敏感型心肌钙蛋白T对早期诊断急性心肌梗死的价值

目的探讨敏感型心肌钙蛋白T（hs-cTnT）对早期诊断急性心肌梗死（AMI）的临床应用价值。方法应用发光免疫法分别测定67例AMI患者和58例非AMI患者,同一份血清标本作标准型心肌钙蛋白I（cTnI）和hs-cTnT检测。结果标准型cTnI检测AMI患者的敏感度和特异性分别为68.7%和53.4%,hs-cTnT为74.6%和51.7%。hs-cTnT检测的接受者操作特征（ROC）曲线下面积（AUC）和诊断灵敏度分别为0.659和70.2%,均高于标准型cTnI检测的0.639和59.7%;标准型cTnI检测的最佳cutoff值为0.035μg/L,hs-cTnT检测为0.0125μg/L。结论应用hs-cTnT早期诊断AMI的准确性和灵敏度优于标准型cTnI的检测。     

心前区疼痛刺激对实验性大鼠急性心梗范围的影响

目的：观察心前区疼痛刺激对急性心梗大鼠心梗范围的影响。方法：SD雄性大鼠40只,随机分为4组：急性心梗对照组,心前区疼痛刺激组,六烃季(Hexamethonium,HEX)注射组,8-对苯磺酸基茶碱(8-p-sulfophenyl)theophylline,8-SPT)注射组。左心室连同室间隔横切,硝基四氮唑兰染色法测量心梗面积。结果：心前区疼痛刺激组较急性心梗对照组心梗面积显著减小。HEX注射组和8-SPT注射组与急性心梗对照组心梗面积无明显改变。结论：心前区疼痛刺激可能通过交感神经兴奋,间接起到心肌保护作用。     

Assessing adaptive and maladaptive coping in the early phase of acute myocardial infarction

We assessed retrospectively symptom management behaviors among 45 patients with acute myocardial infarction (AMI). Cluster analysis was conducted on data from the Structured Interview (SI), in order to group patients according to the global TABP, Anger-In, Potential for Hostility, and a newly derived measure of Behavioral Compensation for Stress (BEH-COMP). Two groups were identified. MALADAPT SI-copers (N = 24) had higher scores on Anger-In and Hostility and lower scores on BEH-COMP in comparison to the ADAPT SI-copers (N = 21), while no difference was observed on TABP. The SI groups were next compared on AMI symptom management behaviors. A hierarchical discriminant analysis found that the MALADAPT group reported greater distraction from AMI symptoms, were relief-seeking behavior, and greater perceived vulnerability to reinfarction. AMI coping behaviors correlated meaningfully with delay in seeking medical assistance. Further research is warranted, given the potential for using the ADAPT/MALADAPT SI-profiles to predict adjustment to AMI.     

急性心肌梗死患者经急诊介入治疗后心肌顿抑的临床观察

目的探讨急性心肌梗死患者经急诊介入治疗后心肌顿抑发生情况,为急性期心功能的维护提供依据。方法筛选62例首次急性前壁及前间壁心肌梗死患者,其中男性43例,女性19例,年龄47—72岁,平均年龄58．76岁。32例行急诊冠状动脉介入治疗（PCI组）,30例为内科保守治疗患者（药物治疗组）,于术后或入院后0（即刻）～2d及10～14d静息状态下分别行超声心动图检查,记录左心室内径（舒张末前后径）、心输出量及左心室射血分数,同时监测肌酸激酶、肌酸激酶同工酶、肌钙蛋白T,找出酶峰值。结果与药物治疗组比较,PCI组术后0（即刻）-2d左心室内径明显增加（P〈0．01）,心输出量明显减少（P〈0．01）,左心室射血分数明显降低（P〈0．01）,心肌酶峰值提前出现,且低于药物治疗组酶峰值（P〈0．05）;治疗前后比较,PCI组术后10。14d较前左心室内径明显减小（P〈0．01）,心输出量增加（P〈0．05）,左心室射血分数明显升高（P〈0．01）,而药物治疗组入院后10-14d较治疗前左心室内径、心输出量及左心室射血分数无显著变化（P〉0．05）。结论急性心肌梗死患者行急诊PCI治疗可有效减少心肌坏死面积,但存在心肌顿抑,因此术后心功能的维护非常重要。     

