老年急性冠状动脉综合征临床分析

急性冠状动脉综合征(ACS)由于发病急,病情变化快,病死率高,已成为当今心血管领城的热点之一[1].本文回顾对比分析153例ACS的临床资料,总结分析67例老年患者的临床特点,旨在提高老年ACS的诊治水平.     

急性冠状动脉综合征药物治疗与介入治疗对比分析

急性冠状动脉综合征(ACS)是冠状动脉急性闭塞的临床表现,它的发生主要是由于冠状动脉内不稳定粥样斑块破裂与出血导致血栓形成,血管再通是其最有效的治疗方法,冠状动脉介入治疗在短期内改善临床征状优势明显[1]。本研究对比分析二种治疗方法的疗效,为临床上ACS合理治疗提供依据。     

重视急性冠状动脉综合征非血运重建患者的药物治疗

急性冠状动脉综合征(ACS)是以冠状动脉粥样硬化斑块的破裂并发血栓形成为主要病理特征,如果血栓是以血小板为主的附壁血栓,由于冠状动脉仍有残存的血流灌注,一般不会导致大范围的透壁心肌梗死,亦无明显的心电图ST段抬高,患者主要表现为不稳定型心绞痛或非ST段抬高型心肌梗死(STEMI),统称为非ST段抬高型ACS(NSTE-ACS);     

急性冠状动脉综合征支架置入术临床分析

目的探讨急性冠状动脉综合征(ACS)患者置入冠状动脉内支架的临床疗效。方法选择2003年5月~2006年5月入院的90例ACS患者,均行多体位多角度选择性冠状动脉造影(CAG),确定靶血管后,经皮腔内冠状动脉成形术(PTCA)预扩张再置入支架76例,直接置入支架14例,观察置入不同大小、类型支架手术成功率,住院和随访期间的临床心脏事件、心功能情况。结果90例患者置入支架115枚。支架直径2.5~4.0mm,长度8~32mm;支架类型为Evolution5枚,MedtronicS660 7枚,Vismed 10枚,B/BRAUN 27枚,Biodiv Ysiooc 47枚,Firebird 19枚。全部随访3至12个月,2例不稳定型心绞痛(UAP)患者手术即刻出现急性心肌梗死(AMI);1例1个月后行冠状动脉旁路移植术;2例术后未规律抗凝,半年后出现支架内再狭窄,重新置入支架;1例多支病变置入3枚支架,1年后死于心肌梗死;1例多发冠状动脉瘤半年后心脏性猝死。手术即刻成功率97.78%,心脏事件发生率6.67%,心功能改善62.50%。结论ACS行支架置入术安全有效,随访心脏事件发生少,心功能得到改善。但多支病变置入多枚支架再狭窄发生率高,易出现心脏事件。     

急性冠状动脉综合征药物治疗现状

急性冠状动脉综合征(ACS)是近20年来心血管疾病研究的热点,由于对ACS的病理基础和发病机制的研究有了引人注目的进展,进而导致了治疗策略的巨大变化.     

急性冠状动脉综合征治疗对策

<正>急性冠状动脉综合征(acute coronary syn-drome,ACS)主要是指由于冠状动脉粥样硬化病变的斑块不稳定、继而出现斑块破裂、冠脉内血栓形成并导致冠脉内血流量减少的一系列病理生理过程的临床综合征。临床表现:包括不稳定性心绞痛(UAP)、急性心肌梗死(AMI)及心脏性猝死(SCD)。它具有发病急、变化快、死亡率高但可救治的特点,这类患者在急诊室以急性胸痛     

98例急性冠状动脉综合征患者介入治疗临床分析

目的观察急性冠状动脉综合征(ACS)患者经皮冠状动脉介入治疗(PCI)的安全性和有效性。方法98例ACS患者,其中不稳定型心绞痛62例,非ST段抬高心肌梗死13例,ST段抬高心肌梗死23例。经右桡(股)动脉穿刺,常规选择性冠状动脉造影,确定病变后,沿指引导管插入0.014英寸导丝,选择合适的球囊预扩张后,再置入合适的支架。结果98例患者,病变血管共135支,单支病变68例、双支病变23例、三支病变7例,慢性完全闭塞病变4例。介入干预病变血管105支,置入支架109枚,全部成功(TIMI血流均为3级)。结论PCI是ACS患者安全而有效的治疗方法。     

