急性心肌梗死后冠状动脉自发再灌注的影响因素及其临床意义

目的:探讨急性心肌梗死(AMI)后冠状动脉自发再灌注(SR)的影响因素及其临床意义.方法:115例首次发作AMI且未经静脉溶栓及其他再灌注治疗的患者,根据选择性冠状动脉造影(CAG)检查结果分成SR组(TIMI≥2级)与无SR组(TIM1 0~1级),分析影响SR的相关因素,并分组比较SR对左室功能和临床转归的影响.结果:①AMI后冠状动脉SR率为42.6%.②SR组患者心功能优于无SR组.③住院期间心脏事件发生率SR组低于无SR组(P<0.05).④梗死前心绞痛、起病至开始治疗时间和梗死相关动脉部位与SR有关(P<0.05).结论:未经静脉溶栓及其他再灌注治疗的AMI患者有一定的SR率(42.6%),梗死前心绞痛、起病至开始治疗时间和梗死相关动脉部位是SR的独立影响因素;SR是判断AMI预后良好的预测指标.     

The effect of recanalization of the occluded coronary artery in acute myocardial infarction on left ventricular function

In 20 patients with acute myocardial infarction a left ventriculogramwas obtained within 6 h after the onset of chest pain and againduring a follow-up study, 2–3 weeks later. In 17 patientsthe infarct-related vessel (IR V) could be recanalized withselective intracoronary infusion of a thrombolytic agent andwas still patent during the second study. In three other casesthe IR V was already patent during the first angiogram and remainedso at the time of the follow-up study. The ejection fractionof these 20 patients increased from 52 to 56% (P < 0.02). In eight other patients the infarct-related artery could notbe recanalized or was reoccluded at the time of the controlstudy. The ejection fraction of these patients with unsuccessfulrecanalization decreased from 49 to 37% (P<0.001). Analysis of regional function in eight patients with anteriorinfarction and seven patients with inferior infarction, allwith a successful recanalization and persistent patency of theinfarct-related vessels, suggests that improvement of globalejection fraction is only partially due to improvement of regionalpump function in the reperfused ‘infarct zone’ butmay also be caused by enhancement of regional function in otherwall regions or by changes in afterload.     

血管内超声参数与非ST段抬高型急性心肌梗死患者冠状动脉病变及左心室功能的关系

[目的]探究血管内超声(IVUS)参数与非ST段抬高型急性心肌梗死(NSTEAMI)患者冠状动脉病变及左心室功能的相关性。[方法]选取2016年6月—2021年12月佛山市三水区人民医院收治的90例NSTEAMI患者为研究对象,根据冠状动脉病变支数分为单支病变组(42例)和多支病变组(48例)。分析NSTEAMI患者冠状动脉病变加重的独立预测因素,构建列线图预测模型并进行评价。采用Pearson检验分析斑块负荷、偏心指数、重构指数、纤维帽厚度与左心室射血分数(LVEF)间的相关性。采用受试者工作特征(ROC)曲线分析IVUS参数变化对NSTEAMI患者冠状动脉病变加重的预测价值。[结果]血清胱抑素C(CysC)>1.54 mg/L(OR=2.115,95%CI:1.377～3.047)、高敏C反应蛋白(hs-CRP)>34.25 mg/L(OR=1.342,95%CI:1.128～2.412)、斑块负荷>60%(OR=1.399,95%CI:1.232～2.405)、偏心指数>6.99(OR=1.357,95%CI:1.035～2.164)、重构指数>0....     

Changes in coronary anatomy and left ventricular function from the acute to the chronic stage of myocardial infarction

Coronary angiography was performed in the acute stage of myocardial infarction in 65 patients. The infarct-related vessel was occluded in 50 patients; it was narrowed >90% in the remaining 15 patients. Control angiography was performed 55±46 d after acute myocardial infarction in 18 patients. In the chronic stage, five of thirteen previously occluded vessels showed antegrade filling of the distal segment. The narrowing at the site of previous obstruction was 80-95%. In two of five patients with a subtotal stenosis, the lumen of the infarct-related vessel was clearly larger in the chronic stage. The end-diastolic volume index increased significantly from 86±23 ml/m² in the acute stage to 110±35 ml/m² in the chronic stage (p<0.001). The increase in the end-systolic volume index from 42±15 ml/m² to 63±31 ml/m² was also statistically significant (p<0.005). Stroke volume index, ejection fraction, and the length of the akinetic segment (AKS) did not change significantly. There was a weak correlation between the end-systolic volume index and the length of the AKS in the acute stage (r = 0.489, p<0.05) and a better correlation in the chronic stage (r = 0.602, p<0.01). The ejection fraction and the length of the AKS correlated in the chronic stage only (r = 0.795, p<0.001). In contrast to the total group, three patients showed improvement in left ventricular pump function. In all three patients there was a collateral flow to the infarct area during the acute stage of myocardial infarction. In two of these patients there was spontaneous recanalization of the infarct vessel. However, vascularity of the infarct area during the acute stage was also found in eleven patients without improvement of left ventricular pump function. Two of these showed recanalization of the infarct vessel. In all four patients with a proximal occlusion of a major coronary artery and avascularity of the infarct area, there was impairment of left ventricular function and an increase in the length of the AKS.     

