急性ST段抬高心肌梗死急诊介入治疗后心肌再灌注不良对近、远期预后的影响

目的 探讨急性心肌梗死急诊经皮冠状动脉介入治疗(PCI)后心肌再灌注状态不良的发生率及其对近、远期临床预后的影响.方法 回顾性收集964例急性ST段抬高心肌梗死(STEMI)行急诊PCI治疗患者的临床资料、冠状动脉造影资料与心电图,以ST段回落程度与心肌梗死溶栓试验心肌灌注(TMP)分级等指标评估心肌再灌注状态.患者分为4组:A组为ST段回落率≥50%并且术后TMP分级为Ⅲ级;B组为ST段回落率<50%并且术后TMP分级为Ⅲ级;C组为ST段回落率≥50%并且术后TMP分级≤Ⅱ级;D组为ST段回落率<50%并且术后TMP分级≤Ⅱ级.以A组代表心肌灌注状态良好者,D组代表心肌灌注状态不良者.分析心肌再灌注不良患者的发生率及其对近远期预后的影响.结果 STEMI急诊PCI术后梗死相关动脉前向血流达到TIMIⅢ级而TMP分级为Ⅱ级以下者占27.3%(237/964),心电图ST段回落小于50%者占30.6%(266/964).11.31%(109/964)的患者发生远端栓塞.A组占总例数的48.9%(425/964),D组占总例数的10.5%(91/964).与A组比较,D组患者在住院期间(RR=64.63,P<0.01)以及随访期间(RR=11.69,P<0.01)均有较高的主要不良心脏事件发生风险.结论 急性心肌梗死急诊PCI后不到50%的患者心肌再灌注良好,心肌再灌注状态与近、远期临床预后显著相关.     

急性ST段抬高心肌梗死急诊介入治疗后心肌再灌注不良对近、远期预后的影响

Objective To explore the prognostic impact of post primary percutaneous coronary intervention (PCI) reperfusion status on outcome in patients with acute ST-elevation myocardial infarction (STEMI). Methods A retrospective analysis was performed in 964 patients undergoing primary PCI for STEMI. Electrocardiogram and TIMI myocardial perfusion grade (TMPG) were analyzed by reader blinded to the clinical course. Patients were divided to four groups according to ST segment resolution (STR) and TMPG: group A were patients with good STR and TMPG(425/964), group B were patients with poor STR and good TMPG (239/964), group C were patients with good STR and poor TMPG (113/964) and group D were patients with poor STR and TMPG (113/964). Results Although TIMI grade Ⅲ flow was achieved after mechanical reperfusion, abnormal reperfusion was still present in about 1/3 patients as shown by poor STR or TMPG. Older age, cardiac dysfunction and diabetes, prolonged time of pain to balloon/emergency room are independent risk factors for abnormal reperfusion post PCI. Major aclverse cardiac events events in hospital ( RR = 64. 63, P < 0. 01 ) and during follow up( RR = 11.69, P < 0. 01 ) were significantly higher in group D than in group A. Conclusion Poor post PCI reperfusion status is associated with higher in hospital and during follow up major aclverse cardiac events event in STEMI patients.     

