实时三维超声心动图评价心肌梗死后心力衰竭患者左心室收缩功能与不同步性

目的 探讨实时三维超声心动图评价心肌梗死后心力衰竭患者左心室收缩功能与不同步性的临床价值。方法对40例心肌梗死后心力衰竭患者（心肌梗死组）及30例健康者（对照组）分别行左室实时三维超声心动图17节段时间一容积分析,获取左室整体收缩功能指标：左室舒张末期容积（LVEDV）、收缩末期容积（LVESV）、射血分数（LVEF）;左室收缩同步性指标：除心尖帽外的16节段从QRS波起点到最小收缩容积的时间的标准差和最大差值（Tmsv16-SD、Tmsv16-Dif）;二者除以心动周期分别得到SDI、Tmsv16-Dif％。分析LVEF与SDI之间的关系。结果与对照组比较,心肌梗死组左室扩大,LVEDV、LVESV增高,LVEF减低,差异均有统计学意义（P〈0．01）,LVEF与LVEDV呈负相关（r=-0．83,P〈0．01）;心肌梗死组SDI高于对照组（P〈0．01）,SDI与LVEF呈负相关（r=0．84,P〈0．01）。结论陈旧性心肌梗死患者左心室重构明显,不但心功能减低而且普遍存在收缩不同步,不同步程度与收缩功能呈负相关。实时三维超声心动图能同时提供左室收缩功能和不同步性的详细信息,是评价心功能的有效手段。     

超声心动图在监测急性心肌梗死合并心力衰竭冠脉内介入术后心功能中的作用

目的探讨超声心动图在观察急性心肌梗死合并心力衰竭患者经皮冠状动脉腔内成形术(PTCA)和冠状动脉内支架植入术后心功能的作用。方法采用超声心动图对36例急性心肌梗死合并心力衰竭患者PTCA加支架植术前,术后1周、1个月和3个月,进行多项心功能指标动态检测。结果与术前比较,术后1周左室收缩功能左室射血分数(LVEF)、左室短轴缩短率(LVFS)、每搏量(SV)、每分输出量(CO)有明显改善(P<0.05);术后1个月和术后3个月,左室容量、左室收缩功能、左室舒张功能等各项指标均有明显改善(P<0.05)。结论超声心动图在监测急性心肌梗死合并心力衰竭患者冠脉内介入治疗后心功能的变化方面具有一定的临床应用价值。     

左室舒张功能不全血清脑钠肽浓度的改变及阿托伐他汀的干预作用

目的：探讨左室舒张功能不全患者血清脑钠肽（BNP）浓度的改变和诊断价值，以及阿托伐他汀干预的作用。方法：采用电化学发光免疫技术检测90例心功能不全患者和16例健康人血清BNP浓度，以心脏彩色多普勒超声诊断仪测定心室结构功能，分为单纯舒张性心功能不全组（34例）和收缩功能不全伴或不伴舒张功能不全组（22例），无症状舒张功能不全组（34例）。结果：心功能不全患者血清BNP浓度升高，且随心功能不全严重程度增加。与NYHA分级正相关。以血清BNP浓度〉100pg／ml为界值，判断单纯舒张心功能不全的敏感性88．2％，特异性87．5％准确性88．1％。多元线性回归分析显示．左室射血分数、NYHA分级是影响血清BNP的因素，无症状舒张功能不全时血清BNP浓度与对照组差异有显著性（P〈0．05）。阿托伐他汀治疗单纯舒张性心功能不全3个月后对BNP水平没有明显影响（P〉0．05）。结论：血清BNP浓度在单纯舒张性心功能不全患者亦明显升高，并有较好的诊断价值，阿托伐他汀治疗未能改善单纯舒张功能不全患者的心脏损害。     

急性心肌梗死后左室重构的动态观察

目的：观察急性心肌梗死前后心肌结构的变化，探讨心梗后左室重构变化规律。方法：16只成年健康犬麻醉后开胸结扎前降支建立心梗模型，经胸超声心动图（2．5HMz）分别于术前、术后2d、术后30d观察心脏形态，心功能及心肌应力变化。结果：术后2d出现左室扩张，收缩和舒张功能减低，心肌应力增高，左房射血力增加。术后30d较术后早期，左室进一步扩张，收缩舒张功能持续降低，心肌应力术后早期高。结论：心肌梗死后早期即出现心室扩张，收缩和舒张功能降低，心肌应力增加，心梗死左室重构贯穿整个疾病过程。     

