老年人急性心肌梗死的肾损伤

本文利用老年人急性心肌梗死患者血清β2-MG水平的改变,对老年人肾功能的影响做一初步探讨。对象与方法(1)研究对象急性心肌梗死(AM)患者66例(男39例,女27例)。年龄60~83岁。平均年龄68·5岁。所有患者均符合1979年WHO关于急性心肌梗死的诊断标准。病情较重,既往除冠心病外无其     

急性心肌梗死患者冠脉介入手术前后血清中缺血修饰白蛋白水平的变化及临床意义

目的:比较急性心肌梗死(AMI)患者行冠脉介入术(PCI)前后血清中缺血修饰白蛋白(IMA)水平的变化,探讨IMA的形成机制及其对心肌缺血早期诊断和疗效观察的临床意义。方法:采用白蛋白钴结合(ACB)试验分别测定对照组和AMI患者PCI前及PCI后不同时间段血清IMA水平。结果:心肌缺血引起血清IMA急性升高(P<0.05),术后3h回复到术前水平,术后6h～30h血清IMA与术前比较显著降低(P<0.05)。结论:心肌缺血可造成AMI患者血中IMA急性升高;PCI可有效改善心肌缺血状况。IMA可作为心肌缺血早期诊断和疗效观察的重要指标。     

急性心肌梗死患者甲状腺功能检测的临床价值

目的 探讨急性心肌梗死患者甲状腺功能检测的临床意义.方法 回顾性分析72例急性心肌梗死（AMI）患者的血清甲状腺激素水平,以30例健康的退休职工为对照组.结果 急性心肌梗死组有4例合并有甲状腺疾病,34例出现正常甲状腺功能病态综合征,急性心肌梗死组（68例）与对照组相比血清总三碘甲状腺原氨酸（TT3）下降,差异有统计学意义（P＜0.001）,总甲状腺素（TT4）,游离三碘甲状腺原氨酸（FT3）下降也有显著性差异（P＜0.01）,游离甲状腺素（FT4）,促甲状腺素（TSH）与对照组比较差异无统计学意义（P＞0.05）.结论 对于急性心肌梗死患者,应该常规检测甲状腺功能,以便更好的进行治疗和预后判断.     

血清肌钙蛋白T对急性心肌梗死早期诊断的价值

本文对临床已经确诊为急性心肌梗死（AMI）并且随机抽取的389例患者入院时及入院24h时的血清肌钙蛋白T（TNT）进行回顾性的分析总结。现报道如下。     

住院患者急性肾损伤的风险预测与关键影响因素分析

急性肾损伤(AKI) 是住院患者常见的危重症之一,具有较高的发病率和死亡率。建立预测模型,对AKI进行预测,并分析影响其发生的危险因素,以便对具有AKI潜在风险患者进行及时干预。选择住院2～14 d的90 780位受试者(其中,AKI患者7 983名,non-AKI患者82 797名,按4∶1划分训练集和独立测试集),收集其住院期间的生化指标、药物的使用情况、基本信息,以及入院科室、合并症情况、住院时间等其他临床信息,分别应用逻辑回归、随机森林、LightGBM等3种机器学习模型,经十折交叉验证法进行训练后,对独立测试集在24 h后是否发生AKI进行预测;并根据受试者特性工作曲线下的面积(AUC)以及召回率和准确率的调和F1值,评估与比较不同模型的性能。结果表明,LightGBM模型最优,其F1、AUC、敏感性与特异性分别为0.800、0.871、0.755和0.987。影响AKI发生的重要因素有:一是一般临床特征,包括年龄、已住院天数、入院科室;二是检验结果,包括首检肌酐值、血液中的钠、钾、氯、尿酸及糖化血红蛋白的含量;三是药物,包括抗感染类药物、非甾体类抗炎症药物、利尿药或脱水药、肾上腺素受体激动剂、造影剂、ACEI/ARB类降压药,以及用药种类,药物治疗天数;四是合并症,如中重度肾病。利用住院患者的临床信息,机器学习模型可以在24 h内有效地预测AKI的发生风险,揭示影响AKI发生的重要因素,对住院患者的合理有效治疗、AKI风险人群的及时干预提供重要依据。     

