新版指南解读：急性ST段抬高型心肌梗死的抗栓治疗

急性ST段抬高型心肌梗死（STEMI）是冠状动脉内血栓形成的急性心血管事件,无论是行急诊经皮冠状动脉介入还是药物溶栓,抗栓始终贯穿于治疗的全过程。由于近年来一些大规模随机临床试验结果的公布,欧洲心脏病学会（ESC）、美国心脏病学会基金会（ACCF）及美国心脏协会（AHA）相继公布了ST段抬高型心肌梗死的新版指南。指南指出：急性STEMI一旦确诊,应立即行抗血小板及抗凝治疗,抗血小板治疗为负荷量的阿司匹林（300 mg）及二磷酸腺苷（ADP）受体拮抗剂（氯吡格雷300～600 mg、普拉格雷60 mg、替格瑞洛180 mg）;ESC指南更倾向于使用替格瑞洛或普拉格雷;2个指南维持量的阿司匹林均倾向于小剂量（75～100 mg/d）。新指南对于低分子量肝素应用于急诊PCI的推荐力度有所下降,建议维持时间≤8 d。基于有效性和安全性的考虑,2个指南均建议在STEMI行急诊PCI时使用比伐芦定,尤其是对于伴有高出血风险的患者。     

急性ST段抬高型心肌梗死诊断和治疗指南

一、前言 2001年,由中华医学会心血管病学分会、中华心血管病杂志编辑委员会和中国循环杂志编辑委员会联合制定了我国的"急性心肌梗死诊断和治疗指南"[1].在此后的9年中,急性心肌梗死(acute myocardial infarction,AMI)的治疗又取得了重要进展.     

ST段抬高心肌梗死抗栓治疗及出血问题

斑块的不稳定、破裂与血栓形成是贯穿ST段抬高心肌梗死（STEMI）发病过程的主要矛盾。许多患者临床症状各异,但冠状动脉却具有非常相似的病理生理改变,即冠状动脉粥样硬化斑块由稳定转为不稳定,继而破裂导致血栓形成。血栓栓塞是动脉粥样硬化进展及并发症发生的重要因素,因此,STEMI的抗栓治疗非常重要,主要包括抗血小板聚集、抗凝和促纤溶等。然而,随着抗栓治疗的发展,出血并发症的发生也随之增多,出血事件对预后的不良影响日益引起关注。在出血相关临床研究中,出血事件的定义各不相同,导致了比较不同临床研究结果时缺乏统一标准。     

急性ST段抬高心肌梗死的抗栓与再灌注治疗

急性ST段抬高心肌梗死(STEMI)治疗的现代治疗策略是"尽早、充分、持续开通梗死相关血管",即再灌注治疗,并已被所有专家认可且极力推荐.当我们不断强调溶栓和急诊PCI优越性的同时,不要忘记或轻视辅助再灌注治疗的抗栓疗法,包括抗血小板治疗和抗凝治疗.     

急性ST段抬高心肌梗死的抗栓与再灌注治疗

急性ST段抬高心肌梗死(STEMI)治疗的现代治疗策略是“尽早、充分、持续开通梗死相关血管”,即再灌注治疗,并已被所有专家认可且极力推荐。当我们不断强调溶栓和急诊PCI优越性的同时,不要忘记或轻视辅助再灌注治疗的抗栓疗法,包括抗血小板治疗和抗凝治疗。     

