Comparison of one-year outcomes of percutaneous coronary intervention versus coronary artery bypass grafting in patients with unprotected left main coronary artery disease and acute coronary syndromes (from the CUSTOMIZE Registry)

Uncertainty surrounds the optimal revascularization strategy for patients with left main coronary artery disease presenting with acute coronary syndromes (ACSs), and adequately sized specific comparisons of percutaneous and surgical revascularization in this scenario are lacking. The aim of this study was to evaluate the incidence of 1-year major adverse cardiac events (MACEs) in patients with left main coronary artery disease and ACS treated with percutaneous coronary intervention (PCI) and drug-eluting stent implantation or coronary artery bypass grafting (CABG). A total of 583 patients were included. At 1 year, MACEs were significantly higher in patients treated with PCI (n = 222) compared to those treated with CABG (n = 361, 14.4% vs 5.3%, p <0.001), driven by a higher rate of target lesion revascularization (8.1% vs 1.7%, p = 0.001). This finding was consistent after statistical adjustment for MACEs (adjusted hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.2 to 5.9, p = 0.01) and target lesion revascularization (adjusted HR 8.0, 95% CI 2.2 to 28.7, p = 0.001). No statistically significant differences between PCI and CABG were noted for death (adjusted HR 1.1, 95% CI 0.4 to 3.0, p = 0.81) and myocardial infarction (adjusted HR 4.8, 95% CI 0.3 to 68.6, p = 0.25). No interaction between clinical presentation (ST-segment elevation myocardial infarction or unstable angina/non-ST-segment elevation myocardial infarction) and treatment (PCI or CABG) was observed (p for interaction = 0.68). In conclusion, in patients with left main coronary artery disease and ACS, PCI is associated with similar safety compared to CABG but higher risk of MACEs driven by increased risk of repeat revascularization.     

直接PCI术前QRS波宽度与术后心肌再灌注不良的相关性

目的 探讨直接PCI术前QRS波宽度与术后心肌再灌注不良的关系.方法 168例急性ST段抬高型心肌梗死患者行直接PCI,根据术后梗死相关动脉TIMI血流分级分为心肌再灌注良好组(TIMI 3级,A组,n=149)和心肌再灌注不良组(TIMI<3级,B组,n=19),以50mm/s的走纸速度并以相同的导联位置记录术前、术后即刻、术后1h 12导联同步体表心电图,计算梗死相关导联QRS宽度均值,对二组间临床及心电图特征的差异进行统计学检验.结果 与A组相比,B组患者术前QRS波总体较宽(93.7±2.8mm Vs 90.9±3.4mm,P<0.001),术后QRS波缩窄量明显较少(3.2±1.9mm Vs 9.1±3.7mm,P<0.001);Logistic回归分析显示:直接PCI术前QRS宽度与术后心肌再灌注不良的发生独立相关.结论 直接PCI术前QRS波宽度可能有助于预测术后心肌再灌注不良的发生.     

血糖对直接经皮冠状动脉介入治疗后患者心肌灌注的影响

目的观察血糖升高对急性心肌梗死(AMI)患者经皮冠状动脉介入治疗(PCI)后的预后和心肌灌注影响。方法选取接受直接PCI治疗的急性ST段抬高心肌梗死患者308例,根据入院第一次随机血糖分为3组,1组<7.8MMOL/L,2组7.8～11.0MMOL/L,3组≥11.0MMOL/L。1组为血糖正常组,2、3组为血糖升高组。结果入院随机血糖高的患者,女性所占比例较高(19.2%比31.4%、37.9%,P<0.05),平均年龄较大[(58.5±11.3)岁比(61.6±11.2)岁、(63.6±11.2)岁,P<0.05)]。3组与1组相比血甘油三酯[(1.53±0.77)MMOL/L比(1.30±0.67)MMOL/L,P<0.05]浓度较高。冠状动脉造影结果中,2、3组多支血管病变较多(53.8%比72.1%、69.7%,P<005)。PCI术后梗死相关血管TIMI血流分级(TFG)3级,三组差异无统计学意义(89.7%、86.0%和86.3%,P>0.05)。血糖升高的两组,PCI术后梗死相关血管的校正TIMI帧计数(CTFC)数值高于第1组[(28.4±18.3)和(27.1±17.2)比(22.3±12.8),P<0.05],TIMI心肌灌注分级(TMPG)0～1级(30.3%和29.0%比17.3%,P<0.05)多见。PCI术后心电图分析:3组1HST段回落≥50%及3HT波倒置较1组少(56.7%比72.0%,58.3%比73.4%,P<0.05)。左室射血分数在2、3组患者明显降低[(54.9±10.0)和(54.8±10.0)比(57.9±9.0),P<0.05]。血糖≥11.0MMOL/L组30D内病死率高于血糖正常组(10.4%比2.6%,P<0.05)。结论入院随机血糖升高的急性ST段抬高心肌梗死患者,进行直接介入治疗后的心肌灌注较差,进而影响心功能,增加患者30D内病死率。     