老年急性ST段抬高心肌梗死急诊介入治疗后心肌组织水平再灌注不良的发生率及其对临床预后的影响

目的探讨老年急性心肌梗死（acute myocardial infarction,AMI）-急诊经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗后心肌组织水平再灌注状态不良的发生率及其对近、远期临床预后的影响。方法回顾性收集398例老年急性ST段抬高心肌梗死（ST-elevationmyocardi-alinfarction,STEMI）行急诊PCI治疗患者的临床资料、冠状动脉造影资料与心电图,以ST段回落程度与TIMI心肌灌注（TIMIMyocardialPerfusion,TMP）分级等指标评估心肌组织水平再灌注状态,患者分为4组,A组为ST段回落率〉50%并且术后TMP分级为Ⅲ级;B组为ST段回落率〈50%而术后TMP分级=Ⅲ级;C组为术后TMP分级≤Ⅱ级而ST段回落率〉50%;D组为ST段回落率〈50%并且术后TMP分级≤Ⅱ级。分析心肌组织水平再灌注不良患者的发生率及其对近远期预后的影响。结果 STEMI急诊PCI术后梗死相关血管（infarctionrelatedartery,IRA）前向血流达到TIMIⅢ级而TMP分级为Ⅱ级以下者占37.2%,心电图ST段回落小于50%者占37.2%,均接近1/3。12.5%的患者具有远端栓塞。术后ST段回落率〉50%并且TMP分级为Ⅲ级者占总人数的39.8%,ST段回落率〈50%,并且术后TMP分级≤Ⅱ级占总人数的14.3%。心肌组织灌注状态不良者与心肌组织灌注状态良好者相比平均住院日更长,左室EF值更低,梗死后心绞痛发生率更高,远端栓塞发生率更高,IABP辅助应用比率更大,心功能恶化、心脏性死亡更高。与D组相比,随访期间MACE的发生风险在C组为43%（P=0.11）,在B组为24%（P〈0.01）,在A组为2.7%（P〈0.01）。结论老年急性心肌梗死行急诊PCI治疗后IRA再通者仅有不到40%的患者其心肌组织水平得到了良好的再灌注,其近、远期预后较好,而剩余约60%的患者其心肌组织水平存在不同程度的再灌注障碍,其中有大概约超过10%的患者其心肌组织水平存在较差的再灌注状态,这些患者在住院期间以及远期随访期间有着极高的MACE发生风险。     

急性ST段抬高心肌梗死急诊介入治疗后心肌组织水平再灌注不良的靶病变冠状动脉造影特征

目的 探讨心肌组织水平再灌注不良的靶病变冠状动脉造影特征,以早期识别高危患者,从而积极防止心肌无再流的发生.方法 回顾性收集964例急性ST段抬高心肌梗死行急诊经皮冠状动脉介入治疗患者的临床资料、冠状动脉造影资料与心电图,应用统计学软件筛选心肌组织水平灌注不良患者的冠状动脉造影预测因子.结果 心肌组织灌注状态不良的发生随胸痛至球囊扩张时间延长、心功能Killip分级的增加、冠状动脉病变复杂程度的增加以及年龄的增加而增加.冠状动脉病变闭塞处影象学为Ⅰ型病变、Ⅱ型病变、Tapered病变、Cut-off病变以及Tapered-cutoff病变与心肌灌注不良的发生均为负相关,OR值分别为0.25、0.84、0.65、0.23与0.75,Fade-out病变、Floating-thrombus病变、Dye-stasis病变以及Big病变与心肌灌注不良的发生均为正相关,OR值分别为4.78、1.19、1.16与1.77.Logistic回归分析显示心肌组织灌注状态不良的预测因素有非前壁心肌梗死、入院心功能分级(Killip)Ⅱ级以上、胸痛至球囊扩张时间、fade-out病变等.结论 梗死相关血管闭塞处有大量血栓并向近段延伸的病变为心肌组织灌注状态不良发生的造影影像独立预测因素.非前壁心肌梗死、入院心功能较差、胸痛至球囊扩张时间以及冠状动脉病变复杂程度等为心肌组织水平再灌注不良发生的临床独立预测因素.具备以上临床与造影影像特征的患者为发生心肌组织水平再灌注不良的高危患者.     