高血压病患者左房室构型与功能变化

目的 探讨高血压病患左房室构型及功能变化的相互关系。方法 采用超声多普勒技术检测30例高血压病患的左房室构型及心功能变化。结果 高血压病患左房室构型按正常构型、单纯左房增大、向心性左室重构、向心性左室肥厚、离心性左室肥厚分型，其所占比例依次为63．53％、5．阳％、3．24％、14．41％、12．94％。构型改变多出现在5年以上病程患，且与病程呈正相关。收缩功能减退出现在左室肥厚的后期，而舒张功能减退出现在各种构型改变之前。结论 舒张功能异常在高血压早期即可发生，而左房室构型改变出现在舒张功能减退之后，收缩功能异常仅出现在左室肥厚之后，左室肥厚非舒张功能异常的唯一原因。     

急性心肌梗死再灌注治疗心电图改变的临床意义

目的：通过心电图观察急性心肌梗死（AMI）用尿激酶溶栓后2h内抬高ST段下降幅度,评价溶栓治疗过程中ST段改变对患者心功能的影响,探讨ST段回落与早期（24h内）T波倒置、酶峰前移的相关性及住院期间临床事件的发生率。方法：选择ST段抬高型急性心肌梗死100例,在发病12h内行尿激酶静脉溶栓,计算2h内ST段抬高振幅总和（∑STE）的下降幅度。结果：溶栓治疗2h后∑STE较溶栓治疗前下降大于50％者,24h内T波倒置者多、肌酸激酶同工酶（CK—MB）峰值前移、左室功能改善好。而溶栓治疗2h后∑STE较溶栓治疗前下降小于50％,24h内T波未倒置者多、CK—MB峰值后移、心功能不同程度受损。结论：ST段抬高型急性心肌梗死的患者经早期溶栓治疗后其抬高的ST段下降幅度大于50％可作为心肌血供恢复的主要预测指标。     

探讨RT-3DE评价急性心肌梗死患者左室功能及收缩同步性的可行性

目的利用实时三维超声心动图容积一时间曲线评价急性心肌梗死患者左室功能及收缩同步性。方法采集63例急性心肌梗死患者（心梗组）及38例健康者（正常组）的三维图像,用Qlab（8．1）软件分析出各参数,将两组各参数进行比较。结果心梗组左室舒张末容积（EDV）、左室收缩末容积（ESV）、大部分节段舒张末容积（rEDV）、节段收缩末容积（rESV）、16节段达最小收缩末容积时间的最大差值、标准差及所在心动周期的百分比（Tmsv-16-Dif、Tmsv-16-Di跳、Tmsv-16-SD、Tmsv-16-SD％）大于正常组（P〈0．05）,心梗组射血分数（EF）、节段射血分数（rEF）小于正常组（P〈0．05）,心梗组EF与Tmsv16-Dif、Tmsv16-Dif（％）、Tmsv16-SD、Tmsv16-SD（％）呈负相关（P〈0．05）,心梗组异常节段的rPER、rPFR小于正常组（P〈0．05）。结论实时三维超声心动图可以定量评估急性心肌梗死患者左室功能及左室收缩同步性。     

急性心肌梗死的超声诊断

目的：提高急性心肌梗死的超声诊断率。方法：回顾性总结了35例急性心肌梗死的超声心动图诊断经验，并进行了随访。结果：34例患者发现节段运动异常，回声减低，舒张功能受损。11例患者发现左室重构。23例发现左室收缩功能不同程度受损。结论：超声心动图对急性透壁性心肌梗死的诊断及鉴别诊断有价值。     