心电图对急性下壁心肌梗死患者梗死相关血管判断的价值

目的探讨心电图(ECG)对急性下壁心肌梗死患者梗死相关血管(IRA)判断的价值。方法筛选2002年7月～2004年7月我院心内科住院的急性下壁心肌梗死患者60例,回顾性分析其症状发作后24小时内ECG改变。结果Ⅰ导联ST段抬高,ST段抬高Ⅲ导联>Ⅱ导联,导联V4RST段抬高≥0.5mm,V1和V2导联ST段抬高或压低,aVR导联ST段压低。5项标准可用于判断急性下壁心肌梗死患者的IRA,而aVR导联ST段压低为一项新的标准。结论aVR导联ST段压低为判断急性下壁心肌梗死患者梗死相关血管(IRA)的新标准。     

Early ventricular fibrillation in patients with acute myocardial infarction: correlation with coronary angiographic findings

To define coronary angiographic characteristics of patientsexperiencing early primary ventricular fibrillation (VF) inthe acute phase of myocardial infarction we studied 266 consecutivepatients without clinical evidence of heart failure. Twenty-sixpatients (group 1) experienced early (< 12 h from the onsetof symptoms of myocardial infarction) primary VF whereas 240patients (group 2) with the same clinical characteristics servedas an appropriately matched cohort. All patients were catheterizedbefore or soon after hospital discharge (1 to 8 weeks afterthe acute event). There was no significant difference in left ventricular ejectionfraction between the two groups of patients (39.6±6%vs 36.9±8%, P = ns). Patients with early VF had a significantlygreater number of diseased vessels than those without VF (3.38±1.05vs 2.03±1.25. P <0.001) and a higher coronary arteriographicGensini score (29.31±4.80 vs 20.16±4.14, P <0.001).The left anterior descending coronary artery was identifiedas the infarct-related vessel in 53.6% of group 1 vs 44.5% ofgroup 2 patients (P <0.05). The mean maximal serum creatinekinase values were not significantly different (1897±1062vs 1426 ±839 IU.l–1, P=ns) between the two groups. These data indicate that patients with early primary VF in thesetting of acute myocardial infarction may have more extensivecoronary artery disease than similar patients without VF. Aworse prognosis could be anticipated for these patients on thebasis of worse coronary anatomy. A more aggressive therapeuticapproach with routine coronary angiography before hospital dischargecould reasonably be justified for patients with early primaryVF complicating acute myocardial infarction.     

体表心电图对老年急性下壁心肌梗死患者梗死相关血管的预测价值

目的探讨体表心电图对老年急性下壁心肌梗死患者梗死相关血管(IRA)的预测价值。方法对70例老年急性下壁心肌梗死患者的入院心电图和冠状动脉造影资料进行回顾性分析,寻找可以预测IRA的心电图改变。结果70例老年急性下壁心肌梗死患者中,IRA为左前降支(LAD)者3例(4%),右冠状动脉(RCA)者53例(76%),左回旋支动脉(LCx)者14例(20%)。经χ2检验,STV1抬高、STⅢ抬高>STⅡ抬高、STⅠ和(或)STaVL压低、STV3压低/STⅢ抬高≤1.2等4项指标提示RCA为IRA。其中,STV1抬高的特异度和阳性预测值最高,均为100%;灵敏度则以STI和(或)STaVL压低为最高,达94%。反之,STV1压低、STⅢ抬高≤STⅡ抬高、STⅠ和(或)STaVL抬高、STV3压低/STⅢ抬高>1.2提示LCx闭塞可能性大。其中灵敏度和阴性预测值以STV1压低为最高,分别为71%和89%,特异度和阳性预测值则以STⅠ和(或)STaVL抬高为最高,均为100%。结论急性下壁心肌梗死时,体表心电图对预测IRA有重要价值。     