糖尿病对急性ST段抬高心肌梗死急诊经皮冠状动脉介入治疗心肌灌注的影响

目的采用心电图ST段回落指数（STR）和冠状动脉造影心肌呈色分级（MBG）评价糖尿病对急性心肌梗死（AMI）直接PCI后心肌灌注以及患者预后影响的价值。方法287例AMI并行急诊PCI的患者依据病史以及入院前是否接受药物和非药物降糖治疗的情况分为糖尿病组（n=95例）和非糖尿病组（n=192例）。所有患者分析心电图STR和MBG,并进行临床随诊。结果与非糖尿病组比较,糖尿病组年龄较大[（65±12）岁比（57±11）岁,P〈0．05]。两组PCI术后TIMIⅢ级血流的患者数差异无统计学意义（P〉0．05）。糖尿病组心肌微循环灌注不良多于非糖尿病组（MBG 0／156．0％比41．1％,P=0．019）,ST段回落不全也多于非糖尿病组（43．2％比30．7％,P=0．038）。糖尿病组患者在随诊期间联合终点事件的发生率明显多于非糖尿病组（27．4％比16．1％,P=0．025）。多因素回归分析显示糖尿病是患者预后不良的独立危险因素（RR=1．83,95％CI：1．04～3．36,P=0．01）。患者接受再灌注的时间（RR=3．63,95％CI：1．27～10．42,P=0．03）、ST段回落不全（RR=11．71,95％CI：1．53～38．70,P=0．03）以及MBG0／1（RR=1．16,95％CI：1．03～1．38,P=0．01）与患者预后不良相关。结论糖尿病是AMI患者在成功接受介入治疗术后预后不良的独立危险因素,这可能与糖尿病患者出现心肌微循环灌注不良有关。     

介入治疗对老年人急性ST段抬高性心肌梗死预后的影响

目的 探讨介入治疗对老年急性ST段抬高性心肌梗死(STEMI)预后的影响. 方法 回顾性分析1998年6月至2008年6月我院心内科住院的STEMI患者1318例,其中老年人338例(25.6%),连续入选符合标准的老年STEMI 316例为研究对象,依据是否行冠状动脉介入治疗(PCI)分两组:PCI组136例(43.0%)和保守治疗组180例(57.0%).收集研究对象的临床资料,并随访2年评价患者预后. 结果 两组患者年龄、性别、高血压、糖尿病、血脂异常、吸烟饮酒史、家族史等比较差异均无统计学意义(P＞0.05).两组患者前壁STEMI、心功能Killip Ⅲ～Ⅳ级、静脉溶栓及恶性室性心律失常例数等比较,差异均无统计学意义(P＞0.05).随访患者急性心肌梗死二级预防:多数患者戒烟限酒、控制饮食、减轻体质量、坚持运动等,较规律服用预防心室重塑、抗血小板、抗动脉粥样硬化等药物:血管紧张素转换酶抑制剂或血管紧张素受体拮抗剂、阿司匹林、β受体阻滞剂、他汀类药物,两组间比较差异无统计学意义(均P＞0.05).2年随访发生再梗死、心功能Ⅲ～Ⅳ级住院人数和1个月病死率比较,保守治疗组均高于PCI组(分别为17.2%与2.2%,OR=9.224,95%CI=2.756～30.876;31.1%与8.1%,OR=5.132,95%CI=2.568～10.257;8.3%与1.5%,OR=6.091,95%CI=1.369～27.105,均P＜0.01).老年STEMI的1年、2年病死率比较,保守治疗组明显高于PCI组(分别为21.1%与2.2%,OR=11.864,95%CI=3.577～39.349;32.2%与4.41%,OR=10.301,95%CI=4.289～24.736,P＜0.01). 结论 PCI可减少老年STEMI发生再梗死、心功能Ⅲ～Ⅳ级住院和1个月病死率,尤其是可明显减少1年、2年病死率.因此,早期PCI可明显改善老年STEMI患者预后.     

