心肌缺血预适应对急性心肌梗死影响的临床分析

目的 观察心肌缺血预适应对急性心肌梗死(AMI)的保护作用。方法 将80例急性心肌梗死患分为缺血预适应组48例和无缺血预适应组32例，将两组临床资料进行对比分析。结果 缺血预适应组小面积心肌梗死的发生率明显高于无缺血预适应组，而心律失常、心衰、心源性休克、再梗等的发生率及病死率明显低于无缺血预适应组，有统计学意义。结论 心肌缺血预适应对AMI具有保护作用。     

Variations in the quality of care of patients with acute myocardial infarction among Swiss university hospitals.

OBJECTIVE: The objective of our study was to assess hospital variations in the quality of care delivered to acute myocardial infarction (AMI) patients among three Swiss academic medical centres. DESIGN: Cross-sectional study. SETTING: Three Swiss university hospitals. STUDY PARTICIPANTS: We selected 1129 eligible patients discharged from these hospitals from 1 January to 31 December 1999, with a primary or secondary diagnosis code [International Classification of Diseases, 10th revision (ICD-10)] of AMI. We abstracted medical records for information on demographic characteristics, risk factors, symptoms, and findings at admission. We also recorded the main ECG and laboratory findings, as well as hospital and discharge management and treatment. We excluded patients transferred to another hospital and who did not meet the clinical definition of AMI. MAIN OUTCOME MEASURES: Percentage of patients receiving appropriate intervention as defined by six quality of care indicators derived from clinical practical guidelines. RESULTS: Among 577 eligible patients with AMI in this study, the mean (SD) age was 68.2 (13.9), and 65% were male. In the assessment of the quality indicators we excluded patients who were not eligible for the procedure. Among cohorts of 'ideal candidates' for specific interventions, 64% in hospital A and 73% in hospital C had reperfusion within 12 hours either with thrombolytics or percutaneous transluminal coronary angioplasty (P = 0.367). Further, in hospitals A, B, and C, respectively 97, 94, and 84% were prescribed aspirin during the initial hospitalization (P = 0.0002), and respectively 68, 91, and 75% received angiotensin converting enzyme inhibitors at discharge in the case of left ventricular systolic dysfunction (P = 0.003). CONCLUSIONS: Our results showed important hospital-to-hospital variations in the quality of care provided to patients with AMI between these three university hospitals.     

急性心肌梗死患者在优化急诊护理流程抢救上的效果观察

目的：探讨急性心肌梗死患者在优化急诊护理流程抢救上的效果。方法：研究我院2014年9月至2015年12月期间收治的80例急性心肌梗死患者,分为对照组和观察组各40例,其中对照组运用常规急诊护理流程抢救,观察组运用优化急诊护理流程抢救,分析两组护理效果差异。结果：在抢救时长、球囊扩张时长和住院时长上,观察组均短于对照组,两组差异具有统计学意义,p<0.05;术后复发率上,观察组为2.5%,对照组为22.5%,两组差异具有统计学意义,p<0.05;再次PCI治疗率上,观察组为12.5%,对照组为27.5%,两组差异具有统计学意义,p<0.05。结论：急性心肌梗死患者通过优化急诊护理流程抢救可以加快患者恢复速度,减少复发率和危险性,护理效果显著。     

心肌损伤标志物在急性心肌梗死诊断中的应用评价（综述）

血清心肌损伤标志物水平的升高是诊断急性心肌梗死的重要依据.寻找能在心梗后早期升高,并能提供早期诊断 而且特异性高的指标一直是努力的方向.就近年来在血清心肌酶以及其它损伤标志物的研究进展和临床应用价值, 尤其是 CK- MB、肌红蛋白、肌钙蛋白 I、肌钙蛋白 T等做一综述.     

A comparison of methods for combining quality and efficiency performance measures: profiling the value of hospital care following acute myocardial infarction

Health plans have begun to combine data on the quality and cost of medical providers in an attempt to identify and reward those that offer the greatest 'value.' The analytical methods used to combine these measures in the context of provider profiling have not been rigorously studied. We propose three methods to measure and compare the value of hospital care following acute myocardial infarction by combining a single measure of quality, in-hospital survival, and the cost of an episode of acute care. To illustrate these methods, we use administrative data for heart attack patients treated at 69 acute care hospitals in Massachusetts in fiscal year 2003. In the first method we reproduce a common approach to value profiling by modeling the two case mix-standardized outcomes independently. In the second approach, survival is regressed on patient risk factors and the average cost of care at each hospital. The third method models survival and cost for each hospital jointly and combines the outcomes on a common scale using a cost-effectiveness framework. For each method we use the resulting parameter estimates or functions of the estimates to compute posterior tail probabilities, representing the probability of being classified in the upper or lower quartile of the statewide distribution. Hospitals estimated to have the highest and lowest value according to each method are compared for consistency, and the advantages and disadvantages of each approach are discussed.     