心电图改变对急性下壁心肌梗死相关血管的预测价值

目的:对急性下壁心肌梗死患者的心电图资料进行回顾性研究,分析和比较心电图改变与冠状动脉造影及临床特点的对应性关系。探讨体表心电图改变对急性下壁心肌梗死患者的临床价值。方法:选取86例急性下壁心肌梗死患者,根据冠状动脉造影结果分为右冠状动脉(RCA)病变组和左冠状动脉(LCA)病变组。对比分析其心电图改变与冠状动脉造影结果及临床特点。结果:Ⅰ、Ⅱ、Ⅲ、aVR导联ST段及aVL导联波形改变对诊断梗死相关血管具有重要价值;V3与Ⅲ导联ST段改变比值预测梗死相关血管部位具有重要价值;伴aVR导联ST段压低患者病情重;伴胸前导联ST段压低者病情重、并发症发生率明显增高。结论:心电图对诊断下壁急性心肌梗死相关血管及其临床特点具有重要的预测价值。     

Use of changes in ST segment elevation for prediction of infarct artery recanalization in acute myocardial infarction

Background: The role of the ECG in evaluating reperfusion statusafter thrombolytic treatment in acute myocardial infarctionis not clear. Dramatic ST segment changes have been observedduring recanalization of an infarct-related artery, but ST criteriahave not been definitively established for prediction of coronaryartery patency. Differences in ST segment changes in relationto infarct localization have not been evaluated, and furtherinvestigation is required into reciprocal ST depression, whichprovides information independent from ST elevation. Therefore,the aim of this study was to evaluate how early changes in STsegment elevations and depressions predict vessel patency afterfibrinolysis for patients with anterior and inferiorllateralinfarcts. Methods and Results: Two hundred patients with a Pardee wavein the ECG and chest pain of less than 6 h duration were giventhrombolytic treatment. The result of the therapy was assessedsimultaneously with coronary angiography. Patients were dividedinto two groups: I (50 patients) without recanalization (TIMIgrade 0, 1 or 2), and II (150 patients) with successful recanalization(TIMI grade 3). Before and after therapy, analysis of the 12lead ECG included maximum ST elevation measurement (H₁, H₂ respectively),the sum of ST elevations (H₁, H₂), the sum of ST segment depressions(h₁, h₂), and the ratios of ST segment changes (R₁ = H₂:H₁,R₂ = H₂:H₁, R₃ = h₂:h₁). The mean interval from the first tothe second ECG was 3.5 ± 1 h. Successive values of R₁and R₂ were examined to find that which best distinguished betweenthe two groups. The best values for prediction of reperfusionwere: (1) For anterior wall infarct Specificity Sensitivity R₁ 0.6 83.3% 88.7% R₂ 0.5 83.3% 92.0% (2) For inferior and lateral infarct R₁ < 0.5 100% 93.8% R₂ < 0.5 100% 92.8% In 13 patients with a complete right or left bundle branch blockin the first or second ECG, the result of treatment was predictedin 11 patients using criteria for factor R₁ and in 12 patientsusing criteria for R₂ Analysis of ST segment depressions revealed a significant correlationbetween normalization of ST segment depressions and elevations(R₃ vs R₁: r = 0.60, P < 0.05; R₃ vs R₂ r = 0.59, P <0.05). Multivariate discriminant analysis showed an independentvalue of R₃for discrimination between the two groups, but onlyin patients with inferiorllateral infarcts. The overall accuracyof the common algorithm in predicting reperfusion was significantlybetter in patients with inferiorllateral infarcts (Chi² test,P = 0.0078). When separate algorithms were used, there was nosignificant difference between patients with anterior or inferiorllateralinfarcts because of the significant improvement in predictionof reperfusion in patients with anterior infarcts (McNemar'stest: P = 0.041). Conclusions: We conclude that analysis of ST segments on thestandard 12-lead ECG offers valuable help in the early identificationof successful recanalization of infarct-related arteries afterthrombolytic therapy in patients with acute myocardial infarction.Use of the ratio of ST segment normalization according to theseparate criteria for anterior and inferiorllateral infarctsgives the test a high sensitivity and specificity, even in thepresence of interventricular conduction disturbances.     

