急性心肌梗死静脉溶栓后早期和晚期冠状动脉造影的改变

对100例急性心肌梗死（AMI）患者应用尿激酶和链激酶静脉溶栓后进行早期和晚期的冠状动脉（冠脉）造影（CAG），结果发现：100例AMI溶栓再通成功60例，失败40例，再通率60．0％。CAG示有残留血栓的84例（84．0％），其中40例（47．6％）为冠脉完全阻塞。早期溶栓成功的60例及溶栓和补救性经皮腔内冠脉成形术（PTCA）均失败的8例，经3～4周后再次CAG发现，有8例狭窄加重，10例狭窄减轻。表明：AMI是由突然冠脉血栓性闭塞所致并可用溶栓剂或机械的方法使闭塞的冠脉再通。溶栓通常是不完全的，使用PTCA可作为改善严重残留狭窄病变的重要疗法。     

急性心肌梗死经皮冠状动脉成形术治疗的近期疗效

目的：观察急性心肌梗死（AMI）经皮冠状动脉成形术（PTCA）及原发性冠状动脉内支架植入术的近期疗效。方法：204例AMI患发病0．5－26h内行急诊冠状动脉造影（CAG），证实冠状动脉闭塞，仅对梗死相关血管直径行TPCA及原发性冠状动脉内支架植入，。结果：全组204例患再通197例，成功率96％，发病至血管再通的时间1－27h，平均5．6h，PTCA失败7例，其中心包填塞2例，钢丝不能通过2 ，术中死亡2例（均发生在伴有心源性休克的前壁心肌梗死患），率为0．9％，5周内死亡2例（经PTCA及支架植入术后心功能未明显改善，死亡心功能不全），2－6个月死亡6例（因再发心肌梗死而死亡，总死亡率4．9％。结论：AMI后早期（6h内）成功的再灌注可挽求涉死的心肌，缩小梗死面积和明显降低死亡率，即使 在较晚时间（＞12h)，病人仍有胸痛及ST段抬高，使梗死的血管再通仍可达到治疗的目的。早期充分的再灌注可明显改善患的预后，急诊TPCA治疗，可命名开通闭塞血管的届时时间提前，PTCA后残余狭窄甚微，再灌注血流充分，极少发生恢复期心肌缺务及心功能不全，在条件的大型A,TPTCA治疗AMI的最佳方法。     

重组葡激酶在急性心肌梗死中的溶栓疗效

目的 :观察重组葡激酶 (r SAK)在急性心肌梗死 (AMI)患者中的溶栓疗效。方法 :入选AMI患者 5例 ,年龄 <6 0岁 ,胸痛持续 <6h。冠状动脉造影 (CAG)明确梗死相关血管后 ,予r SAK 15mg静脉溶栓结合静脉肝素抗凝治疗 ,在溶栓后 15、30、45、6 0、90min ,1～ 2周重复CAG ,观察溶栓后梗死相关血管TIMI血流和残余狭窄 ,记录胸痛缓解情况、再灌注心律失常、ST段的演变、心肌酶峰值时间、相关并发症及心脏事件。结果 :CAG显示右冠状动脉近端病变和第一对角支近端病变各 1例 ;前降支近端病变 3例 ,溶栓前均完全闭塞。r SAK溶栓后血管再通率 10 0 % ,90min血流达TIMIⅢ级者 2例 ,TIMIⅡ～Ⅲ级者 2例 ,TIMIⅡ级者 1例 ,平均再通时间为(34 .0± 14.7)min。 5例均符合临床冠状动脉再通标准。随访中未见严重出血和心脏事件发生。结论 :r SAK 15mg静脉溶栓有较佳的效果 ,患者有良好的耐受性。     