An improved questionnaire for assessing quality of life after acute myocardial infarction

This paper reports our experience with the use of an improved self-administered questionnaire for assessing quality of life (QOL) after acute myocardial infarction. The modified questionnaire significantly increased the proportion of patients able to answer all questions from 84%–92%. The additional questions in the improved questionnaire increased the total variance explained by the Emotional, Physical and Social QOL factors from 65.8%–66.5%. Internal consistency and construct validity were assessed and found to be high. Overall, we have found that this improved questionnaire is easy to administer and that it possesses desirable properties of validity and reliability.This work was supported by a grant from the National Health and Medical Research Council of Australia (NH&MRC).     

Mortality after acute myocardial infarction according to income and education

OBJECTIVE: To study how income and educational level influence mortality after acute myocardial infarction (AMI). DESIGN AND SETTING: Prospective analysis using individual level linkage of registries in Denmark. PARTICIPANTS: All patients 30-74 years old hospitalised for the first time with AMI in Denmark in 1995-2002. MAIN OUTCOME MEASURES: Relative risk (RR) of 30 day mortality and long term mortality (31 days until 31 December 2003) associated with income (adjusted for education) or educational level (adjusted for income) and further adjusted for sex, age, civil status, and comorbidity. RESULTS: The study identified 21 391 patients 30-64 years old and 16 169 patients 65-74 years old. The 30 day mortality was 7.0% among patients 30-64 years old and 15.9% among those 65-74 years old. Among patients surviving the first 30 days, the long term mortality was 9.9% and 28.3%, respectively. The adjusted RR of 30 day mortality and long term mortality among younger patients with low compared with high income was 1.54 (95% confidence interval 1.36 to 1.79) and 1.65 (1.45 to 1.85), respectively. The RR of 30 day and long term mortality among younger patients with low compared with high education was 1.24 (1.03 to 1.50) and 1.33 (1.11 to 1.59), respectively. The RR of 30 day and long term mortality among older patients with low compared with high income was 1.27 (1.15 to 1.41) and 1.38 (1.27 to 1.50), respectively. Older high and low education patients did not differ in mortality. CONCLUSION: This study shows that both educational level and income substantially and independently affect mortality after AMI, indicating that each indicator has specific effects on mortality and that these indicators are not interchangeable.     

急性心肌梗死院前急救68例回顾分析

目的:研究院前急救措施对急性心肌梗死预后的影响.方法:根据症状和ECG的表现将患者分成:A组(典型表现组),一般处理的基础上给予硝酸甘油 尿激酶;B组(疑似组)一般处理和硝酸甘油治疗;C组(不典型组),仅给予一般处理.观察各组的入院后恶性心律失常发生率与病死率的比较.结果:A组的病死率与B组病死率差异有显著意义(P＜0.05),A组恶性心律失常率与B,C组差异具有显著性(P＜0.05).     

女性患者急性心梗后心理困扰与生活质量的随访研究

目的 探讨女性急性心梗患者出院后半年内的心理困扰程度和生活质量.方法 使用任意抽样,选取2015年10月至2016年4月间于西安交通大学第一附属医院重症心脏病监护病房(CCU)住院治疗的符合纳入排除标准的女性急性心梗患者61例.使用心理困扰评定量表(K10)和简明健康测量量表(SF-36)于患者出院前、出院后1个月、3个月和6个月分别进行测量和分析.结果 研究对象4个测量时点心理困扰得分分别为27.42±7.83、23.46±6.51、22.67±6.09、16.60±4.28,差异有统计学意义(F=10.34,P<0.05).4个测量时点生活质量总均分分别为50.01±21.16、53.10±21.68,56.78±22.02,61.26±19.56,差异有统计学意义(F=8.26,P<0.05).各时点上心理困扰与生活质量均有明显相关性.心梗后早期有心理困扰和无心理困扰患者,在不同时点上生活质量均具有显著性差异(t值分别为2.35、2.05、2.50、2.17,均P<0.05).结论 女性心梗患者住院治疗期间的心理问题应引起重视.适时有效的干预措施,不仅可以缓解患者住院期间的不良情绪,对患者出院后的生活质量改善也能起到一定的促进作用.     

