老年急性非ST段抬高心肌梗死合并心房颤动患者不同抗栓治疗方案对比研究

目的探讨老年急性非ST段抬高心肌梗死(NSTEMI)合并心房颤动(房颤)患者采取不同抗栓策略的有效性和安全性。方法选取NSTEMI合并永久性房颤的老年患者129例,出院后给予不同的抗栓策略分为4组,A组41例:阿司匹林(100mg/d)+氯吡格雷(75mg/d),B组31例:华法林(国际标准化比值2.0².5),C组35例:华法林(国际标准化比值2.02.5),C组35例:华法林(国际标准化比值2.0².5)+阿司匹林(100mg/d)/氯吡格雷(75mg/d),D组22例:华法林(国际标准化比值2.02.5)+阿司匹林(100mg/d)/氯吡格雷(75mg/d),D组22例:华法林(国际标准化比值2.0².5)+阿司匹林(100mg/d)+氯吡格雷(75mg/d),对出血和主要心脏复合终点(死亡,再发心肌梗死、脑栓塞)随访1年,行多变量Cox回归分析。结果 A组、B组、C组、D组病死率分别为12.2%、16.1%、14.3%、9.1%。观察1年,8.5%因出血再次入院,20.2%因主要心脏事件再次入院,各组出血及主要心脏事件无统计学差异,但与B组比较,D组出血风险最高(HR=1.267,95%CI:0.3402.5)+阿司匹林(100mg/d)+氯吡格雷(75mg/d),对出血和主要心脏复合终点(死亡,再发心肌梗死、脑栓塞)随访1年,行多变量Cox回归分析。结果 A组、B组、C组、D组病死率分别为12.2%、16.1%、14.3%、9.1%。观察1年,8.5%因出血再次入院,20.2%因主要心脏事件再次入院,各组出血及主要心脏事件无统计学差异,但与B组比较,D组出血风险最高(HR=1.267,95%CI:0.340⁴.718,P=0.25)。C组有低风险趋势(HR=0.911,95%CI:0.3194.718,P=0.25)。C组有低风险趋势(HR=0.911,95%CI:0.319².597,P=0.37)。结论随着抗栓力度的增强,阿司匹林+氯吡格雷+华法林相对出血的风险加大,华法林联合一种抗血小板药物对于主要心脏复合终点有降低的趋势。     

Unstable angina and non-ST elevation myocardial infarction

Non-ST elevation acute coronary syndromes are responsible for approximately 1 million admissions to U.S. hospitals and twice as many to European hospitals each year. Thus, they are among the most common serious illnesses in adults, and are associated with an in-hospital mortality of approximately 5%. The most common cause is rupture of an atherosclerotic coronary plaque, resulting in subtotal coronary occlusion. Diagnosis is based on the clinical picture of retrosternal chest pain, aided by electrocardiographic findings of ST segment deviations and biomarker abnormalities (elevation of troponin and natriuretic peptides) and cardiac imaging (myocardial scans showing perfusion defects). Treatment involves antiischemic agents (nitrates and β blockers), antiplatelet drugs (aspirin, P2Y(12), and glycoprotein IIb/IIIa receptor blockers), and anticoagulants (unfractionated and low-molecular-weight heparins). Patients should undergo risk stratification, and those with high-risk factors should undergo coronary arteriography promptly with the intent to carry out coronary revascularization. Those at low risk should continue to receive intensive antiischemic and antithrombotic therapy. At discharge, patients should receive intensive lipid-lowering therapy with high doses of a statin, as tolerated.     

Prognostic significance of fragmented QRS in patients with non-ST elevation myocardial infarction

Objectives

The aim of this study was to evaluate the predictive value of fragmented QRS (fQRS) among non-ST elevation acute coronary syndrome (ACS) patients.

Design

The fQRS on standard 12-lead ECGs in 179?patients (63% males, mean age 60.9?±?12.3?years) were analyzed. Cardiac events and cardiac mortality were regarded as two outcomes to determine whether fQRS was a clinical prognostic factor; its prognostic value was then assessed adjusting for other covariates.

Results

Cardiac mortality (18 (17.0%) vs. 4 (5.5%)) and major cardiac event rate (46 (43.4%) vs. 22 (30.1%)) were higher in the fQRS group compared with the non-fQRS group during a mean follow-up of 12?months. A Kaplan–Meier survival analysis revealed significantly lower event-free survival for cardiac events (p?=?0.030) and cardiac mortality (p?=?0.020). Multivariate Cox regression analysis revealed that significant fQRS was an independent significant predictor for cardiac events and cardiac mortality.

