution and myocardial blush grade. Time-to-treatment was defined as the time from symptom-onset to the first balloon inflation. Time-to-treatment was significantly associated with the extent of ST-segment resolution, myocardial blush grade, enzymatic infarct size, and 1-year mortality. After adjustment for baseline confounding factors, time-to-treatment was still associated with impaired ST-segment resolution (adjusted OR [95% CI]=1.01 [1.01-1.02], p<0.001) and myocardial blush (adjusted OR [95% CI]=1.01 [1.01-1.02], p<0.0001). CONCLUSIONS: This study shows that in patients with STEMI treated by primary angioplasty prolonged ischaemic time is associated with impaired myocardial perfusion, larger infarct size, and higher 1-year mortality. Therefore, all efforts should be made to shorten ischaemic time as much as possible to achieve better myocardial perfusion and myocardial salvage in primary angioplasty for STEMI.     

老年急性心肌梗死早期溶栓对心率变异性的影响

目的　 研究老年急性心肌梗死 (AMI)早期溶栓治疗对心率变异性 (HRV)的影响。　 方法 　测定AMI组 13 6例和健康对照组 3 0例HRV时域 6项指标 ,并作对比分析。　 结果 　AMI组的平均R R间期的标准差 (SDAR R)、平均R R间期标准差均值 (SD)、平均R R间期标准差的标准差 (SDSD)、相邻R R间期差值均方根的均值 (mSASD)低于健康对照组 ,分别为 ( 3 9± 14 )ms和 ( 5 2± 2 6)ms(P <0 0 1)、( 3 1± 12 )ms和 ( 4 3± 17)ms(P <0 0 1)、( 11± 6)ms和 ( 15± 7)ms(P <0 0 5 )、( 2 0± 10 )ms和 ( 2 8± 18)ms(P <0 0 5 ) ;AMI再通组的平均R R间期(AVGR R)、SDAR R、平均R R间期的变异系数 (CV )、SD、SDSD和rmSASD高于未溶栓组和溶栓未通组 ,P <0 0 1,但与健康对照组相比无统计学意义 ;前壁心肌梗死溶栓后SDAR R( 5 8± 18)ms低于下壁心肌梗死 ( 72± 2 5 )ms ,但无统计学意义 ;溶栓再通后心源性死亡者SD低于溶栓再通后的存活者。　 结论　成功的溶栓治疗可提高HRV ,改善AMI后自主神经系统功能失衡 ,减少由此引起的致命性心律失常等事件的发生 ,改善患者预后     

急性心肌梗死伴与不伴心脏破裂临床病理分析

目的探讨急性心肌梗死(AMI)心脏破裂的原因、好发部位及与冠状动脉狭窄的关系。方法AMI死亡并行尸体解剖检查63例,其中AMI伴心脏破裂18例,不伴心脏破裂45例。结果AMI伴心脏破裂组高血压、溶栓治疗及首次心肌梗死发生率明显升高(P<0．05),而性别、梗死后心绞痛、心源性休克、心肌酶谱峰值、梗死面积与心脏破裂无明显关系(P>0．05)。心脏破裂多发生在AMI后3d内,第1天占33．3％,多见于前壁、心尖部及下壁。尸体解剖示破裂处心肌变薄伴出血,梗死相关血管多为高度狭窄。结论高血压、溶栓治疗及首次心肌梗死均为心脏破裂的危险因素。AMI的超急性期是心脏破裂的高发期。前降支及右冠状动脉高度狭窄导致心脏破裂增加。     

溶栓治疗对急性心肌梗死患者预后的影响

目的 :探讨溶栓治疗对急性心肌梗死 ( AMI)患者急性期和远期预后的影响。方法 :将14 3例 AMI患者分为溶栓再通组 ( 35例 )、未通组 ( 2 3例 )和对照组 ( 85例 ) ,比较急性期和远期预后。结果 :急性期心脏性死亡率再通组 ( 2 .9% )、未通组 ( 13.0 % )明显低于对照组 ( 2 5 .9% ) ;其它心脏事件发生率、左室功能及运动耐量比较 ,再通组均明显优于其他两组 ,而未通组大多数指标亦优于对照组 ( P <0 .0 5～ 0 .0 1)。远期随访 ,再通组、未通组 3年生存率分别为 94.3%和 82 .6% ,明显高于对照组 ( 71.8% ) ( P <0 .0 5～ 0 .0 1) ;但心绞痛、再梗、左室功能及运动耐量三组间无显著性差异( P >0 .0 5 )。结论 :溶栓治疗能显著改善 AMI患者急性期预后 ,即使临床间接指征判定未通者 ,其部分指标亦优于对照组。溶栓治疗能提高 AMI患者 3年生存率 ,但对远期再梗、心绞痛、左室功能及运动耐量改善不明显。     