急性心肌梗死就地抢救与直接送医院病死率对照分析

目的对比急性心肌梗死(AMI)就地抢救与直接送医院病死率的差别。方法就地抢救组除一般治疗外，还进行了溶栓、电复律和电除颤治疗。结果就地抢救30例，28例安全送院，死亡2例，病死率6．67％；直接送院216例中,在路途死亡28例，在急诊室死亡52例，病死率分别为12．96％和24．07％，合计37．03％。结论就地抢救能显著地降低AMI的病死率。     

Sex differences in risk factors, treatment and mortality after acute myocardial infarction: an observational study

BACKGROUND: Coronary heart disease is the major cause of death of postmenopausal women in industrialised countries. Although acute myocardial infarction (AMI) affects men in greater numbers, the short-term outcomes for women are worse. In the longer term, studies suggest that mortality risk for women is lower or similar to that of men. However, length of follow up and adjustment for confounding factors have varied and more importantly, the association between treatment and outcomes has not been examined. STUDY OBJECTIVE: To investigate the association between sex differences in risk factors and hospital treatment and mortality after AMI. DESIGN: A prospective observational study collecting demographic and clinical data on cases of AMI admitted to hospitals in Yorkshire. The main outcome measures were mortality status at discharge from hospital and two years later. SETTING: All district and university hospitals accepting emergency admissions in the former Yorkshire National Health Service (NHS) region of northern England. PARTICIPANTS: 3684 consecutive patients with a possible diagnosis of AMI admitted to hospitals in Yorkshire between 1 September and 30 November 1995. MAIN RESULTS: AMI was confirmed by the attending consultant for 2196 admissions (2153 people, 850 women and 1303 men). Women were older and less likely than men to be smokers or have a history of ischaemic heart disease. Crude inhospital mortality was higher for women (30% versus 19% for men, crude odds ratio of death before discharge for women 1.78, 95% confidence intervals 1.46, 2.18, p=0.00). This difference persisted after adjustment for age, risk factors and comorbidities (adjusted OR 1.29, 95% CI 1.04, 1.63, p=0.02), but was not significant when treatment was taken into account. Women were less likely to be given thrombolysis (37% versus 46%, p<0.01) and aspirin (83% versus 90%, p<0.01), discharged with beta blockers (33% versus 47%, p<0.01) and aspirin (82% versus 88% p<0.01) or be scheduled for angiography, exercise testing or revascularisation. Adjustment for age removed much of the disparity in treatment. Crude mortality rate at two years was higher for women (OR 1.81, 95%CI 1.41, 2.31, p=0.00). Age, existing risk factors and acute treatment accounted for most of this difference, with treatment on discharge having little additional influence. CONCLUSIONS: Patients admitted to hospital with AMI should be offered optimal treatment irrespective of age or sex. Women have a worse prognosis after AMI and under-treatment of older people with aspirin and thrombolysis may be contributing to this.     

急性心肌梗死120例护理探讨

目的：探讨急性心肌梗死整体护理的优越性及早期护理干预的重点和内容。方法：以入院至治疗时间、冠脉再通率及各种并发症（心律失常、心衰、低血压、休克、死亡）发生率等作为观察指标，分析整体护理的益处及早期护理干预的重点和内容。结果整体护理缩短了治疗时间（溶栓组24±1．9min，PTCA组25±1．5min），减少了心衰和休克的发生率（20％、8．8％），降低了病死率（6．7％），提高了疗效。两组冠脉再通率差异无显著（P〉0．05），PTCA组中严重心律失常及低血压发生率明显增高。结论：急性心肌梗死整体护理具有优越性，早期干预护理的重点应是监测心律、血压及预防心衰的发生。     