Conclusion

These results indicate that the occurrence of fQRS in the ECG is a powerful predictor of decreased survival in NSTEMI. The prognostic importance of fQRS was incremental to clinical and conventional factors.     

Fragmented QRS may predict new onset atrial fibrillation in patients with ST-segment elevation myocardial infarction

Background

Fragmented QRS (fQRS) has been shown to be a marker of local myocardial conduction abnormalities, cardiac fibrosis in previous studies. It was also reported to be a predictor of sudden cardiac death and increased morbidity and mortality in selected populations. However, there is no study investigating the role of fQRS in the development of atrial fibrillation in patients with ST segment elevation myocardial infarction (STEMI). In this study we aimed to investigate the relationship between the presence of fQRS after primary percutaneous coronary intervention (pPCI) and in-hospital development of new-onset atrial fibrilation (AF) in patients with STEMI.

Circulating endothelial progenitor cells and coronary collaterals in patients with non-ST segment elevation myocardial infarction

BACKGROUND: Endothelial progenitor cells (EPCs) are bone marrow-derived cells that are augmented in response to ischemia and incorporated into neovascularization sites. We sought to determine whether circulating EPCs are related to collateral formation following non-ST segment elevation myocardial infarction (NSTEMI). METHODS: Twenty patients who underwent percutaneous coronary intervention (PCI) within a week of NSTEMI were divided into two groups: patients without collaterals (coll-, n=10) and patients with Rentrop grade 3--4 collaterals (coll+, n=10). Blood samples were drawn before PCI and 24+/- 2 h after PCI. EPC colonies were grown from peripheral blood mononuclear cells, characterized, and counted. Using flow cytometry the percentage of cells co expressing vascular endothelial growth factor receptor-2 and CD 133 was determined. RESULTS: The coll+ group had higher degree of culprit vessel stenosis and lower initial thrombolysis in myocardial infarction flow grade. The relative number of EPCs before PCI was significantly higher in the coll+ group than in the coll- group (1.49 +/- 0.9% vs. 0.77+/- 0.4%, p= 0.045). There were no significant intergroup differences in the number of EPC colony-forming cells. The number of EPC colonies increased in the coll- group after PCI (9.5 +/- 4.8 to 14.0 +/- 5.9/10(6) cells, p=0.01). CONCLUSIONS: This study supports an association between circulating EPC levels and collateral formation in patients with an NSTEMI.     

Safety and effectiveness of drug eluting stent in patients with ST elevation myocardial infarction undergoing primary angioplasty

Background : Drug eluting stents (DES) have recently been proven to further reduce restenosis and revascularization rate in comparison to bare metal stents in elective procedures. Most early DES trials did not include patients undergoing primary percutaneous coronary intervention (PCI) for ST‐segment elevation MI, because these patients tend to have lower restenosis rates than other patient groups and delayed endothelization of these stents raises concern about a possible increase of thrombotic complications in the setting of STEMI. Aim : To confirm the safety and effectiveness of DES in patients with STEMI in a real‐world scenario. Methods : From January 2004 to December 2006, clinical and angiographic data of 370 patients with STEMI treated with primary PCI have been analyzed. Patients were retrospectively followed for the occurrence of major adverse cardiac events (MACE): death, reinfarction and target vessel revascularization (TVR). Results : Overall, 120 patients received DES (32%, DES group) and 250 received bare metal stents (68%, BMS group) in the infarct related artery. Compared with the BMS group, DES patients were younger, (mean age 56 ± 12 vs. 65 ± 10; P < 0.001) had more often diabetes mellitus (47% vs. 14% P < 0.001), anterior localization (65% vs. 45%; P < 0.0011) and less cardiogenic shock at admission (4% vs. 7%; P < 0.001). The angiographic characteristics in the DES group showed longer lesions (23 mm vs. 19 mm) and smaller diameter of vessels (2.5 mm vs. 3.0 mm). After a median follow‐up of 24 ± 9 months, there was no significant difference in the rate of stent thrombosis (1.6% in the DES group vs. 1.2% in the BMS group, P = ns). The incidence of MACE was significantly lower in the DES group compared with the BMS group (HR 0.56 [95% CI: 0.3–0.8]; P = 0.01), principally due to the lower rate of TVR (HR 0.41 [95% CI: 0.2–0.85]; P = 0.01). Conclusions : Utilization of DES in the setting of primary PCI for STEMI, in our “real world,” was safe and improved the 3‐year clinical outcome compared with BMS reducing the need of TVR. © 2008 Wiley‐Liss, Inc.     

