急性冠状动脉综合征患者血清中可溶性L-选择素的变化规律

目的 :观察急性冠状动脉综合征 (ACS)不同分型患者血清中可溶性L 选择素 (sL selectin)水平的变化规律及心肌梗死 (MI)患者sL selectin水平与肌酸激酶 同工酶 (CK MB)和MI面积的相关性。方法 :将 5 9例冠心病患者分为 3组 :急性MI组 2 6例 ,不稳定型心绞痛 (UAP)组 18例 ,稳定型心绞痛 (SAP)组 15例 ;另设正常对照组 19例。血清sL selectin水平应用ELISA方法测定 ;预测MI面积应用Michelle等公式。结果 :①SAP组血清sL selectin水平为 (0 .84± 0 .12 )mg/L ,明显低于正常对照组 (1.0 5± 0 .18)mg/L ,P <0 .0 5 ;②UAP组和急性MI组sL selectin测定值分别为 (1.0 9± 0 .19)、(1.4 0± 0 .6 4 )mg/L ,与SAP组相比明显增高 (P <0 .0 5 ) ;③sL se lectin与CK MB无相关性 ,与MI面积亦无相关性。结论 :sL selectin与ACS的发生发展密切相关 ,sL selectin不能反映心肌坏死的程度     

Outcomes of patients with acute coronary syndromes and prior percutaneous coronary intervention: a pooled analysis of three randomized clinical trials.

AIMS: We sought to characterize the outcomes of patients with a prior percutaneous coronary intervention (PCI) who presented with a non-ST-segment elevation acute coronary syndrome (ACS). METHODS AND RESULTS: We analysed the 30 and 180 day outcomes of 3012 patients with prior PCI and 21 154 patients without prior PCI enrolled in three randomized ACS trials (GUSTO IIb, PURSUIT, and PARAGON-B). The median (25th, 75th percentile) interval between the prior PCI and randomization was 647 (123, 1585) days. Patients with prior PCI had significantly more adverse baseline clinical characteristics, left ventricular dysfunction, and multi-vessel coronary artery disease. After adjusting for baseline characteristics and treatment, we found that patients with prior PCI had a significantly lower mortality rate at 30 days [hazard ratio (HR), 0.60; 95% confidence interval (CI), 0.45-0.80; P=0.0006] and 180 days (HR, 0.81; 95% CI, 0.66-0.98; P=0.029). However, no difference was observed in the composite of death or myocardial infarction (MI) at 30 days (HR, 0.95; 95% CI, 0.83-1.08; P=0.42) or 180 days (HR, 1.01; 95% CI, 0.90-1.13; P=0.90). Patients with prior PCI had a higher rate of MI at 180 days (13.3 vs. 12.0%; P=0.045). Prior-PCI patients had lower incidences of in-hospital cardiogenic shock, congestive heart failure (CHF), and atrial fibrillation. CONCLUSION: Patients with prior PCI who present with non-ST-segment elevation ACS have a lower mortality rate than those without prior PCI.     

选择性5-羟色胺再摄取抑制剂治疗肠易激综合征疗效的系统评价

目的:系统评价选择性5-羟色胺再摄取抑制剂(selective serotonin reuptake inhibitor,SSRI)治疗肠易激综合征(irritable bowel syndrome,IBS)的有效性及安全性.方法:计算机检索PubMed、Embase、Cochrane图书馆临床对照试验数据库、中国生物医学文献数据库(CBM)、中国期刊全文数据库(CNKI),查找SSRI治疗肠易激综合征的所有随机对照试验(randomized controlledtrials,RCTs),应用Cochrane协作网提供的Revman5.0软件进行分析评价.结果:共纳入5项试验,共300例患者.治疗使用的药物包括氟西汀、西酞普兰、帕罗西汀.RCT表明,SSRI改善IBS总体症状缓解率无统计学意义[RR=2.09,95%CI=(0.97,4.47),P<0.05];严重不良反应的发生率与安慰剂组相比无明显统计学差异[RR=1.38,95%CI=(0.68,2.82),P>0.05].结论:SSRI对缓解IBS患者的总体症状与安慰剂相比未见明显疗效差别,不良事件发生率无统计学意义.     