髓过氧化酶水平可预测急性心肌梗死后的结果

英国Leicester大学的Sohail Q．Khan博士及其同事在7月的《心脏》（Heart，2007；93：826—831．）杂志上报道，髓过氧化酶（MPO）水平可增加急性ST段抬高心急梗死（STEMI）后患者的风险。     

感染性休克患者CRP/ALB比值对预测急性呼吸窘迫综合征的临床价值

目的 探讨感染性休克患者血清C反应蛋白(C reactive protein,CRP)、白蛋白(albumin,ALB)比值(CRP/ALB)对预测急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)的临床价值.方法 回顾性分析2013年1月至2015年5月我院ICU感染性休克患者65例.患者于入ICU后采外周静脉血,检测CRP、ALB,前7d每天进行急性生理功能和慢性健康状况评分系统Ⅱ(acute physiology and chronic health evaluation-Ⅱ,APACHE-Ⅱ),根据7d内是否合并ARDS分成感染性休克组和ARDS组.比较两组CRP、ALB和CRP/ALB,APACHE Ⅱ评分,Spearman相关分析入选时CRP/ALB、APACHE-Ⅱ评分的关系,受试者工作特征(ROC)曲线下面积法检验CRP/ALB的预测效力.结果 感染性休克组与ARDS组患者CRP、ALB含量差异无统计学意义(P＞0.05),而CRP/ALB比值差异具有统计学意义(=5.93,P＜0.05).CRP/ALB和APACHE-Ⅱ预测脓毒症的ROC曲线下面积分别为0.904(95％,CI:0.821 ～0.998),0.748(95％,CI:0.625 ～0.903).CRP/ALB与APACHEⅡ评分呈正相关(r=0.74,P＜0.05).结论 CRP/ALB可预测感染性休克即将发生的ARDS,可能是一个有价值的临床指标,值得进一步研究.     

早期急性心肌梗死患者血清白细胞介素-1受体拮抗蛋白变化的临床价值

目的探讨血清白细胞介素-1受体拮抗蛋白（IL-1Ra）在早期诊断急性心肌梗死（AMI）患者中的临床价值。方法比较IL-1Ra、肌红蛋白（MYO）、肌钙蛋白I（cTnI）、肌酸激酶同功酶（CK-MB）四种物质定量检测对诊断发病6h内的AMI的敏感性、特异性和准确性。结果 AMI组IL-1Ra水平高于非急性心肌梗死组和正常对照组（P均〈0.01）;AMI组和非急性心肌梗死组患者血清IL-1Ra含量进行Logistic回归分析得知,IL-1Ra诊断AMI的最佳临界值为210pg/ml。IL-1Ra诊断发病3h和6h内的AMI的敏感性显著高于cTnI和CK-MB（P〈0.05）,特异性差异则无统计学意义（P〉0.05）,诊断准确性高于MYO、cTnI和CK-MB。结论 IL-1Ra在AMI患者中早期升高对发病〈3h的AMI患者有诊断意义,提示检测IL-1Ra可作为早期诊断AMI的一个重要的辅助指标。     