冠状动脉造影评价急性心肌梗死溶栓疗法的疗效

目的：冠状动脉造影（ＣＡＧ）评价静脉溶栓治疗急性心肌梗死（ＡＭＩ）的疗效及安全性。方法：１１０例ＡＭＩ患者应用国产尿激酶及进口链激酶开始溶栓治疗后９０分钟行ＣＡＧ。结果：尿激酶和链激酶血管开通率分别为６０．８％及６３．０％；ＣＡＧ提示有残留血栓的分别为８６．９％及８１．５％；５周病死率分别为８．６％及７．４％；严重出血并发症分别为１．８５％及２．１７％，均无统计学意义。加大尿激酶剂量至２００ＩＵ，并不增加血管开通率反而增加出血并发症。结论：ＡＭＩ是由突然冠状动脉血栓性闭塞所致。尿激酶和链激酶用于静脉溶栓治疗可使闭塞的冠状动脉再通，两种溶栓剂疗效相似     

急性心肌梗塞后重复溶栓疗法的安全性和疗效

溶栓疗法广泛用于治疗急性心肌梗塞(AMI)以降低死亡率和保护左心室功能。然而冠状动脉血栓的溶解可引起梗塞相关冠状动脉不稳定的内皮损伤,且常有残留血栓,血管造影证实溶栓后早期再闭塞率约20%。作者报告31例有威胁生命的再     

直接经皮腔内冠状动脉成形术治疗急性心肌梗塞

1995年8月至1996年10月急性心肌梗塞（AMI）胸痛后1．0～6．0小时（平均3．6±1．2小时）入院患者28例行直接经皮腔内冠状动脉成形术（PTCA），结果：25例（89．3％）血管再通，再通血管残留狭窄平均为14．5％±10．3％（0％～40％），血管再通距胸痛发病时间平均为5．6±2．2小时（3～9小时），23例再通存活患者中1例（4．3％）发生梗塞后早期（起病后30天内）心绞痛，认为直接PTCA在AMI治疗中占有重要位置。     

基层医院急性心肌梗死早期溶栓治疗104例观察

目的观察基层医院对急性心肌梗死（AMI）患者在无条件做急诊冠状动脉介入治疗时，早期溶栓治疗的临床疗效。方法对发病3h内符合溶栓条件的104例AMI患者实施瑞替普酶（Reteplase）溶栓治疗。溶栓前查血常规、血小板计数、出凝血时间、血型、心肌酶谱及心电图，给予吸氧、镇静、止痛、心电监护。溶栓前口服阿司匹林300mg，静脉推注肝素5000IU，然后2min内静脉推注瑞替普酶10MU，间隔30min再静脉推注10MU。第1次静脉推注肝素1h后开始静脉点滴肝素700-1000IU／h，持续24-48h。结果104例AMI患者中有94例溶栓后符合冠状动脉再通指标，可判断为再通，再通率为90．4％。住院死亡7例（6．7％），脑出血1例（0．96％），消化道出血3例（2．9％），牙龈出血17例（16．3％）。结论基层医院对AMI患者在无条件做急诊冠状动脉介入治疗时早期溶栓治疗疗效显著。     

爱通立静脉溶栓治疗急性心肌梗死46例临床观察

将98例急性心肌梗死（AMI）患者随机分为观察组46例和对照组52例．分别应用小剂量（50mg）爱通立（rT—PA）和尿激酶（UK）静脉溶栓治疗。结果冠状动脉总再通率观察组为82．6％、对照组为50．0％．发病后6h内静脉溶栓治疗再通率分别为89．29％、60％，两组比较P均〈0．01；5周病死率分别为6．5％和9．6％；P〉0．05。认为小剂量rT—PA静脉溶栓治疗AMI疗效优于UK,发病后6h内治疗效果更佳，且并发症少。     

急性心肌梗塞溶栓失败患者行补救性经皮腔内冠状动脉成形术临床研究

为评价溶栓失败急性心肌梗塞（AMI）行补救性经皮腔内冠状动脉成形术（PTCA）的疗效及安全性，对35例AMI患者溶栓后90min行冠状动脉造影。根据梗塞相关动脉开通情况，16例成功者（甲组）中12例7～21d后行延迟PTCA治疗；19例失败者（乙组）中13例（乙1组）即刻行补救性PTCA，其余6例（乙2组）溶栓失败而未行PTCA者给一般药物治疗。结果表明，甲级中12例行延迟PTCA，成功11例（91．6％），正例于PTCA中出现冠状动脉急性闭塞并致小灶下壁心肌梗塞；乙1组13例行补救PTCA，全部成功（100％）。甲组住院期总心脏事件发生率（19％）与乙1组（23％）相似，且出院前心功能无显著差异。而乙2组6例中住院期死亡率（33％）及总心脏事件发生率（50％）增高。提示AMI溶栓失败患者补救PTCA成功率高、并发症少，能减少住院期心脏事件并促进左心室功能改善。     

