The impact of anthropomorphic indices on clinical outcomes in patients with acute ST-elevation myocardial infarction.

AIMS: Multiple studies have focused on the relationship of body anthropometric measures with clinical events in ST-elevation myocardial infarction (STEMI) patients, highlighting the 'obesity paradox'. However, the relative prognostic importance of these measures over other baseline variables is less known. METHOD AND RESULTS: We performed a retrospective analysis of 94,108 STEMI patients from seven clinical trials evaluating various reperfusion strategies to study the relationship and prognostic importance of height, weight, body mass index (BMI), and body surface area (BSA) with 30-day death and in-hospital cardiogenic shock, major bleeding, and stroke. Main outcome measures of interest included 30-day death and in-hospital cardiogenic shock, major bleeding, and stroke. Weight, BMI, and BSA were inversely and independently related to all clinical events. Despite being statistically significant (P<0.0001), the prognostic information contributed by weight beyond that conferred by baseline clinical factors was minimal (<1% of total prognostic information) making it of limited clinical relevance for predicting 30-day death and cardiogenic shock. In contrast, weight accounted for 8.4% and 4.3% of the prognostic information in the logistic regression models for major bleeding and for stroke. BMI or BSA added little incremental value over simple measure of weight. CONCLUSION: Although statistically significantly related to most outcomes in patients with STEMI including death and shock, body weight provided clinically relevant prognostic information only for the risk of major bleeding and of stroke. Furthermore, BMI or BSA contributed little incremental prognostic information beyond that provided by weight alone. Thus, the existing large body of information concerning the strong prognostic importance of anthropometric measures with outcomes after STEMI should be interpreted in the context of other more important risk factors.     

Acute myocardial infarction: Clinical features and outcomes in young adults in Singapore

AIM: To investigate the clinical features and in-hospital outcomes of young adults with acute myocardial infarction (AMI) in Singapore. METHODS: Between January 2005 to September 2010, 333 consecutive patients aged ≤ 45 years old were diagnosed to have AMI at our institution. As Singapore is a multi-ethnic society, we also analysed whether ethnic differences exist between the three dominant ethnic groups, Malay, Chinese and Indian with regards to the clinical features. Clinical data was collected retrospectively on demographic characteristics, presenting signs and symptoms, blood investigation, angiographic findings and in-hospital clinical outcomes. RESULTS: The mean age at presentation was 40.2 ± 4.0 years with male predominance (94%). The majority of patients were Chinese (51%) followed by Indians (31%) and Malays (18%). The most common risk factor was smoking (74%) followed by hypertension (28.5%) and hyperlipidemia (20.0%). 37% of patients were obese. The majority of patients had single vessel disease (46%) on coronary angiography. The mean total cholesterol, low-density lipoprotein and highdensity lipoprotein levels were 5.6±1.2 mmol/L, 3.8±1.1 mmol/L and 0.93±0.25 mmol/L respectively. The mean left ventricular function was 44%±10% with the incidence of heart failure 3% and cardiogenic shock 4.5%. Overall in-hospital mortality was low with 4 deaths (1.2%). For ethnic subgroup analysis, Indians have a 3-fold risk of developing premature AMI when compared to other ethnic groups. CONCLUSION: Young AMI patients in Singapore are characterized by male predominance, high incidence of smoking and obesity. Overall in-hospital clinical outcomes are favourable. Among the 3 ethnic groups, Indians have the highest risk of developing premature AMI.     

Trends in management, hospital and long-term outcomes of elderly patients with acute myocardial infarction

Purpose

The number of elderly patients with acute myocardial infarction (AMI) is growing rapidly, and their early and postdischarge mortality is high. Several studies have reported a decline in mortality after myocardial infarction; however, the magnitude of the decline among the elderly has not been fully investigated.

Methods

We assessed trends in management, in-hospital, and long-term outcomes of 1475 elderly patients (aged ≥75 years, 42% women) hospitalized with AMI in all 25 operating coronary care units in Israel between 1992 and 2002, from our prospective nationwide biennial surveys.

Results

Between 1992 and 2002, a significant increase was observed in the use of acute reperfusion therapy (27%-48%), coronary angiography (6%-47%), percutaneous coronary intervention (3%-33%), coronary bypass (2%-8%), aspirin (53%-88%), beta-blockers (18%-65%), angiotensin-converting enzyme inhibitors (26%-63%), and lipid-lowering drugs (0%-43%). These changes were associated with a 42% reduction in 30-day mortality (27.6%-16.1%; adjusted odds ratio 0.57; 95% confidence interval [CI], 0.36-0.93). One-year cumulative mortality declined by 20% (37%-29%; adjusted odds ratio 0.74; 95% CI, 0.49-1.13).