The impact of GP IIb/IIIa inhibitors during primary percutaneous coronary intervention in acute myocardial infarction patients

The use of glycoprotein (GP) IIb/IIIa inhibitors during percutaneous coronary interventions (PCI) in the acute phase of myocardial infarction (AMI) is still a matter of debate. The aim of the present study was to compare the outcomes of patients with acute ST-segment elevation myocardial infarction who underwent primary PCI and were concomitantly treated with GP IIb/IIIa inhibitors with those who were not treated with these drugs. Between January 1996 and November 2003, a total of 418 consecutive patients underwent PCI in the setting of ST-segment elevation AMI. At the operator's discretion, 287 patients were concomitantly treated with GP IIb/IIIa inhibitors and 115 patients were not. Angiographic success and final TIMI 3 flow in the infarct-related artery was achieved more frequently in patients treated with GP IIb/IIIa inhibitors (90% vs. 77%; p=0.001). The in-hospital composite endpoint of death, reinfarction and bleeding complications was significantly better in patients treated with GP IIb/IIIa inhibitors (4% vs. 12%; p=0.005). Furthermore, the adjusted 12-month survival rate was significantly better in these patients (RR: 2.99, CI: 1.29-6.9; p=0.01). Therefore, adjunctive therapy with GP IIbIIIa inhibitors during primary PCI is associated with improved short-term outcomes and one-year survival without an increased risk of bleeding.     

血栓抽吸治疗在急性ST段抬高心肌梗死直接介入治疗中应用的安全性和有效性研究

目的:评价血栓抽吸治疗在急性ST段抬高心肌梗死(STEMI)直接经皮冠状动脉介入治疗术(PCI)中应用的安全性和有效性.方法:59例STEMI患者被随机分为血栓抽吸组和传统PCI组(对照组),对2组之间的冠状动脉造影结果(TIMI 3级血流率、校正TIMI帧数、TMP分级)、心电图ST段回落百分比(sumSTR)和临床结果[肌酸激酶(CK)和肌酸激酶同工酶(CK-MB)峰值、术后1周左室射血分数(LVEF)、6个月主要不良心血管事件]进行分析比较.结果:血栓抽吸组PCI后梗死相关动脉TIMI 3级血流率、TMP3级及sumSTR>70%发生率均显著高于对照组,校正TIMI帧数、TMP0～1级及sumSTR<30%均显著低于对照组.血栓抽吸组CK、CK-MB峰值显著低于对照组 ,术后1周LVEF显著高于对照组.随访6个月主要不良心血管事件2组差异无统计学意义.结论:在急性STEMI直接PCI中应用血栓抽吸治疗是安全有效的,能够改善心肌灌注,降低心肌梗死面积,提高LVEF.     

Heterogeneity of the No-Reflow Group After Primary Percutaneous Coronary Intervention Due to ST-Segment Elevation Myocardial Infarction - Are There Sex Differences?