急性心肌梗死再灌注治疗后心肌组织灌注评价

急性心肌梗死（AMI）的再灌注治疗，包括急诊经皮冠状动脉（冠脉）介入治疗（PCI）和溶栓治疗，能使血栓性闭塞的冠脉迅速再通，恢复心肌再灌注，已成为治疗AMI的首选方法。然而，有研究发现冠脉再通后心肌再灌注可能并不完全、甚至无再灌注，称为心肌组织无再流（myocardial no-reflow），其发生率高达37％～43％。心肌无再流是发生于再灌注后逐渐发展的动态过程，其结果是心肌彻底坏死、梗死范围扩大，心室扩张和重构，心力衰竭和恶性心律失常的发生率增高，住院病死率增加5～10倍，严重影响AMI患者的预后。因此，实现心肌组织完全再灌注是现代AMI再灌注治疗的最重要目标和再灌注治疗后时代的研究重点，准确、有效地评价心肌组织灌注也已成为当今临床工作的重要任务，目前的评价方法包括以下几个方面。     

Early and Late Coronary Angiographic Changes After Thrombolysis in Acute Myocardial Infarciton

Objective The coronaryanatomic feature and development after thrombolysis in acute myocardial infarction (AMI) were studied. Mehtods 100 patients with AMI received urokinase and strepokinase. Coronary angiography (CAG) was performed at 90 minuts and again at 3 to 4 weeks. Results Successful thrombolysis occurred in 60 cases, but failed in 40. The ratio of reperfusion was 60%. CAG showed there were residual thrombi in 84 patients (84% ) and complete coronary occlusion in 40(40% ). Angiography at 3 to 4 weeks after thrombolysis showed the stenosis worsened in 8 patients and improved in 10. Conclusion AMI is caused by sudden coronary thrombotic occlusion and can be reperfused by using thrombolytic agent or mechanical methods. Throm-bolytic agents usually can not resolve thrombi completely. So percutaneous transluminal coronary angiography (PTCA) is recommended as an important method to improve serious residual stenosis.     

Reappraising the role of immediate intervention following thrombolytic recanalization in acute myocardial infarction

Early studies indicated that after successful thrombolytic recanalization, adjunctive percutaneous transluminal coronary angioplasty (PTCA) was not appropriate, even when a significant residual stenosis was present. The aim of this study was to assess in-hospital clinical outcomes of patients with acute myocardial infarction (AMI) who underwent successful recanalization after thrombolytic therapy. The relation between repeat AMI/unstable angina and the severity of the stenosis, as well as other angiographic and clinical features was also examined. One hundred patients with AMI of <10 hours underwent coronary angiography 2 hours after receiving thrombolytic therapy. Salvage PTCA +/- stenting was performed if recanalization was unsuccessful (Thrombolysis In Myocardial Infarction [TIMI] trial grade 0 to 2), and no PTCA was undertaken if there was brisk anterograde flow (TIMI 3). Angiographic analysis was performed to assess the severity of the residual lesion, as well as the presence or absence of thrombus. Forty patients had unsuccessful recanalization, and of these, 36 underwent attempted PTCA. Of the 60 patients with TIMI 3 flow, 15 required repeat angiography and PTCA after repeat AMI (n = 13) or unstable angina (n = 2) within 5 days. Receiver-operating characteristic analysis indicated an optimum percent diameter stenosis predictor of 85% for repeat AMI/unstable angina. There was no additional relation to age, gender, time to thrombolysis, the infarct-related artery, or the presence of culprit lesion thrombus. After recanalization, a high-grade stenosis >85% is common (n = 25, 42.4%). This is associated with a 54% repeat AMI/unstable angina risk-a ninefold increase in the incidence of such events than in patients with lesions <85%. Thus, patients with narrowings >85% may benefit from early intervention rather than a conservative approach. Narrowings <85% have a 94% probability of no repeat AMI/unstable angina and do not require early intervention.     