急性ST段抬高型心肌梗死与急性非ST段抬高型心肌梗死的对比性研究

目的对比急性ST段抬高型心肌梗死(acute ST-segment elevation myocardial infarction,STEMI)与急性非ST段抬高型心肌梗死(acute non-ST-segment elevation myocardial infarction,NSTEMI)的临床特征。方法收集2012年1月至2013年12月在高淳区人民医院住院的急性心肌梗死(acute myocardial infarction,AMI)患者480例的临床资料,分为STEMI组205例,NSTEMI组275例。对比两组相关临床资料。应用多因素Logistic逐步回归分析AMI患者中发生NSTEMI的危险因素。结果与STEMI组比较,NSTEMI组女性、既往合并心纹痛、心肌梗死及经皮冠状动脉介入治疗、原发性高血压(高血压)、三支病变、侧支循环的患者比例偏高,差异有统计学意义(P0.05);空腹血糖、总胆固醇、低密度脂蛋白胆固醇、纤维蛋白原、超敏C-反应蛋白浓度偏低,差异有统计学意义(P0.05)。陈旧性心肌梗死、侧支循环、心纹痛是发生NSTEMI的独立危险因素(OR=8.049,95%CI:2.081~31.130,P=0.003;OR=3.327,95%CI:1.387~7.981,P=0.007;OR=2.435,95%CI:1.418~4.181,P=0.001)。结论陈旧性心肌梗死病史、侧支循环建立、心纹痛病史可能是AMI患者中发生NSTEMI的独立危险因素。     

急性ST段抬高型心肌梗死的治疗策略

急性ST段抬高型心肌梗死(STEMI)是由于冠状动脉粥样硬化斑块破裂、激活血小板和凝血过程而使冠状动脉血栓性完全阻塞引发的心肌细胞缺血性坏死。早期、持续、有效的心肌再灌注治疗是STEMI的首选治疗方式,明显缩小心肌梗死(MI)面积,挽救心功能,显著改善临床预后。近年,随着对急性心肌梗死(AMI)再灌注治疗策略认识的提高和辅助治疗手段的不断发展,STEMI 12 h内再灌注治疗成功率提高40%,院内和30 d病死率降低50%。以直接经皮冠状动脉介入治疗(PCI)为主的心肌梗死“绿色通道”已在大多数医院得到建立。同时,药物洗脱支架的临床应用使STEMI 1年无事件生存率明显改善,再次血运重建率显著降低。     

急性ST段抬高型心肌梗死诊断和治疗指南（2019）

  目的  探讨提前肝素化对ST段抬高型心肌梗死（STEMI）患者急诊经皮冠状动脉介入（PCI）治疗前梗死相关血管（IRA）血流的影响及其时间依赖性。  方法  选取发病12 h内的接受急诊PCI的STEMI患者376例,随机分为试验组（n=181）和对照组（n=195）。试验组患者确诊后立即静脉推注普通肝素（UFH）60 U/kg,最大剂量5000 U。对照组患者穿刺成功后动脉内应用UFH 2000U。两组患者PCI前均补充至（80～100）U/kg。比较两组患者PCI前IRA血流情况及PCI后慢血流、院内死亡、心力衰竭、出血的比例与住院时间。分析症状出现至UFH给药时间与UFH给药至冠脉造影时间对IRA再通的影响。  结果  试验组患者PCI前IRA再通比例高于对照组,血栓抽吸、住院时间低于对照组,差异有统计学意义（均P<0.05）; PCI前冠脉内可见血栓、PCI后慢血流,院内心衰、出血及死亡的比例差异无统计学意义。提前肝素化与PCI前IRA再通呈正相关（OR=1.819,95%CI：1.166～2.837,P<0.01）。在试验组和对照组患者中,症状出现至UFH给药时间和IRA再通之间存在时间依赖性（<3 h：50.0% vs. 29.2%,P<0.05;其余时段无统计学差异）,与PCI前IRA再通负相关（OR=0.945,95%CI：0.816～0.986,P<0.05）。在试验组患者中,UFH给药至冠脉造影时间>30 min的患者PCI前IRA再通比例较高,差异有统计学意义（P<0.05）,与PCI前IRA再通呈正相关（OR=2.610,95%CI：1.153～5.911,P<0.05）。  结论  提前肝素化能提高STEMI患者急诊PCI前IRA再通比例,改善患者预后,且不增加出血风险。症状出现后越早给予UFH,改善IRA再通的作用越强。确诊后立即应用UFH可作为无UFH禁忌症的STEMI患者PCI的辅助抗凝方案。     

2015年急性ST段抬高型心肌梗死诊断和治疗指南解析

<正>最近,中华医学会心血管病学分会动脉粥样硬化和冠心病学组组织专家对我国2010年《急性ST段抬高型心肌梗死(STEMI)诊断和治疗指南》作了修订(以下简称《新指南》),并在2015年第5期《中华心血管病杂志》上发表。现对《新指南》作一解析,希望能为临床医生提供指导。1心肌梗死分型《新指南》采用2012年由欧洲心脏病学会(ESC)、美国心脏病学会基金会(ACCF)、美国心脏     