AimsAssessment of the diversity in the no-reflow population after primary percutaneous coronary intervention (pPCI) due to ST-segment elevation myocardial infarction (STEMI). Are there any gender-related differences?Material and methodsAnalysis of 1063 STEMI patients with Thrombolysis in Myocardial Infarction (TIMI) grade 0 or 1 following pPCI. The study group consisted of 685 patients with TIMI grade 0 and of 378 patients with TIMI grade 1. We analyzed clinical characteristics, in-hospital mortality and 2-year follow-up in both groups.ResultsAmong women with the TIMI grade 1 an atrial fibrillation, tachycardia and impaired ejection fraction were more common than in men. The vessel responsible for myocardial infarction was most commonly the left anterior descending (LAD) in women, whereas the right coronary artery (RCA) in men. These differences were not observed in group with TIMI grade 0. We observed a higher incidence of in-hospital death in the population with TIMI grade 0 compared with TIMI grade 1 (21.9% vs 17.2%; p 0.0189). In the TIMI grade 1 group there was significantly higher incidence of in-hospital mortality in women compared to men (13.2% vs 22.7%; p 0,0159). Among women with postprocedural TIMI grade 0 in all periods of long-term follow-up the mortality was significantly higher compared to men (9.5% vs 17%; p 0,0111; 11.8% vs 19.7%; p 0.0139 and 16.7% vs 23.9%; p 0.043 for 6-,12-months and 2-years of follow up respectively).ConclusionsPatients with no-reflow phenomenon in infarct related artery after pPCI constitute a more diverse group than previously thought. Some differences are most likely gender-specific. The female sex might have an adverse effect on in-hospital mortality in case of TIMI grade 1 and on the long-term prognosis among patients with TIMI grade 0.     

Multivessel percutaneous coronary intervention in Chinese patients with acute myocardial infarction and simple nonculprit arteries

BACKGROUND: Multivessel percutaneous coronary intervention (PCI) for patients during acute myocardial infarction (AMI) is currently controversial. In this study, we investigated the significance of multivessel PCI in Chinese patients with ST-segment elevation AMI and relatively simple lesions in nonculprit arteries. METHODS: We reviewed all consecutive primary PCI of ST-segment elevation AMI in our hospital between 2002 and 2005. The patients with multivessel disease and ACC/AHA type A/B1 lesions in nonculprit arteries who underwent multivessel PCI were identified (n = 105, multivessel PCI group), and 120 patients with single-vessel disease and treatment with primary PCI were enrolled as control subjects (single-vessel PCI group). The primary end points were the occurrences of 6-month major adverse cardiac events (cardiogenic death, nonfatal reinfarction, and target vessel revascularization). The secondary end points included procedure time, angiographic success rate, TIMI grade, reperfusion arrhythmia, ST-segment resolution, and left ventricular ejection fraction. RESULTS: All patients with multivessel PCI tolerated the operations well and had similar TIMI 3 and angiographic success rates but longer procedure times than those patients with single-vessel PCI. There were no significant differences in reperfusion arrhythmia, ST-segment resolution, left ventricular ejection fraction, or 6-month MACEs between both groups. CONCLUSIONS: This study suggests that multivessel PCI is effective and safe for Chinese patients with ST-segment elevation AMI and simple lesions in nonculprit arteries.     

Hyperglycemia is an important predictor of impaired coronary flow before reperfusion therapy in ST-segment elevation myocardial infarction

OBJECTIVES: This study was designed to investigate whether elevated glucose is associated with impaired Thrombolysis In Myocardial Infarction (TIMI) flow before primary percutaneous coronary intervention (PCI). BACKGROUND: Reperfusion before primary PCI in patients with ST-segment elevation myocardial infarction (STEMI) is associated with an improved outcome. Hyperglycemia in patients with STEMI is associated with an adverse prognosis. Hyperglycemia may induce a pro-thrombotic state and therefore be of influence on TIMI flow before PCI. METHODS: A total of 460 consecutive patients with STEMI treated with primary PCI were included in this analysis. Hyperglycemia was defined as a glucose > or =7.8 mmol/l (140 mg/dl). RESULTS: Hyperglycemia was observed in 70% and TIMI flow grade 3 before primary PCI in 17% of the patients. Patients with hyperglycemia less often had TIMI flow grade 3 before primary PCI (12% vs. 28%, p < 0.001). After adjustment for differences in baseline variables, hyperglycemia was a strong predictor of absence of reperfusion before primary PCI (odds ratio 2.6, 95% confidence interval 1.5 to 4.5). CONCLUSIONS: Hyperglycemia in patients with STEMI is an important predictor of impaired epicardial flow before reperfusion therapy has been initiated. Investigation of methods improving coronary flow before primary PCI in these patients is warranted.     