急性心肌梗塞直接经皮冠状动脉腔内成形术

目的观察急性心肌梗塞（ＡＭＩ）患者应用直接经皮冠状动脉腔内成形术（ＰＴＣＡ）的安全性和有效性。方法对１１４例ＡＭＩ患者在发病１２小时内行直接ＰＴＣＡ术,其中有５例心原性休克的患者。梗塞相关血管（共１１５支血管）：左主干３例（２．６％）,前降支５６例（４８．７％）,回旋支１２例（１０４％）,右冠状动脉４４例（３８．５％）。ＴＩＭＩ血流：０级８２例（７１．３％）,１级１７例（１４．７％）,２级１６例（１４．０％）。结果１１１例患者手术成功,ＴＩＭＩ血流３级（９７．４％）。住院期间死亡３例（２．６％）,均为心原性休克患者,其中２例经紧急冠状动脉旁路移植术后死亡。８５例患者置入了冠状动脉内支架（７３．９％）。随访９５例患者,２例后期死于心力衰竭,９例出院后出现心肌缺血,其中８例再次行ＰＴＣＡ术。结论直接ＰＴＣＡ是治疗急性心肌梗塞的安全有效措施,成功率较高,并发症少;术后复发心肌缺血发生率较溶栓治疗低。     

体表心电图对老年急性前壁心肌梗死左前降支闭塞部位的预测价值

目的探讨体表心电图对老年急性前壁心肌梗死左前降支（LAD）闭塞部位的预测价值。方法对62例老年急性前壁心肌梗死患者的入院心电图和冠状动脉造影资料进行回顾性分析,寻找可以预测LAD闭塞部位的心电图改变。结果62例老年急性前壁心肌梗死患者均为LAD闭塞,其中近段闭塞者45例（72.6%）,远段闭塞者17例（27.4%）。经χ2检验,STⅠ抬高、STaVL抬高、STaVF压低或至少2个下壁导联ST段压低等指标提示LAD近段闭塞（P均〈0.05）。其中,STaVF压低或至少2个下壁导联ST段压低的特异度和阳性预测值最高,为94%左右,灵敏度以STaVL抬高最高,为56%;反之,STaVL压低和STⅢ抬高则在预测LAD远段闭塞上有显著意义（P均〈0.05）,特异度和阳性预测值以STaVL压低为最高,均为100%。结论急性前壁心肌梗死时,体表心电图对预测LAD闭塞部位有重要价值。     

Coronary spasm producing coronary thrombosis in a patient with acute myocardial infarction

A 62-year-old man had an acute myocardial infarction with successful thrombolysis. Coronary spasm was documented in the following angiographic study. This case demonstrated that coronary spasm is implicated in the pathogenesis of coronary thrombosis and subsequent myocardial infarction.     

老年急性心肌梗死患者急诊冠状动脉支架术的临床评价

目的　探讨老年急性心肌梗死 (AMI)患者急诊冠状动脉支架术的临床疗效和安全性。方法　共对 95例住院老年AMI患者的 10 4支靶血管、114处靶病变急诊植入冠状动脉支架 110枚。患者术前合并心源性休克 2 9例 ,心肺复苏 3例 ,急诊冠状动脉造影示多支病变 5 8例 ,梗死相关动脉 (IRA)狭窄 99%～ 10 0 % ,心肌梗死溶栓试验 (TIMI)血流 0级 72例 ,1～ 2级 2 3例。结果　IRA开通率 10 0 % ,110枚支架均植入成功 ,术后平均残余狭窄 (0 .4± 3.5 1) % ,全部恢复TIMI 3级血流 ,无操作并发症 ,即刻成功率 10 0 %。从入导管室至IRA开通时间平均 (17.6± 1.87)min。术后共 6例死亡 ,住院期间总病死率 6 .3% ,其中 4例死于不可逆心源性休克 (休克病死率 13.8% )。对出院的 89例随访 1～ 5 2个月 ,平均 (2 5 .1± 12 .3)个月 ,87例存活 ,存活率 97.8%。 2 8例造影随访者中 5例支架内再狭窄 (再狭窄率17.8% )。结论　急诊支架术对老年AMI患者具有理想的即刻和长期疗效。合理选择器械、操作技术熟练和围术期并发症处理经验是保证老年AMI急诊冠状动脉支架术获得高成功率的 3个关键。     

Anomalous origin of the left coronary artery from the pulmonary artery: A case report with remarkable improvement of myocardial function following subclavian artery—Coronary artery anastomosis

A 3 2/12-year-old boy with anomalous origin of the left coronary artery from the pulmonary artery was successfully treated by anastomosis of the left subclavian artery to the anomalous vessel. A remarkable improvement in left ventricular function and electrocardiogram has occurred postoperatively. This case report supports the postulation that chronically hypoperfused, electrically silent, and minimally contractile myocardial tissue may acquire its electrical activity and function with the establishment of adequate coronary perfusion.     