急性冠状动脉综合征病人治疗前后血浆脑钠肽N末端前体水平

目的观察急性冠状动脉综合征病人血浆脑钠肽N末端前体（N-terminal pro—brain natrluretic peptide,NT—proBNP）水平变化,评价该指标在急性冠状动脉综合征病人治疗中的临床意义。方法急性冠状动脉综合征病人60例（冠心病急性心肌梗死29例,不稳定型心绞痛31例）,稳定性心绞痛33例,正常对照28例。采用电化学发光双抗体夹心免疫法分析检测血浆NT—proBNP水平,以超声心动图评价心功能．同时对急性心肌梗死25例经皮冠状动脉介入术前后上述指标进行分析。结果急性冠状动脉综合征组病人血浆NT-proBNP水平为3630ng／L（95％可信区间1412～9332）,明显高于对照组75．8ng／L（95％可信区间40～144）（P〈0．001）,而稳定性心绞痛组与对照组之间差异无统计学差异（P〉0．05）。且25例急性冠状动脉综合征病人在经皮冠状动脉介人术后12～24小时内血浆NT—proBNP水平从术前4732ng／L（95％可信区间为1828～12246）降至344ng／L（95％可信区间为192～616）,差异有统计学意义（P〈0．01）。结论急性冠状动脉综合征病人血浆NT-proBNP含量明显升高,提示NT—proBNP可作为早期评估急性冠状动脉综合征病人的心功能情况。治疗后含量明显降低,可作为观察疗效的一个指标。     

心肌灌注显像对非ST段抬高的急性冠脉综合征介入治疗心肌再灌注的研究

目的通过心肌灌注断层显像研究急性冠脉综合征(ACS)冠脉介入治疗(PCI)前后心肌再灌注的变化。方法2000-012005-01对中山大学附属第五医院的106例ACS患者用99m锝甲氧基异丁基异腈心肌灌注断层显像测定心肌再灌注后的心肌复活面积情况。结果PCI后心肌显像心肌缺损面积较PCI前缩小,两者相比差异具有显著性[(12·8±4·6)%对(26·7±4·9)%,P<0·05];PCI后冠状动脉造影TIMI血流Ⅲ级者再灌注后心肌缺损面积缩小率明显大于冠状动脉造影TIMI血流≤Ⅱ级者(43·4%对14·6%,P<0·05);PCI后预后不良组心肌缺损面积明显高于预后较好组[(25·81±5·7)%,n=19对(13·6±4·2)%,n=87,P<0·05]。PCI后开通二级以上冠状动脉2支以上血管的心肌缺损面积缩小率明显高于开通1支血管的患者(39·1%,n=31对23·7%,n=71,P<0·05)。结论心肌灌注断层显像可作为ACS无创性心肌再灌注疗效评价较准确的手段。     

Variation in the use of stress testing and outcomes in patients with non-ST-elevation acute coronary syndromes: insights from GUSTO IIb.

AIMS: Non-invasive risk stratification of low- and intermediate-risk non-ST-elevation acute coronary syndromes (NSTE ACS) patients has been recommended, but limited data exist about the variation in clinical practice of stress testing in these patients and the impact of such testing on their outcomes. METHODS AND RESULTS: Patients with NSTE ACS enrolled in the GUSTO IIb (Global Use of Strategies To Open occluded coronary arteries in acute coronary syndromes-IIb) trial (n = 8011) were analysed to evaluate patterns of stress testing in US and non-US patients and to further evaluate the clinical characteristics, procedure use, and outcomes of patients who underwent stress testing compared with those who did not. Stress testing was performed in 1878 (24%) patients. Compared with patients not undergoing stress testing, those undergoing stress testing had low-risk characteristics and significantly lower death (0.6% vs. 4.8%), and death or myocardial infarction (MI, 3.9% vs. 11%) rates at 30 days. Stress testing was performed as often after as before coronary angiography. Importantly, stress testing was helpful in stratifying patients into low (equivocal or negative test) or high (positive test) risk groups (30 day death 3.1% vs. 5%). Stress testing was performed more often in non-US than US patients, and US patients were 3.5 times more likely to undergo imaging as part of stress testing. However, the risks of 30-day death or MI; 6-month death, MI or revascularization; and 1-year death did not differ between US and non-US patients. CONCLUSION: Stress testing is commonly performed in low-risk NSTE ACS patients and provides modest additional prognostic information in this cohort. Significant geographical variation exists in the use of stress testing. Therefore, in the current practice environment where cardiac catheterization is often the first diagnostic modality used in patients with NSTE ACS, the role of non-invasive testing both before and after invasive procedure is in need of further study.     