Conclusions

The management of elderly patients with AMI changed substantially during the last decade. This change was associated with a significant reduction in early mortality, whereas cumulative 1-year mortality improved only slightly. Better adherence to in-hospital management guidelines and better implementation of postdischarge health policy may further decrease mortality and morbidity in the elderly after AMI.     

主动脉内球囊反搏术在急性心肌梗死治疗中的应用和对近期预后的影响

目的了解急性心肌梗死（AMI）治疗中主动脉内球囊反搏术（IABP）的应用、并发症发生率和对近期预后的影响。方法单中心注册研究。连续入选2004年10月至2008年7月间,就诊于北京安贞医院28病房置入IABP的所有AMI患者。结果806例AMI患者中,共有121例（15.0%）置入IABP。最常见指征为高危冠状动脉（冠脉）造影和（或）PCI术中和术后提供血流动力学支持（66.9%）和心源性休克（26.4%）。IABP置入成功率为98.3%,平均使用时间为34±16h。严重并发症发生率为0%。所有患者均进行了冠脉造影,93.4%在出院前施行了冠脉血管重建。总住院死亡率为13.2%（其中心源性休克患者34.4%）,住院死亡率因置入IABP指征不同和施行冠脉血管重建与否存在很大差异。结论IABP可成功应用于AMI的多种高危状况并提供必要的血流动力学支持,严重并发症罕见,联合冠脉血管重建治疗可降低死亡率。     

心肌缺血再灌注时内皮细胞损伤功能改变与心肌梗塞面积的关系

目的旨在探讨内皮细胞损伤、功能改变在心肌缺血再灌注（ＭＩＲ）损伤中的发病机制及其与心肌梗塞面积的关系及卡托普利的保护作用。方法用２４只麻醉兔随机分为三组，（１）ＭＩＲ组，（２）ＭＩＲ＋卡托普利治疗组，（３）假手术对照组，观察心肌缺血半小时，再灌注０．５、１．５、６小时血循环内皮细胞（ＣＥＣ），一氧化氮（ＮＯ），内皮素（ＥＴ）的含量变化及其与心肌梗塞面积的关系，静注卡托普利观察其对梗塞面积及上述指标的影响。结果（１）与假手术组比较，再灌注半小时，血ＮＯ下降，ＥＴ升高，其变化于再灌注６小时最明显（Ｐ＜０．０５），ＣＥＣ则以再灌注１．５小时明显增高（Ｐ＜０．０５）；（２）再灌注６小时心肌梗塞范围较治疗组明显增加（Ｐ＜０．０５），且同一时相点血ＮＯ与心肌梗塞面积呈负相关（ｒ＝－０．９６１，Ｐ＜０．０１），血ＥＴ与心肌梗塞面积呈正相关（ｒ＝０．９２３，Ｐ＜０．０５）；（３）用卡托普利干预后，血ＮＯ有所回升，ＥＴ明显下降，心肌梗塞面积明显缩小。结论ＭＩＲ可诱发内皮功能紊乱，而内皮功能紊乱是再灌注心肌损伤加重的始动因素     

心肌灌注断层显像对急性心肌梗死再灌注的研究

目的　通过心肌灌注断层显像研究急性心肌梗死 (AMI)患者经尿激酶或冠状动脉介入治疗前后心肌梗死面积的变化。方法　用99m锝甲氧基异丁基异腈心肌灌注断层显像测定 12 0例AMI患者心肌再灌注前后的心肌梗死面积。结果　再灌注组 (n =81)和无再灌注组 (n =36 )首次心肌显像心肌缺损面积无显著性差异 (P >0 0 5 ) :再灌注组再次显像心肌缺损面积明显小于首次显像 (2 2 3± 3 1%和 31 9± 5 6 % ,P <0 0 5 ) ;无再灌注组再次显像心肌缺损面积与首次显像无明显差异 (2 9 6± 2 8%和 32 4± 5 l% ,P >0 0 5 ) ;预后不良组心肌缺损面积明显高于预后较好组 (35 8± 6 1% ,n =32和2 0 6± 4 0 % ,n =88,P <0 0 5 )。结论　心肌灌注断层显像可作为AMI再灌注疗效评价较准确的手段     

