90分钟冠状动脉造影评价急性心肌梗塞血管开通及临床再通指标价值

通过经静脉溶栓开始后９０分钟冠状动脉造影（ＣＡＧ），观察国产尿激酶（天普洛欣，ＵＫＴＰ）静脉溶栓治疗急性心肌梗塞（ＡＭＩ）血管开通疗效，并评价临床再灌注标准的判断价值如何。方法：从ＵＫＴＰ多中心治疗ＡＭＩ１４０６例中，汇集其中所行冠状动脉造影（ＣＡＧ）共１２４例资料。结果提示：（１）１２４例ＡＭＩ患者，在溶栓开始后９０分钟时的梗塞相关血管的血流达ＴＩＭＩⅢ级者５２例（４１．９％）、Ⅱ级３８例（３０．７％），梗塞相关血管再开通率为７２．６％；（２）溶栓距起病时间愈早，具有愈高的开通趋势，但差异无统计学意义；（３）以ＣＡＧ为金标准，临床标准对血管开通判断敏感性为８８％，特异性为６９％，准确性为８３％。结论：ＵＫＴＰ静脉溶栓治疗ＡＭＩ血管开通疗效肯定，临床标准判断血管再通的敏感性较高，但特异性欠佳，有待提高。     

急性心肌梗死时尿激酶溶栓加即刻准备的冠状动脉内支架置入术

目的：探讨急性心肌梗死（AMI）时尿激酶溶栓加即刻血管造影，TIMIⅡ级或以下时进行冠状动脉内支架置入术（支架术）的安全性。方法：选择1999年1月至2001年12月AMI（发病6h以内）患25例，常规应用尿激酶（商品名：天普洛欣）150万U0.5h内静脉滴注，其中6例无创指标未见再通，25例患90min后即刻血管造影，其中13例TIMIⅡ级或以下进行冠状动脉内支架置入术。结果：13例TIMIⅡ级或以下均成功进行冠状动脉内支架置入术，术后冠脉血流均达到TIMIⅡ级，未见需要输血的严重出血并发症。结论：AMI时尿激酶溶栓加即刻准备的支架术安全、疗效好。     

“天普络欣”溶栓治疗急性心肌梗塞的临床疗效

目的：观察国产"天普络欣"（尿激酶）在急性心肌梗塞（AMI）静脉溶栓治疗中的临床疗效和不良反应，对其安全性和疗效作出评价。方法：根据天普络欣溶栓治疗急性心肌梗塞协作方案，共收集48例病例。治疗中辅以肝素钙和肠溶阿司匹林。所有入选病例均符合入选和不入选标准。给予尿激酶（UK）100万U－150万U，在30分钟内滴完，观察血管再通的临床指标，过敏反应及出血并发症等。结果：总共48例病人中，血管再通率为68．8％，4周病死率为8．3％，UK的不良反应中，寒颤发生率为4．2％，低血压为6．3％，出血发生率为6.3％，均为轻度出血倾向，…     

胸痛缓解对于判断急性心肌梗死溶栓治疗后冠脉再通的意义

目的研究胸痛缓解对于判断急性心梗溶栓治疗后冠脉再通的意义。方法选择我院AN／患者76例，采用静脉尿激酶溶栓治疗后90min行冠状动脉造影，判断冠脉罪犯血管是否再通，分析胸痛缓解对于判定冠脉再通的敏感性及特异性。结果胸痛缓解对于判断急性心梗．溶栓治疗后冠脉再通的敏感性为71．4％，特异性为92．5％，准确性78．9％，阳性预测值94、5％。结论胸痛缓解是一种简便的判定急性心梗溶栓治疗后冠脉再通的临床指标，虽然敏感性不高，但特异性强，阳性预测值高。     

溶栓治疗在基层医院的优势

目的观察尿激酶溶栓治疗急性心肌梗死的效果和心脏事件的情况。方法 64例急性心肌梗死病人依发病到就诊时间的早晚分为尿激酶溶栓组和非溶栓组,溶栓组以150万U尿激酶静脉溶栓,非溶栓组给予一般治疗,1周后做冠状动脉造影观察冠状动脉再通情况并记录心脏事件。结果静脉溶栓组血管再通率67.7%,非溶栓组血管再通率27%,溶栓组心功能损害较非溶栓组轻。结论静脉溶栓治疗仍可以是基层医院治疗急性心肌梗死的主要方法 ,转院将延误再灌注治疗。     