前壁及广泛前壁心肌梗死患者溶栓前后心脏储备功能观察

目的 :通过容量负荷试验评价急性心肌梗死 (AMI)溶栓再通与溶栓未通或未溶栓者早期的基础心功能及心脏储备功能的动态演变。方法 :选择 30例前壁及广泛前壁AMI患者分为溶栓再通组与溶栓未通或未溶栓组 ,在溶栓前后 2 4h内行漂浮导管连续监测及容量负荷试验 ,进行溶栓前后及组间的比较。结果 :①溶栓再通组溶栓后 4h心功能出现明显改善 ,平均肺动脉压、肺嵌压明显下降 (P <0 .0 5 ,<0 .0 1) ,心脏指数明显升高(P <0 .0 5 )。②溶栓后 6h溶栓再通组负荷试验阴性率为 72 .2 % ,至 2 4h负荷试验阴性率为 10 0 %。③基础心功能处于正常低限者 ,负荷试验后表现为负荷试验阳性。结论 :溶栓再通后 ,随着基础心功能的改善 ,心脏储备功能也逐渐得以恢复 ,心脏储备功能的恢复要晚于基础心功能的改善。     

溶栓治疗对急性心肌梗死患者运动耐量的影响

目的 :探讨溶栓治疗对急性心肌梗死 (AMI)患者急性期和远期运动耐量的影响。方法 :将 143例 AMI患者分为溶栓再通组 (35例 )、未通组 (2 3例 )和非溶栓组 (85例 ) ,比较三组急性期和远期运动耐量。结果 :急性期 ,再通组的运动量、运动时间、最大心率、心率血压乘积均明显高于未通组和非溶栓组 (P<0 .0 5 ) ,运动诱发的心绞痛或血压下降≥ 10 m m Hg(1m m Hg=0 .133k Pa)的比率明显低于后两者 (P <0 .0 5 )。远期随访 ,三组的运动量、最大心率、运动时间、心率血压乘积及运动诱发心绞痛或血压下降的比率均无显著性差异 (P >0 .0 5 )。结论 :溶栓再通能显著提高 AMI患者急性期运动耐量 ,但对远期运动耐量改善不明显     

高龄急性心肌梗死患者静脉溶栓治疗的临床观察

目的：探讨高龄（≥75岁）急性心肌梗死（AMI）患者静脉溶栓治疗的疗效和安全性。方法：将61例高龄AMI患者随机分为溶栓组和常规治疗组，溶栓组30例，在常规治疗基础上采用尿激酶（UK）静脉溶栓＋口服阿斯匹林（ASA）。常规治疗组31例，除不用UK外，其余治疗均与溶栓组相同。结果：血管再通率溶栓组为66．7％（20／30），常规治疗组为12．9％（4／31），两组血管再通率比较，差异有显著性（P＜0．05）。溶栓组住院4周病死率为3．3％，常规治疗组为22．6％，两组比较差异亦有显著性（P＜0．05）。溶栓组未见严重出血等并发症。结论：UK＋ASA治疗高龄AMI可以提高冠脉再通率，降低病死率和改善预后。     

糖尿病患者静脉溶栓治疗急性心肌梗塞临床对比研究

目的探讨糖尿病患者静脉溶栓治疗急性心肌梗塞临床近期疗效。方法冠心病监护病房(CCU)收治的182例急性心肌梗塞患者,分成糖尿病(DM-AMI)组、非糖尿病(NDM-AMI)组。其中DM-AMI组66例、NDM-AMI组116例。两组同时给予国产尿激酶静脉溶栓治疗。结果①DM-AMI组住院病死率为15.15％,明显高于NDM-AMI组的6.03％(χ2=4.17,P＜0.05);DM-AMI组静脉尿激酶溶栓治疗梗塞相关血管(IRA)的再通率为45.45％,明显低于NDM-AMI组的62.93％(χ2=5.23,P＜0.05),②DM-AMI组静脉血糖(BS)、肌酐(CR)、尿素氮(BUN)、胆固醇(TC)和甘油三酯(TG)浓度均显著高于NDM-AMI组(P＜0.01,P＜0.05);③DM-AMI组合并症明显高于NDM-AMI组,尤以心力衰竭最显著(36.36％vs12.97％,χ2=13.72,P＜0.001),其次为心源性休克(16.67％vs6.03％,χ2=5.33,P＜0.05)。结论静脉溶栓治疗急性心肌梗塞对非糖尿病患者合并急性心肌梗塞近期疗效显著,但对于糖尿病患者合并的急性心肌梗塞近期疗效不明显。     