介入治疗对老年人急性ST段抬高性心肌梗死预后的影响

Objective To investigate the effect of percutaneous eoronary intervention (PCI) on the prognosis of acute ST-segment elevation myocardial infarction (ASTEMI) in the elderly.Methods The 1318 ASTEMI patients in our hospital from June 1998 to June 2008 were retrospectively analyzed. Among them, 338 (25.6%) elderly patients were over 60 years old, and 316patients consistent with inclusion and exclusion criteria were consecutively enrolled in our research.Then they were divided into two groups: PCI group (136 cases, 43.0%) and conservative drug treatment group (180 cases, 57. 0%). The clinical data of study objects were collected. Then they were followed up regularly for two years. Results There were no statistically significant differences between the two groups in mean age, gender, hypertension, diabetes, dyslipidemia, excess smoking,wine and family history (all P＞ 0.05). And there were no statistically significant differences in anterior wall STEMI, Killip Ⅲ-Ⅳ class, thrombolysis therapy and malignant ventricular arrhythmia (all P＞0. 05). Most of the objects proceeded therapeutic lifestyle improvements, such as giving up smoking, restricting wine, regulating diet, losing weight and insisting on exercises, and so on.Secondary prevention drugs of acute myocardial infarction including angiotensin converting enzyme inhibitor, angiotensin receptors blockers, beta receptor, aspirin and statins were regularly administrated in the two follow-up years. In the retrospective research, incidence rates of reinfarction, NYHA (New York Heart Association) Ⅲ-Ⅳ class heart function and one-month mortality were much higher in conservative treatment group than in PCI group (17.2% vs. 2. 2%, OR=9. 224,95% CI: 2. 756-30. 857; 31.1% vs. 8.1%,OR=5.132, 95%CI: 2. 568-10. 257; 8. 3% vs. 1.5%,OR= 6. 091, 95% CI: 1. 369-27. 105, respectively; all P ＜ 0. 01). Above all, one and two-year mortalities were much higher in conservative treatment group than in PCI group (21.1% vs. 2. 2 %,OR=11.864, 95%CI: 3.577-39.349; 32.2% vs. 4.4%, OR=10.301, 95%CI: 4.289-24.736,respectively; all P＜0. 01). Conclusions PCI may reduce the re-infarction, NYHA Ⅲ-Ⅳ class heart function and one-month mortality, especially so in view of the one and two-year mortality. PCIcan significantly improve the prognosis of ASTEMI in the elderly.     

急性ST段抬高性心肌梗死急诊介入治疗后单导联ST段回落不良对预后的影响

目的探讨急性ST段抬高性心肌梗死（STEMI）急诊介入治疗后单导联ST段回落程度对预后的影响。方法回顾性分析248例急性STEMI行急诊PCI治疗患者的临床资料,将患者分为两组,A组为ST段回落良好组（回落率950％）,B组为ST段回落不良组（回落率〈50％）。比较两组的预后情况。结果A组172例（69．40％）,B组76例（30．60％）。随访2年,B组发生主要心脏不良事件（MACE）的比例高于A组,B组在随访期间发生MACE的相对危险度（RR值）为42．48（P〈0．05）。结论急性STEMI急诊介入治疗后ST段回落程度与临床预后显著相关。     

急性心肌梗死介入治疗后细胞因子变化与心肌灌注的关系

目的 探讨急性心肌梗死(AMI)患者急诊经皮冠状动脉介入治疗(PCI)后白细胞介素8(IL-8)、可溶性细胞间黏附分子1(sICAM-1)变化与心肌灌注的关系. 方法急性ST段抬高型心肌梗死患者98例,接受急诊PCI治疗,于术前5 min,术后6 h、12 h、24 h分别抽取动脉血标本,采用酶联免疫双抗体夹心法(ELISA)检测ICAM-1及IL-8.PCI术后1个月做双核素心肌灌注显像(DISA SPECT)检查,根据心肌灌注程度分为心肌灌注不良组、心肌灌注良好组. 结果 IL-8在PCI术前5 min两组均已呈现升高趋势(P＞0.05),术后6 h心肌灌注不良组进一步升高达峰值(P＜0.01),术后12 h、24 h心肌灌注不良组[分别为(94.3±169.9)和(44.1±27.8)ng/L]仍高于心肌灌注良好组[分别为(27.4±26.8)和(21.5±12.2)ng/L,P＜0.01和P＜0.05].两组sICAM-1在PCI术前5 min比较,差异无统计学意义(P＞0.05);术后6 h、12 h、24 h均持续高于心肌灌注良好组(P＜0.05). 结论 急性心肌梗死PCI术后心肌灌注不良患者血浆IL-8、sICAM-1水平明显高于心肌灌注良好者,提示细胞因子IL-8、sICAM-1参与血运重建后心肌灌注障碍的发生、发展.     