Rheolytic thrombectomy with percutaneous coronary intervention for infarct size reduction in acute myocardial infarction: 30-day results from a multicenter randomized study.

OBJECTIVES: The goal of this work was to determine whether rheolytic thrombectomy (RT) as an adjunct to primary percutaneous coronary intervention (PCI) reduces infarction size and improves myocardial perfusion during treatment of ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Primary PCI for STEMI achieves brisk epicardial flow in most patients, but myocardial perfusion often remains suboptimal. Distal embolization of thrombus during treatment may be a contributing factor. METHODS: This prospective, multicenter trial enrolled 480 patients presenting within 12 h of symptom onset and randomized to treatment with RT as an adjunct to PCI (n = 240) or to PCI alone (n = 240). Visible thrombus was not required. The primary end point was infarct size measured by sestamibi imaging at 14 to 28 days. Secondary end points included final Thrombolysis In Myocardial Infarction (TIMI) flow grade, tissue myocardial perfusion (TMP) blush, ST-segment resolution, and major adverse cardiac events (MACE), defined as the occurrence of death, new Q-wave myocardial infarction, emergent coronary artery bypass grafting, target lesion revascularization, stroke, or stent thrombosis at 30 days. RESULTS: Final infarct size was higher in the adjunct RT group compared with PCI alone (9.8 +/- 10.9% vs. 12.5 +/- 12.13%; p = 0.03). Final TIMI flow grade 3 was lower in the adjunct RT group (91.8% vs. 97.0% in the PCI alone group; p < 0.02), although fewer patients had baseline TIMI flow grade 3 in the adjunct RT group (44% vs. 63% in the PCI alone group; p < 0.05). There were no significant differences in TMP blush scores or ST-segment resolution. Thirty-day MACE was higher in the adjunct RT group (6.7% vs. 1.7% in the PCI alone group; p = 0.01), a difference primarily driven by very low mortality rate in patients treated with PCI alone (0.8% vs. 4.6% in patients treated with adjunct RT; p = 0.02). CONCLUSIONS: Despite effective thrombus removal, RT with primary PCI did not reduce infarct size or improve TIMI flow grade, TMP blush, ST-segment resolution, or 30-day MACE.     

SYNTAX评分预测急性ST段抬高型心肌梗死介入后无复流

目的：评价急性ST段抬高型心肌梗死（ST segment elevation myocardial infarction,STEMI）患者诊断性冠状动脉造影获得的SYNTAX评分,与经皮冠状动脉介入治疗（percutaneous coronary intervention,PCI）后无复流现象的相关性。方法：入选在发病后12h内行PCI治疗的397例STEMI患者,进行回顾性分析。根据单纯冠状动脉病变心脏外科与介入治疗狭窄冠状动脉研究（Synergy between percutaneous coronary intervention with TAXUS and cardiac surgery,SYNTAX）评分的中位数,将患者分为高分组和低分组。将冠状动脉造影结果作为无复流的判断标准。采用多元Logistic回归分析,评价SYNTAX评分与急诊PCI后无复流现象的的相关性。结果：PCI术后发生无复流现象的患者共79例（19.9%）,其中SYNTAX评分高分组无复流发生率显著高于低分组。多元Logistic回归分析显示,年龄≥55岁（OR=2.46,95%CI=1.72～3.41;P〈0.001）、入院前服用β阻滞剂（OR=0.62,95%CI=0.41～0.92;P=0.021）、术前Killip分级（4级,OR=3.78,95%CI=2.14～6.48;P〈0.001）、再灌注时间（≥2h,OR=1.37,95%CI=1.02～1.79;P=0.036）、及SYNTAX评分≥15.75（OR=1.16,95%CI=1.01～2.45;P〈0.001）是直接PCI术无复流现象的独立预测因素。结论：STEMI患者急诊PCI前通过冠状动脉造影获得的SYNTAX评分对于预测STEMI患者PCI后无复流现象并进行危险分层具有一定参考价值。     

