急诊与择期血运重建对急性心肌梗死后心脏胶原重塑的影响

目的评价急诊与择期血运重建对急性心肌梗死（AMI）后心脏胶原重塑的影响差异。方法45例AMI患者依据不同干预方法分为择期血运重建组（急诊组,25例）和急诊血运重建组（择期组,20例）,采用酶联免疫法测定患者在AMI发病后1周、3个月及6个月时的血清Ⅰ型前胶原羧基端肽（PICP）、Ⅲ型前胶原（PCⅢ）。结果急诊组3个月和6个月的PⅠCP及1周时点的PCⅢ浓度分别为（7．61±4．05）ng／ml、（10．44±4．36）ng／ml和（27．91±8．71）ng／ml,均低于择期组的（10．79±4．17）ng／ml、（13．20±4．42）ng／ml和（37．71±13．64）ng／ml,均P〈0．05。结论急诊血运重建对AMI后半年内心脏胶原合成代谢的抑制作用强于择期血运重建。     

急诊血运重建对急性心肌梗死患者心脏胶原合成与降解的影响

目的:探讨急诊血运重建对急性心肌梗死(AMI)患者心脏胶原合成和降解代谢的影响。方法:对33例AMI患者分别予常规药物治疗(常规组,14例)和急诊血运重建治疗(急诊组,19例),应用酶联免疫法分别检测AMI后1周、6个月及12个月的血清Ⅰ型前胶原羧基端肽(PⅠCP)、Ⅲ型前胶原(PCⅢ)、基质金属蛋白酶-1(MMP-1)及组织抑制因子-1(TIMP-1)含量。以30例正常人为对照组。结果:与对照组比较,常规组和急诊组各时点的PⅠCP、PCⅢ均明显增高(P<0.05),MMP-1和TIMP-1均显著降低(P<0.05)。急诊组6个月的PⅠCP、PCⅢ和12个月的PCⅢ均低于常规组同期相应指标(P<0.05),急诊组6个月的TIMP-1高于同期常规组(P<0.05)。结论:急诊血运重建抑制AMI后中期(6～12个月)心脏胶原重构的作用强于常规药物治疗。     

心肌梗死后心脏胶原重塑的意义及干预研究

心肌梗死后心脏发生修复性纤维化和反应性纤维化等胶原重塑改变 ,参与心力衰竭的发生、发展。针对病理性胶原重塑的深入研究为防治心肌梗死后心力衰竭的发生、发展开辟了新的思路。     

不同血运重建方法对陈旧前壁心肌梗死合并左心室室壁瘤患者预后的影响

目的探讨不同血运重建方法对陈旧前壁心肌梗死合并左心室室壁瘤患者的左心室重塑指标、心功能以及远期预后的影响。方法共入选Euro Score评分中低危的患者223例,分为经皮冠状动脉介入治疗(PCI)组129例和冠状动脉旁路移植术(CABG)组94例。患者分别于血运重建术前、术后6个月行超声心动图检查,随访36个月记录主要终点事件(全因死亡、脑卒中、心肌梗死)及主要不良心脏事件(MACE)发生情况。结果接受血运重建术前,PCI组与CABG组患者左心室舒张末期内径(LVEDd)[(58.12±10.01)mm比(61.75±5.85)mm]、左心室射血分数(LVEF)[(43.57±9.41)%比(42.98±10.98)%]、左心室质量指数(LVMI)[(122.47±15.36)g/m2比(126.22±16.58)g/m2]比较,差异均无统计学意义(均P>0.05)。PCI组术后6个月较术前LVEDd[(52.32±4.23)mm比(58.12±10.01)mm,P<0.05]、LVEF[(56.56±9.65)%比(43.57±9.41)%,P<0.05]和LVMI[(107.54±15.25)g/m2比(122.47±15.36)g/m2,P<0.05]显著改善。CABG组术后6个月较术前LVEDd[(53.65±3.72)mm比(61.75±5.85)mm,P<0.05]、LVEF[(57.70±10.65)%比(42.98±10.98)%,P<0.05]和LVMI[(109.43±14.35)g/m2比(126.22±16.58)g/m2,P<0.05]也显著改善。累积36个月随访发现,PCI组主要终点事件和MACE发生率高于CABG组,但差异无统计学意义(13.2%比12.8%,χ2=0.29,P>0.05;12.4%比6.4%,χ2=2.22,P>0.05)。结论不同血运重建方法均显示术后6个月LVEF升高、LVMI降低,但在心功能、左心室重塑、主要终点事件以及MACE改善方面,CABG术与PCI术间差异无统计学意义。     

