管腔狭窄程度与急性心肌梗死

急性心肌梗死是在易损斑块破裂基础上继发血栓形成并堵塞冠状动脉管腔所致。目前普遍认为导致急性心肌梗死的斑块绝大多数表现为轻、中度管腔狭窄,但近两年来此观点愈来愈受到质疑与挑战。现将近几年关于管腔狭窄严重程度与急性心肌梗死关系的研究进展进行综述。     

Pulmonary Extravascular Fluid Volume and Hypoxaemia in Myocardial Infarction**

Pulmonary extravascular fluid volume (P.E.V.) obtained by a radioisotope technique, arterial blood gases, and veno-arterial shunting were measured within 48 hours of myocardial infarction in 14 patients admitted to a Coronary Care Unit. Six of the 14 patients showed elevated values for PEV. As a group these patients showed greater initial hypoxaemia, greater veno-arterial shunting, and clinical evidence of more severe disease than did those whose P.E.V. was not elevated. Cardiac output, intrathoracic blood volume, anatomical shunting and alveolar atelectasis or airways closure with distal air trapping was not significantly different. Hypoxaemia after myocardial infarction results mainly from veno-arterial shunting. The mechanisms differ from patient to patient, but increased PEV and airways closure are important factors.     

Acute Myocardial Infarction in Pregnancy

Cardiovascular disease, and particularly ischemic heart disease, is a leading cause of maternal morbidity and mortality in high-income countries. The incidence of acute myocardial infarction has been rising over the past 2 decades due to increasing maternal age and a higher prevalence of cardiovascular risk factors in the pregnant population. Causes of acute myocardial infarction in pregnancy are diverse and may require specific considerations for their diagnosis and management. In this narrative review, we provide an overview of physiologic changes, risk factors, and etiologies leading to acute myocardial infarction in pregnancy, as well as diagnostic tools, reperfusion strategies, and pharmacological treatments for this complex condition. In addition, we outline considerations for labor and delivery planning and long-term follow-up of patients with acute myocardial infarction in pregnancy.     

Tachyarrhythmias in Acute Myocardial Infarction

Summary: In 1 505 patients with acute myocardial infarction (Ml) serious ventricular arrhythmias were commoner in those with transmural ECG changes, and were associated with an increase in mortality and in the incidence of left ventricular failure (LVF) as well as higher peak serum lactic dehydrogenase (LDH) levels. Arial fibrillation (AF) occurred more often in older patients and in those with LVF and clinical evidence of pericarditis.     

Pericarditis in Acute Myocardial Infarction

Summary: In 1505 patients with acute myocardial infarction (Ml) pericarditis was diagnosed most often in those with anterior transmural ECG changes. Those with pericarditis had a significantly greater hospital mortality and peak serum lactic dehydrogenase (LDH) levels and a greater incidence of left ventricular failure (LVF).
The patients reported here¹ and our methods of study^{2, 4} have been described.     

Thrombolytic Therapy in Acute Myocardial Infarction

Thrombolytic trials in acute myocardial infarction have progressively increased in size, with the GUSTO study including over 40,000 patients. New thrombolytic drugs are unlikely to lead to further major reductions in fatality, and demonstrating small differences from existing compounds would require even larger trials to establish mortality benefits. New agents may, however, have advantages, such as a greater ease of administration or a reduced cost, and the problem is how to assess such new agents in the most efficient way. The concept of equivalence as a clinical trial endpoint is discussed, and the INJECT study, comparing reteplase and streptokinase in acute myocardial infarction, is described as a prototype equivalence trial.     

Multi-Link Stenting in Acute Myocardial Infarction

ACS Multi-Linka stent is a stainless steel balloon expandable stents composed of 12 rings connected by multiple links giving a great flexibility and radial strength. Multi-Link stenting offers good clinical and angiographic results in patients with unstable and stable angina, but there are few reports about Multi-Link stent placement in acute myocardial infarction (AMI). In this study, the experience of Multi-Link stenting during primary PTCA is described. RESULTS: 38 Multi-Link stents were placed in the culprit vessel in 34 patients with AMI. Mean age was 67 +/- 14 years, 25 (74%) were male, 12 (35%) were in Killip class III or IV and 20 (59%) had multi-vessel disease. All 38 Multi-Link stents (100%) could be successfully delivered. Angiographic success was achieved in 32 patients (94%). After stenting, stenosis decreased from 95 +/- 9% to 9 +/- 5% (p < 0.001) and minimal lumen diameter increased from 0.2 +/- 0.5 to 2.9 +/- 0.5 mm (p < 0.001). One patient (3%) suffered a subacute thrombosis requiring a new PTCA, but no patient needed surgical revascularization. Seven patients (20.6%; 95% CI: 8.7D37.9%) died during hospitalization, 6 of whom were in cardiogenic shock at admission. Mortality in patients with and without cardiogenic shock at admission was 85.7% (95% CI: 42.1D99.6%) and 3.7% (95% CI: 0.1%D20.0%) respectively (p < 0.001). CONCLUSION: The Multi-Link stent offers good angiographic results in patients with AMI. The in-hospital mortality in patients without cardiogenic shock at admission is low.     