老年人急性肺水肿为主要表现的急性心肌梗死44例临床分析

目的分析以急性肺水肿为主要表现的老年人急性心肌梗死（AMI）的临床特点，探讨其心力衰竭的发生机制。方法回顾性分析44例以急性肺水肿为主要表现的AMI老年患者的临床特点，根据NYHA心功能分级及超声心动图所示左室射血分数（LVEF）探讨AMI时发生急性肺水肿的机制。结果44例中，29例（65．9％）为无痛性梗死；32例（72．7％）为急性非透壁性梗死，7例并发完全性左束支传导阻滞；超声心动图LVEF〈40％26例，≥40％18例。随访24例，半年内死亡7例（29．2％）。结论以急性肺水肿为主要表现的AMI多为无痛性梗死，心电图表现多为急性非透壁性梗死。AMI时发生急性肺水肿的机制为左室收缩功能及舒张功能的严重损害。     

自体外周血单个核细胞移植老年急性心肌梗死：5年心功能评价

背景：心肌梗死患者出现心室重构及心功能不全是其常见的并发症,老年患者因其自身生理特点上述情况发生可能性更高。近年来干细胞移植治疗急性心肌梗死及心力衰竭成为研究热点,其可行性及安全性已得到证实,但其对于老年患者长期效果尚未明确。 目的：评价自体外周血单个核细胞移植对老年急性心肌梗死患者左室重构和心功能的长期影响。 方法：自2003年8月至2006年8月共入选老年急性心肌梗死患者（年龄≥60岁）30例,分为2组,移植组在常规治疗（药物与介入）基础上经冠状动脉输注自体外周血单个核细胞;对照组经常规方法（药物与介入）治疗。在外周血单个核细胞动员、采集及经冠状动脉回输过程中观察其不良反应。在治疗前及治疗后6,12,24,60个月应用超声心动图评价左室形态及心功能变化。 结果与结论：治疗前两组左室容量及心功能指标比较差异无显著性意义。与治疗前比较,治疗后6,12,24,60个月移植组左室舒张末容积、左室收缩末容积显著降低,左室射血分数显著增高。与治疗前比较,治疗后6,12,24,60个月对照组左室舒张末容积、左室收缩末容积、左室射血分数差异均无显著性意义。与对照组相比较,各个时间点移植组左室舒张末容积、左室收缩末容积均显著降低,左室射血分数增高。随访期间均未发现移植相关不良反应及心血管事件。结果可见自体外周血单个核细胞移植可显著、长期改善老年急性心肌梗死患者的左室重构及心功能情况,且安全性良好。     

急诊床旁超声心动图在急重症心血管疾病中应用

目的探讨急诊床旁超声心动图检查在急重症心血管疾病诊断中价值。方法回顾性分析188例行急诊床旁超声心动图检查的急重症心血管疾病患者的临床资料。结果超声心动图诊断与临床诊断相符161例,其中单纯急性心肌梗死14例,非急性心肌梗死后左心功能不全44例,急性心肌梗死合并左心功能不全20例,心包积液47例,慢性肺源性心脏病7例,A型主动脉夹层4例,肺栓塞11例,主动脉瓣狭窄2例,心肌炎2例,肥厚型心肌病6例,风湿性心脏病合并左心房血栓3例,主动脉窦瘤破裂1例,诊断符合率为85．6％。结论急诊床旁超声心动图在急重症心血管疾病的早期诊断中有重要价值。     

Essentials of the diagnosis of heart failure

Although heart failure is a common clinical syndrome, especially in the elderly, its diagnosis is often missed. A detailed clinical history is crucial and should address not only current signs and symptoms of heart failure but also signs and symptoms that point to a specific cause of the syndrome, such as coronary artery disease, hypertension or valvular heart disease. It is important to determine whether the patient has had a previous cardiac event, in particular a myocardial infarction. The physical examination should include Valsalva's maneuver, a test that is highly specific and sensitive for the detection of left ventricular systolic and diastolic dysfunction in patients with heart failure. An electrocardiograph and a chest radiograph should also be obtained. Two-dimensional echocardiography of the heart helps differentiate systolic from diastolic dysfunction. Coronary angiography is indicated in patients with heart failure and anginal chest pain and should be strongly considered in patients with an electrocardiogram suggestive of ischemia or myocardial infarction.     