冠状动脉造影评价急性心肌梗死溶栓疗法的疗效

目的：冠状动脉造影（ＣＡＧ）评价静脉溶栓治疗急性心肌梗死（ＡＭＩ）的疗效及安全性。方法：１１０例ＡＭＩ患者应用国产尿激酶及进口链激酶开始溶栓治疗后９０分钟行ＣＡＧ。结果：尿激酶和链激酶血管开通率分别为６０．８％及６３．０％；ＣＡＧ提示有残留血栓的分别为８６．９％及８１．５％；５周病死率分别为８．６％及７．４％；严重出血并发症分别为１．８５％及２．１７％，均无统计学意义。加大尿激酶剂量至２００ＩＵ，并不增加血管开通率反而增加出血并发症。结论：ＡＭＩ是由突然冠状动脉血栓性闭塞所致。尿激酶和链激酶用于静脉溶栓治疗可使闭塞的冠状动脉再通，两种溶栓剂疗效相似     

国产尿激酶与进口链激酶溶栓治疗急性心肌梗塞对比研究

为观察对比国产尿激酶及进口链激酶静脉溶栓治疗急性心肌梗塞的临床疗效及副作用。选取确诊为急性心肌梗塞，发病１２ｈ内，无溶栓禁忌证的患者，给予尿激酶２００万Ｕ（４０例）或链激酶１５０万Ｕ（２３例）静脉溶栓，并与对照组（２６例）比较，观察血管再通及副作用情况。结果：尿激酶再通率７０．０％，链激酶再通率６９．６％，Ｐ＞０．０５。两组病死率均明显低于对照组     

急性心肌梗塞重组链激酶静脉榕栓治疗临床观察

应用古巴生产重组链激酶商品名海见克栓，静脉溶栓治疗３１例急性心肌梗塞，以评价其疗效和安全性。溶栓治疗时间为５．１±２．５ｈ（２８例≤６ｈ，３例外＞６ｈ）。根据临床血管再通指标判断溶栓治疗再通率为７７．４％（２４／３１）。其中８例于溶栓治疗后２ｈ内行冠状动脉造影，６例（７５．０％）梗塞相关血管再通。副作用为寒颤（１４．３％），低血压（２例）和轻度出血倾向（２２．９％），未发性脑出血或严重内脏出血。临     

急性心肌梗塞重组链激酶静脉溶栓治疗临床观察

应用古巴生产重组链激酶商品名海见克栓，静脉溶栓治疗３１例急性心肌梗塞，以评价其疗效和安全性。溶栓治疗时间为５．１±２．５ｈ（２８例≤６ｈ，３例＞６ｈ）。根据临床血管再通指标判断溶栓治疗再通率为７７．４％（２４／３１）。其中８例于溶栓治疗后２ｈ内行冠状动脉造影，６例（７５．０％）梗塞相关血管再通。副作用为寒颤（１４．３％），低血压（２例）和轻度出血倾向（２２．９％），未发生脑出血或严重内脏出血。临床观察证明重组链激酶为一安全、有效的溶栓剂。     

大剂量尿激酶治疗急性心肌梗塞疗效分析

为观察大剂量国产尿激酶（UKTP）静脉溶栓治疗急性心肌梗塞（AMI）的临床有效性及安全性。152名急性心肌梗塞患者接收大剂量UKTP治疗。其中118例给予200万U，34例给予300万U，对其中41例溶栓后90分钟进行冠状动脉造影。结果显示：梗塞相关血管再通率为76．3％；90分钟冠状动脉造影开通率为80．5％；住院死亡率为5．3％；轻度出血发生率为14．5％；无大出血及脑卒中发生。比较200万U和300万U的临床疗效，结果显示300万U血管开通率及轻度出血发生率均有增加的趋势。结论：大剂量UKTP治疗AMI安全、可能提高血管开通率。     