氯吡格雷抵抗对急性心肌梗死合并糖尿病患者冠脉介入治疗预后的影响

目的：观察急性心肌梗死合并糖尿病且接受直接经皮冠脉介入治疗的患者氯吡格雷抵抗发生的情况及其对远期预后的影响。方法：连续入选2011年1月1日~2012年12月31日在我院接受直接经皮冠脉介入治疗,出院后随访>1年的急性心肌梗死合并糖尿病患者119例,所有患者均在服用氯吡格雷负荷量24 h后进行血栓弹力图检测,根据ADP诱导的血小板抑制率分为对照组(ADP抑制率≥50%,82例)和观察组(即氯吡格雷抵抗组,ADP抑制率<50%,37例)。记录患者的临床特点、生化指标、随访期间死亡和主要不良心血管事件(main adverse cardiac events,MACE)发生情况。结果：临床随访平均(783±241) d,氯吡格雷抵抗的发生率为31%。随访1年内总的MACE发生率为7.6%。氯吡格雷抵抗组1年内的MACE发生率明显高于对照组(16.2% vs.3.7%,P=0.025)。氯吡格雷抵抗和长期(1年以上)MACE发生无关(P=0.334);多因素Cox回归分析,氯吡格雷抵抗对患者的长期死亡率无明显影响。结论：接受直接经皮冠状动脉介入治疗的糖尿病合并急性心肌梗死患者存在明显的氯吡格雷抵抗现象。氯吡格雷抵抗会增加这些患者介入术后1年内发生主要心脏不良事件的风险,而对其1年以上的长期预后无显著影响。     

大鼠急性心肌梗死模型制作方法的改良

目的:为大鼠急性心肌梗死模型制作提供更快、更稳定的方法。方法:所有大鼠按气管插管方法-开胸扩开第3肋间隙方法随机分为:灌胃针-开睑器组(传统组)、灌胃针-缝合线开睑器组、自制插管-开睑器组、自制插管-缝合线开睑器组(改良组),麻醉后分别用相应方法行气管插管和开胸,暴露术野,结扎冠状动脉前降支,记录每组大鼠气管插管时间、气管插管次数、手术时间、术后呼吸道哮鸣音发生率、肺损伤程度和死亡率。术后第2天和第4天随机取各组大鼠5只,行心电图、左心室插管和心肌染色检测模型心功能及心肌梗死面积。结果:使用自制插管的两组插管时间和次数与使用灌胃针的两组差别无统计学意义,但术后呼吸道哮鸣音发生率及死亡率明显低于使用灌胃针两组;使用缝合线开睑器的两组手术时间、术中肺损伤程度及术后死亡率明显低于使用开睑器的两组;各组间心功能及心肌梗死面积差异无统计学意义,改良组组内心功能及梗死面积差异性较小。结论:改良后大鼠急性心肌梗死模型制作方法简单、成活率较高、模型质量较高,值得推广。     

老老年急性心肌梗死患者介入治疗的疗效及近期安全性评价

目的评价老老年（≥80岁）急性心肌梗死（AMI）患者行急诊与择期经皮冠状动脉介入治疗术（PCI）的有效性和近期安全性。方法将120例老老年冠心病患者分为急性心肌梗死组（AMI组）和非心肌梗死组（对照组）,其中AMI组发病12h内行直接PCI的患者为AMI急诊组,其他AMI患者（AMI择期组）和对照组患者均行择期PCI,两组合称为非急诊组,对各组的临床资料及冠脉介入特点进行回顾性分析。结果 AMI急诊组PCI即刻成功率（72.2%）低于非急诊组（92.2%）,差异有统计学意义（P=0.036）。AMI急诊组并发症比非急诊组和AMI择期组高,差异有统计学意义（P〈0.001,P=0.039）,AMI组并发症及主要不良心脏事件发生率、院内死亡率均比对照组高（P〈0.05）。结论在老老年AMI患者中,急诊与择期PCI手术成功率均较高,虽然急诊PCI术发生并发症的风险较高,但两者在院内死亡率和主要不良心脏事件发生率方面差异无统计学意义。     