苯妥英钠对大鼠急性心肌梗死后心室重塑的影响

目的 探讨苯妥英钠促进心肌梗死后组织修复的机制.方法 将175只Wistar大鼠随机分为苯妥英钠组、对照组和假手术组三组.苯妥英钠组及对照组开胸结扎冠状动脉,建立AMI模型.造模后苯妥英钠组腹腔注射苯妥英钠100 ms/(ks·d),对照组腹腔注射等量的生理盐水;假手术组开胸后不结扎冠状动脉,亦不用药.分别于造模后第1、3、7、14 d时各处死动物61只,取心室分为两部分,一部分用组织学方法分析Ⅰ/Ⅲ型胶原比值、心肌横断面积、胶原容积分数和梗死区厚度;另一部分分割为梗死区和非梗死区,采用Gelatin Zymography测定梗死区基质金属蛋白酶(MMP)-2和MMP-9活性.结果 苯妥英钠组14 d时梗死区厚度大于对照组(P＜0.01),非梗死区心肌横断面积14 d时小于对照组(P＜0.01);梗死区胶原容积分数整体呈上升趋势,在同一时间点高于对照组,14 d时变化尤为明显(P＜0.01).梗死区MMPs活性明显高于假手术组,其中MMP-9活性在1 d后迅速升至最高峰,此后逐渐下降,14 d时尚未回至正常水平,而MMP-2活性则持续升高,14 d时最高,并有继续上升趋势.对照组整体变化趋势与苯妥英钠组相同,但后者MMPs活性增强更为明显,1 d时活化型MMP-9已表现出这一特点.结论 苯妥英钠可促进AMI后早期梗死区胶原合成,有效减缓早期梗死区的膨展;MMP-2和MMP-9活性在AMI后呈现动态升高趋势;苯妥英钠通过加强这一变化、促进炎症反应的进程,从而加速梗死区的自身修复.     

急性心肌梗死后心脏重塑及其临床意义

近年来 ,急性心肌梗死 (ＡＭＩ)早期存活率有明显改善 ,但心力衰竭 (ＨＦ)的死亡率却日益增加 ;调查资料显示 ,ＡＭＩ后所造成的心血管事件死亡率和发病率持续升高〔1〕。研究证实ＡＭＩ后心脏重塑与ＨＦ、心律失常密切相关 ,亦是ＡＭＩ后心血管事件的原因 ,因此心脏重塑也就成为ＡＭＩ后ＨＦ治疗靶点。1 　ＡＭＩ后心脏重塑的定义通常认为ＡＭＩ后心脏重塑是基因表达及分子、细胞水平的变化 ,在临床上表现为心脏大小、形态和功能的改变。心脏重塑涉及成分包括心肌细胞、成纤维细胞、胶原纤维及冠状动脉系统。相关的过程包括缺血、细胞坏死…     

多普勒组织成像技术评价血运重建对急性心肌梗死患者心功能的影响

目的 应用多普勒组织成像(DTI)评价血运重建对急性心肌梗死(AMI)患者心功能的影响.方法 对65例AMl患者分别予以常规强化内科保守治疗(常规治疗组,20例)和在此基础上的血运重建治疗(血运重建组,45例).应用二维超声心动图和DTI分别观察两组AMI后1周、3个月及6个月的左室射血分数(LVEF)、二尖瓣血流舒张早期流速与心房收缩期流速的比值(VE/VA)、二尖瓣环6个位点节段的二尖瓣环收缩期运动速度峰值(Sa)、舒张早期运动速度峰值(Ea)和舒张晚期运动速度峰值(Aa).20名健康人为对照组.结果 常规治疗组和血运重建组各时点亚组的LVEF、VE/VA、Sa和Ea及常规治疗组3个月和6个月亚组的Ea/Aa均小于对照组(P<0.05),血运重建组3个月、6个月亚组的Sa、Ea和6个月亚组的LVEF较常规治疗组显著升高(P<0.05),而两组同时点各亚组间的VE/VA、Aa及Ea/Aa比较,差异无统计学意义(P>0.05).结论 血运重建是改善AMI后左室收缩、舒张功能的重要手段.DTI技术在评价AMI后心脏整体收缩、舒张功能变化方面较二维超声心动图更为敏感.     