Novel and innovative dosing regimens in thrombolytic therapy for acute myocardial infarction

Conclusions This review has dealt primarily with the rationale and results associated with the bolus administration of rt-PA and related compounds. The aim of bolus therapy is to increase the proportion of patients treated with thrombolytic therapy who can enjoy the benefits of early, complete, and sustained coronary patency. Bolus rt-PA appears to be a promising method of achieving very high early and complete coronary patency as outlined earlier. The reocclusion rate, however, appears to be similar to more standard regimens. Novel mutant and chimeric fibrinolytic agents may be the answer to the problem of sustained patency, but it seems more likely that adjuvent agents such as activated protein C or hirulog that can neutralize the thrombin released upon clot dissolution will not only accelerate thrombolysis, producing higher patency rates, but also greatly diminish the tendency to reocclusion [28,29].Thus, the ideal thrombolytic regimen of the future will probably comprise a single bolus of a fibrinolytic agent that rapidly dissolves clot but leaves the circulation quickly to minimize bleeding complications (a so-called hit and run drug) plus perhaps an infusion of a thrombin inhibitor that acts synergistically with the fibrinolytic agent during initial clot dissolution but remains present for long enough to prevent reocclusion until intervention can be undertaken. In any event, the current wealth of research encourages us that such a goal is now within reach.     

左旋卡尼丁对急性心肌梗死患者肌钙蛋白T和C-反应蛋白的影响及意义

目的探讨左旋卡尼丁(L-CN)对急性心肌梗死患者肌钙蛋白T(cTnT)和C-反应蛋白(CRP)含量的影响。方法2004年1~12月在沈阳医学院附属沈洲医院住院治疗的急性心肌梗死(AMI)患者25例,为试验组,给予L-CN4.0g/d,共用7d;另选AMI患者25例作为对照组。所有患者于用药前、用药第3天后,用药结束后检测cTnT和CRP。并于用药前和用药结束后行超声心动图检查及心肌灌注显像分析。结果用药前cTnT和CRP含量两组间差异无显著性意义(P>0.05)。用药第3天后试验组cTnT和CRP较对照组下降但差异无显著性意义;用药结束后试验组cTnT和CRP较对照组显著减低(P<0.05)。试验组在用药后左心室射血分数(LVEF)较对照组明显改善(P<0.05),心肌缺损面积缩小(P<0.05)。结论心肌梗死时给予L-CN治疗可降低血循环中cTnT和CRP含量,有利于心肌修复,缩小梗死面积。     

超高龄急性心肌梗死患者住院病死率及相关因素分析

目的 探讨超高龄急性心肌梗死(AMI)患者的院内病死率及相关因素.方法 采用回顾性队列研究方法,对自2002年1月至2010年2月期间住院年龄≥80岁超高龄AMI患者进行分析.结果 499例患者住院期间死亡97例,病死率为19.4％,其中ST段抬高急性心肌梗死(STEAMI)297例,死亡69例,病死率23.2％,非ST段抬高心肌梗死202例,死亡28例,病死率13.9％,两者差异有统计学意义(P=0.009).死亡组与存活组临床资料单因素比较显示:死亡组感染、消化道出血、高血压病史、完全性房室传导阻滞、心脏破裂、心功能KillipⅢ、Ⅳ级、肾功能不全及STEAMI的比例显著高于存活组(P值均＜0.05);而行急诊经皮冠状动脉介入治疗(PCI)的比例显著低于存活组(P＜0.05).多因素logistic回归分析显示:心功能Killip分级、完全性房室传导阻滞、肾功能不全、急诊支架植入及心肌梗死类型为高龄AMI患者院内死亡的独立预测因素.结论 心功能Killip分级、完全性房室传导阻滞、肾功能不全、是否行急诊植入支架及MI类型为超高龄AMI患者院内死亡的独立预测因素,对超高龄AMI患者在掌握适应证的前提下行PCI可提高其住院存活率.     