糖化血红蛋白对老年急性心肌梗死患者接受直接经皮冠脉介入治疗远期预后的影响

目的:评价糖化血红蛋白(glycosylatedhemoglobin,HbA1c)对老年急性心肌梗死患接受直接经皮冠脉介入治疗远期预后的影响.方法:入选2008年6月31日~2012年12月31日在我院接受直接经皮冠脉介入治疗,年龄60岁以上,入院后24小时内测定HbA1c并且出院后随访>1年的急性心肌梗死患233例,根据HbA1c水平分为3组,组I(HbA1c≤5.6%,46例)、组II(5.7%≤HbA1c≤6.4%,92例)、组III(HbA1c≥6.5%,95例).分析三组患1年内主不良心脏事件(mainadversecardiacevents,MACE)和全因死亡率,了解患入院后HbA1c水平与急性心肌梗死1年以上长期预后的关系.结果:临床随访平均(977±438)d,随访1年死亡12例(5.2%),发生不良心脏事件18例(7.7%).将入选患分为否认糖尿病组和糖尿病组,否认糖尿病组患1年内MACE发生率与死亡率三组均一致,组III(12.5%)明显高于组II(2.6%)和组I(0%;P=0.026),但组I与组II之间无明显差异;糖尿病组患将组I与组II合并后与组III比较在1年内的MACE发生率(P=0.059)及死亡率(P=0.328)上无统计学差异.多因素Cox回归分析,校正其他因素后,HbA1c是患长期(1年以上)死亡率的独立预测因子(HR:1.258;95%CI:1.114~1.421;P<0.001).结论:在接受直接经皮冠状动脉介入治疗的老年急性心肌梗死患,HbA1c是长期死亡发生的独立预测因子.对于既往无糖尿病病史患,HbA1c≥6.5%与其1年内发生死亡和主心脏不良事件显著相关..     

Aortic intimal sarcoma with acute myocardial infarction

An autopsy case of aortic sarcoma who died of acute myocardial infarction caused by coronary involvement is reported. The patient was a 54 year old woman who was admitted because of an undiagnosed fever and general fatigue of 6 months duration. Magnetic resonance imaging (MRI) showed a tumor in the aortic arch. Total aortic arch replacement was performed, it was diagnosed as a malignant mesenchymal tumor of the aorta. The patient died of acute myocardial infarction 10 months after the operation. At autopsy, the tumor had invaded the luminal surface and intima of the proximal anastomosis (the remnant ascending aorta and the graft), the aortic valves, the distal anastomosis (surgical line of the thoracic aorta plus the graft), and the coronary arteries. The left main coronary artery showed complete obstruction by fibrin thrombus with tumor invasion in the intima, which was responsible for acute myocardial infarction. Primitive and bizarre tumor cells proliferated with many slit-like tissue spaces. Most of the tumor except for its luminal surface showed necrosis. Ultrastructurally, there were spaces between tumor cells, suggesting lumen formation, and some of them had microvilli. This sarcoma was considered to be the so-called aortic intimal sarcoma.     

急性心肌梗死介入治疗进展

血栓形成确认为急性心肌梗死的病理基础后 ,80年代起再灌注治疗开创了急性心肌梗死 (ＡＭＩ)治疗的里程脾。多项临床试验证实静脉溶栓治疗显著降低了心肌梗死 (ＭＩ)的死亡率 ,大大改善了心肌梗死患者的预后。然而 ,静脉溶栓治疗仍有不足之处 ,如能接受溶栓治疗的患者仅 1/ 3,血管再通率只有 60 %～ 80 % ,而实际上溶栓后梗死相关血管冠状动脉造影达ＴＩＭＩ 3级血流 (即完全再灌注 )的仅50 %～ 55% ,ＴＩＭＩ 2级血流 (即部分再灌注 )虽达再灌注标准 ,但并不降低死亡率 ,Ａｎｄｅｒｓｏｎ等报告90ｍｉｎ梗死相关血管达ＴＩＭＩ 3级血流者 3…     