Management of Patients with Heparin-Induced Thrombocytopenia: Focus on Recombinant Hirudin

It remains controversial whether percutaneous transluminal coronary angioplasty (PTCA) performed 24 hours after the onset of acute myocardial infarction (AMI) in coronary arteries with 99% stenosis is useful in preserving left ventricular function. We investigated the effectiveness of PTCA in preventing left ventricular remodeling when it was performed 24 hours after the onset of AMI in infarct-related coronary arteries (IRCAs) having 99% stenosis and thrombolysis in myocardial infarction (TIMI) grade 3 flow. The subjects were 19 patients with AMI (anterior wall, 9 patients; inferior wall, 7 patients; and non-Q, 3 patients) who, within 24 hours of the onset of AMI, underwent coronary angiography and left ventriculography during the acute and/ or chronic phases. The patients were divided into a PTCA group, comprised of patients in whom PTCA was successfully performed 24 hours after the onset of AMI (n = 10), and a non-PTCA group (n = 9). The non-PCTA group included patients who were successfully reperfused by thrombolysis and did not include patients who had spontaneous reperfusion or reperfusion after PTCA. In the non-PTCA group, the left ventricular end-diastolic volume (mean ± SD) was significantly increased in the chronic phase (86 ± 23 mL/m² as compared with the acute phase (67 ± 13 mL/m², whereas in the PTCA group no significant difference was observed between end-diastolic volumes in the acute and chronic phases (67 ± 26 and 68 ± 13 mL/m², respectively). Left ventricular remodeling is prevented by PTCA when it is performed 24 hours after the onset of AMI in IRCAs with 99% stenosis and TIMI grade 3 flow.     

Comparative efficacy of primary angioplasty with stent implantation and thrombolysis in restoring basal coronary artery flow in acute ST segment elevation myocardial infarction: quantitative assessment using the corrected TIMI frame count

Following thrombolysis and primary percutaneous transluminal coronary angioplasty (PTCA) for acute ST segment elevation myocardial infarction, basal flow in the culprit artery is known to influence prognosis. The purpose of this study was to determine if differences exist in basal flow in culprit and nonculprit coronary arteries in patients with acute ST segment elevation myocardial infarction who were treated with thrombolysis or primary PTCA with stent implantation. Twenty patients were randomized to thrombolysis (with recombinant tissue plasminogen activator) and 24 to primary PTCA with stent implantation within 3 hours of onset of acute ST segment elevation myocardial infarction. Coronary angiography was performed 90-120 minutes after thrombolysis or immediately after PTCA with stent implantation and again at 18-36 hours after intervention in both groups. Patients who failed to achieve thrombolysis in myocardial infarction (TIMI) grade 2 or 3 flow were excluded. The corrected TIMI frame count was used as the index of basal coronary artery flow. Early after intervention the mean corrected TIMI frame count in the culprit coronary artery was significantly lower in the primary PTCA with stent group (27.4 +/- 7.7 frames) than in the thrombolysis group (39.8 +/- 10 frames, p < 0.001). Eight thrombolysis patients (40%) and 20 primary PTCA patients (83%, p < 0.01) achieved TIMI grade 3 flow early after intervention. By 18-36 hours after intervention there were no significant differences in the mean correct TIMI frame count between the thrombolysis and primary PTCA with stent groups. There were no significant differences in the mean corrected TIMI frame count between these two groups in the nonculprit coronary artery, either early after intervention or at 18-36 hours. In successfully reperfused coronary arteries following acute ST segment elevation myocardial infarction, primary angioplasty with stent implantation reestablished TIMI grade 2 or 3 flow faster and more effectively than thrombolysis did.     