急性心肌梗死合并心源性休克的特点及预后

目的 观察再灌注治疗时代急性心肌梗死(AMI)合并心源性休克(CS)积极干预治疗对预后的影响.方法 连续入选AMI合并cs的患者89例,保守治疗50例,再灌注治疗39例,其中再灌注成功28例,不成功11例.早置组18例,CS发生1 h内放置主动脉内球囊反搏(IABP)晚置组35例,1 h后放置IABP未放置IABP组36例.结果 IABP早置组病死率明显低于晚置组和未置组(33.3%、74.2%、86.1%,P＜0.01).再灌注成功组病死率明显低于再灌注不成功和保守治疗组(42.8%、81.8%、84.0%,P＜0.01).logistic回归分析显示IABP放置时机(OR 0.22,95% CI 0.063～0.764,P=0.017)和成功再灌注(OR 4.232,95% CI 1.407～12.730,P=0.01)是死亡相关的独立危险因素.结论 积极成功再灌注和尽早应用IABP是降低AMI合并心源性休克病死率的重要和有效治疗措施.     

急性心肌梗死再灌注治疗后心肌灌注的评价及其与临床预后的关系

本文综述了急性心肌梗死再灌注治疗后心肌灌注的评价方法及其与临床预后关系方面最新的研究进展,主要从心肌灌注的造影评价方法及联合应用两方面加以介绍。     

Comparison between type-2 and type-1 myocardial infarction: clinical features, treatment strategies and outcomes

Objective To assess the differences in incidence, clinical features, current treatment strategies and outcome in patients with type-2 vs. type-1 acute myocardial infarction (AMI). Methods We included 824 consecutive patients with a diagnosis of type-1 or type-2 AMI. During index hospitalization, clinical features and treatment strategies were collected in detail. At 1-year follow-up, mortality, stroke, non-fatal myocardial infarction and major bleeding were recorded. Results Type-1 AMI was present in 707 (86%) of the cases while 117 (14%) were classified as type-2. Patients with type-2 AMI were more frequently female and had higher co-morbidities such as diabetes, previous non-ST segment elevation acute coronary syndromes, impaired renal function, anaemia, atrial fibrillation and malignancy. However, preserved left ventricular ejection fraction and normal coronary arteries were more frequently seen, an invasive treatment was less common, and anti-platelet medications, statins and beta-blockers were less prescribed in patients with type-2 AMI. At 1-year follow-up, type-2 AMI was associated with a higher crude mortality risk (HR: 1.75, 95% CI: 1.14?2.68; P = 0.001), but this association did not remain significant after multivariable adjustment (P = 0.785). Furthermore, we did not find type-2 AMI to be associated with other clinical outcomes. Conclusions In this real-life population, compared with type-1, type-2 AMI were predominantly women and had more co-morbidities. Invasive treatment strategies and cardioprotective medications were less used in type-2, while the 1-year clinical outcomes were similar.     

Novel predictors and adverse long-term outcomes of No-reflow phenomenon in patients with acute ST elevation myocardial infarction undergoing primary percutaneous coronary intervention

ObjectivesThe no-reflow phenomenon occurs in 25% of patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), and may be associated with adverse outcomes. The aim of our study was to detect novel predictors of no-reflow phenomenon and the resulting adverse long term outcomes.MethodsWe enrolled 400 STEMI patients undergoing primary PCI; 228 patients had TIMI flow 3 after PCI (57%) and the remaining 172 patients had TIMI flow <3 (43%). Fibrinogen to albumin ratio (FAR), high sensitive C-reactive protein to albumin ratio (CAR), and atherogenic index of plasma (AIP) were calculated. Long term mortality and morbidity during 6 months follow up were recorded. These data were compared among both groups.ResultsIn multivariate regression analysis, old age (OR = 1.115, 95% CI: 1.032–1.205, P = 0.006), higher troponin level >5.6 ng/mL (OR = 1.040, 95% CI: 1.001–1.080, P = 0.04), diabetes mellitus (OR = 4.401, 95% CI: 1.081–17.923, P = 0.04) and heavy thrombus burden (OR = 16.915, 95% CI: 5.055–56.602, P < 0.001) could be considered as predictors for the development of no-reflow. Interestingly, CAR >0.21, FAR >11.56, and AIP >0.52 could be considered as novel powerful independent predictors (OR = 3.357, 95% CI: 2.288–4.927, P < 0.001, OR = 4.187, 95% CI: 2.761–6.349, P < 0.001, OR = 16.794, 95% CI: 1.018–277.01, P = 0.04, respectively). Higher long term mortality (P < 0.001) and heart failure (P < 0.001) was also strongly related to incidence of no-reflow.ConclusionNo-reflow could be attributed to novel predictors as CAR, FAR, and AIP. This phenomenon was associated with long term adverse events as higher mortality and pump failure.     

