急性ST段抬高型心肌梗死患者冠脉侧支循环形成不良的影响因素及对预后的指导意义

目的 探讨急性ST段抬高型心肌梗死（STEMI）患者冠脉侧支循环(CCC)形成不良的影响因素及对预后的影响。 方法 选取2016年5月至2020年1月在我院心血管内科住院并接受PCI手术治疗的STEMI患者110例,依据Rentrop分级将患者分为CCC形成良好组和CCC形成不良组,比较两组患者临床资料,采用Logistic回归法分析STEMI患者CCC形成不良的影响因素,并建立CCC形成不良的预测模型。术后对患者随访1年,比较两组患者心血管事件发生率及全因死亡率。 结果 单因素和多因素Logistic回归分析结果显示,无梗死前心绞痛、无梗死后心肌缺血、Killip心功能分级≥Ⅱ级、病变血管支数及冠状动脉狭窄程度均为STEMI患者CCC形成不良的独立危险因素（P<0.05）。利用以上独立危险因素构建列线图模型,其一致性指数（C-index）为0.756（95%CI:0.711~0.801）,ROC曲线AUC为0.766（95%CI:0.709~0.823）,具有较好的区分度;Calibration校准曲线评价结果提示模型准确性较好。两组患者术后1年心血管事件发生率无显著差异,但CCC形成良好组STEMI患者全因死亡率与CCC形成不良组比较显著降低（P<0.05）。 结论 无梗死前心绞痛、无梗死后心肌缺血、Killip心功能分级≥Ⅱ级、病变血管支数及冠状动脉狭窄程度是STEMI患者CCC形成不良的独立危险因素,CCC形成良好与否对STEMI患者PCI术后1年心血管事件发生率无显著影响,但CCC形成良好对降低STEMI患者全因死亡率具有积极作用。     

心肌缺血预适应及冠脉侧支循环对急性心肌梗塞患者的保护

目的：探讨心肌缺血预适应（IP）与冠脉侧支循环形成是否独立或协同地对急性心肌梗塞（AMI）患者起保护作用。方法：收集2006年9月~2010年4月择期行冠脉介入治疗（PCI）的103例初发AMI患者的住院资料,按梗塞前24~48 h内有、无心绞痛分为缺血预适应组（IP组,有心绞痛）53例,无缺血预适应组（NIP组,无心绞痛）50例。根据冠脉造影结果,每组再按有无梗塞相关冠脉侧支循环形成分为两个亚组。计算各组在心梗面积,左室射血分数（LVEF）,并发症等方面的差异。结果：①与NIP组比较,IP组的肌酸激酶[CK,（2163.2±962.1）U/L∶（1312.4±681.1）U/L],肌酸激酶同工酶[CK-MB,（292.6±126.7）U/L∶（161.8±58.9）U/L]峰值,心电图QRS积分[（11.6±4.6）分∶（6.9±2.3）分],肌钙蛋白I[cTnI,（29.8±13.4）U/L∶（15.7±6.1）U/L]峰值水平,以及严重心律失常（26.00%∶13.61%）、Killip分级（Ⅱ~Ⅲ）（26.00%∶16.98%）、心源性休克（14.00%∶7.55%）、室壁瘤发生率（12.00%∶5.66%）等显著降低（P均〈0.05）;IP组的LVEF[（55.5±5.6）%]显著高于NIP组[（45.1±6.1）%,P〈0.05];②两组内亚组间相比,有侧支循环亚组的Killip分级、心源性休克、室壁瘤形成率等,显著低于无侧支循环亚组（P均〈0.05）,而有侧支循环亚组的LVEF显著高于无侧支循环亚组（P均〈0.05）;而严重心律失常发生率,两组的两亚组间均无显著差异（P〉0.05）。结论：心肌缺血预适应和冠脉侧支循环形成均能减少急性心肌梗塞患者的心梗面积,阻止室壁瘤形成,改善左室收缩功能,并存在协同保护关系。     

急性心肌梗死患者梗死相关冠脉侧支循环形成的影响因素

目的 研究急性心肌梗死(AMI)时影响冠脉侧支循环(CCC)形成的因素。方法 共入选142例就诊我院的首次AMI患者,均在AMI发作1 d内行冠状动脉造影术(CAG),依照Rentrop侧支循环分级,分为侧支循环良好组(良好组:侧支循环Ⅱ、Ⅲ级)和侧支循环不良组(不良组:侧支循环0、Ⅰ级),将两组患者的临床资料和冠脉造影资料进行对比分析。结果 冠脉侧支循环形成与糖尿病呈负相关,与梗死前心绞痛病程(>3个月)及冠脉病变支数呈正相关,而与年龄、性别、吸烟史、血脂水平、高血压病等无关。结论 梗死前心绞痛病程(>3个月)、冠脉病变支数是AMI患者形成侧支循环的有利因素,糖尿病不利于侧支循环形成。     