Free wall rupture (FWR) in patients with acute ST-elevation myocardial infarction (STEMI) receiving fibrinolytic therapy (FT): a 7-year prospective study

Previous studies have shown a paradoxical increase in early mortality in older patients (>70 years) with acute STEMI treated with fibrinolytic therapy (FT), which has been attributed to the development of free wall rupture (FWR). Our aim was to assess occurrence of FWR in STEMI patients receiving FT. In this 7-year prospective study, data from 1701 consecutive patients were obtained. We analyzed predictors of the in-hospital mortality in patients > 70 years old. The independent contribution of several variables to overall mortality and FWR development was assessed using multiple logistic regression analyses. The mortality of entire cohort was 18% (306/1701). Diabetes mellitus, anterior infarction, smoking, female gender and hypercholesterolemia were independent predictors of in-hospital mortality. FT was given to 18% of all patients (304/1701) of which 13% died (39/304). FWR was 18.4-times more often in patients who received FT. Among patients younger than 70 years who received FT there was no FWR, while in patients ≥70 years of age FWR was found in almost half of the deceased (30/68; 44%). Application of FT in STEMI patients is not associated with higher mortality, but significantly increases number of FWR, especially in patients over 70 years of age.     

Late myocardial salvage: time to recognize its reality in the reperfusion therapy of acute myocardial infarction.

The prevailing opinion in the reperfusion therapy of patients with acute myocardial infarction (AMI) is that the benefit of reperfusion is mostly confined to the first 12 h after the symptom onset. This opinion is based on the results of the prior megatrials of thrombolytic therapy and the experimental studies. Thrombolytic studies have unequivocally proven that the efficacy of thrombolysis to salvage ischaemic myocardium is drastically reduced with the increase in the time-to-treatment interval. A relatively large number of patients present beyond the limit efficacy of thrombolysis and are considered ineligible for this reperfusion modality. Recent experimental and clinical evidence indicates that a large amount of viable myocardium is still present in the area at risk in patients with AMI presenting late after symptom onset and considered ineligible for thrombolysis. In this review, we summarized the existing data demonstrating that this viable myocardium is salvageable given the primary percutaneous coronary intervention (PCI) is used as a reperfusion therapy. By emphasizing this fact, we do not mean to contest the concept of time dependence of myocardial necrosis following coronary occlusion and time dependence of efficacy of interventions performed early (within 2-3 h) after symptom onset or to dissuade the early coronary interventions in patients with AMI. Instead, we strongly recommend the primary PCI in patients with AMI presenting late after onset of myocardial ischaemia.     

急性心肌梗塞早期溶栓后心电图ST段改变与预后

目的:探索急性心肌梗塞(AMI)早期溶栓治疗后,心电图抬高的ST段回降的幅度对临床预后的影响。方法: 描记88例AMI早期患者溶栓治疗后1 h、2 h、3 h、1 d、3 d等时段的心电图,根据有、无早期(溶栓后2 h)ST段的恢复分为三组:A组,ST段基本恢复至等电线,即回降的幅度≥90％;B组,ST段回降的幅度在50％～90％之间; C组,ST段回降的幅度不到50％。比较三组心肌酶、左心功能及住院病死率。结果:血清肌酸激酶(CK)峰值、左室射血分数(LVEF)及病死率,A组与B组、C组相比较有显著差异(P<0．05,或<0．01):A组CK峰值低、LVEF 高、预后好;C组则相反。结论:AMI早期溶栓后的心电图ST段变化,有助于对临床预后的评估。     

心肌梗死后室间隔穿孔患者的外科治疗体会

目的分析急性心肌梗死（acute myocardial infarction,AMI）后室间隔穿孔患者的外科手术治疗方法和疗效。方法回顾性分析自2006年1月至2009年12月10例AMI后室间隔穿孔患者的临床资料,其中5例患者同期行室壁瘤切除术,1例患者同期接受冠状动脉旁路移植术,着重分析外科手术治疗的疗效。结果手术死亡2例,手术死亡率20%（2/10）,均死于严重低心排血量综合征。超声心动图检查提示所有患者未发现有室间隔残余分流,7例有轻度二尖瓣反流。术后左心室舒张期末内径（LVEDD）与术前比较有减小,差异无统计学意义[（54.0±8.2）mm vs.（48.0±8.3）mm,t=1.6262,P=0.1213];左心室射血分数（LVEF）较术前有提高,差异无统计学意义（48%±12%vs.50%±6.2%,t=0.4682,P=0.6452）。结论外科手术是AMI后室间隔穿孔的有效治疗手段。手术时机的合理选择,围手术期的积极治疗能明显提高术后患者的生存率。