决策树算法应用于MIMIC-Ⅲ数据库的ICU患者急性肾损伤预测研究

目的 急性肾损伤(acute kidney injury,AKI)是重症监护病房(intensive care unit,ICU)最常见的并发症和致死因素之一.准确预测具AKI风险的患者,明确与AKI发生相关的关键因素,可为临床决策与风险患者干预提供有效指导.方法 采用公开的重症监护室数据库MIMIC-III,提取30020例患者记录(包括AKI患者17222名,Non-AKI患者12798名),收集其住ICU期间基本信息、生理生化指标、药物使用、合并症等临床信息.将患者按4:1比例随机划分训练集和独立测试集,应用逻辑回归、随机森林与LightGBM 3种机器学习方法,分别建立24 h、48 h与72 h 3个时间点的AKI预测模型,采用十折交叉验证法,对各种模型进行训练与测试,预测患者是否发生AKI,并获取重要特征.此外,利用24 h预测模型,在一周时间窗口内对ICU患者进行每隔24 h预测.结果 3种学习模型中,LightGBM性能最优,其24 h、48 h和72 h模型预测AKI的受试者工作特征曲线(receiver operator characteristic curve,ROC曲线)下面积(area under curve,AUC)值分别为0.90、0.88、0.87,F1值分别为0.91、0.88、0.86,在每隔24 h预测时,提前1 d、2 d和3 d预测AKI的成功率分别为89％、83％、80％.已住院时长、体质量、白蛋白、收缩压、碳酸氢盐、葡萄糖、白细胞计数、体温、舒张压、血尿素氮等是预测ICU患者AKI的重要特征,仅使用24个重要特征,模型仍能取得良好的预测性能.结论 基于ICU患者的基本信息、生理生化指标、药物使用及合并症等临床信息,应用机器学习模型,可对其是否发生AKI进行多时间点的有效预测,并明确其关键风险因素.     

New Horizons of Acute Myocardial Infarction: From the Korea Acute Myocardial Infarction Registry

As the first nationwide Korean prospective multicenter data collection registry, the Korea Acute Myocardial Infarction Registry (KAMIR) launched in November 2005. Through a number of innovative approaches, KAMIR suggested new horizons about acute myocardial infarction (AMI) which contains unique features of Asian patients from baseline characteristics to treatment strategy. Obesity paradox was existed in Korean AMI patients, whereas no gender differences among them. KAMIR score suggested new risk stratifying method with increased convenience and an enhanced accuracy for the prediction of adverse outcomes. Standard loading dose of clopidogrel was enough for Asian AMI patients. Triple antiplatelet therapy with aspirin, clopidogrel and cilostazol could improve clinical outcomes than dual antiplatelet therapy with aspirin and clopidogrel. Statin improved clinical outcomes even in AMI patients with very low LDL-C levels. The rate of percutaneous coronary intervention was higher and door-to-balloon time was shorter than the previous reports. Zotarolimus eluting stents as the 2nd generation drug-eluting stent (DES) was not superior to the 1st generation DES, in contrast to the western AMI studies. KAMIR made a cornerstone in the study of Korean AMI and expected to be new standards of care for AMI with the renewal of KAMIR design to overcome its pitfalls.     

The Association of Socioeconomic Status with Three-Year Clinical Outcomes in Patients with Acute Myocardial Infarction Who Underwent Percutaneous Coronary Intervention

The aim of this study was to evaluate whether the clinical outcomes were associated with socioeconomic status (SES) in patients with acute myocardial infarction (AMI) who underwent percutaneous coronary intervention (PCI). The author analyzed 2,358 patients (64.9 ± 12.3 yr old, 71.5% male) hospitalized with AMI between November 2005 and June 2010. SES was measured by the self-reported education (years of schooling), the residential address (social deprivation index), and the national health insurance status (medical aid beneficiaries). Sequential multivariable modeling assessed the relationship of SES factors with 3-yr major adverse cardiovascular events (MACEs) and mortality after the adjustment for demographic and clinical factors. During the 3-yr follow-up, 630 (26.7%) MACEs and 322 (13.7%) all-cause deaths occurred in 2,358 patients. In multivariate Cox proportional hazards regression modeling, the only lower education of SES variables was associated with MACEs (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.04-1.91) and mortality (HR, 1.93; 95% CI, 1.16-3.20) in the patients with AMI who underwent PCI. The study results indicate that the lower education is a significant associated factor to increased poor clinical outcomes in patients with AMI who underwent PCI.