Rationale for the early clinical application of markers of ischemia in patients with suspected acute coronary syndromes

Mandates for more rapid treatment of patients with acute myocardial infarction (AMI) are driving public education initiatives aimed at having patients present earlier in the course of their symptoms. This will make it less likely that markers of necrosis will provide the level of diagnostic sensitivity needed. In fact, the goal is to identify and treat these patients sooner in order to prevent necrosis from occurring. Given the limitations of the standard 12-lead ECG to detect ischemia, other technologies are being evaluated: the value of echocardiography and technetium-based myocardial perfusion imaging have been proven. However, the goal is to develop a simple, rapid-turn-around biochemical marker that can provide this same function, and clear progress is being made toward this end. Emergent, rapid restoration of blood flow via pharmacologic revascularization or primary percutaneous interventions can reduce morbidity and mortality when applied in the setting of acute myocardial injury seen on the ECG. Exciting new research suggests that the protection of myocytes agains ischemic injury is possible if initiated early, which can limit cellular damage and improve clinical outcomes. Thus, the ability to rapidly detect ischemia will have profound therapeutic possibilities that could further reduce the morbidity and mortality associated with acute coronary syndrome.     

急性冠脉综合征抗栓治疗致出血并发症相关因素分析

目的 探讨急性冠脉综合征抗栓治疗患者发生院内出血的危险因素.方法 纳入936例急性冠脉综合征阿斯匹林及氯吡格雷进行抗栓治疗的患者,对其年龄,性别,既往粘膜、腔道出血史,心绞痛病史等20项可能出血的因素指标与发生院内出血及分级进行单因素分析,对单因素有意义危险因素再进行多因素logistic回归分析.结果 ACS患者总的出血发生率为3.10%,大出血发生率为1.06%,其中不稳定型心绞痛、非ST段抬高型心肌梗死、ST段抬高型心肌梗死的患者大出血发生率分别是0.76%、1.44%及1.51%.经多因素logistic回归分析,年龄,既往粘膜、腔道出血史,体重指数,血红蛋白,内生肌酐清除率5项因素,为ACS患者出血的主要影响因素.结论 年龄,既往粘膜、腔道出血史,体重指数,血红蛋白,内生肌酐清除率是急性冠脉综合征单纯抗栓治疗发生院内出血的危险因素,但临床仍需更大样本病例进一步证实.     

The use of revascularization strategies in patients with acute coronary syndromes admitted to hospitals without catheterization facilities: Results from the ALERT-CZ registry

AimPercutaneous coronary intervention (PCI) became the standard of care for patients (pts) with acute coronary syndromes (ACS). Czech Republic is among European countries with well developed networks of PCI and non-PCI hospitals. Ample data about PCI-treated pts is available from many registries. Much less is known about treatments and outcomes of ACS pts admitted to hospitals without cath-lab. ALERT-CZ registry was designed specifically to analyze these pts presenting to local non-PCI hospitals. The aim was to see, whether the ESC guidelines are implemented in these local, small hospitals.Methods and resultsA total of 6265 pts with first hospital admission for ACS has been enrolled in 32 Czech community hospitals without cath-lab during a 3-year period (7/2008–6/2011). The mean age was 69.7±12.3 years, 39.5% were females, 35.4% had known diabetes mellitus, 76.0% hypertension, 28.3% previous myocardial infarction and 12.0% previous stroke. Twenty-five percent pts had signs of acute heart failure (Killip II in 19.0%, Killip III in 4.8% and Killip IV in 1.1%). The discharge diagnosis was ST-elevation myocardial infarction (STEMI) in 26.1%, non-STEMI in 53.1% and unstable angina pectoris (UAP) in 20.9%.Emergent interhospital transport to coronary angiography (CAG) and PCI within <12 h from symptom onset was indicated in 73.4% of STEMI pts, elective CAG was indicated in 15.9% of STEMI, CAG was not indicated in 9.9% of STEMI and 0.9% STEMI pts refused CAG. Among non-STE ACS pts CAG was performed within <24 h in 16.2%, between 24–72 h in 18.2%, later in 38.1%, not indicated in 22.7%, refused by pts in 4.8%. The median stay in the PCI center was 2.0 days and only 37% pts returned after CAG (±PCI) to the referring community hospital, the rest was discharged from PCI center directly to home.Among STEMI pts the median time intervals were: pain—first medical contact (FMC) 120 min, FMC—community hospital door 30 min, door-in–door-out for emergency transfer 23 min. Thrombolysis was used in 0.4% of STEMI—in rare situations when immediate transfer was logistically not possible.PCI was performed in 41.6% pts overall (65.9% STEMI, 35.8% non-STEMI and 26.4% UAP). CABG was performed in 2.9% pts overall (2.1%, 3.1% and 3.6% per diagnosis). Detailed pharmacotherapy data as well as indirect comparison with a separate PCI centers registry is beyond the space frame of this abstract and will be presented.The overall in-hospital mortality was 7.2%. Mortality per final diagnosis was 9.5% (STEMI), 8.7% (non-STEMI) and 0.5% (UAP). Mortality per age group was 16.2% (>80 years), 8.0% (70–80 years) and 2.4% (<70 years).ConclusionPatients presenting to non-PCI hospitals undergo revascularization procedures less frequently than those directly admitted to PCI centers. This may be related to baseline differences. The outcomes are influenced by these facts.     