葛根素加脉安定对急性心肌梗死溶栓再灌注心律失常的疗效观察

为探讨葛根素和脉安定早期静滴对急性心梗（AMI）溶栓再灌注心律失常（RA）的临床疗效,将102例AMI患者随机分为两组进行观察治疗,其中试验组加用葛根素和脉安定,对照组用极化液,两组均常规用溶栓和其他治疗,结果试验组RA较对照组显著减少（P＜0．01）,综合评价其总有效率试验组为96．1％,对照组为82．4％（P＜0．01）,研究提示,葛根素和脉安定对AMI溶栓RA有明显的防治效果。     

氟伐他汀对兔心肌梗死再灌注血清白细胞介素-8及梗死面积的影响

目的:观察氟伐他汀预处理对血清白细胞介素8(IL8)及心肌梗死面积的影响,探讨其对心肌梗死再灌注损伤保护作用的可能机制。方法:健康新西兰白兔24只,随机分为3组:假手术组、对照组、氟伐他汀组(氟伐他汀10mg·kg-1·d-1),每组8只。除假手术组外,其余2组通过结扎冠状动脉前降支60min,然后松开180min建立心肌梗死再灌注动物模型。在实验终点采右心房血,分离血清,检查IL8、CKMB含量,处死动物取出心脏,用1%氯化三苯基四氮唑染色后计算梗死心肌面积,并检测梗死区心肌髓过氧化酶(MPO)含量。结果:对照组、氟伐他汀组IL8、MPO活性明显高于假手术组(均P<0.05),氟伐他汀组IL8、MPO活性低于对照组(均P<0.05)。对照组血清CKMB明显高于假手术组(P<0.01),氟伐他汀组CKMB也明显高于假手术组(P<0.05),但较对照组明显降低(P<0.05)。氟伐他汀组心肌梗死面积[(26.90±1.81)%]较对照组[(31.22±2.31)%]小(P<0.05)。结论:氟伐他汀能通过抑制IL8的合成,减少中性粒细胞的浸润,从而改善心肌缺血再灌注损伤。     

再灌注时代β受体阻滞剂在急性心肌梗死防治中的地位再评价

<正>1背景β受体阻滞剂作为急性心肌梗死(acute myocardial infarction,AMI)一级及二级预防药物已经广泛使用40余年,其应用领域涉及高血压、心绞痛、围术期心脏保护、围术期房颤预防以及心律失常等。目前AMI诊治指南建议在无禁忌证的情况下所有患者均应在住院期间开始并无限期服用β受体阻滞剂[1-2]。这些建议是基于几项大型临床试验得出的,这些研究的开展时间多为20世纪80年代,那时再灌注治疗,甚至阿司匹林和     

Differences in prognostic factors and outcomes in African Americans and whites with acute myeloid leukemia

Whites have a more favorable prognosis than African Americans for a number of cancers. The relationship between race and outcome is less clear in acute myeloid leukemia (AML). Using data from 7 Cancer and Leukemia Group B studies initiated from 1985 to 1997, we conducted a retrospective cross-sectional analysis of 2570 patients (270 African American and 2300 white) with de novo AML who received induction chemotherapy. African Americans were younger than whites (48 versus 54 years, P <.001). African Americans also had different cytogenetic risk group distributions than whites (P <.001): they were more commonly classified in the favorable (23% versus 14%) and unfavorable (31% versus 23%) groups, and less commonly classified in the intermediate group (47% versus 63%). African American men had a lower complete remission (CR) rate (54%, compared with 64% for white men, 65% for white women, and 70% for African American women, P =.001) and a worse overall survival compared with all other patients (P =.004), when known risk factors are taken into account. African Americans and whites with AML differ with respect to important prognostic factors. African American men have worse CR rates and overall survival than whites and African American women, and should be considered a poor-risk group.     