miR-221在急性心肌梗死大鼠中表达及其作用

目的 探讨miR-221在急性心肌梗死（AMI）大鼠中的表达及其作用。方法 在45只SD清洁级雄性大鼠中随机抽取35只通过冠状动脉左前降支结扎大鼠建立AMI模型,将其中建模成功的30只大鼠随机分为AMI组、对照组及抑制组,每组各10只;另抽取未建模的10只大鼠设立假手术组,采用冠状动脉左前降支穿线不结扎。其中对照组用携带绿色荧光蛋白（GFP）的慢病毒空载体miR-221阴性对照以4×10⁷病毒数量进行心肌组织局部注射转染,抑制组用携带miR-221 inhibitor慢病毒以4×10⁷病毒数量进行心肌组织局部注射转染,AMI组和假手术组每天给予等量生理盐水,隔日1次连续2周;记录大鼠心脏功能。采用原位末端凋亡法（TUNEL）检测心肌凋亡指数（AI）,RT-PCR法检测miR-221表达,Western blot法检测Bax、Bcl-2、PI3K和p-AKT蛋白表达。结果 与假手术组大鼠miR-221表达量（0.18±0.02）比较,AMI组（1.16±0.12）和对照组（1.18±0.12）大鼠的miR-221表达量均升高（均P<0.01）,抑制组大鼠miR-221表达量（0.30±0.03）均低于AMI组和对照组大鼠的miR-221表达量（均P<0.01）;与假手术组大鼠Bax（0.13±0.01）、Bcl-2（0.53±0.05）、PI3K（0.45±0.04）和p-AKT（0.87±0.09）蛋白表达量比较,AMI组和对照组大鼠的Bax蛋白表达量均上调（均P<0.01）,Bcl-2、PI3K和p-AKT蛋白表达量均下调（均P<0.01）;抑制组大鼠较AMI组和对照组大鼠Bax表达量均下调（P<0.01）,Bcl-2、PI3K和p-AKT 蛋白表达量均上调（P<0.01）。结论 miR-221在AMI大鼠心肌组织中高表达,下调miR-221表达可通过激活PI3K/AKT信号通路调控下游蛋白Bax及Bcl-2的表达抑制AMI大鼠心肌细胞凋亡。     

Variations in patterns of care and outcomes after acute myocardial infarction for Medicare beneficiaries in fee-for-service and HMO settings

OBJECTIVE: To assess revascularization and mortality after acute myocardial infarction (AMI) for all Medicare patients in fee-for-service (FFS) and health maintenance organization (HMO) settings in California. DATA SOURCES/STUDY SETTING: Hospital discharge abstract and death certificate data linked with Medicare enrollment files for patients aged 65 and over with Medicare coverage (69,040) discharged from a California-licensed hospital in 1994-1996. STUDY DESIGN: Risk-adjusted results were assessed for HMOs and FFS, as well as for FFS beneficiaries from areas served by each plan. DATA COLLECTION/EXTRACTION METHODS: Risk models were based on all sampled patients. The HMO patients were aggregated into 17 pseudoplans: 5 individual plans, 4 large plans split geographically (10 observations), and 2 "pseudoplans" of small HMOs. Observed versus expected 30-day mortality rates, lengths-of-stay (LOS) during the index hospitalization and any transfers, revascularization (coronary artery bypass graft [CABG] surgery and/or percutaneous transluminal coronary angioplasty [PTCA]) during the index hospitalization or 30 days after admission, were calculated for each pseudoplan. PRINCIPAL FINDINGS: Risk-adjusted death rate was slightly higher in FFS than in HMO settings (p < .01 with one risk adjustment model, n.s. with another). Three pseudoplans had significantly (p < .01) better than expected mortality rates. One pseudoplan was significantly worse (p < .05) with one risk adjustment model but not the other. The LOS and revascularization rates varied widely, but were not associated with outcomes. Plans with among the best results had the lowest LOS and revascularization rates. These pseudoplans were less likely to have their patients initially admitted to a hospital with revascularization capability, but the hospitals they used had higher CABG volumes. Even if CABG facilities were available during the index admission, in these plans with better than expected mortality rates, revascularization was often postponed or carried out elsewhere. CONCLUSIONS: For Medicare patients having an AMI in the mid-1990s in California, risk-adjusted outcomes were no different, or slightly better on average, for those in HMOs than in FFS. Not all plans performed equally well, so understanding what leads to differences in quality is more important than simple comparisons of HMOs versus FFS.     