老年急性冠状动脉综合征的抗血栓药物治疗

急性冠状动脉综合征 (ａｃｕｔｅｃｏｒｏｎａｒｙｓｙｎ ｄｒｏｍｅ ,ＡＣＳ)是一组冠状动脉粥样硬化斑块不稳定、破裂、血小板粘附、聚集甚至血栓形成而致急性心肌缺血的临床综合征。根据ＳＴ段是否抬高而将其分成ＳＴ段抬高的ＡＣＳ ,即ＳＴ段抬高心肌梗死(ＳＴＥＭＩ)和非ＳＴ段抬高的ＡＣＳ ,后者又包括不稳定性心绞痛与非ＳＴ段抬高心肌梗死 (ｎｏｎ ＳＴｓｅｇ ｍｅｎｔｅｌｅｖａｔｉｏｎｍｙｏｃａｒｄｉａｌｉｎｆａｒｃｔｉｏｎ ,ＮＳＴＥＭＩ) [1] 。近年来随着ＡＣＳ基础研究的不断深入以及有关大规模、随机、对照的临床试验结…     

急性冠状动脉综合征的治疗新对策和新模式

急性冠状动脉综合征 (ａｃｕｔｅｃｏｒｏｎａｒｙｓｙｎｄｒｏｍｅ ,ＡＣＳ)包括ＳＴ段抬高的心肌梗死 (ｍｙｏｃａｒｄｉａｌｉｎｆａｒｃｔｉｏｎ ,ＭＩ)和无ＳＴ段抬高的ＡＣＳ ,后者又包括无ＳＴ段抬高的ＭＩ和不稳定型心绞痛 ,这二者可统称为不稳定型冠状动脉疾病。一、ＡＣＳ干预对策的演变以ＳＴ段抬高的ＭＩ为例 ,6 0年代以前 ,ＡＭＩ病人是收在普通内科病房治疗 ,主要治疗手段是长期卧床 ,休息和止痛。这些手段不能改变病人的预后 ,如同链霉素和雷米封问世前的结核病治疗状态 ,治疗是消极的 ,住院死亡率高达 30 %。6 0 80年代是…     

115例女性急性冠状动脉综合征临床资料分析

目的探讨女性急性冠状动脉综合征的临床及冠状动脉造影特点。方法对115例确诊的女性急性冠状动脉综合征病人的临床资料和冠状动脉痛变特点进行分析，并与186例男性急性冠状动脉综合征病人作比较。结果①女性急性冠状动脉综合征病人年龄大。症状不典型，搪尿病、高血压病、高脂血症等高危因素多，尤其糖尿病的发生率明显高于男性；②女性急性冠状动脉综合征病人发生心功能不全（NYHAⅢ级、Ⅳ级）、左室射血分数值下降（≤45％），与男性相比有统计学意义；③冠状动脉造影特点以多支病变压中重度狭窄为主，单支病变较少。结论女性急性冠状动脉综合征病情及冠状动脉病变程度较男性更严重。     

急性冠状动脉综合征的抗血小板治疗

急性冠状动脉综合征 (ACS)发生的成因主要由冠状动脉内不稳定的斑块形成及破损。在此基础上 ,血小板发生活化并介导血栓形成 ,因此抗血小板药物在 ACS的治疗中有着重要的地位。本文就抗血小板药物应用进展作一综述     

Medication performance measures and mortality following acute coronary syndromes

PURPOSE: To identify patient and health care factors which are related to the use of medical treatments that comprise quality measures and to assess the relation of these measures with mortality. METHODS: The study sample consisted of 20 140 patients with acute coronary syndromes from the international GRACE registry. Multivariable logistic regression modeling was used to determine predictors of quality performance. Quality indicators were use of aspirin and beta-blockers within 24 hours and at hospital discharge, use of angiotensin-converting enzyme (ACE) inhibitors at discharge, and in-hospital mortality. RESULTS: Use of medications in eligible patients at discharge ranged from 73% for ACE inhibitors to 93% for aspirin. High-risk features (eg, heart failure, older age) were related to failure to use aspirin and beta-blockers. Being at a teaching hospital and care by a cardiologist were associated with better use of aspirin and beta-blockers. Coronary artery bypass surgery was associated with failure to use ACE inhibitors and aspirin. When hospitals were divided into quartiles of quality performance, adjusted in-hospital mortality was 4.1% in the top versus 5.6% in the bottom quartile, representing a 27% (95% confidence interval: 11% to 42%) lower relative mortality. CONCLUSION: Identification of factors associated with failure to use proven treatments, including high-risk groups that would derive particular benefit from effective therapies, provides an opportunity to focus quality improvement interventions. The association of lower hospital mortality with better use of selected medical treatments supports their measurement to improve quality of care.     