急性ST段抬高性心肌梗死患者直接经皮冠状动脉介入治疗再灌注时间对ST段回落的影响

目的探讨直接经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗中症状发作-球囊扩张时间(symptom-onset-to-balloon,SOTB)对再灌注后心电图ST段的回落、住院期间左心室射血分数、6个月内总的主要心血管事件(包括心绞痛、再发心肌梗死、因心血管事件再入院、心力衰竭和死亡等)发生率的影响。方法回顾性分析2005年1月至2006年7月于北京大学深圳医院行直接PCI治疗的ST段抬高性心肌梗死(ST-elevation myocardial infarction,STEMI)患者225例的基线资料、心电图资料以及随访资料,比较不同时间SOTB(>3 h及≤3 h)术前、术后1 h ST段抬高总和恢复百分比(sumSTR)%、住院期间超声心动图所测的左心室射血分数、随访6个月的主要心血管事件发生率。结果SOTB≤3 h组PCI治疗后1 h ST段完全回落≥70%的患者比例明显高于SOTB>3 h组,差异有统计学意义(57.4%vs.43.2%,P=0.005);住院期间左心室射血分数高于SOTB>3 h组,差异有统计学意义(57.69%±7.64%vs.53.80%±9.03%,P=0.014);6个月主要心血管事件发生率低与SOTB>3 h组,差异有统计学意义(14.9%vs.35.4%,P=0.001)。结论 STEMI患者PCI治疗中SOTB短,ST段回落就迅速而完全,住院期间的左心室射血分数高,6个月主要心血管事件发生率低。     

药物支架和裸支架治疗急性ST段抬高心肌梗死患者的随访研究

Objective To evaluate the effects of drug-eluting stents (DES) versus bare-metal stents (BMS) on clinical outcomes in patients with acute ST-segment elevation myocardial infarction (ASTEMI) receiving primary percutaneous coronary intervention (PPCI). Methods The 217patients with ASTEMI receiving PPCI from Jan. 2005 to Dec. 2007 were enrolled in this study. And they were divided into two groups: DES group (n=92) and BMS group (n=125). The baseline characteristics including age, gender, angiographic characteristics, stents characteristics, Killip classification, cardiac troponin I(CTnI)levels, left ventricular ejection fraction(LVEF), hemoglobin levels, hypertension, diabetes, hyperlipidemia, obesity and smoking of the two groups were collected.Clinical follow-up end point were major adverse cardiac event(MACE)including death, acute myocardial infarction, stent thrombosis and stent restenosis. Clinical follow-up duration was(16.8±11.3) months (6-38 months). Results The average age (years), rate of Killip classification (class 2, 3, 4), average diameter (mm) of stent were significantly higher in BMS group than in DES group(64.6±11.9 vs. 61.2±11.8, t=2.09, P=0.037;25.9% vs. 12.2%, χ2=5.53, P=0.019;3.07±0.38 vs. 2.91±0. 40, t=2.78, P=0.006). And the average LVEF (%) was significantly lower in BMS group than in DES group (55.4±11.9 vs. 60.3±12.8, t= -2.57, P=0.011). The average length (mm) of stent, rate of stent post dilatation and diabetes were significantly higher in DES group than inBMSgroup (32.8±16.2 vs. 26.2±11.2, t=-3.54, P=0.001;45.7% vs. 21.6%, χ2=13.85, P=0. 000;28.2% vs. 16.0%, χ2=4.77, P=0.030). MACE occurred in 36 patients during clinical follow-up, 6 in DES group and 30 in BMS group. Incidence of MACE was significantly lower in DES group than in BMS group(6.5% vs. 24.0%, χ2=11.70, P＜0.01). Conclusions Using DES in ASTEMI patients is safe and may improve clinical outcomes by reducing incidence of MACE compared with BMS.     