急性心肌梗死合并心原性休克患者的血运重建治疗

心源性休克是急性心肌梗死患者最严重的并发症。虽然已经有了多种药物治疗、综合的监护管理以及先进的器械辅助,但急性心肌梗死合并心源性休克患者依旧保持着较高的死亡率。多项研究表明,尽早进行血运重建治疗是目前唯一可以明显改善急性心肌梗死合并心源性休克患者预后的治疗措施。因此尽早进行血运重建治疗是急性心肌梗死合并心源性休克患者治疗中最重要的一环。该文综述了其研究进展。     

急诊血运重建对急性心肌梗死左心室功能的影响

目的应用二维超声心动图及多普勒组织成像（Doppler tissue imaging,DTI）评价急诊血运重建（包括静脉溶栓或者急诊冠状动脉支架置入术）对急性心肌梗死（acute myocardial infarction,AMI）左心室收缩和舒张功能的影响。方法入院后根据AMI患者治疗方法分为常规组和治疗组。常规组30例给予内科常规治疗;治疗组20例在内科常规治疗基础上实施静脉溶栓或急诊冠状动脉支架置入术。应用DTI检测左心室射血分数、二尖瓣血流舒张早期流速峰值（peak velocity at early diastole,VE）和舒张晚期流速峰值（peak velocity at late diastole,VA）比值（VE／VA）,DTI成像模式检测二尖瓣环后间隔、侧壁、前壁、下壁、前间隔和后壁6个节段的收缩期运动速度峰值（peak velocity during systole,Sa）、舒张早期运动速度峰值（peak velocity at early diastole,Ea）和心房收缩期流速峰值（peak velocitv at atrial contraction,Aa）,并计算Ea／Aa比值。各取6个节段的平均值。结果所有AMI患者于发病后1周、3月末左心室射血分数、VE／VA、Sa、Ea和Ea／Aa均较对照组降低;予急诊血运重建的AMI患者于AMI发病后3个月S。和E。较本组发病后1周增高,并较未行急诊血运重建干预组（常规组）发病后3个月增高。结论AMI后左心室收缩和舒张功能受损,实施急诊血运重建可以有效改善心脏功能．应用DTI技术检测二尖瓣环运动速度可以精确反映AMI患者局部节段性心功能的恢复。     

梗死相关血管延迟血运重建对急性心肌梗死的临床疗效

目的 探讨梗死相关血管延迟血运重建对急性心肌梗死的临床疗效.方法 将275例急性心肌梗死患者分为延迟血运重建治疗组（124例）和药物治疗组（151例）.对所有患者随访4～88个月,观察住院期间和随访期间的临床不良事件和超声心动图的变化及利用QRS计分评估梗死范围的变化.结果 延迟血运重建组平均住院时间[（13.8±9.7）日]显著少于药物治疗组[（19.8±8.9）日]（P〈0.05）;延迟血运重建组的复合终点事件发生率显著少于药物治疗组（P〈0.05）;随访期间,延迟血运重建组的心力衰竭及复合终点事件的发生率显著低于药物治疗组（P〈0.05）.超声心动图随访结果示延迟血运重建组的左室射血分数显著高于药物治疗组（P〈0.05）,延迟血运重建组的左室舒张末期内径显著小于药物治疗组（P〈0.05）.延迟血运重建组的心肌梗死范围回缩率（0.376±0.129）显著大于药物治疗组（0.173±0.098）（P〈0.05）.结论 延迟血运重建能减少住院和随访期间心脏事件发生率、改善左心室功能、使心肌梗死面积缩小,改善急性心肌梗死病人的预后.     