Associations between ECG changes and echocardiographic findings in patients with acute non-ST elevation myocardial infarction

Background

ST segment depression (STD) and T wave inversion (TWI) are typical electrocardiographic (ECG) findings in non-ST elevation myocardial infarction (NSTEMI). In ST elevation myocardial infarction, ST changes represent transmural ischemia. The pathophysiological mechanisms of the ECG changes in NSTEMI are unclear.

成人继发孔型房间隔缺损并发房颤患者三种治疗方法分析

目的介绍成人房间隔缺损（ASD）并发心房颤动（AF）患者的几种治疗方法,并分析其治疗效果。方法：回顾分析本院136例ASD并发有明显临床症状且药物治疗无效的AF病例,其中36例接受介入封堵＋经导管射频消融术（导管射频消融组）,84例体外循环下ASD补术＋改良迷宫术（改良迷宫组）,16例单纯介入封堵术（未行经导管射频消融术,单纯介入封堵组）,术前,术后12月用心脏超声仪评价右心房、右室内径及肺动脉压力和心电图变化。结果：所有病例的术中、术后均未出现严重并发症,所有病例均无死亡,随访12个月,36例接受介入封堵＋经导管射频消融术28例转复为窦性心律,8例仍为AF,后行二次射频消融术转为窦性心律,84例ASD补术＋改良迷宫手术患者中有66例转复窦性,14例失败仍为AF,4例为交界性心律,单纯介入封堵组16例8例成功,8例术后仍为AF,与术前比较,各组心脏超声检查示右心房、右心室内径均较术前明显缩小,肺动脉压力明显下降（均P〈0．05）。各组之间无显著差异。经导管射频消融组和改良迷宫手术组AF治愈率高（对比单纯介入组,均P〈0．05）,患者心慌不适更能得到改善,生活质量更高。结论：介入封堵及外科手术均能安全有效治疗ASD并发AF,每种方法各有利弊,可依据患者临床具体情况选择。     

Incidence and predictors of myocardial infarction among patients with atrial fibrillation

OBJECTIVES: We sought to evaluate the utility of excluding myocardial infarction (MI) in patients presenting to the emergency department (ED) with atrial fibrillation (AF) and to identify predictors of MI in this group. BACKGROUND: Patients with AF are frequently admitted to the hospital, in part, to exclude an associated MI. There are no prospective data on unselected patients to support this common practice. METHODS: We conducted a prospective cohort study of all patients who presented to a single-center ED with the primary diagnosis of AF. RESULTS: Of a total of 255 patients, 190 (75%) were admitted to the hospital, and 109 of them underwent a standard "rule-out MI" protocol. Of these 109 patients, six (5.5%) were identified as having an acute MI at the time of admission. Chest pain was present in 39% of patients, with a sensitivity and specificity for the occurrence of MI of 100% and 65%, respectively. ST segment elevation or depression was present in 43% of patients, with a sensitivity and specificity of 100% and 51%. The presence of either major ST segment depression (>2 mm) or elevation on the admission electrocardiogram (ECG) was present in 6%, with a sensitivity of 100% and a specificity of 99%. The resulting positive and negative predictive values were 86% (95% confidence interval [CI] 42% to 99%) and 100% (95% CI 96% to 100%), respectively. Use of this criterion would have reduced the number of rule-out MIs in our study group by 94%, with no loss of sensitivity. CONCLUSIONS: Chest pain and ST segment depression are extremely common findings in patients presenting to the ED with AF and have limited power to predict MI. In contrast, ECG evidence of ST segment elevation or depression >2 mm appears to be a reliable discriminator of which patients are at risk for MI. Patients without significant ST segment changes are at very low risk for MI and may not require performance of the rule-out MI protocol or hospital admission if clinically stable.     

尼可地尔对高龄非ST段抬高型急性心肌梗死患者的心肌保护作用

目的探讨尼可地尔对高龄非ST段抬高型急性心肌梗死患者的心肌保护作用。方法收集我院心内科收治的高龄非ST段抬高型急性心肌梗死患者96例,随机分为试验组48例和对照组48例。2组均给予积极的心肌梗死综合治疗,试验组在综合治疗基础上口服尼可地尔5mg,3次/d。2组患者均治疗4周。观察2组治疗前和治疗后1、3、7、10d血清肌钙蛋白I(cTnI)水平;观察2组治疗前后心电图改善情况。结果试验组治疗3、7和10d血清cTcI水平明显低于对照组[(3.24±4.31)μg/L vs(10.47±4.72)μg/L,P0.05;(0.53±0.31)μg/L vs(2.50±1.45)μg/L,P0.01;(0.09±0.07)μg/L vs(0.41±0.26)μg/L,P0.01]。心电图改善情况明显优于对照组(P0.05)。结论口服尼可地尔对高龄非ST段抬高型急性心肌梗死患者有一定心肌保护作用。