冠脉内小剂量替罗非班在急性STEMI急诊介入时应用观察

目的:探讨急性ST段抬高型心肌梗死(STEMI)患者行急诊经皮冠状动脉介入治疗(PCI)时冠脉内小剂量应用替罗非班对介入治疗安全性和有效性。方法:入选77例STEMI急诊介入治疗患者,全部患者入院后立即给予阿司匹林300 mg嚼服,氯吡格雷300 mg口服,随机分为替罗非班组(试药组,39例)和对照组(38例,未用替罗非班)。PCI术后梗死相关血管的心肌梗死溶栓(TIMI)血流分级、术后24 h ST段完全回落率、术后1周左心室射血分数(LVEF)、术后30 d主要心血管事件(死亡、再发心肌梗死、靶血管血运重建、反复心绞痛发作)及TIMI出血事件作为评价指标。结果:术前两组患者基线资料(年龄、性别、危险因素)差异无统计学意义。术后即刻TIMIⅢ级血流获得率试药组明显高于对照组(P0.05)。术后24h ST段完全回落率及1周时LVEF试药组明显高于对照组(均P0.05,P0.01)。术后30 d随访两组主要心血管事件和主要出血事件的发生率差异均无统计学意义。结论:对急性STEMI患者急诊介入治疗时,冠脉内应用小剂量替罗非班可以获得较好的即刻造影结果,且安全、有效。     

急性心肌梗死患者经皮冠状动脉介入治疗术后ST段回落不良的分析

目的探讨ST段抬高急性心肌梗死(AMI)患者直接PCI术后ST段回落不良的相关因素。方法173例符合ST段抬高AMI诊断并行直接PCI的患者,计算其心电图ST段回落指数,运用logistic回归分析影响ST段回落的相关因素。结果冠状动脉造影心肌呈色分级0/1(OR=2.936)、病变部位(OR=2.121)、胸痛开始到再灌注的时间(OR=1.314)、梗死前心绞痛(OR=1.053)是影响术后心电图ST段恢复的相关因素。结论AMI直接PCI术后心电图ST段恢复程度与上述因素有关。     

大剂量替罗非班对急性ST段抬高型心肌梗死患者急诊介入治疗短期疗效及安全性研究

目的探讨急性ST段抬高型心肌梗死(STEMI)患者行急诊经皮冠状动脉介入治疗(PCI)时,早期应用大剂量替罗非班对介入治疗疗效的影响。方法入选116例STEMI急诊介入治疗的患者,所有患者均于冠状动脉造影前给予阿司匹林300 mg、氯吡格雷600 mg,按随机数字法分为大剂量替罗非班组(A组25μg/kg,负荷剂量静脉推注)39例,常规剂量组(B组10μg/kg,负荷剂量静脉推注)39例,替罗非班负荷剂量均于3 min内静脉推注,继之0.15μg·kg~(-1)·min~(-1)静脉维持泵入36 h。对照组(C组)38例。PCI术后梗死相关血管的心肌梗死溶栓(TIMI)血流分级、TIMI心肌灌注分级(TMPG)、术后即刻和24 h ST段完全回落率、术后1周左右(5～7 d)的左心室射血分数(LVEF)、术后1个月的主要心血管事件(死亡、再发心肌梗死、靶血管血运重建、反复心绞痛发作)及TIMI出血事件作为评价指标。结果术前3组患者基线资料(年龄、性别构成、危险因素、心功能Killip分级、治疗时间段、住院天数等)差异无统计学意义,具有可比性。术后即刻TIMI 3级血流获得率A组(97.4%)和B组(89.7%)高于C组(76.3%),差异有统计学意义(均为P<0.05),但A、B组相比差异无统计学意义(P>0.05)。PCI术后3组的TMPG 3级率相比差异有统计学意义(A组:82.1%,B组:69.2%,C组:47.4%,P<0.01)。术后24 h ST段完全回落率及1周左右的LVEF,A组显著高于C组(64.1%比42.2%,61%±9%比55%±9%,P<0.05)。术后1个月随访,3组在主要心血管事件的发生率上差异无统计学意义(P>0.05),仅A组术后1个月反复心绞痛的发作率明显低于C组(2.6%比13.2%,P=0.04)。3组在主要出血事件的发生率上差异无统计学意义(均为P>0.05)。结论对于急性STEMI患者,早期应用大剂量替罗非班可以获得更好的即刻造影结果,且并未明显增加主要出血事件的发生率,可提高临床预后。     