药物支架和裸支架治疗急性ST段抬高心肌梗死患者的随访研究

Objective To evaluate the effects of drug-eluting stents (DES) versus bare-metal stents (BMS) on clinical outcomes in patients with acute ST-segment elevation myocardial infarction (ASTEMI) receiving primary percutaneous coronary intervention (PPCI). Methods The 217patients with ASTEMI receiving PPCI from Jan. 2005 to Dec. 2007 were enrolled in this study. And they were divided into two groups: DES group (n=92) and BMS group (n=125). The baseline characteristics including age, gender, angiographic characteristics, stents characteristics, Killip classification, cardiac troponin I(CTnI)levels, left ventricular ejection fraction(LVEF), hemoglobin levels, hypertension, diabetes, hyperlipidemia, obesity and smoking of the two groups were collected.Clinical follow-up end point were major adverse cardiac event(MACE)including death, acute myocardial infarction, stent thrombosis and stent restenosis. Clinical follow-up duration was(16.8±11.3) months (6-38 months). Results The average age (years), rate of Killip classification (class 2, 3, 4), average diameter (mm) of stent were significantly higher in BMS group than in DES group(64.6±11.9 vs. 61.2±11.8, t=2.09, P=0.037;25.9% vs. 12.2%, χ2=5.53, P=0.019;3.07±0.38 vs. 2.91±0. 40, t=2.78, P=0.006). And the average LVEF (%) was significantly lower in BMS group than in DES group (55.4±11.9 vs. 60.3±12.8, t= -2.57, P=0.011). The average length (mm) of stent, rate of stent post dilatation and diabetes were significantly higher in DES group than inBMSgroup (32.8±16.2 vs. 26.2±11.2, t=-3.54, P=0.001;45.7% vs. 21.6%, χ2=13.85, P=0. 000;28.2% vs. 16.0%, χ2=4.77, P=0.030). MACE occurred in 36 patients during clinical follow-up, 6 in DES group and 30 in BMS group. Incidence of MACE was significantly lower in DES group than in BMS group(6.5% vs. 24.0%, χ2=11.70, P＜0.01). Conclusions Using DES in ASTEMI patients is safe and may improve clinical outcomes by reducing incidence of MACE compared with BMS.     

辛伐他汀对急性心肌梗死冠状动脉经皮介入治疗后心肌血流灌注的影响

目的 探讨辛伐他汀对急性心肌梗死患者急诊冠状动脉经皮介入治疗术后心肌血流灌注的影响.方法 81例行急诊冠状动脉经皮介入治疗术的急性心肌梗死患者,按之前服用辛伐他汀的情况分为四组:A组15例,服用时间超过6个月;B组19例,服用时间1～6个月;C组17例,服用时间少于1个月;D组30例,未服用.比较各组校正的TIMI帧数计数(CTFC)和1 h内ST段回落情况.结果 A组和B组CTFC较D组较小(P＜0.01),且术后1 h ST段回落较D组明显(P＜0.01).结论 长期服用辛伐他汀,可有效改善急性心肌梗死患者急诊冠状动脉经皮介入治疗术后心肌血流灌注.     

急诊经桡动脉冠状动脉介入治疗疗效和安全性评价

Objectives To compare the safety and efficacy of radial artery access versus femoral artery access for percutaneous coronary intervention in acute myocardial infarction population. Methods From June 2004 to December 2006, 446 patients with acute myocardial infarction treated with percutaneous stenting were reviewed retrospectively. The radial artery approach was used in 242 patients, and the femoral artery approach in 204 patients. The success of the procedure, procedure duration, X-ray exposition, volume of contrast, incidence of major adverse cardiac events and complications were compared between the radial artery and femoral artery approach. Results Total procedure duration, X-ray exposition, the immediate success of the procedure and the proportion of patients with reperfusion time above 60min are higher in patients with radial artery acess than that with femoral artery access [(62. 1 ± 23. 4) min vs(56. 8 ± 16. 7)min,(2829. 4 ± 1365.2) mGY vs (2352. 3 ± 903.1) mGY, 4% vs 0.9% and 7.44% vs 2.94%respectively, all P ＜ 0. 05]. Conclusions In non-selected patients with acute myocardial infarction treated with primary stent implantation, the success rate of the radial artery approach is lower than the femoral artery approach and could prolong the reperfusion time. It is suitable to change artery access immediately if abnormality is found via radial artery access.