Pneumomediastinum mimicking acute ST-segment elevation myocardial infarction

Pneumomediastinum is characterized by dissecting air within the connective tissues supporting the mediastinum. This condition has been associated with multiple electrocardiographic abnormalities including T-wave inversion, electrical alternans, loss of R wave progression, and low voltage QRS. We describe a case of pneumomediastinum with electrocardiographic changes mimicking acute ST-segment elevation myocardial infarction. Laboratory studies and echocardiography demonstrated no evidence of myocardial injury, and the electrocardiographic abnormality promptly resolved with resolution of the pneumomediastinum. The apparent ST-segment elevation appeared to be the result of electrocardiographic artifact, possibly related to epidermal stretch synchronous with the cardiac cycles.     

Hypercalcemia-induced ST-segment elevation mimicking acute myocardial infarction

We describe a patient who presented with abdominal pain radiating to the chest and ST elevation in the precordial leads, mimicking acute myocardial infarction. Urgent coronary angiography revealed normal coronary arteries and his serum troponin has not increased. Subsequently, he was found to have severe hypercalcemia. ST segment elevation resolved after correction of hypercalcemia. This phenomenon of ST elevation secondary to hypercalcemia has been described only two times in the English literature to date.     

ST-segment elevation myocardial infarction

Opinion statement ST-segment elevation myocardial infarction (MI) is an emergency medical condition. Expediting the steps leading to coronary reperfusion is of critical importance in improving survival after acute MI. After the diagnosis of acute MI is made, patients should be treated with oxygen, aspirin, nitroglycerin, beta-blockers, heparin, and analgesics, barring any contraindications. If an experienced cardiac catheterization laboratory is available within 60 to 90 minutes, then catheter-based reperfusion therapy is recommended; otherwise, thrombolysis should be considered as an alternate therapy. Therapy with a reduced-dose thrombolytic agent and a glycoprotein IIb/IIIa receptor inhibitor appears to be of an added benefit in establishing TIMI (Thrombolysis in Myocardial Infarction) 3 flow, but this approach awaits final approval prior to widespread use. The adjunctive use of glycoprotein IIb/IIIa receptor inhibitors with percutaneous transluminal coronary angioplasty, with or without stenting, appears to be beneficial and is being used more frequently in the acute setting. Coronary angiography should be performed in patients who fail to respond to thrombolytic therapy or who have evidence of recurrent ischemia. This procedure should not be routinely performed in patients who have responded to thrombolytic therapy. Four to 6 days after an acute MI event, assessment of left ventricular function is recommended. Submaximal exercise test (with or without nuclear or echocardiographic imaging) should be considered in patients prior to discharge from the hospital—an exception can be made in patients with one-vessel disease treated successfully with percutaneous transluminal coronary angioplasty. After discharge, a regular exercise test should be obtained 4 to 6 weeks after an uncomplicated acute MI event. Secondary prevention measures such as weight loss, cessation of smoking, aspirin, beta-blockers, lipid-lowering agents, and angiotensin-converting enzyme inhibitors should be considered in all patients, barring contraindications.     

Cellular protection in acute myocardial infarction with ST-segment elevation

About half of the patients with acute myocardial infarction who undergo successful fibrinolytic treatment or primary percutaneous coronary artery rechanneling continue to have abnormal microcirculatory blood flow. Various medications have been designed to protect the myocardial cell and have been investigated in human beings as coadjuvants to rechanneling procedures. Overall, they can be divided into: a) medications that act on the inflammatory response triggered by ischemia/reperfusion, such as anti-CD11/CD18 antibodies and anti-complement, and b) medications that enhance metabolic tolerance, such as glucose-insulin-potassium solution and inhibitors of the Na+/H+ ion exchange system. Despite the importance of the problem, the results so far obtained have been inconclusive and it was concluded that new studies are needed. Some of these studies have already been undertaken in attempt to find a satisfactory response to the question.