D-二聚体联合CHA2DS2-VASc评分对老年急性心肌梗死患者介入术后无复流的预测价值

目的探讨血浆D-二聚体水平联合CHA2DS2-VASc评分对老年急性ST段抬高型心肌梗死(STEMI)患者PCI术后无复流的预测价值。方法选择2018年1月~2019年8月大连市友谊医院心内科接受直接PCI的老年STEMI患者117例,根据TIMI血流和心肌呈色分级分为复流组92例,无复流组25例。又根据D-二聚体水平分为高D-二聚体组75例(D-二聚体>1.01 mg/L),低D-二聚体组42例(D-二聚体≤1.01 mg/L)。比较复流组和无复流组血浆D-二聚体水平及CHA2DS2-VASc评分,分析两者对无复流现象的预测价值。结果无复流组D-二聚体及CHA2DS2-VASc评分明显高于复流组(1.72 mg/L vs 0.48 mg/L,P=0.001;4.00分vs 3.00分,P=0.002)。ROC曲线分析显示,D-二聚体联合CHA2DS2-VASc评分预测无复流的曲线下面积为0.777(95%CI:0.683~0.870,P=0.001),较两者单独预测无复流效果更好。高D-二聚体组血栓抽吸和无复流比例明显高于低D-二聚体组,差异有统计学意义(P<0.05,P<0.01)。多元logistic回归分析显示,血浆D-二聚体及CHA2DS2-VASc评分是无复流的独立预测因素(P<0.05,P<0.01)。结论血浆D-二聚体水平联合CHA2DS2-VASc评分预测无复流现象较单用D-二聚体水平或CHA2DS2-VASc评分更敏感。     

血栓抽吸联合替罗非班对急性ST段抬高心肌梗死患者心肌再灌注的影响

目的 探讨急性ST段抬高心肌梗死急诊经皮冠状动脉介入治疗（PCI）中联合应用ZEEK血栓抽吸导管和替罗非班对心肌组织灌注及临床预后的影响.方法 84例经冠脉造影证实为血栓负荷病变的急性ST段抬高心肌梗死患者随机分为血栓抽吸＋替罗非班42例（A组）和标准PCI 42例（B组）,比较两组患者手术后即刻梗死相关动脉（IRA）的心肌梗死溶栓（TIMI）血流、心肌灌注分级（MBG）、心电图ST段回落百分比、左心室射血分数（LVEF）及住院期间主要心脏不良事件（MACE）和出血性并发症发生率.结果 A组术后即刻TIMI血流、MBG、ST段抬高回落百分比及LVEF均明显优于B组（P〈0.05）,两组住院期间的MACE发生率及出血并发症比较差异无统计学意义（P〉0.05）.结论 在急性心肌梗死急诊PCI中联合使用ZEEK导管血栓抽吸和替罗非班安全可行,可有效清除冠状动脉内血栓,改善心肌组织灌注和术后心脏功能,并且不增加主要心脏不良事件的发生率.     