Selective and specific I(f) inhibition with ivabradine: new perspectives for the treatment of cardiovascular disease

Heart rate is a major determinant of myocardial oxygen demand and supply, and increased heart rate adversely affects the pathophysiology of myocardial ischemia. High resting heart rate is a risk factor in cardiovascular disease. The development of the heart rate-lowering agent ivabradine showed that heart rate was also an important treatment target, notably in coronary artery disease and heart failure. Indeed, heart rate reduction with ivabradine, a selective and specific I(f) inhibitor, reduces myocardial oxygen demand, increases diastolic perfusion time and improves energetics in ischemic myocardium. Ivabradine protects the myocardium during ischemia, improves left ventricular function in heart failure and reduces remodeling following myocardial infarction. It improves prognosis in patients with coronary artery disease, left ventricular dysfunction and heart rate ≥70 beats per minute, as well as in patients with heart failure and left ventricular dysfunction. Ivabradine is safe, well tolerated and can be used in combination with the main drugs for cardiovascular disease.     

The role of intracardiac hemodynamic parameters in prognosis of cardiac failure in myocardial infarction patients

Two-dimensional echocardiography was used to study intracardiac hemodynamics (end systolic, end diastolic volumes and left atrial ejection fraction; end systolic, end diastolic volumes and left ventricular fraction; mean pressure in the pulmonary artery; myocardial mass of the left ventricle) in 49 patients 2, 10 and 30 days after onset of macrofocal myocardial infarction (MI). It was found that patients with and without cardiac failure after one year of the diseases significantly differed by volume and function of the left ventricle and atrium registered since MI day 2. Probability of cardiac failure in the postinfarction period may be estimated since the disease day 2 by an increase in the end-systolic and end-diastolic volumes and left ventricular ejection fraction. A restrictive type of left ventricular diastolic dysfunction is one of the early prognostic criteria of cardiac failure in postinfarction period.     

参麦川芎嗪对心肌梗死后心力衰竭心室重构的影响

目的:探讨参麦合用川芎嗪注射液对急性心肌梗死后心力衰竭、心室重构的影响。方法:选择急性心肌梗死住院患者43例,分为应用参麦、川芎嗪注射液组(治疗组)及未用参麦、川芎嗪注射液组(对照组),观察两组心力衰竭发生率并通过心脏彩超检测两组心脏左室舒张末期内径、左室舒张末期容积、左室收缩末期容积、左室射血分数及左室短轴缩短率。结果:治疗后4周,治疗组左室射血分数和左室短轴缩短率与本组治疗后1周及同期对照组相比差异有统计学意义(P<0.05);对照组左室舒张末期容积、左室收缩末期容积与本组治疗后1周及同期治疗组比较差异有统计学意义(P<0.05);治疗组心力衰竭发生率比对照组明显降低(P<0.05)。结论:参麦、川芎嗪注射液联合应用能抑制或减轻急性心肌梗死后左室重构,降低心力衰竭发生率,从而改善预后。     

斑点追踪成像技术评价冠状动脉不同狭窄程度患者的左室扭转运动

目的 应用斑点追踪成像(STI)技术评价冠状动脉不同狭窄程度患者左室扭转运动的特点及规律性.方法 临床拟诊为冠心病患者117例,根据冠状动脉造影或冠状动脉CT结果分成心肌梗死组(60例)、心肌缺血组(31例)及对照组(26例),常规超声测量左室收缩及舒张末期内径(LVDs,LVDd)、容积(LVVESV,LVEDV)及射血分数(LVEF),组织多普勒测量二尖瓣后瓣环收缩期峰值运动速度(S')及Tei指数,运用STI技术分析左室二尖瓣水平与心尖水平旋转运动、整体扭转运动,测定旋转角度/率、扭转角度/率.结果 与心肌缺血组及对照组比较,心肌梗死组LVDd、LVDs、LVEDV、LVESV及Tei指数均增大,LVEF及S'减低,差异均有统计学意义(P<0.05).与对照组比较,心肌梗死组及心肌缺血组左室心尖水平旋转角度/率、二尖瓣水平旋转率、扭转角度/率均减低,差异均有统计学意义(P<0.05),以心肌梗死组减低更为显著(P<0.01).左室整体的扭转角度与LVEF呈较强的正相关(r=0.618,P<0.001).结论 冠心病患者的冠状动脉狭窄程度越严重,左室整体的扭转运动受损越明显,以心肌梗死组减低更为显著.应用STI评价左室的扭转运动与常规超声参数相比较,能更好地反映心肌缺血患者的左心室收缩运动.     