螺内酯对急性心肌梗死后胶原异常增生的抑制作用

目的 :研究醛固酮抑制剂螺内酯对不能进行溶栓治疗或溶栓未成功的急性心肌梗死 (AMI)患者心肌胶原合成指标的影响。方法 :AMI患者 6 5例 ,随机分为两组。常规治疗组 32例 ,接受血管紧张素转换酶抑制剂 (ACEI)、β受体阻滞剂、抗血小板等常规药物治疗。螺内酯组 33例 ,在常规治疗基础上加用螺内酯 ( 2 0mg ,bid)。应用放射免疫法测定两组患者AMI后第 5、15、30、90天血清Ⅰ型前胶原羧基端肽 (PICP)和Ⅲ型前胶原氨基端肽 (PⅢNP)浓度。 30例健康人作为对照组。结果 :两组患者第 5、15、30、90天的血清PICP和PⅢNP水平均比对照组明显升高 (P <0 .0 5～ 0 .0 1)。第 90天时螺内酯组的血清PICP和PⅢNP水平均明显低于常规治疗组(均 P <0 .0 5～ 0 .0 1)。结论 :螺内酯可抑制未进行溶栓治疗、溶栓未成功的AMI患者心肌胶原异常增生。     

螺内酯对急性心肌梗死患者血浆Ⅲ型前胶原氨基末端肽含量的影响

目的 :探讨螺内酯对急性心肌梗死 (AMI)后血浆Ⅲ型前胶原氨基末端肽 (PⅢNP)的影响。方法 :将6 0例前壁AMI患者随机分为两组 ,对照组采用常规治疗 ,治疗组在常规治疗基础上口服螺内酯 2 5mg ,bid。两组均在入院后第 1、7、2 8、6 0天采血检测PⅢNP含量。结果 :AMI后血清PⅢNP增加 ,与正常人PⅢNP水平相比差异有统计学意义 [(3.2 4± 2 .13)∶(2 .12± 1.78) μg/L ,P <0 .0 5 ]。治疗第 2 8天后 ,治疗组PⅢNP水平明显低于对照组 [(4 .78± 2 .0 1)∶(5 .98± 2 .6 5 ) μg/L ,P <0 .0 5 ]。结论 :在AMI后早期使用螺内酯治疗可以降低PⅢNP含量 ,减少Ⅲ型胶原的产生。     

Predictors of contractile recovery after revascularization in patients with anterior myocardial infarction who received thrombolysis

BACKGROUND:

Identification of viable myocardium after myocardial infarction has gained paramount importance with the current progress in coronary revascularization.

OBJECTIVE:

To explore the prognostic power of certain patient characteristics to predict myocardial contractile recovery after revascularization in patients presenting with acute anterior ST elevation myocardial infarction (STEMI) who received thrombolytic therapy.

METHODS:

Seventy-three consecutive patients presenting with first acute anterior STEMI who had received thrombolytic therapy and had significant coronary stenosis or occlusion of the infarct-related artery amenable for revascularization were enrolled. All patients underwent echocardiographic assessment of regional wall motion and left ventricular ejection fraction. Patients underwent coronary revascularization by either percutaneous angioplasty or surgical bypass. Echocardiography was repeated two to three months following revascularization. Patients were classified into two groups: group 1 had evidence of contractile recovery after revascularization at follow-up echocardiography and group 2 had no such evidence of recovery.

RESULTS:

Predictors of contractile recovery after revascularization included a shorter time from symptom onset to the institution of thrombolytic therapy, a lower baseline wall motion score index, the presence of grade 3 collaterals to the infarct-related artery and the use of beta-blockers. Instead, the presence of diabetes mellitus and a totally occluded infarct-related artery predicted poor contractile recovery.

CONCLUSIONS:

Myocardial contractile recovery after revascularization in patients presenting with first acute anterior STEMI may be predicted by the absence of diabetes, a shorter time from symptom onset to thrombolytic therapy, the use of beta-blockers, a lower initial wall motion index score and the presence of collaterals to the infarct-related artery.     