替罗非班和急诊介入治疗富含血栓病变的心肌梗死

目的 观察国产血小板糖蛋白Ⅱb/Ⅲa受体拮抗药替罗非班对富含血栓病变的急性心肌梗死患者行急诊经皮冠状动脉介入术(primary percutaneous coronary intervention,pPCI)的疗效.方法 2004年1月～2006年10月,我院确诊急性ST段抬高型心肌梗死并接受pPCI 92例,急诊冠状动脉造影特征为梗死相关血管富含血栓病变,比较使用替罗非班组和对照组患者pPCI后靶血管心肌梗死溶栓治疗临床试验血流(thrombolysis in myocardial infarction,TIMI)3级例数,校正TIMI帧数(corrected TIMI Frame Count,CTFC),术后2 h抬高的ST段回落程度,心肌型肌酸激酶同工酶(MB isoenzyme of creatine kinase,CK-MB)峰值及峰值时间,无复流或慢血流现象发生率、住院期间及术后6个月主要心血管事件发生率.结果 两组患者一般临床基线特征差异无统计学意义.pPCI后梗死相关血管的TIMI 3级血流率差异未见统计学意义,但替罗非班组在反映心肌灌注水平的指标包括CTFC、术后2 h ST段回落率、CK-MB峰值及酶峰值时间均优于对照组,无复流及慢血流发生率及住院期间主要心血管事件发生率低于对照组,但住院期间出血并发症发生率则高于对照组.结论 对于富含血栓病变的急性心肌梗死患者pPCI再灌注治疗中联合应用替罗非班能减少无复流及慢血流现象的发生,并明显改善急性ST段抬高型心肌梗死患者的心肌灌注,降低住院期间主要心血管事件发生率.     

Comparison of myocardial reperfusion in patients undergoing percutaneous coronary intervention in ST-segment elevation acute myocardial infarction with versus without diabetes mellitus (from the EMERALD Trial)

Diabetes mellitus is strongly associated with increased cardiovascular morbidity and mortality in patients with ST-segment elevation myocardial infarction. It is unknown whether myocardial perfusion is decreased in diabetic compared with nondiabetic patients after primary percutaneous coronary intervention (PCI), which may contribute to their worse prognosis. We compared myocardial perfusion and infarct sizes between diabetic and nondiabetic patients undergoing PCI for acute ST-segment elevation myocardial infarction in the EMERALD trial. EMERALD was a prospective, randomized, multicenter study evaluating distal embolic protection during primary PCI in ST-segment elevation myocardial infarction. End points included final myocardial blush grade, complete ST-segment resolution (STR) 30 minutes after PCI, and final infarct size as determined by technetium-99m single proton emission computed tomography measured between days 5 and 14. Of 501 patients, 62 (12%) had diabetes mellitus. Diabetic patients had impaired myocardial perfusion after PCI as measured by myocardial blush grade 0/1 (34% vs 16%, p = 0.002) and lower rates of complete 30-minute STR (45% vs 65%, p = 0.005). Infarct size (median 20% vs 11%, p = 0.005), development of new onset severe congestive heart failure (12% vs 4%, p = 0.016), and 30-day mortality (10% vs 1%, p <0.0001) were also greater in diabetic patients. After multivariate adjustment, diabetes remained associated with lack of complete STR and mortality at 6 months. Use of distal protection devices did not improve outcomes in diabetic or nondiabetic patients. In conclusion, in patients with ST-segment elevation myocardial infarction undergoing primary PCI, diabetes is independently associated with decreased myocardial reperfusion, larger infarct, development of congestive heart failure, and decreased survival.     

Markers of myocardial reperfusion as predictors of left ventricular function recovery in acute myocardial infarction treated with primary angioplasty