早期静脉溶栓治疗对老年人急性心肌梗塞近期预后的影响

为探讨静脉溶栓治疗对老年（６０岁以上）急性心肌梗塞（ＡＭＩ）患者近期预后的影响。方法对比分析２０例尿激酶静脉溶栓治疗与３８例非溶栓治疗的老年人ＡＭＩ患者住院期间临床疗效。结果显示溶栓组住院期间４周内病死率明显低于非溶栓组（Ｐ＜０．０５）,且心绞痛、心力衰竭及严重心律失常、泵衰竭的发生率明显低于非溶栓组（Ｐ＜０．０５）。临床判断梗塞相关血管（ＩＲＡ）再通率为７５．０％（１５／２０）,０～６小时ＩＲＡ再通率为８３．３％（１０／１２）,６～１２小时为６２．５％（５／８）,溶栓组无一例发生颅内出血及过敏反应。结论　提示用尿激酶静脉溶栓治疗老年ＡＭＩ为一种安全有效的方法,ＡＭＩ后梗塞相关血管及时有效再灌注有利于改善心肌梗塞的近期预后。     

急性心肌梗死患者心肌灌注状况对经皮冠状动脉介入术后心功能的影响

目的采用经冠状动脉超声心肌声学造影(MCE)评价急性心肌梗死(AMI)患者心肌灌注状况对经皮冠状动脉介入术(PCI)后心功能改善的影响,并探讨其相关临床意义。方法 18例AMI患者于PCI前及术后15 min分别经左主干或右冠状动脉注射超声声学造影剂,进行MCE实时显影,以视觉评分方式定性分析PCI前后相应心肌节段灌注状况;术后1个月经二维超声评价左心室室壁运动;利用灌注评分指数(PSI)及室壁运动评分指数(WMSI)分析PCI前后心肌灌注水平对心功能改善的影响。结果术前心肌灌注评分为0分的30个心肌节段中,20个(66.7%)术后1个月室壁运动评分为3~5分;而术前心肌灌注评分为2分的11个心肌节段中,有8个(72.7%)1个月时室壁运动评分为1~2分;统计学分析显示,PCI前心肌灌注与1个月室壁运动状况有关(P0.05)。术后心肌灌注评分为0分的12个心肌节段中,11个(91.7%)术后1个月室壁运动评分为3~5分;而术后心肌灌注评分为2分的22个心肌节段中,有17个(77.2%)1个月时室壁运动评分为1~2分;统计学分析显示,PCI后心肌灌注与1个月室壁运动状况有关(P0.01)。结合WMSI及PSI综合评价术后心肌灌注水平与左心室收缩功能的关系,发现二者存在明显相关性(P0.01)。结论 AMI患者心肌灌注状况对PCI后心功能改善有明显影响;经冠状动脉MCE可较准确的判断AMI患者微循环灌注范围,评估术后心功能,故可能对患者的临床预后判断有一定预测价值。     

尿激酶与组织型纤溶酶原激活剂静脉溶栓治疗急性心肌梗塞的对比研究

为比较尿激酶（UK）及组织型纤溶酶原激活剂（t-PA）静脉溶栓辅以阿司匹林及肝素对急性心肌梗塞的效果及其副作用。对急性心肌梗塞患者发病6h内者，42例给予静脉UK15例静脉内t-PA溶栓辅以静脉肝素及阿司匹林治疗。结果表明，t-PA组、UK组临床血管再通率分别为86．7％与57．1％（P＜0．05），前者消化道与呼吸道出血并发症为13．3％，而后者为0（P＜0．05）。本研究提示静脉t-PA溶栓血管再通率显著高于静脉UK，但出血合并症的发生t-PA组显著高于UK组。     

Relation of left ventricular volume and function over one year after acute myocardial infarction to infarct size determined by technetium-99m sestamibi