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Acute Kidney Injury after Using Contrast during Cardiac Catheterization in Children with Heart Disease

Acute kidney injury (AKI) is closely associated with the mortality of hospitalized patients and long-term development of chronic kidney disease, especially in children. The purpose of our study was to assess the evidence of contrast-induced AKI after cardiac catheterization in children with heart disease and evaluate the clinical usefulness of candidate biomarkers in AKI. A total of 26 children undergoing cardiac catheterization due to various heart diseases were selected and urine and blood samples were taken at 0 hr, 6 hr, 24 hr, and 48 hr after cardiac catheterization. Until 48 hr after cardiac catheterization, there was no significant increase in serum creatinine level in all patients. Unlike urine kidney injury molecule-1, IL-18 and neutrophil gelatinase-associated lipocalin, urine liver-type fatty acid-binding protein (L-FABP) level showed biphasic pattern and the significant difference in the levels of urine L-FABP between 24 and 48 hr. We suggest that urine L-FABP can be one of the useful biomarkers to detect subclinical AKI developed by the contrast before cardiac surgery.

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Surgically Metabolic Resection of Pericardial Fat to Ameliorate Myocardial Mitochondrial Dysfunction in Acute Myocardial Infarction Obese Rats

BackgroundPericardial fat (PF) is highly associated with cardiovascular disease but the effectiveness of surgical resection of PF is still unknown for myocardial mitochondrial structure and function in acute myocardial infarction (AMI) with obesity. The aim of this study was to demonstrate the difference in myocardial mitochondrial structure and function between obese AMI with additionally resected PF and those without resected PF.MethodsObese rats with 12-week high fat diet (45 kcal% fat, n = 21) were randomly assigned into 3 groups: obese control, obese AMI and obese AMI with additionally resected PF. One week after developing AMI and additional resection of PF, echocardiogram, myocardial mitochondrial histomorphology, oxidative phosphorylation system (OXPHOS), anti-oxidative enzyme and sarcoplasmic reticulum Ca²⁺ ATPase 2 (SERCA2) in the non-infarcted area were assessed between these groups.ResultsThere was significant improvement of systolic function in AMI with PF resection compared with the AMI group in the echocardiogram. Even though the electron microscopic morphology for the mitochondria seems to be similar between the AMI with PF resection and AMI groups, there was an improved expression of PGC-1α and responsive OXPHOS including NDUFB3, NDUFB5 and SDHB are associated with the ATP levels in the AMI with PF resection compared with those in the AMI group. In addition, the expression levels of antioxidant enzymes (MnSOD) and SERCA2 were improved in the AMI with PF resection compared with those in the AMI group.ConclusionSurgical resection of PF might ameliorate myocardial mitochondria dysfunction in obese AMI.     

Urinary Biomarkers for Early Detection of Recovery in Patients with Acute Kidney Injury

Urinary biomarkers of acute kidney injury (AKI) have been revealed recently to be useful for prior prediction of AKI. However, it is unclear whether these urinary biomarkers can also detect recovery from established AKI. Urinary biomarkers, including neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C, were measured every 2 days for 8 days in 66 patients with AKI. At day 0, there were no significant differences in plasma creatinine, BUN, and urine cystatin C between AKI patients in the recovery (n = 33) and non-recovery (n = 33) groups. Plasma creatinine concentrations were significantly lower in the recovery group (3.0 ± 2.0 mg/dL) than in the non-recovery group (5.4 ± 1.9 mg/dL) on day 4 after AKI diagnosis (P < 0.001). In contrast, there were significant differences in urine NGAL between the two groups starting on day 0 (297.2 ± 201.4 vs 407.6 ± 190.4 ng/mL, P = 0.025) through the end of the study (123.7 ± 119.0 vs 434.3 ± 121.5 ng/mL, P < 0.001). The multiple logistic regression analysis showed that urine NGAL could independently predict recovery from AKI. Conclusively, this prospective observational study demonstrates that urine NGAL can be a highly versatile marker for early detection of the recovery phase in established AKI patients.     