BACKGROUND: Myocardial blush grade (MBG), corrected TIMI frame count (cTFC), and ST-segment reduction are indices of myocardial reperfusion. HYPOTHESIS: We evaluated their predictive value for left ventricular (LV) function recovery by gated single-photon emission computed tomography (SPECT) after acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI). METHODS: In 40 patients with AMI, gated SPECT was performed at admission and repeated 7 and 30 days after PCI. Left ventricular function recovery was defined as an increase > or = 10 points in SPECT LV ejection fraction from baseline to 1 month. The MBG, cTFC, and ST-segment elevation index 1 h after PCI were determined to evaluate reperfusion. RESULTS: Twenty-four patients (Group 1) had LV function recovery and 16 (Group 2) did not. A significant correlation was found between LV function recovery and MBG (r = 0.66; p = 0.0001), and ST-segment elevation index at 1 h (r = -0.55; p = 0.0001), but not with cTFC. Univariate predictors of LV function recovery were MBG (p = 0.0003) and ST-segment elevation index 1 h after intervention (p = 0.0026), but not cTFC. In a multivariate analysis, MBG was the only predictor of LV function recovery. Myocardial blush grade > or = 2 and ST-segment elevation index reduction had the same accuracy (88%) for predicting LV function recovery. Lower accuracy (75%) was shown by fast cTFC (< 23 frames). Myocardial blush grade > or = 2 showed the better negative likelihood ratio, and ST-segment elevation index reduction had the higher positive likelihood ratio in predicting LV function recovery. CONCLUSIONS: Myocardial blush grade was the best parameter for prediction of LV function recovery: MBG > or = 2 and ST-segment elevation index reduction showed good accuracy in predicting LV function recovery. The cTFC failed to be a significant predictor.     

The relationship of coronary flow to neutrophil/lymphocyte ratio in patients undergoing primary percutaneous coronary intervention

Purpose

It has been known that inflammatory mechanisms play an important role in the coronary artery disease. Our aim in this study was to investigate the relationship between the neutrophil/lymphocyte (N/L) ratio and coronary flow velocity after primary percutaneous coronary intervention (PCI) in patients presenting with ST-segment elevation myocardial infarction (STEMI).

Methods

Two hundred and ten patients who had undergone primary PCI were included. The coronary flow velocities were evaluated using the recorded PCI procedures by Thrombolysis in Myocardial Infarction (TIMI) flow grades and corrected TIMI frame counts (cTFC) values. A value of >40 for the final cTFC was accepted as an index of insufficient coronary blood flow. The white blood cell subtypes and counts were determined in the blood samples obtained at the clinics.

Results

In 165 (78%) of the investigated patients, reperfusion was found to be sufficient (Group I) while in 45 (22%) of them (Group II) insufficient reperfusion was observed (Group II). In-hospital mortality was 7.2% (n=12) in Group I, whereas it was 17.7% (n=8) in Group II (P=0.033). Similarly, one-year mortality was higher in Group II (26.6%, n=12) than in Group I (13.3%, n=22) (P=0.031). N/L ratio was determined to be higher in Group I than in Group II (8.3±6.1 vs. 6.2±5.0; P=0.034). Also, N/L ratio was found as an independent predictor of severe no-reflow development (TIMI 0-1) and of one-year mortality (P=0.01 and P=0.047, respectively).

Conclusions

N/L ratio has been found to be an independent indicator for no-reflow development in patients who have undergone PCI for acute STEMI. This simple and low-cost parameter can provide useful information for the relevant risk evaluation in these patients.KEY WORDS : Inflammation, acute ST-segment elevation myocardial infarction (acute STEMI), neutrophil/lymphocyte ratio (N/L ratio)     

Clinical features of early myocardial rupture of acute myocardial infarction

We assessed the clinical features of patients with myocardial rupture within 48 to 72 hours, defined as early myocardial rupture, after percutaneous coronary intervention (PCI) for ST-segment elevation acute myocardial infarction (STEMI). Six patients (4 men, 66 ± 13 years) with early myocardial rupture were identified from 1252 consecutive patients undergoing PCI for STEMI. We evaluated the degree of microvascular reperfusion using thrombolysis in myocardial infarction (TIMI) myocardial perfusion (TMP) grade and a resolution of sum of ST-segment elevation in a 12-lead electrocardiogram (ECG). Time from PCI to myocardial rupture was 11 ± 7 hours. All patients showed TMP grade 0 or 1 and an increase in sum of ST-segment elevation after PCI (1.9 ± 0.5 vs 2.5 ± 0.7 mV; P = .032), suggesting severely failed reperfusion at the level of microcirculation as the common feature to develop early myocardial rupture after PCI for STEMI.