Twenty patients with a first acute myocardial infarction (AMI) (15 anterior, 5 inferior) who received successful reperfusion therapy underwent tomographic imaging with technetium-99m (Tc-99m) sestamibi and radionuclide ventriculography at discharge, 6 weeks, and 1 year after AMI. Patency of the infarct-related artery after reperfusion (thrombolysis, 8 patients; coronary angioplasty, 12 patients) was confirmed by angiogrpahy in all patients. Tc-99m sestamibi perfusion defect at discharge (a measure of infarct size) was quantitated using previous methods and expressed as a percentage of the left ventricle (28 +/- 19%, range 0 to 59%). This perfusion defect size correlated closely with ejection fraction at discharge (r = -0.87), 6 weeks (r = -0.81) and at 1 year (r = -0.78, all p less than 0.0001). Perfusion defect size at discharge also correlated closely with end-systolic volume index at discharge (r = 0.71, p less than 0.0005), 6 weeks (r = 0.63, p less than 0.005) and at 1 year (r = 0.76, p less than 0.0001). Perfusion defect size at discharge did not correlate significantly with end-diastolic volume index at discharge or at 6 weeks, but did correlate at 1 year (r = 0.66, p less than 0.005). There was no significant group change in end-systolic or end-diastolic volume indexes from discharge to 1 year later, although 7 patients had definite individual changes in end-diastolic volume index (3 increased and 4 decreased). There was no relation between defect size and late changes in end-systolic volume index, but there was a weak correlation between defect size and late changes in end-diastolic volume index (r = 0.42, p = 0.07).(ABSTRACT TRUNCATED AT 250 WORDS)     

Development of early reperfusion after the first episode of acute pulmonary embolism

IntroductionFactors influencing the early reperfusion after pulmonary embolism (PE), with possible impact on development of chronic thromboembolic disease and chronic thromboembolic pulmonary hypertension (CTEPH), have not been completely identified yet.Study population and methodsThe total of 85 patients hospitalized with the first episode of acute PE underwent a ventilation–perfusion lung scan before hospital discharge. The reperfusion was evaluated based on clinical, echocardiographic and laboratory parameters.ResultsThe study population consisted of 37 men and 48 women, mean age 60 years. A high-risk PE was present in 9.4% of patients, medium-risk PE in 49.4% and low-risk PE in 41.2% of patients. 26 (30.5%) of patients were diagnosed with provoked pulmonary embolism. Prior to discharge, the residual perfusion defects were detectable in 66 patients, in 18 patients the perfusion was normal. The two groups did not significantly differ in clinical, echocardiographic or laboratory parameters.ConclusionThe analysis did not identify risk factors significantly associated with the absence of early reperfusion of the PE. This points toward the need of further follow-up of patients after a PE with the aim of identifying the patients with the high risk of developing the chronic thromboembolic disease and CTEPH.     

尿激酶治疗急性心肌梗塞多中心临床试验1406例总结

为观察尿激酶天普洛欣（ＵＫＴＰ）经静脉溶栓治疗急性心肌梗塞（ＡＭＩ）的临床有效性及安全性。收集协作组１４８家医院１９９４年１１月至１９９６年４月经静脉ＵＫＴＰ溶栓治疗ＡＭＩ患者１４０６例，观察临床疗效、副作用及病死率等。其中１２４例行９０分钟冠状动脉造影评价梗塞血管开通情况。结果：梗塞血管临床再灌注率为７３．５％，９０分钟冠状动脉造影血管开通率为７２．６％，５周总病死率为７．８％（１０９／１４０６），轻度出血１０．２％（１４３／１４０６），中重度出血０．４３％（６／１４０６），脑出血０．５０％（７／１４０６）。老年（＞６５岁）甚至高龄（＞７５岁）患者溶栓及距发病超过６小时者，其用药仍然安全有效，ＵＫＴＰ合适的用药剂量可能为１５０万Ｕ左右。结果提示ＵＫＴＰ治疗ＡＭＩ安全有效。     

Usefulness of simultaneous evaluations of contractile reserve, perfusion, and metabolism during dobutamine stress for predicting wall motion reversibility (myocardial stunning) after successful PTCA