自发性冠状动脉夹层并血栓形成致急性心肌梗死2例

急性心肌梗死(AMI)是心内科的常见急症,其病死率和致残率较高。自发性冠状动脉夹层(SCAD)可因假腔压迫及合并血栓形成导致冠状动脉闭塞,是AMI的罕见病因之一。本文报告2例SCAD并血栓形成致AMI,并行冠状     

Coronary artery rupture during transluminal coronary recanalization and angioplasty in a case of acute myocardial infarction and shock

Percutaneous transluminal coronary angioplasty (PTCA) is a widely performed and effective therapy for coronary artery disease. Evolution of the dilatation instruments during the last decade has led to an increased success rate of PTCA and to the development of newer techniques such as recanalization of totally occluded coronary arteries. We report a case of coronary artery recanalization complicated by fatal coronary artery rupture.     

急性心肌梗死患者连续心率减速力的临床研究

目的探讨急性心肌梗死患者的连续心率减速力（heart rate deceleration runs,DRs）危险分层与心率减速力（deceleration capacity,DC）、心率变异性总标准差（SDNN）、左室射血分数（left ventricular ejection fraction,LVEF）以及冠状动脉狭窄程度之间的关系。方法38例急性心肌梗死患者和20例体检者接受24 h动态心电图和超声心动图检查,测定其DC值、DRs、HRV时域指标SDNN以及LVEF;对急性心肌梗死患者进行冠状动脉造影,记录冠脉狭窄程度。按照DRs结果分为低危组（17例）、中危组（15例）、高危组（6例）、对照组（20例）,比较4组间年龄、DC值、SDNN、LVEF及冠脉狭窄程度。结果①高危组的年龄比低危组明显增大,差异有统计学意义（P〈0.05）;②从对照组到高危组,DC值和SDNN值逐渐降低,高危组与其他3组相比明显降低,其差异有统计学意义（P〈0.05）;③DRs分层与冠脉狭窄程度无明显相关性。结论急性心肌梗死患者DRs分层和DC值、SDNN间有显著相关性,均能评估急性心肌梗死患者迷走神经张力,联合应用可提高心肌梗死后猝死的预警。     

Normal coronary arteries are rare in young patients with acute myocardial infarction.

OBJECTIVE: To delineate the angiographic extent of coronary atherosclerosis in young patients (<45 years) with acute myocardial infarction (MI). BACKGROUND: Prior studies suggest 20% of young patients with acute MI have normal coronary arteries. However, most such studies defined "normal" as absence of stenoses >50% luminal diameter, ignoring the presence of nonflow limiting disease that may harbor culprit plaques. METHODS: We retrospectively analyzed 131 patients <45 years old with ST-segment elevation MI undergoing emergency catheterization. Angiograms were analyzed for the presence and extent of disease, including lesion "complexity" indicative of plaque instability. "Normal" vessels were defined as absence of any disease. RESULTS: Mean patient age was 40 +/- 7 years. The infarct related artery and an obvious complex culprit lesion was identified in all (100%) cases (left anterior descending 44%, right coronary 38%, and circumflex 18%). Single vessel disease involving the culprit vessel only was identified in 60% of cases, whereas additional disease was found in 40% of others (two-vessel in 29% and three-vessel disease in 11% of patients). CONCLUSION: These findings demonstrate that young patients with acute MI typically manifest an identifiable complex culprit atherosclerotic coronary lesion. Furthermore, they often have multivessel atherosclerosis.     

急性下壁ST段抬高心肌梗死直接冠脉内支架置入术靶血管判定及预后评估

目的 总结急诊介入治疗（PCI）的急性下壁心肌梗死患者心电图及临床资料,分析其对急性下壁心肌梗死患者罪犯血管判定及预后评估的作用.方法 选择2007年1月到2010年7月进行急诊PCI的急性下壁心肌梗死患者280例,根据冠脉造影结果分为右冠状动脉（RCA）梗死组及左冠回旋支（LCX）梗死组;根据临床结果分为高危急性下壁心梗组（高危组）及低危组.分析各组的心电图表现、危险因素及预后.结果 RCA组与LCX组比较,STⅢ＞STⅡ、STavL或STⅠ＞1 mm下移更多见于RCA梗死.高危组年龄比低危组偏大,糖尿病患者更多,更多出现心肌梗死溶栓治疗（TIMI）分级中的0级（无灌注）及1级（渗透而无灌注）,RCA近端闭塞及双支、三支病变患者,心电图出现STV3R-5R↑、STV7-V9↑、STV4-6↓、STV1↑、STAVR↓的比例更高.结论 心电图在急性下壁心肌梗死进行急诊PCI的患者诊断及预后判断中有重要作用,对进行急诊PCI靶血管判定有一定的协助作用.冠脉造影TIMI 0、1级,RCA近端闭塞,双支、三支病变患者,年龄偏大患者和糖尿病患者整体预后均较差.