充血性心力衰竭10年临床回顾性分析

目的 :了解充血性心力衰竭 (CHF)住院患者一般情况、病因、药物治疗、转归及死亡等 10年间变化。方法 :将入选的 6 4 5例CHF患者 ,分成 1988～ 1990年段组 (A组 )和 2 0 0 0～ 2 0 0 2年段组 (B组 )。分别对两组住院病历进行回顾性分析及比较。结果 :①入选的 6 4 5例患者中 ,男 371例、女 2 74例 ,平均年龄 (6 5 .4± 18.3)岁～ (6 7.2± 12 .5 )岁 ;B组较A组病程 [(5 8.3± 6 3.2 )∶(95 .6± 77.3)个月 ,P <0 .0 1]和住院时间 [(2 0 .8± 2 4 .6 )∶(30 .5±32 .5 )d ,P <0 .0 1]缩短。②心力衰竭 (心衰 )病种主要是冠心病、风湿性瓣膜病及原发性高血压 (EH) ,10年间冠心病已从 34.5 %上升到 5 6 .0 % (P <0 .0 1) ,EH从 10 .3%升至 15 .1% (P >0 .0 5 ) ,风湿性瓣膜病由 30 .6 %下降到16 .2 % (P <0 .0 1)。③住院期间治疗心衰的药物仍以利尿剂、硝酸酯类和洋地黄类制剂为主 ,洋地黄类制剂的使用有下降的趋势 (4 3.4 %∶39.0 % ,P >0 .0 5 ) ,β受体阻滞剂 (8.8%∶2 1.1% ,P <0 .0 1)和血管紧张素转换酶抑制剂 (2 4 .1%∶6 0 .9% ,P <0 .0 1)的应用明显上升。④住院期间症状明显改善率升高 (19.9%∶2 3.3% ,P >0 .0 5 ) ,住院病死率明显降低 (12 .4 %∶6 .3% ,P <0 .0 5 )。结论 :10年间 ,住院的CHF     

Validation of the GRACE score for prognosis in Indian patients with acute coronary syndromes

AimTo validate the global registry of acute coronary events (GRACE) score in acute coronary syndromes (ACS) patients and study its angiographic correlation.Methods and resultsTwo-hundred and thirty-five ACS patients were studied for the combined endpoint of all-cause in-hospital mortality and non-fatal infarction/reinfarction. We tested the predictive accuracy of the composite GRACE score using the receiver operating characteristics (ROC) curve.Lower systolic blood pressure (SBP) (odds ratio [OR] 7.93, P=0.005), ST-segment deviation (OR 7.79, P=0.02) and cardiac biomarker positivity (OR > 6.52, P=0.01) were significantly associated with events. Serum creatinine > 1.4 mg/dL showed a trend towards statistical significance (OR 4.14, P=0.05), whereas age > 50 years (OR 3.62, P=not significant [NS]) and Killips class 4 (OR 2.71, P=NS) showed good association. The best value for predicting events was a GRACE score of > 217 and these patients were more likely to have double/triple vessel disease (P = 0.0009). The C statistic for the GRACE score was 0.75.ConclusionHigher GRACE score predicts in-hospital events and more severe angiographic coronary artery disease (CAD).     

Percutaneous coronary intervention in diabetic patients with non-ST-segment elevation acute coronary syndromes.

Key pathophysiologic mechanisms of diabetes-related coronary disease include inflammation and a prothrombotic state. In the setting of non-ST-segment elevation acute coronary syndromes diabetic patients are at high risk for subsequent cardiovascular events. At the same time, they derive greater benefit than non-diabetic counterparts from aggressive antithrombotic therapy, early coronary angiography, and stent-based percutaneous coronary intervention. The mainstays of antithrombotic therapy for diabetic patients undergoing percutaneous revascularization include aspirin, clopidogrel, platelet glycoprotein IIb/IIIa receptor antagonists, and heparin or low-molecular-weight heparin. Despite dramatic reduction in restenosis conferred by drug-eluting stents, diabetic patients remain at increased risk for repeat revascularization. More efforts are needed both in terms of local drug elution as well as systemic pharmacologic therapies to further contain the excessive neointimal proliferation that characterizes the diabetic response to vascular injury.     