The optimal diagnostic approaches using contractile reserve, perfusion, and free fatty acid metabolism together for identifying myocardial stunning after reperfusion have not been clarified in the clinical setting. We investigated the usefulness of simultaneous evaluation of these parameters during myocardial stunning to predict the functional recovery in infarct-related myocardium after reperfusion. In 43 patients (60.7 +/- 10.4 years) with successful coronary angioplasty early after a first myocardial infarction, low-dose (5 to 10 microg/kg/min) dobutamine stress thallium-201/iodine-123 beta-methyl-iodophenyl pentadecanoic acid (BMIPP) dual-isotope single photon emission computed tomography was performed with echocardiography in the acute phase within 1 week after reperfusion. Regional wall motion and the uptake of each tracer were obtained simultaneously in the infarct-related segments. In 93 segments with dyssynergy in the acute phase after reperfusion, the sensitivity, specificity, and accuracy using contractile reserve for predicting the final functional recovery in the chronic phase more than 3 months after PTCA were 81.3%, 67.2%, and 72%, respectively. More accurate predictions were obtained by simultaneous measurements of thallium-201 and BMIPP uptakes (93.8%, 66.7%, and 79.4%, respectively). The final functional recovery in the stunned myocardium after early reperfusion following acute myocardial infarction was predicted more accurately by simultaneous evaluation of these parameters at dobutamine stress testing.     

Thrombolysis in myocardial infarction myocardial perfusion grade in angiography correlates with myocardial salvage in patients with acute myocardial infarction treated with stenting or thrombolysis

OBJECTIVES: We sought to assess the relationship between the Thrombolysis In Myocardial Infarction (TIMI) myocardial perfusion (TMP) grade and myocardial salvage as well as the usefulness of TMP grade in comparing two different reperfusion strategies. BACKGROUND: The angiographic index of TMP grade correlates with infarct size and mortality after thrombolysis for acute myocardial infarction (AMI). Its relationship to myocardial salvage and its usefulness in comparing different reperfusion strategies are not known. METHODS: We analyzed the TMP grade on angiograms obtained at one to two weeks after treatment in 267 patients enrolled in two randomized trials that compared stenting with thrombolysis in AMI. Patients were classified into two groups: 159 patients with TMP grade 2/3 and 108 patients with TMP grade 0/1. Two scintigraphic studies were performed: before and one to two weeks after reperfusion. The salvage index was calculated as the proportion of the area at risk salvaged by reperfusion. RESULTS: Patients with TMP grade 2/3 had a higher salvage index (0.49 +/- 0.42 vs. 0.34 +/- 0.49, p = 0.01), a smaller final infarct size (15.4 +/- 15.5% vs. 22.1 +/- 16.2% of the left ventricle, p = 0.001), and a trend toward lower one-year mortality (3.8% vs. 8.3%, p = 0.11) than patients with TMP grade 0/1. The relationship between TMP and salvage index was independent of the form of reperfusion therapy. The proportion of patients with TMP grade 2/3 was significantly higher after stenting than after thrombolysis (70.9% vs. 48.1%, p = 0.001). CONCLUSIONS: These findings show that the TMP grade is a useful marker of the degree of myocardial salvage achieved with reperfusion and a sensitive indicator of the efficacy of reperfusion strategies in patients with AMI.     

The importance of the determination of the myocardial area at risk in the evaluation of the outcome of acute myocardial infarction in patients

On the basis of animal studies, we postulated that the size of the perfusion field (risk area) of an occluded coronary artery would be an important determinant of outcome in patients with acute myocardial infarction. To test this hypothesis, we measured size of the risk area in 27 patients with acute myocardial infarction by the intracoronary injection of 99mTc-macroaggregated albumin and gated nuclear imaging. After injection of the albumin spheres (5.3 +/- 1.4 hr after the onset of chest pain) streptokinase was administered and in 16 of 27 patients (59%) effective thrombolysis was achieved. Since none of the patients had evidence of a prior acute myocardial infarction, the 3 day nuclear left ventricular ejection fraction (LVEF) was considered an index of infarct size. Response to thrombolysis was analyzed according to success or failure of reperfusion and the size of the risk area (small risk area less than 25%, large risk area greater than 25% of left ventricular surface area). Standard clinical indexes correlated poorly with size of the risk area: electrocardiographic variables (r = .37), left ventricular end-diastolic pressure (r = .23), cardiac index (r = .55), and the LVEF obtained from a right anterior oblique contrast ventriculogram (r = .31). The coronary vessel responsible for the acute myocardial infarction significantly influenced size of the risk area (left anterior descending, 38 +/- 5% [mean +/- SD] vs circumflex or right coronary artery, 17 +/- 4%). However, knowledge of the site of coronary occlusion within a vessel was not helpful in predicting the size of the area at risk.(ABSTRACT TRUNCATED AT 250 WORDS)