Predicting left heart failure after a myocardial infarction: a preliminary study of the value of echocardiographic measures of left ventricular filling and wall motion

Heart failure occurs from both systolic and diastolic dysfunction. To determine whether simple Doppler echocardiographic measures of left ventricular filling could improve upon the ability of systolic function to predict heart failure after infarction, patients with acute myocardial infarction were studied within the first 36 hours by Doppler and two-dimensional echocardiography. Forty-eight patients who did not have heart failure before the Doppler echocardiographic study and who did not have myocardial revascularization, moderate or severe mitral regurgitation, or other complications during recovery were monitored for 6 months or to the onset of heart failure (n = 10). The univariate predictors of heart failure were age (p less than 0.05), anterior infarction (p less than 0.05), early diastolic peak filling velocity (p = 0.05), filling velocity with atrial systole (p less than 0.05), the ratio of these velocities (p less than 0.001), the percentage of filling with atrial systole (p less than 0.001), and the wall motion score index (p less than 0.001). However, the only independent predictors of heart failure by use of multivariant stepwise logistic regression analysis were the wall motion score index (p less than 0.05) and either the ratio of early and late peak filling velocities (p less than 0.001) or the percentage of filling with atrial systole (p less than 0.001). The combined use of a measure of systolic function and measures of the relative contribution of atrial systole to ventricular filling were useful predictors in identifying patients likely to develop subsequent heart failure after myocardial infarction.     

干细胞移植急性心肌梗死合并心力衰竭患者的心功能变化：2年随访

背景：很多动物实验和临床试验均证实,干细胞移植可改善心脏功能,减少心室扩张及心室重构,在治疗心肌梗死合并心衰方面已经表现出传统治疗方法所无可比拟的优越性。 目的：观察单次自体外周血干细胞移植在急性心肌梗死后心衰患者中的临床疗效。 方法：选择2005年8月至2006年9月收治的急性ST段抬高心肌梗死合并心衰患者23例,将入选者分成两组,细胞移植组11例,对照组12例,均急诊行冠状动脉造影及药物洗脱支架置入（PCI）。细胞移植组于支架置入后5d,采集经粒细胞集落刺激因子动员5d的外周血干细胞（CD34＋细胞,大约1×10^8）,用冠脉造影注射法注入梗死相关血管。细胞移植后随访2年,观察患者心功能变化及不良反应。 结果与结论：细胞移植组移植前与随访至6个月时相比,心功能明显改善（P〈0．05）,左室射血分数提高（6．2±0．2）％,左室舒张末期容积减少（4．7±2．9）mm,而移植后随访至1年、2年时结果并无明显区别（P〉0．05）,未发现细胞移植的不良反应。对照组随访至6个月时,左室射血分数下降（0．5±0．1）％,左室舒张末期容积增大（0．4±0．3）mm,并且逐年恶化。证实经皮经冠状动脉内自体外周血干细胞单次移植6个月时,能明显改善急性心肌梗死患者的左室功能,减小左室容量,阻止或延缓左室重构,且安全有效,但随访至2年,心功能没有得到进一步的改善。     

Assessing diagnosis in heart failure: which features are any use?

We assessed the value of symptoms, past history, medications and signs in the evaluation of patients who might have heart failure secondary to left ventricular systolic dysfunction. An open-access echocardiography service was set up to help identify patients with left ventricular systolic dysfunction who might benefit from treatment with an angiotensin-converting-enzyme inhibitor. History and examination were recorded for each of these patients. The patients were divided into groups according to whether left ventricular systolic function was preserved or not and whether various clinical features were present or not. Of 259 consecutive patients studied, 41 had impairment of left ventricular systolic function as assessed by echocardiography. Past history of myocardial infarction and displaced apex beat were the best single predictors of left ventricular systolic dysfunction as assessed by echocardiography. The combination of past history of myocardial infarction and displaced apex had the best positive predictive value of all. Patients with such clinical features or combinations of clinical features may not need echocardiography, and where access to this resource is limited, it could be reserved for patients without such diagnostic features.