Trends in Hospitalized Acute Myocardial Infarction Patients with Heart Failure in Korea at 1998 and 2008

Heart failure (HF) complicating acute myocardial infarction (AMI) is common and is associated with poor clinical outcome. Limited data exist regarding the incidence and in-hospital mortality of AMI with HF (AMI-HF). We retrospectively analyzed 1,427 consecutive patients with AMI in the five major university hospitals in Korea at two time points, 1998 (n = 608) and 2008 (n = 819). Two hundred twenty eight patients (37.5%) in 1998 and 324 patients (39.5%) in 2008 of AMI patients complicated with HF (P = 0.429). AMI-HF patients in 2008 were older, had more hypertension, previous AMI, and lower systolic blood pressure than those in 1998. Regarding treatments, AMI-HF patients in 2008 received more revascularization procedures, more evidence based medical treatment and adjuvant therapy, such as mechanical ventilators, intra-aortic balloon pulsation compared to those in 1998. However, overall in-hospital mortality rates (6.4% vs 11.1%, P = 0.071) of AMI-HF patients were unchanged and still high even after propensity score matching analysis, irrespective of types of AMI and revascularization methods. In conclusion, more evidence-based medical and advanced procedural managements were applied for patients with AMI-HF in 2008 than in 1998. However the incidence and in-hospital mortality of AMI-HF patients were not significantly changed between the two time points.     

Percutaneous Coronary Intervention for Acute Myocardial Infarction in Elderly Patients with Renal Dysfunction: Results from the Korea Acute Myocardial Infarction Registry

This study aimed to evaluate the effects of percutaneous coronary intervention (PCI) on short- and long-term major adverse cardiac events (MACE) in elderly (>75 yr old) acute myocardial infarction (AMI) patients with renal dysfunction. As part of Korea AMI Registry (KAMIR), elderly patients with AMI and renal dysfunction (GFR<60 mL/min) received either medical (n=439) or PCI (n=1,019) therapy. Primary end point was in-hospital death. Secondary end point was MACE during a 1 month and 1 yr follow-up. PCI group showed a significantly lower incidence of in-hospital death (20.0% vs 14.3%, P=0.006). Short-term and long-term MACE rates were higher in medical therapy group (31.9% vs 19.0%; 57.7% vs 31.3%, P<0.001), and this difference was mainly attributed to cardiac death (29.3% vs 17.6%; 51.9% vs 25.0%, P<0.001). MACE-free survival time after adjustment was also higher in PCI group on short-term (hazard ratio, 0.67; confidence interval, 0.45-0.98; P=0.037) and long-term follow-up (hazard ratio, 0.61, confidence interval, 0.45-0.83; P=0.002). In elderly AMI patients with renal dysfunction, PCI therapy yields favorable in-hospital and short-term and long-term MACE-free survival.     

Safety and Efficacy of Overlapping Homogenous Drug-Eluting Stents in Patients with Acute Myocardial Infarction: Results from Korea Acute Myocardial Infarction Registry