Acute Myocardial Infarction in Diabetic Patients

ABSTRACT. All patients hospitalized during a 3-year period with an acute myocardial infarction were followed for the occurrence of reinfarction or death. The patients with diabetes mellitus (n=95) were compared with the non-diabetic population (n=545). The diabetics had a higher mortality rate (relative death rate of 1.44 vs. 0.93, p<0.01) and a higher frequency of reinfarctions (18.9 vs. 10.8%, p=0.04) than the non-diabetic population. A larger proportion of the diabetics had suffered a previous infarction, but the excess mortality was also present in those without a previous infarction. Established risk factors for death after myocardial infarction, such as age, infarct size, infarct localization and heart size, could not account for the difference in mortality. It is suggested that the increased mortality among the diabetics may be due to an increase in the rate of progression of the atherosclerotic heart disease.     

Analgetic Treatment in Acute Myocardial Infarction

ABSTRACT In a randomized double-blind study with flexible dosage, morphine, nicomorphine and pethidine were compared with regard to analgetic effect, dose requirements, dose intervals and adverse reactions. A total of 275 patients were included, and 28 patients were excluded due to adverse reactions (n= 16) and for practical reasons, etc. Acute myocardial infarction (AMI) was diagnosed in about 60% of the patients, and about 30% had ischemic heart disease without AMI. All three analgesics provided equally efficient pain relief in relative doses of morphine 10, nicomorphine 10 and pethidine 75 mg/ml. Severe adverse reactions were few (allergy 3 cases, respiratory insufficiency 4, severe bradycardia 4), whereas nausea was recorded in 20–30%, vomiting in 5–15% and dizziness in 10–30% of the patients, with no difference between the three drugs. Significant blood pressure drop (>30 mmHg) was seen in 3–8% of the patients, with no significant differences between the drugs.     

急性心肌梗死与反应性高血糖

在急性心肌梗死患者中,合并反应性高血糖即应激性高血糖是非常普遍的,其显著增加住院期间患者死亡率。产生反应性高血糖的主要原因是激素调节异常和细胞因子的大量分泌以及胰岛素抵抗。高血糖主要是通过能量供需矛盾、纤溶失活、氧化应激及内皮功能失衡等机理影响患者近期预后,因此,一些研究提示反应性高血糖可作为急性心肌梗死患者近期预后不良的敏感、简便、直观的预测因子：现就近年来急性心肌梗死合并反应性高血糖的研究进展作一综述。     

Acute Revascularization in ST-Segment-Elevation Myocardial Infarction

We briefly and comprehensively present some of the novel findings in the field of revascularization therapy and management of ST-segment-elevation myocardial infarction (STEMI). We highlight the latest evidence-based advancements in the pharmacological and mechanical treatment of patients who presented with STEMI. Since the last updates to the international guidelines (American College of Cardiology/American Heart Association and the European Society of Cardiology) were published in 2011 and 2012, there have been changes and several important studies have presented their final outcomes. We also highlight some controversial approaches as part of the current debates in the cardiology community. In addition, we share our recent experience in the field of biodegradable scaffold stents as a treatment strategy in STEMI.     

Treatment of Acute Myocardial Infarction

Persons 75 years of age or older constitute 6.1% of the US population but account for 36% of acute myocardial infarctions (MI) and 60% of deaths. Unfortunately, despite the fact that patients over age 75 represent a large subgroup with an exceptionally high case-fatality rate, most randomized clinical trials have enrolled few patients in this group. As a result, therapeutic recommendations for managing acute MI in the very elderly are often extrapolated from studies conducted in younger patients. This article reviews current evidence-based guidelines for early treatment of acute MI in the elderly. As in younger patients, aspirin, β blockers, and angiotensin-converting enzyme inhibitors should be considered standard therapy in appropriately selected elderly patients. Although the benefits of reperfusion therapy (i.e., thrombolysis and primary angioplasty) are less well established, advanced age per se should not be considered a contraindication to the use of these interventions. Given the relative paucity of data in the very elderly, additional studies are needed to define optimal pharmacologic and nonpharmacologic treatment of acute MI in this rapidly growing, high-risk population.     

急性心肌梗死与高血糖

无论有无糖尿病病史,急性心肌梗死患者常伴有高血糖。急性血糖升高可对心血管造成许多有害影响,并可加重患者的不良转归。强化高血糖控制措施可改善急性心肌梗死患者的预后。因此,提高对急性心肌梗死与高血糖之间相关关系、产生机制及其防治的认识,具有重要的意义。     

Heparin After Acute Myocardial Infarction

Heparin is commonly, but by no means universally, used after acute myocardial infarction. When used the dose, route of administration, and duration of therapy varies considerably. The role of heparin is reviewed with particular reference to its use in conjunction with other commonly used therapies, such as aspirin and thrombolytic agents. Intravenous heparin after thrombolytic therapy remains untested in patients treated with aspirin. When used, benefit is seen in a narrow aPTT range, and there have been unexpected increases in mortality in patients with the greatest heparin effect. The addition of delayed subcutaneous heparin to aspirin and thrombolytic therapy does not provide a mortality benefit. In patients not treated with thrombolysis, there is no clear evidence that heparin confers significant mortality benefit if patients are treated with aspirin. Heparin therapy may reduce the incidence of intraventricular thrombus after anterior wall infarction, but there is no clear evidence that it reduces the clinically important sequelae of cerebral embolism and stroke. Given concerns about increased hemorrhagic rates with heparin and unknown benefit, it is reasonable to conclude that its role in the management of patients with acute myocardial infarction remains unclear.