住院期间血糖升高对急性冠状动脉综合征患者近期预后的影响

目的:观察住院期间血糖升高对急性冠状动脉综合征(ACS)患者近期预后的影响。方法:对786例ACS患者入院4d内进行空腹血糖测定。根据空腹血糖,把患者分为糖尿病血糖异常组(空腹血糖>6·67mmol/L)、非糖尿病血糖异常组、血糖正常组(空腹血糖≤6·67mmol/L)。结果:496例(63·1%)ACS患者空腹血糖>6·67mmol/L,其中确诊糖尿病患者218例(27·7%),血糖升高组多为高龄女性,住院期间心肌缺血事件发生率及病死率明显高于血糖正常组(P<0·05)。结论:住院期间血糖升高是影响ACS患者预后的一个重要的危险因素,对血糖升高的患者应给予积极的治疗。     

Significant improvement in overall survival among patients diagnosed with low‐risk myelodysplastic syndrome treated with selective serotonin reuptake inhibitors

The severity of β‐thalassaemia (β‐thal) intermedia is mainly correlated to the degree of imbalanced α/non α‐globin chain synthesis. The phenotypic diversity of β‐thal depends on this imbalance and reflects all possible combinations of α‐ and β‐globin genotypes, levels of fetal haemoglobin (HbF) and co‐inheritance of other modulating factors. This study aimed to demonstrate the validity of a new surrogate of α/non α‐globin biosynthetic ratio by measuring the soluble α‐Hb pool in lysed red blood cells. Our results confirm that the α‐Hb pool measurement allows a good discrimination between β‐thal intermedia patients, controls and α‐thal patients (P < 0·003). Receiver operator characteristic analyses revealed an area under the curve of 0·978 for the α‐Hb pool measurement at a threshold of 120 ng free α‐Hb/mg of total Hb/ml of haemolysate (ppm) with a sensitivity and specificity of 86% and 100%, respectively, to discriminate between β‐thal and not β‐thal subjects. Significant correlations were observed between the α‐Hb pool and biological parameters of β‐thal, the most significant association being observed with red cell hexokinase activity. This study indicates that the α‐Hb pool could be a new marker for assistance in diagnostic orientation of β‐thal intermedia patients and may be clinically useful for monitoring the evolution of the disequilibrium of globin synthesis in response to treatments.     

Electrocardiographic diagnosis of non-ST-segment elevation acute coronary syndromes: current concepts for the physician

With several myocardial infarction (MI) registries reporting a decline in the incidence of ST-elevation MI (STEMI) and an increase in non-ST-elevation MI (NSTEMI) and unstable angina (UA), it is important that future healthcare resources are directed towards this increased volume of patients, ECG technology, core to the early diagnosis of these patients, has lagged behind relative to other techniques and little progress has been as far as acute coronary syndrome triage is concerned beyond ST-segment deviation. We present a review of the literature on current electrocardiographic changes which will allow admitting physicians to better risk stratify those patients with “non-diagnostic ECGs.” These ECGs may become diagnostic with careful evaluation, use of serial ECGs and when additional lead sets are used.     

Predictors and outcomes associated with gastrointestinal bleeding in patients with acute coronary syndromes

Background Potent antiplatelet and anticoagulant agents along with early revascularization are increasingly used in patients hospitalized with acute coronary syndromes (ACS). An important complication associated with these therapies is gastrointestinal bleeding (GIB); yet, the predictors, optimal management, and outcomes associated with GIB in ACS patients are poorly studied. Methods We investigated the incidence, predictors, pathological findings, and clinical outcomes associated with GIB in patients with ACS hospitalized at a United States tertiary center between 1996 and 2001. Results Three percent (80/3,045) of ACS patients developed clinically significant GIB. Predictors of GIB were older age, female gender, non-smoking status, peak troponin I, and prior heart failure, diabetes, or hypertension. Patients with GIB were more critically ill with lower blood pressure and higher heart rates. GIB was associated with an increased need for transfusion, mechanical ventilation, and inotropes/pressors. In-hospital mortality was significantly higher in ACS patients with versus without GIB (36% vs. 5%, P < 0.001). Thirty patients (38%) with GIB underwent endoscopy with no procedural complications of death, arrhythmia, urgent ischemia, or hemodynamic deterioration. Conclusion In patients with ACS, GIB is associated with older age, female sex, peak troponin I, non-smoking status, diabetes, hypertension, and heart failure. Hospital mortality is increased eightfold when ACS patients experience GIB. More studies are needed to establish the safety of and optimal timing of endoscopy in these patients.     