急性心肌梗塞再灌注损伤临床表现及分析

目的:对急性心肌梗塞(AMI)再灌注后出现的特殊临床表现进行分析。方法:对50例AMI患者静脉溶栓后冠状动脉造影(显示为TIMI血流3级)的资料进行分析。结果:再灌注后有48例胸痛迅速缓解,有2例患者在再灌注后胸痛突然加重;有44例患者出现心律失常;40例出现一过性低血压;8例出现一过性ST段抬高。结论:冠脉血管再通后绝大部分患者胸痛迅速缓解,但大多有心律失常发生,一过性低血压,少数患者可出现ST段一过性胸痛加重;故溶栓后应进行持续心电图和血压监测。     

北京市急性ST段抬高心肌梗死患者转诊现况调查

目的 了解北京市急性ST段抬高心肌梗死(STEMI)患者的转诊现况以及对再灌注治疗和近期预后的影响.方法 入选2006年1月1日至12月31日期间就诊于北京市19所具备急诊经皮冠状动脉介入治疗(PCI)能力的医院并于发病后24 h内到院的STEMI患者.根据到院前是否经历转诊,将患者分为转诊组和非转诊组.通过调查问卷及查阅病历收集资料.结果 789例STEMI患者中,236例(29.9%)经历过转诊.由3级以下级别医院向3级医院转诊者占76.7%(181/236),由3级医院向3级医院转诊者占22.9%(54/236).由非直接PCI中心向直接PCI中心转诊者占67.4%(159/236),由直接PCI中心向直接PCI中心转诊者占32.6%(77/236).转诊组与非转诊组的直接PCI率(62.7%比66.4%,P=0.328)和进门-球囊扩张时间(132 min比135 min,P=0.473)差异无统计学意义.转诊组的发病-球囊扩张时间显著长于非转诊组(397 min比246 min,P<0.001).转诊组与非转诊组的住院病死率差异无统计学意义(4.7%比5.8%,P=0.609).结论 北京市急性STEMI患者的转诊情况复杂,转诊对近期预后无影响,有必要建立规范的STEMI转诊网络.     

老年急性非ST段抬高型心肌梗死临床特点分析

目的：分析老年非ST段抬高型心肌梗死（NSTEMI）患者的临床特点。方法：回顾分析我院2008年1月至2010年12月43例急性NSTEMI患者的临床特点。结果：43例急性NSTEMI患者中,（1）危险因素及病史：38例（88．4％）患者伴有2～4个危险因素,40例（93．0％）有心绞痛病史,14例（32．6％）有陈旧性心肌梗死;（2）临床表现：36例有胸痛（83．7％）,35例（81．3％）NYHA心功能2—3级,40例（93．1％）心电图见ST—T段改变,43例（100．0％）心肌肌钙蛋白T水平升高,32例（74．4％）肌酸激酶-同工酶水平升高≥2倍;（3）冠脉造影检查,37例（100％）均有单支或多支病变,多支病变患者35例（94．6％）;（4）治疗、合并症及预后：在常规内科药物治疗基础上,31例（72．1％）行PCI治疗,3例（7．0％）行冠状动脉旁路移植术,合并急性左心衰竭13例（30．2％）,心源性休克5例（11．6％）,恶性心律失常5例（11．6％）,死亡6例（14．0％）。结论：老年非ST段抬高心肌梗死患者合并冠心病的危险因素多,多支病变常见,心功能不全多见,血运重建率高,远期预后较差。     

依达拉奉治疗急性心肌梗塞的疗效观察

目的：观察依达拉奉治疗急性心肌梗塞（AMI）的疗效。方法：60例发病48h内行溶栓或经皮冠状动脉介入治疗（PCI）后的心肌梗塞患者被随机分为对照组（32例）、依达拉奉组（28例）,治疗2～3周后比较疗效。结果：与对照组相比,依达拉奉组患者左室射血分数（LVEF）明显升高[51．9±4．99）％：（55．31±5．36）％,P〈0．05],住院期间恶性心律失常发生率明显降低（25．9％：13．3％,P〈0．05）,但两组患者住院期间总体病死率无明显差异（P〉0．05）。结论：依达拉奉作为一种新型氧自由基清除剂,治疗急性心肌梗塞有明显的疗效。     

老年人急性心肌梗塞的临床特点

目的：研究60岁以上老年人急性心肌梗塞的临床特点。方法：对86例老年人急性心肌梗塞资料进行临床分析,并与同期255例小于60岁的急性心肌梗塞病人进行对比。结果：老年急性心肌梗塞患者女性的比例较60岁以下者明显增多(P＜0.01),老年无痛性心肌梗塞比例(30.5%)明显增多(P＜0.05),并发症心力衰竭(P＜0.01)、心律失常(P＜ 0.05),死亡率(P＜0.01)也明显增多。结论：老年人无痛性急性心肌梗塞多见,并发症发生率、死亡率高,应予重视。