盐酸替罗非班对急性冠脉综合征并冠脉内血栓的疗效观察

目的探讨冠状动脉内注射盐酸替罗非班治疗急性冠脉综合征并冠脉内血栓的疗效。方法对2005年12月至2006年9月首都医科大学附属北京友谊医院心血管中心经冠状动脉造影证实为急性冠脉综合征并冠脉血栓病变患者38例,随机分为替罗非班组19例和对照组19例。替罗非班组在经皮腔内冠脉成形术(PT-CA)和(或)支架置入治疗前(后)行冠状动脉内注射盐酸替罗非班10~30mL,之后进行支架置入,术后静脉滴注盐酸替罗非班0.15μg/(kg.min)持续24~48h。对照组采用常规经皮冠状动脉介入治疗(PCI)。观察两组PCI术前、术后心肌梗死血栓溶解(TIMI)积分、TIMI血流、无复流或慢血流、校正的TIMI帧计数(cTFC)、心肌灌注分级(MBG),术后左心室射血分数(LVEF)及住院期间出血并发症与包括死亡、再发心肌梗死、再次血运重建等的主要心血管不良事件(MACE)发生情况。结果盐酸替罗非班组与对照组相比治疗后TIMI血栓积分明显下降(0.90±0.14对1.53±0.54,P<0.01),最后TIMI血流改善[(2.78±0.32)%对(2.14±0.23)%,P<0.01],cT-FC降低[(17.9±5.1)%对(25.3±13.2)%,P<0.01],MBG改善[(2.70±0.54)%对(2.06±0.38)%,P<0.01];盐酸替罗非班组左室射血分数显著高于对照组[(57.1±12.6)%对(51.0±13.9)%,P<0.01];两组住院期间出血并发症与MACE比较差异无显著性意义。结论盐酸替罗非班可改善合并冠脉血栓病变的急性冠状动脉综合征的血栓负荷、冠状动脉血流、心肌灌注和左室收缩功能,且不增加患者住院期间主要并发症的发生。     

45例急性冠状动脉综合征患者血液中基质金属蛋白酶含量变化

目的探讨基质金属蛋白酶(MMP)与冠状动脉粥样硬化斑块稳定性的相关性。方法急性冠状动脉综合征(ACS)患者在入院即刻、入院一周、出院时,测定血浆MMP浓度,并与对照组比较分析。结果ACS组血清MMP浓度明显高于对照组,且差异有统计学意义。结论MMP与冠状动脉斑块不稳定性呈密切相关,可望作为冠状动脉斑块不稳定性的参考指标。     

髓过氧化物酶活性升高在急性冠状动脉综合征患者中的临床意义

目的探讨急性冠状动脉综合征(ACS)患者血清髓过氧化物酶(MPO)活性变化的临床意义。方法采用比色法测定实验组和对照组血清MPO活性。结果(1)ACS包括不稳定型心绞痛/无ST段抬高的心肌梗死(UAP/NSTEMI)和ST段抬高的心肌梗死(STEMI)患者血清MPO活性明显升高,与正常对照组(Control组)、稳定型心绞痛(SAP)组比较有显著性差异(P<0.001)。STEMI患者血清MPO活性高于UAP/NSTEMI(P<0.001)。(2)SAP血清MPO活性高于Control组(P<0.001)。(3)ACS患者接受经皮冠状动脉介入治疗(PCI)术后MPO活性较术前显著升高(P<0.001)。(4)ACS患者血清MPO活性与白细胞计数(WBC)呈正相关(r=0.619,P=0.001),与年龄、性别、高敏感C反应蛋白、总胆固醇、低密度脂蛋白、高密度脂蛋白、三酰甘油无相关性。结论血清MPO活性升高可能与ACS的发生有关。MPO是一种预测ACS的炎症标志物。     

Bleeding and blood transfusion issues in patients with non-ST-segment elevation acute coronary syndromes.

Antithrombotic therapy and invasive risk stratification in selected high-risk patients have improved outcomes from non-ST-segment elevation acute coronary syndromes (NSTE-ACS), but carry a risk of bleeding and blood transfusion. Although the true incidence of bleeding depends on the population studied (i.e. clinical trial vs. registry), the definition used, and the use of invasive procedures, it is becoming clear that bleeding is associated with an increased risk for adverse outcomes including myocardial infarction and death. Blood transfusion itself may carry a risk for ischaemic outcomes that is independent of bleeding. Therefore, therapies that provide an adequate level of anticoagulation to reduce ischaemia while simultaneously minimizing the risk of bleeding and transfusion have the potential to improve outcomes among patients with NSTE-ACS. Anticoagulants studied in recent clinical trials that have focused on bleeding reduction include fondaparinux and bivalirudin. In this review, we discuss the clinical trial evidence for these agents, the association between bleeding and clinical outcomes, the biology of blood transfusion and potential mechanisms underlying its association with adverse outcomes, and propose strategies to deal with bleeding complications. Future directions for research and clinical practice are also discussed.