Combined revascularization strategy for acute myocardial infarction in patients with intracoronary thrombus: preceding intracoronary thrombolysis and subsequent mechanical angioplasty

Thrombus in the infarct-related artery is one of the limitations for flow restoration in primary percutaneous transluminal coronary angioplasty (PTCA) treatment for acute myocardial infarction (AMI). The present study investigated the benefit of preceding intracoronary thrombolysis (ICT) by retrospectively analyzing acute phase flow restoration in 80 AMI patients with intracoronary thrombus: 40 undergoing primary PTCA alone (primary PTCA group) and 40 treated with preceding ICT plus PTCA (combined group). Acute phase Thrombolysis in Myocardial Infarction (TIMI) grade flow was as follows: TIMI 0/1: 35.0% vs 12.5% for the primary PTCA group and the combined group, p=0.06; TIMI 2: 7.5% vs 15.0%, p=NS; TIMI 3: 57.5% vs 72.5%, p=NS). In the subgroup analysis, it was also less in the combined group among 33 patients with a left anterior descending coronary artery (LAD) lesion (42.1 % vs 7.1%, p=0.08), but not among the remaining 47 with either a right coronary artery or left circumflex artery lesion. The combined therapy may potentially provide better acute phase flow restoration in AMI patients with an intracoronary thrombus in a LAD lesion.     

Intracoronary urokinase for intracoronary thrombus accumulation complicating percutaneous transluminal coronary angioplasty in acute ischemic syndromes

Intracoronary urokinase was used to treat flow-limiting intracoronary thrombus accumulation that complicated successful percutaneous transluminal coronary angioplasty (PTCA) during acute ischemic syndromes in 48 patients who were followed up through the acute phase of their illness. The study group comprised 10 patients with unstable angina pectoris, 18 patients with an evolving acute myocardial infarction, and 20 patients with postinfarction angina. The initial mean percent coronary diameter stenosis for the entire population was 95 +/- 7% and decreased with initial PTCA to 41 +/- 20% (p less than 0.001), with improved corresponding coronary flow by Thrombolysis in Myocardial Infarction trial (TIMI) grade. However, thrombus accumulation then resulted in a significant increase in percent diameter stenosis to 83 +/- 17% (p less than 0.001); a corresponding significant reduction in coronary flow also occurred by TIMI grade. After administration of intracoronary urokinase (mean dose, 141,000 units; range, 100,000-250,000 units during an average period of 34 minutes), with additional PTCA, mean percent diameter stenosis significantly decreased to 34 +/- 17% (p less than 0.001); a correspondingly significant improvement in mean coronary flow by TIMI grade occurred to 2.9 +/- 0.2. Overall, the angiographic success rate was 90%. There were no ischemic events requiring repeat PTCA and no procedure-related myocardial infarctions or deaths before hospital discharge. One patient was referred for urgent coronary artery bypass graft surgery after a successful PTCA. Plasma fibrinogen levels were obtained in 15 patients, and in no patient was the level below normal for our laboratory.(ABSTRACT TRUNCATED AT 250 WORDS)     

QT-interval dispersion in acute myocardial infarction is only shortened by thrombolysis in myocardial infarction grade 2/3 reperfusion