Postmortem diagnosis of acute myocardial infarction in patients with acute respiratory failure: demographics, etiologic and pulmonary histologic analysis

OBJECTIVES:

Acute respiratory failure is present in 5% of patients with acute myocardial infarction and is responsible for 20% to 30% of the fatal post-acute myocardial infarction. The role of inflammation associated with pulmonary edema as a cause of acute respiratory failure post-acute myocardial infarction remains to be determined. We aimed to describe the demographics, etiologic data and histological pulmonary findings obtained through autopsies of patients who died during the period from 1990 to 2008 due to acute respiratory failure with no diagnosis of acute myocardial infarction during life.

METHODS:

This study considers 4,223 autopsies of patients who died of acute respiratory failure that was not preceded by any particular diagnosis while they were alive. The diagnosis of acute myocardial infarction was given in 218 (4.63%) patients. The age, sex and major associated diseases were recorded for each patient. Pulmonary histopathology was categorized as follows: diffuse alveolar damage, pulmonary edema, alveolar hemorrhage and lymphoplasmacytic interstitial pneumonia. The odds ratio of acute myocardial infarction associated with specific histopathology was determined by logistic regression.

RESULTS:

In total, 147 men were included in the study. The mean age at the time of death was 64 years. Pulmonary histopathology revealed pulmonary edema as well as the presence of diffuse alveolar damage in 72.9% of patients. Bacterial bronchopneumonia was present in 11.9% of patients, systemic arterial hypertension in 10.1% and dilated cardiomyopathy in 6.9%. A multivariate analysis demonstrated a significant positive association between acute myocardial infarction with diffuse alveolar damage and pulmonary edema.

CONCLUSIONS:

For the first time, we demonstrated that in autopsies of patients with acute respiratory failure as the cause of death, 5% were diagnosed with acute myocardial infarction. Pulmonary histology revealed a significant inflammatory response, which has not previously been reported.     

微血管损伤对急性心肌梗死患者的影响

心肌梗死患者即使心外膜冠状动脉血流得以成功恢复,仍有相当比例的患者受到严重的微血管灌注损伤,且除外主动脉夹层、栓塞、痉挛及狭窄等原因,这种心肌组织仍低灌注的现象称为无复流或微血管损伤.其潜在的病理生理学机制可能是复杂的、多因素的.微循环损伤的发生是影响心肌梗死患者预后的相关因素,且其个体差异性较大,目前尚未建立完善有效的防治策略.迄今为止大多数临床研究结果都不尽如人意,进行深入研究以减少或避免微血管损伤带来的影响是目前急需解决的关键问题.     

Clinical outcomes of second- versus first-generation drug-eluting stents in patients with acute myocardial infarction: a meta-analysis of randomized controlled trials

Introduction

It remains unclear whether the clinical outcomes of patients with acute myocardial infarction (AMI) receiving second- and first-generation drug-eluting stents (DES) are identical. The study aimed to investigate the differences in clinical utility between the two generations of DES in these specific subjects by a meta-analysis.

Material and methods

We systemically searched PubMed and EMBASE databases and the Cochrane Library up until January 2013. Randomized trials, which compared clinical outcomes of second-generation DES (everolimus- (EES) or zotarolimus-eluting stents (ZES)) with first-generation DES (sirolimus- or paclitaxel-eluting stents) in patients with AMI were included.