International differences in in-hospital revascularization and outcomes following acute myocardial infarction: a multilevel analysis of patients in ASSENT-2.

BACKGROUND: Revascularization rates vary substantially between countries in patients with acute ST-elevation myocardial infarction (STEMI). The impact of early revascularization on clinical outcomes in such patients remains uncertain. The ASSENT-2 fibrinolytic trial provides the opportunity to compare revascularization rates following STEMI in patients across 29 countries, and to explore the relationship between revascularization and clinical outcome. METHODS: Countries participating in ASSENT-2 were grouped into tertiles according to their in-hospital revascularization rates (<15%, 15-39%, >39%). Baseline characteristics, medication and procedure use, and clinical outcomes of the 16949 patients enrolled were compared. Multiple Cox regressions were used to assess the relationship between the tertiles and 30-day mortality, the primary endpoint of the ASSENT-2 trial. Multilevel logistic regression models were developed to validate and further extend the findings from the single-level analyses. RESULTS: Patients in highest tertile countries were younger, heavier, and more often diabetic or hypertensive. They were more likely to have had a previous myocardial infarction or revascularization procedure. Time to treatment and hospital length of stay were shorter in the highest tertile, and beta-blocker use was more frequent. Stroke rates were low and similar across tertiles, with no statistically significant difference in rates of intracranial haemorrhage. Recurrent ischaemia and reinfarction were less common in the highest tertile. Mortality rates at 30 days were lower for countries with the highest revascularization rates (5.1% vs 6.9% vs 6.5% for the lower two tertiles, P<0.001). At 1 year, mortality remained significantly lower in the highest tertile countries (8.4% vs 10.6% vs 9.9%, P=0.001). Following adjustment for baseline patient characteristics, Cox regression analysis confirmed an excess of 30-day and 1-year mortality in the lowest and intermediate tertiles compared to the highest tertile. The multilevel analyses validated these findings, and demonstrated that a country's life expectancy and the hospital volume were inversely related to both 30-day and 1-year mortality. CONCLUSIONS: The highest rate of in-hospital revascularization following fibrinolytic therapy for acute myocardial infarction in this international study was associated with a reduction in recurrent ischaemia, reinfarction, and improved survival at both 30 days and at 1 year. The optimal rates of revascularization in this setting remain to be determined.     

干细胞治疗与急性心肌梗死后左心室重构:随机对照试验的荟萃分析

目的急性心肌梗死(AMI)后的心力衰竭,是影响AMI患者长期预后的重要因素。近来的临床试验提示干细胞治疗可改善左室功能,但其对左室重构的影响尚无定论。本研究拟系统评价急性心肌梗死患者干细胞治疗前后左室舒张末期容积(Left ventricular end-diastolic volume,LV-EDV)的变化,为探讨干细胞治疗是否改善左室重构提供一些线索。对象与方法系统检索PubMed(1967.1-2009.12)、Embase(1967.1-2009.12)、Cochrane Library、综述及相关文章的参考文献,并通过阅读相关综述及文章的参考文献进一步获取信息。对目前已发表的评估干细胞治疗对AMI患者LV-EDV影响的随机对照试验进行荟萃分析。应用固定效应模型(Fixed-effect models)计算加权平均差(Weighted mean difference,WMD)及其95%可信限(CI),用以描述干预前(基线)后(随访时)LVEDV的净差值。结果共13项研究(合计AMI病例926人,其中,合计接受干细胞干预者452人,未接受干细胞治疗者474人)纳入荟萃分析。结果显示:与未接受干细胞治疗者相比,接受干细胞治疗者LVEDV有降低趋势,但无显著统计学意义(WMD:-1.76,95%可信限-4.61～1.08,P=0.233)。结论本研究提示干细胞治疗不能改善AMI患者的左室重构。     

Early degradation and serum appearance of type I collagen fragments after myocardial infarction