非典型急性心肌梗死患者的早期诊断及急诊处理

目的探讨对非典型急性心肌梗死患者的早期诊断及急诊处理的临床效果。方法选取2007年8月～2011年6月于某院治疗的非典型AMI患者46例,对患者临床进行回顾性分析。结果 46例患者初诊误诊为急性心功能衰竭1例,心律失常1例,急性胃炎2例,急性肠炎1例,急性胆囊炎2例,休克1例;经治疗,46例患者痊愈出院17例(36.96%),好转出院26例(56.52%),死亡3例(6.52%),临床治疗有效43例(93.48%)。结论及时准确的诊断和急诊处理可以有效实现对梗死部位心肌细胞的再灌注,缩小心肌缺血面积,减少心肌损伤,减少各种并发症的发生和患者死亡率,对非典型AMI患者的临床预后具有重要作用。     

护理干预预防急性心肌梗死病人并发症的研究

目的：探讨护理干预措施,对提高急性心肌梗死病人的救护质量的作用。方法：对入选的心肌梗死病人随机分为观察组72例和对照组66例,观察组的病人在不同时期适时给予护理干预措施,并与对照组进行比较心律失常、心力衰竭、心源性休克、再梗死的发生率及平均住院天数。结果：经统计学分析,出院时比较两组患者心肌梗死病人发生在住院期间患者心律失常、心力衰竭、心源性休克、死亡人数、再梗死、住院天数均明显低于对照组,有显著的统计学差异（P〈0.05）。结论：对急性心肌梗死病人实施有效的护理干预和健康教育,提高了急性心肌梗死病人救护质量、生存质量和生活质量。     

急性心肌梗死Q-T离散度的临床分析

目的:为了解急性心肌梗死Q-T离散度的动态变化,以及与恶性室性心律失常、左房负荷(PTFV1)的关系。方法:测量80例急性心肌梗死病人包括死亡前)住院期间Q-T离散度,比较急性心肌梗死(AMI)入院与出院时Q-T离散度(Q-Td)及校正Q-T离散度(Q-Tcd),比较Q-Td与PTFV1及恶性室性心律失常的相关性。结果:80例AMI住院期间Q-Td动态变化揭示了Q-Td与恶性室性心律失常、PTFV1的密切关系,62例急性心肌梗死Q-Td及Q-Tcd入院时较出院有非常明显延长(P<0.05)。结论:Q-Td可作为预测恶性室性心律失常及心功能不全的一项敏感指标,不失为无创性评估急性心肌梗死预后的手段之一。     

心肌梗死和脑梗死并存80例临床分析

目的 探讨心肌梗死和脑梗死并存的临床特点。方法 回顾分析80例心、脑梗死并存患者的临床资料。结果两组有某些共同的危险因素。统计脑梗死和急性心肌梗死发病的时间间隔,在2月以内的比例均较高,心、脑梗死组为83.3％,脑、心梗死组为55.3％,尤其以2周之内突出,心、脑梗死组为45.2％,脑、心梗死组为34.2％。心、脑梗死组右室心肌梗死伴发率及左室肥大、室壁瘤的比例均高于脑、心梗死组,而EF值、入院时的舒张压均明显低于脑、心梗死组。两组年龄≥65岁患者住院病死率均明显增高(P<0.05)。结论 老年(≥65岁)可能是心、脑梗死和脑、心梗死预后危险因素,心肌梗死和脑梗死时应积极防治并发症,争取获得最好的转归。     

Impact of an acute myocardial infarction report card in Ontario, Canada.

OBJECTIVES: Acute myocardial infarction (AMI) 'report cards' are being developed using administrative databases in many jurisdictions, but little is known about their acceptance by and their usefulness to the medical community. The purpose of this study was to determine the impact of the publication of Cardiovascular Health and Services in Ontario: An ICES Atlas (Naylor CD, Slaughter P. (eds), 1999, Toronto: ICES), the first report featuring hospital-specific AMI performance measures to be published in Canada. DESIGN: We conducted a mail survey of physicians at Ontario hospitals to determine their views on the usefulness of various atlas performance measures for assessing and improving quality of care, the types of quality initiatives launched at their hospital in response to the atlas, and their views on the concept and limitations of reporting hospital-specific AMI mortality data. RESULTS: Respondents to the survey indicated that information on process of care measures such as post-infarction beta-blocker and angiotensin-converting enzyme (ACE) inhibitor use, and cardiac procedure waiting times were the most useful, and outcomes data (e.g. 30-day and 1-year risk-adjusted AMI mortality rates) the least useful of the multiple performance measures published in the atlas (P = 0.0385). Fifty-four percent of respondents reported launching one or more quality of care initiatives at their hospital in response to the atlas. The majority of respondents (65%) indicated that they support the public release of hospital-specific AMI mortality data, although many had concerns about potential miscoding in administrative databases and the adequacy of risk-adjustment methods. CONCLUSION: The publication of the first AMI report card in Canada stimulated quality of care initiatives at many Ontario hospitals. Inclusion of performance measures other than mortality in health care report cards may lead to greater acceptance and use by the medical community.