BACKGROUND: Increased QT interval dispersion (QTd) has been found in patients with acute myocardial infarction (AMI). In previous studies this has been shown to decrease with thrombolysis. HYPOTHESIS: The aim of this study was to compare the effects of reperfusion by primary percutaneous transluminal coronary angioplasty (PTCA) and by thrombolysis on QTd and correlate these results with the degree of reperfusion. METHODS: We studied 60 patients with a first AMI. The study cohort included 40 consecutive patients who had received thrombolysis (streptokinase or rt-PA); 20 additional consecutive patients with successful primary PTCA, all with preselected Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow by predefined selection criteria (12 stents); and 20 controls. A 12-lead ECG for QTd calculation was recorded before thrombolysis or PTCA and immediately after the procedure. All values were corrected according to Bazett's formula (QTcd). QTd and QTcd values before and after each procedure in three groups and the respective percent changes of deltaQTd and deltaQTcd were compared separately. RESULTS: QTd and QTcd were significantly increased before thrombolysis/PTCA versus normals. An angiogram performed after thrombolysis showed adequate reperfusion (TIMI grade 2/3) in 20 patients, while in the other 20 only TIMI 0/1 reperfusion was achieved. Thrombolysis-TIMI flow 2/3 and PTCA significantly reduced QTd (from 68 +/- 10 to 35 +/- 8 ms, p < 0.001, deltaQTd = 48 +/- 11%, in the Thr-TIMI flow 2/3 group,and from 79 +/- 11 to 38 +/- 9 ms, p < 0.001, deltaQTd = 52 +/- 9%, in the PTCA group), while in the Thr-TIMI flow 0/1 group no significant changes were recorded. A percent QTd decrease > 30 s had 96% sensitivity, 85% specificity, and 93% positive and 94% negative predictive value, respectively, for TIMI 2/3 flow. CONCLUSIONS: A significant decrease in QT dispersion may provide an additional electrocardiographic index for successful (TIMI 2/3) reperfusion.     

溶栓禁忌证的老年急性心肌梗死患者直接介入治疗的探讨

目的　探讨不能溶栓的老年急性心肌梗死 (AMI)患者直接介入治疗的安全性与有效性。方法　对 31例 70岁以上的患者 ,3例 6 0～ 6 9岁有溶栓禁忌证的老年心肌梗死的患者进行了直接经皮冠状动脉腔内成形术 (PTCA)与冠状动脉内支架术。结果　有 34例梗死相关动脉 (IRA)心肌梗死溶栓试验 (TIMI)血流 0级 2 7例 ,1级 7例。 31例直接行PTCA成功 ,其中 4例患者直接PTCA后其残余狭窄 <10 %且无明显的内膜撕裂和夹层。 2 7例IRA具有支架置入的适应证 ,即刻造影IRATIMI血流达 3级。 2例行冠状动脉旁路移植术 (CABG)。有 1例因IRA完全闭塞 ,PT CA未能成功。直接介入成功率 97%。 31例患者经过平均 (11.4± 3.7)个月随访 ,无再梗死及急诊再次血运重建 ,但 4例有心绞痛 ,造影证实为冠状动脉支架再狭窄再次行PTCA成功。结论　对溶栓有禁忌证的老年AMI患者行直接介入治疗 ,具有较高的成功率及安全性。     

重组组织型纤溶酶原激活剂加补救性冠状动脉介入术与直接冠状动脉介入术对急性心肌梗死的疗效研究

目的：为比较急性心肌梗死（AMI）患应用重组组织型纤溶酶原激活剂（rt-PA)50mg治疗，加补救性经皮冠状动脉腔内成形术（PTCA）或冠状动脉内支架（Stent）置入术与直接PTCA／Stent置入术临床疗效。方法：135例首次AMI患随机给予以静脉rt-PA溶栓加补救性PTCA／Stent(A组）和直接PTCA／Stent(B组）。68例患用阿司匹林和肝素后，接受rt-PA50mg治疗，67例直接PTCA和支架。行急诊冠状动脉造影 （CAG），以TIMI血流分级法评估，必要时做PTCA／Stent。本研究终点包括分析两组患的梗死相关血管（IRA）开通率，并发症发生率、病死率及左心室功能。结果：A组IRA开通率为91．0％，B组IRA开通率95．5％。患于首次PTCA前及在3周后用超声心电图测定两组患左心室射血分数（LVEF）。两组患到达导管室时IRA血流已达TIMI3级（n=34其中A组24例，B组10例），最初和恢复期EF值分别为60．8％和62．5％，经介入治疗后变为TIMI3级（n=80），其中A组75％（33／44），B组为84．2％（47／57），最初EF57．0％和恢复期EF57．2％。从未获TIMI3级（n=21），其最初EF54．1％和恢复期EF53．2％为最低。结论：溶栓剂rt-PA50mg治疗加补救性PTCA／Stent与直接PTCA／Stent,在AMI中的疗效比较，可使IRA开通，有利于保护AMI患的左心室功能和不增加副作用。