The aim of this study was to compare safety and efficacy of 4 homogenous overlapping drug-eluting stents (DES) in acute myocardial infarction (AMI) patients. We selected 1,349 consecutive patients (62.1 ± 14.9 yr, 69.4% male) who received homogenous overlapping DESs in diffuse de novo coronary lesions from Korea Acute Myocardial Infarction Registry from April 2006 through September 2010. They were divided into 4 groups based on type of DES implanted - Paclitaxel (PES), Sirolimus (SES), Zotarolimus (ZES) and Everolimus (EES)-eluting stents. Primary endpoint was 12-month MACE. We also studied EES versus other DESs (PES + SES + ZES). Mean stent length was 26.2 ± 7.5 mm and mean stent diameter was 3.1 ± 0.4 mm. Average number of stents used per vessel was 2.2 ± 0.5. Incidence of major adverse cardiac events (MACE) in PES, SES, ZES, and EES groups were 9.5%, 9.2%, 7.5%, and 3.8%, respectively (P = 0.013). In EES group, overall MACE and repeat revascularization were lowest, and no incidence of stent thrombosis was observed. Non-fatal MI was highest in PES, almost similar in SES and EES with no incidence in ZES group (P = 0.044). Cox proportional hazard analysis revealed no differences in the incidence of primary endpoint (P = 0.409). This study shows no significant differences in 12-month MACE among 4 groups.     

冠脉介入治疗对冠心病急性心肌梗死患者 心肌损伤及心室重塑的影响

目的 观察冠脉介入治疗对冠心病急性心肌梗死患者心肌损伤及心室重塑的影响。方法 选取我院自2017年9月~12月收治的64例冠心病急性心肌梗死患者作为观察对象,随机分为研究组33例和对照组31例。对照组给予吸氧、镇静、对症治疗,并给予氯吡格雷+阿司匹林口服,研究组在此基础上进行冠脉介入治疗,对比两组CK、CK-MB、BNP及LVEF、LFESV、LVEDV变化情况。结果 在治疗3 d、7 d后,研究组BNP水平均低于对照组,差异有统计学意义（P＜0.05）。研究组CK峰值、CK-MB峰值与对照组比较,差异无统计学意义（P＞0.05）,但研究组CK峰值、CK-MB峰值出现时间均短于对照组,差异有统计学意义（P＜0.05）。治疗7 d后,两组患者LVEF均升高,LFESV、LVEDV均降低,且研究组LVEF高于对照组,LFESV、LVEDV低于对照组,差异均有统计学意义（P＜0.05）。结论 冠脉介入治疗冠心病急性心肌梗死患者可降低患者BNP水平,改善患者心肌损伤,促进心室重塑,具有较高的应用价值。     

The Prognostic Value of the Left Ventricular Ejection Fraction Is Dependent upon the Severity of Mitral Regurgitation in Patients with Acute Myocardial Infarction

The prognostic value of the left ventricle ejection fraction (LVEF) after acute myocardial infarction (AMI) has been questioned even though it is an accurate marker of left ventricle (LV) systolic dysfunction. This study aimed to examine the prognostic impact of LVEF in patients with AMI with or without high-grade mitral regurgitation (MR). A total of 15,097 patients with AMI who received echocardiography were registered in the Korean Acute Myocardial Infarction Registry (KAMIR) between January 2005 and July 2011. Patients with low-grade MR (grades 0-2) and high-grade MR (grades 3-4) were divided into the following two sub-groups according to LVEF: LVEF ≤ 40% (n = 2,422 and 197, respectively) and LVEF > 40% (n = 12,252 and 226, respectively). The primary endpoints were major adverse cardiac events (MACE), cardiac death, and all-cause death during the first year after registration. Independent predictors of mortality in the multivariate analysis in AMI patients with low-grade MR were age ≥ 75 yr, Killip class ≥ III, N-terminal pro-B-type natriuretic peptide > 4,000 pg/mL, high-sensitivity C-reactive protein ≥ 2.59 mg/L, LVEF ≤ 40%, estimated glomerular filtration rate (eGFR), and percutaneous coronary intervention (PCI). However, PCI was an independent predictor in AMI patients with high-grade MR. No differences in primary endpoints between AMI patients with high-grade MR (grades 3-4) and EF ≤ 40% or EF > 40% were noted. MR is a predictor of a poor outcome regardless of ejection fraction. LVEF is an inadequate method to evaluate contractile function of the ischemic heart in the face of significant MR.