Results

Five trials with 1720 AMI subjects were included in the meta-analysis. Pooled analysis demonstrated a trend toward lower incidence of stent thrombosis with the second-generation DES relative to the first-generation one (risk ratio (RR), 0.53; 95% confidence intervals (CI): 0.25–1.13; p = 0.10). However, the second-generation DES did not offer a significant advantage over the first-generation DES in reducing the incidence of target lesion revascularization (TLR) (RR = 1.73; 95% CI: 0.83–3.64; p = 0.15), major adverse cardiac events (MACEs) (RR = 0.97; p = 0.90), or all-cause death (RR = 1.00; p = 1.0). In addition, in elderly patients the second-generation DES seemed to reduce the occurrence of MACEs (RR = 0.65; p = 0.10) and stent thrombosis (RR = 0.40; p = 0.08), and the second-generation EES showed a potential benefit in lowering the MACE rate (RR = 0.55; p = 0.06).

Conclusions

The second-generation DES appeared to lower the risk of stent thrombosis in AMI patients. There might be a lower incidence of MACEs associated with the second-generation EES.     

药物洗脱支架用于急性心肌梗死的临床观察

目的评价药物涂层支架用于急性心肌梗死的安全性及临床疗效。方法34例发病1周以内的急性心肌梗死患者梗塞相关动脉机械性再灌注治疗时使用药物涂层支架,并于术后3～12个月进行门诊及电话随访,必要时复查冠状动脉造影,观察住院及随访期间心血管事件发生率(死亡、再发急性心肌梗死及血管重建术)。结果37枚药物涂层支架(CYPHER15枚,TAXUS22枚)植入34个梗塞相关动脉(其中3处病变各植入2枚支架),支架长度(22.7±9.0)mm,支架直径(3.1±0.3)mm;10例(29.4%)接受直接经皮冠状动脉介入治疗(PCI),3例(8.8%)为挽救性PCI。支架植入成功率100%。1例(2.9%)支架内急性血栓形成,行急诊血管重建术。平均随访间期(5.9±2.8)个月,2例(5.9%)于随访期间因再发原部位心肌梗死入院治疗,1例因非靶血管病变致心绞痛于术后10个月入院治疗。住院及随访期间无死亡病例发生。结论研究提示药物涂层支架用于急性心肌梗死患者治疗梗塞相关动脉行机械性再灌注安全,可获得与药物涂层支架用于择期的、相对简单的冠状动脉病变的类似疗效。     

急性心肌梗死后心脏性猝死的探讨

目的探讨急性心肌梗死后心脏性猝死（SCD）预防的关键环节。方法回顾56例急性心肌梗死后心脏性猝死患者的病历及随访资料,分析其原因或诱因、发病季节与发病时间、溶栓治疗与SCD的关系、致命性心律失常与SCD的相关性与预后等。结果严重心律失常为SCD的主要诱因,冬秋季多于春夏季,白天多于晚上,上午多于下午;住院治疗1周后、出院1周后为SCD的高发期,血钾偏低者多见,前壁多于下壁,未溶栓及溶栓未再通者SCD死亡率高。结论综合分析患者病例资料,密切观察病情变化,加强对关键环节的管理,对降低急性心肌梗死后心脏性猝死的发生具有积极的意义。     

普伐他汀减轻大鼠急性心肌梗死后瞬时外向钾电流的表达

 目的 探讨普伐他汀对大鼠急性心肌梗死（AMI）后瞬时外向钾电流（Ito）表达的影响。方法 结扎大鼠前降支建立AMI模型,分为24h组、1周组、4周组及普伐他汀干预（20 mg/kg）组,并设假手术组,Real-Time PCR及Western-Blot分别检测大鼠右心室游离壁Kv1.4、Kv4.2、Kv4.3mRNA及蛋白质表达。结果 Kv1.4mRNA及蛋白质表达在AMI后24h开始增高;Kv4.2mRNA及蛋白质表达在AMI后24h逐渐降低,4周组更低;Kv4.3mRNA及蛋白质表达在AMI后各时间点均降低,24h组最低;普伐他汀组与4周组比较, Kv1.4mRNA（P＜0.01）及蛋白质（P＜0.05）表达更低,而Kv4.2(P＜0.05,P＜0.05)及Kv4.3(P＜0.01,P＜0.05)mRNA及蛋白质表达增高。结论 大鼠AMI后Kv1.4mRNA及蛋白质表达明显增高,而Kv4.2及Kv4.3mRNA及蛋白质表达明显降低,普伐他汀可能减轻上述变化。     