Prognostic significance of multiple-detector computed tomography in conjunction with TIMI risk score for patients with non-ST elevation acute coronary syndrome

Risk stratification among patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) has been made by clinical scoring. Recently, multiple-detector computed tomography (MDCT) appeared to provide noninvasive coronary angiography (CAG). To clarify the prognostic significance of MDCT, we aimed to evaluate the clinical utility of MDCT in the early management and in predicting the long-term prognosis of NSTE-ACS with low to intermediate risk. Among 84 consecutive patients with NSTEACS, risk stratification using a TIMI risk score was done. A total of 48 patients were categorized as low to intermediate risk. Multiple-detector CT was performed in 30 patients using 16-slice MDCT. MDCT detected coronary stenoses in 18 patients. Compared to invasive CAG, MDCT successfully depicted the coronary stenosis (P < 0.005), with sensitivity of 100% and specificity of 86%. The incidence of in-hospital major adverse clinical events (death, subsequent myocardial infarction, revascularization) was significantly higher in patients with a positive MDCT than in those with a negative MDCT test (44% vs 0%, P < 0.005). Moreover, a Kaplan-Meier analysis showed a significant difference in the event — free survival between MDCT positive and negative groups (33% vs 100%, respectively, P < 0.0001) during the mean follow-up period of 9.9 ± 7.5 months. Sixteen-slice MDCT in conjunction with a TIMI risk score appeared to demonstrate prognostic significance in patients with NSTE-ACS.     

血清妊娠相关蛋白-A在急性冠状动脉综合征时显著升高

目的探讨血清妊娠相关蛋白鄄A对急性冠状动脉综合征的临床识别和预测作用。方法收集急性冠状动脉综合征患者63例,其中急性心肌梗死29例,不稳定心绞痛34例,稳定性心绞痛38例及正常人20例。采用ELISA方法检测入院时和入院6小时后的血清妊娠相关蛋白鄄A浓度。结果入院时,急性心肌梗死与不稳定心绞痛患者血清妊娠相关蛋白鄄A浓度分别为(20±9)mIU/L和(17±8)mIU/L,明显高于稳定性心绞痛患者(8.4±4.2)mIU/L和正常人(7.2±3.8)mIU/L(P<0.01);入院6小时后与入院时比较,各组间差异无统计学意义。超出10mIU/L病例,急性冠状动脉综合征患者有58例(92%),稳定性心绞痛患者7例(18%),正常人2例(10%),其敏感性和特异性分别为92%和84%。结论急性冠状动脉综合征血清妊娠相关蛋白鄄A明显升高,可以作为诊断急性冠状动脉综合征的辅助新标记物。     

Psychological and clinical predictors of return to work after acute coronary syndrome.

AIMS: Resumption of paid employment following acute coronary syndrome (ACS) is an important indicator of recovery, but has not been studied extensively in the modern era of acute patient care. METHODS AND RESULTS: A total of 126 patients who had worked before hospitalization for ACS were studied with measures of previous clinical history, ACS type and severity, clinical management, and sociodemographic characteristics. Depressed mood (Beck Depression Inventory) and type D personality were measured 7-10 days following admission. Among them, 101 (80.2%) had returned to work 12-13 months later. Failure to resume work was associated with cardiac factors on admission (heart failure, arrhythmia), cardiac complications during the intervening months, and depression scores during hospitalization. It was not related to age, gender, socioeconomic status, type of ACS, cardiac history, acute clinical management, or type D personality. In multivariate analysis, the likelihood of returning to work was negatively associated with depression, independently of clinical and demographic factors [adjusted odds ratio 0.90, CI 0.82-0.99, P=0.032]. CONCLUSION: Depressed mood measured soon after admission is a predictor of returning to work following ACS. The management of early depressed mood might promote the resumption of economic activity and enhance the quality of life of cardiac patients.     

Prevalence of lipid abnormalities and cholesterol target value attainment in Egyptian patients presenting with an acute coronary syndrome

Background

Effective management of hyperlipidemia is of utmost importance for prevention of recurring cardiovascular events after an acute coronary syndrome (ACS). Indeed, guidelines recommend a low-density lipoprotein cholesterol (LDL-C) level of <70?mg/dL for such patients. The Dyslipidemia International Study II (DYSIS II) – Egypt was initiated in order to quantify the prevalence and extent of hyperlipidemia in patients presenting with an ACS in Egypt.