Although extracellular matrix-degrading enzymes matrix metalloproteinases (MMPs) are activated within minutes after myocardial infarction (MI), the time course of early MI-induced type I cardiac collagen degradation has not been assessed, nor has the ability of MMP inhibitor compounds, such as doxycycline (DOX), to limit these events. The objective of this study was to assess serum biomarker evidence of myocardial type I collagen degradation early (<48 h) after coronary occlusion (CO) and determine the capacity of DOX to ameliorate its release. CO studies were performed in untreated and DOX pre-treated pigs. Treated animals received DOX at 30 mg/kg/d. Radioimmunoassays were performed for serum levels of C-terminal telopeptide of collagen type I (ICTP) fragments. ICTP groups peaked by 6 h after MI. However, in DOX-treated animals, ICTP values returned to normal by 8 h. Average serum concentrations for ICTP values from 0 to 48 h post-MI were significantly inhibited by DOX treatment. In conclusion, serum biomarker results indicate that type I collagen degradation occurs within minutes after MI and that DOX likely reduces its degradation.     

High-sensitivity C-reactive protein and left ventricular remodeling in patients with acute myocardial infarction

 Inflammatory cytokines are suspected to play an important role in the pathophysiology of left ventricular (LV) remodeling. We investigated whether high-sensitivity C-reactive protein (CRP) (hs-CRP) is a predictor for LV remodeling in patients with acute myocardial infarction (AMI) with successful reperfusion, and also whether such a situation can be avoided by the administration of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB). The subjects were 139 patients with an initial attack of anterior myocardial infarction successfully treated by reperfusion therapy. They were randomly divided into the following two groups: an angiotensin (AG) group (91 patients treated with ACEI/ARB) and a NON-AG group (48 patients not treated with ACEI/ARB). Levels of hs-CRP, creatine kinase, human atrial natriuretic polypeptide, brain natriuretic peptide (BNP), fasting blood glucose, serum lipids, fibrinogen, fibrin degradation product, prothromloin time, and activated partial thromboplastin time were measured immediately after 1, 2, 3, and 7 days, and 1 months after the onset of AMI. ACEI or ARB administration lowered hs-CRP levels and prevented the development of LV remodeling. Peak CRP levels significantly correlated with BNP levels during the acute stage (r = +0.54, P < 0.0001), end-diastolic volume index (r = +0.78, P < 0.0001), end-systolic volume index (r = +0.36, P = 0.0405), ejection fraction (r = −0.45, P = 0.0052), left ventricular end-diastolic diameter (r = +0.61, P < 0.0001), cardiac output (r = −0.52, P = 0.0005), cardiac index (r = −0.41, P = 0.0099), and systolic pulmonary arterial pressure (r = +0.48, P = 0.0017) 1 month after the onset of AMI in the NON-AG group but not in the AG group. Logistic multivariate analysis revealed that peak CRP alone was an independent risk factor for the development of LV remodeling in the NON-AG group (odds ratio = 1.79, P = 0.002). These results suggest that hs-CRP is a useful factor for predicting LV remodeling. Furthermore, ACEI or ARB administration to AMI patients showing increased hs-CRP levels during the early stage of the disease could prevent LV remodeling. Received: October 18, 2002 / Accepted: February 7, 2003     

Tei指数在选择再血管化治疗急性心肌梗死适应证的价值

目的:用Tei指数的变化评价再血管化治疗急性心肌梗死区心肌功能的恢复情况,探讨Tei指数在选择再血管化治疗适应证的作用. 方法:选择再血管化治疗的32例急性心肌梗死患者,按照是否为跨壁心梗及疤痕情况分为两组.在再血管化治疗的术前、术后10 d、3个月、6个月分别测定Tei值和左室射血分数(LVEF),比较并分析前后变化. 结果:32例患者在术前及术后10 d的Tei指数及LVEF无明显变化;24/32例(术前Tei值＜0.54,LVEF＞46%)术后3个月及6个月时心功能有明显的变化,8/32例(术前Tei＞0.66、LVEF＜37%)在再血管化术后没有明显的变化. 结论:急性心肌梗死患者选择作再血管化治疗适应证时,Tei＜0.54的患者是比较合适的,而Tei＞0.66的患者再血管化治疗的效价比较低.