T波电交替对急性心肌梗死患者恶性心律失常的预测价值

目的探讨时域法微伏级T波电交替（MTWA）对急性心肌梗死（AMI）患者住院期间恶性心律失常的预测价值。方法 105例AMI患者（AMI组）,其中男性77例,女性28例;年龄32~84岁,平均年龄62岁。38例冠状动脉正常者（对照组）,其中男性25例,女性13例;年龄41~79岁,平均年龄59岁。分析2组24h动态心电图检查资料。依据住院期间有无室性心动过速或心室纤颤,将105例AMI患者分为恶性心律失常组（34例）和非恶性心律失常组（71例）。结果 AMI组MTWA高于对照组（P〈0.05）。AMI患者中恶性心律失常组与非恶性心律失常组MTWA差异具有显著统计学意义（P〈0.01）。以MTWA≥25μV为截点,预测AMI患者发生恶性心律失常的灵敏度、特异度、阳性预测值、阴性预测值分别为50.00%、80.28%、54.84%、77.03%。结论时域法测量MTWA对AMI患者住院期间恶性心律失常的发生有预测价值,可用于AMI患者的危险分层。     

SRI对急性前壁STEMI患者心肌存活的早期预测价值

目的探讨应变率成像（SRI）对急性前壁ST段抬高心肌梗死（STEMI）患者心肌存活的早期预测价值。方法行急诊经皮冠状动脉介入术（PCI）的前壁STEMI患者在术后测量室间隔心尖段的SRI指标,当收缩末期应变（SES）≥-7%时则纳入研究,并于6个月后复查,评价急性期SRI指标对心肌存活的预测价值。结果 46例前壁STEMI患者纳入研究,其中25例在6个月时SES〈-7%,我们定义为存活心肌;21例随访时SES≥-7%,我们定义为失活心肌。存活心肌组SES、收缩后应变（SPS）、收缩期应变率（SRS）及舒张早期应变率（SRE）等指标明显优于失活心肌组（P〈0.01）,而收缩后应变率、舒张晚期应变率两组间无明显差异（P〉0.05）。SRS、SRE、SPS、SES均能预测心肌的存活,其中SRS曲线下面积最大（0.803,P〈0.01）,当临界值取-0.31s-1时,其预测存活心肌的敏感性、特异性、阳性预测值、阴性预测值分别为83%、68%、76%、71%。结论在行急诊PCI的前壁STEMI患者中,SRI技术能早期预测受累心肌的存活性。     

microRNA-208在急性心肌梗死患者外周血中的表达及意义

目的:通过分析microRNA-208在急性心肌梗死(acute myocardial infarction,AMI)患者外周血中含量的变化,探讨microRNA-208在AMI疾病进展中的作用.方法:连续性收集2013年1月~2013年12月滁州市第一人民医院心血管内科和急诊科收治的急性心肌梗死(AMI)患者42例,不稳定心绞痛(unstable angina,UA)患者22例,健康体检志愿者20名,荧光定量 PCR测定外周血microRNA-208的含量,电化学发光法检测血浆cTnI和CK-MB的水平.AMI组患者根据不同冠脉病变支数和接受急诊经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗进行分组,对比各组患者外周血microRNA-208水平的差异.结果:AMI患者外周血microRNA-208的水平显著高于UA组和健康对照组,差异具有统计学意义(P<0.01),AMI患者外周血microRNA-208的水平与血清CTnI含量呈正相关(r=0.700,P=0.000).24例行冠状动脉造影术的AMI组患者中,microRNA-208的表达在两支及三支病变中高于单支病变(P<0.01),17例成功接受急诊PCI治疗的AMI患者,其症状发作后的24h血浆microRNA-208水平较入院即刻时明显降低(P<0.01).结论:心肌细胞特异性的microRNA-208在心肌梗死后外周血含量明显升高,随着血管狭窄严重程度的升高其浓度也显著变化,可以作为辅助监测急性心肌梗死的敏感的生物学指标.