重组人生长激素对急性心肌梗死大鼠冠状动脉侧支循环的影响

目的 :探讨重组人生长激素 (rh GH)对急性心肌梗死 (AMI)大鼠冠状动脉侧支循环及血管内皮细胞生长因子 (VEGF)、成纤维细胞生长因子 (bFGF)的影响。方法 :5 0只Wistar大鼠经 10 %戊巴比妥钠麻醉后开胸 ,剪开心包腔 ,经左冠状动脉前降支结扎术致其发生AMI ,术后 2 4h存活者 37只被随机分为治疗组 (19只 )和对照组 (18只 )。治疗组以rh GH 0 .2 5IU/kg肌内注射 ,对照组肌内注射同等容积的0 .9%氯化钠溶液 ,3周后处死大鼠 ,开胸经升主动脉向冠状动脉内灌注 4 %多聚甲醛 2 0～ 30min固定心脏 ,心脏标本经切片处理。分别测定血浆和心肌的VEGF、bFGF的量及左室毛细血管密度。结果 :治疗组与对照组在AMI后 3周其血浆bFGF、VEGF浓度均较实验开始时明显增加 (P <0 .0 5 )。治疗组较对照组升高更加显著 ,分别为 (6 8.72± 4 .5 7)∶(35 .6 0±4 .31)和 (4 7.0 5± 5 .13)∶(32 .13± 5 .70 ) (均P <0 .0 5 )。大鼠心肌内bFGF及VEGF治疗组均较对照组高 ,分别为 (79.0 5± 6 .96 )∶(30 .7± 3.4 9)和 (72 .0 5± 6 .73)∶(39.33± 6 .78) (均P <0 .0 1)。血浆bFGF、VEGF的浓度与心肌内毛细血管密度呈正相关 (r分别为 0 .91和 0 .86 ,均P <0 .0 1)。结论 :rh GH能促进AMI大鼠心肌细胞生长因子bFGF和VEGF的表达和分泌     

Effect of the collateral circulation on myocardial salvage in patients with acute myocardial infarction]

The effects of the extent of coronary collateral circulations, the duration of myocardial ischemia and recanalization of infarct-related vessels on left ventricular function were evaluated in 43 patients with acute anteroseptal myocardial infarction. All patients had complete occlusions of their proximal left anterior descending coronary arteries and were treated with intra-coronary thrombolytic therapy within 8 hours after the onset of their chest pain. The 43 patients were categorized in 4 groups based on the extent of their coronary collaterals in the early period of myocardial infarction and the results of thrombolysis. Group A consisted of 11 patients with well-developed collaterals who had successful thrombolysis. Group B was comprised of 14 patients with poorly developed or no collaterals, and successful thrombolysis. In group C, there were 9 patients with well-developed collaterals and unsuccessful thrombolysis. In group D, there were 9 patients who had poorly or not developed collaterals, and all had unsuccessful thrombolysis. Four weeks after the intervention, ejection fraction (EF) and regional wall motion (RWM) were calculated from the data of the left ventricular angiograms. There was no significant difference in patients' age, sex, nor in peak serum creatine kinase among the 4 groups or the duration of myocardial ischemia between groups A and B. Patients with successful thrombolysis (groups A and B) had significantly higher EF and preserved RWM of infarct areas compared to patients with unsuccessful thrombolysis (groups C and D, p less than 0.05). Thirteen patients with early reperfusion (within 4 hours after the onset of chest pain) had significantly higher EF and better RWM than did 12 patients with late reperfusion and 18 patients with unsuccessful thrombolysis (p less than 0.01). However, there was no significant correlation between the duration of myocardial ischemia and RWM of the infarct areas among 25 patients who had successful thrombolysis (r = -0.3, NS). Patients in group A had higher EF and better RWM of infarct areas than did patients in groups B, C and D (p less than 0.01). In addition, 3 patients with well-developed collaterals had good RWM despite late reperfusion which occurred more than 4 hours after the onset of symptoms. These results suggest that the extent of coronary collaterals during the early period of myocardial infarction and the time delay from the onset of symptoms to the initiation of thrombolytic therapy are important factors for the salvage of left ventricular function in patients with myocardial infarction.     

既往心绞痛对急性心肌梗死患者冠状动脉侧支循环及左心室功能的影响

目的　探讨既往心绞痛对急性心肌梗死 (AMI)患者冠状动脉侧支循环及左心室功能的影响。方法　行选择性冠状动脉造影和左心室造影的 30 7例首次急性心肌梗死患者 ,分析既往心绞痛与肌酸激酶 (CK)峰值浓度、冠状动脉侧支循环和左心室功能等的关系。结果　① 30 7例患者中 ,有既往心绞痛者 192例 (A组 ) ,无既往心绞痛者 115例 (B组 )。②A组CK和CK MB峰值浓度均显著低于B组(P <0 0 5 )。③A组梗死相关动脉有良好侧支循环的比率显著高于B组 (P <0 0 5 )。④A组左心室射血分数 (LVEF)显著高于B组 (P <0 0 1) ,而室壁运动Cortina计分明显低于B组(P <0 0 1)。结论　既往心绞痛可能促进冠状动脉侧支循环的建立 ,对急性心肌梗死后的心脏功能起保护作用     

白藜三醇对猪急性闭塞冠状动脉侧支循环的影响

目的 应用冠状动脉内多普勒超声评价白藜三醇对急性闭塞冠状动脉侧支循环的影响.方法 将18头健康家猪随机分为3组:白藜三醇组、硝酸甘油组和对照组.通过闭胸法建立急性冠状动脉左回旋支(LCX)闭塞的动物模型,应用冠状动脉内多普勒超声测量LCX正常状态、急性闭塞后及药物干预后相关的血流频谱.结果 在冠状动脉闭塞即刻,闭塞血管远端血流平均峰值流速(APV)明显低于正常水平[(0.85±0.25) cm/s比(24.83±3.43) cm/s,P＜0.05],持续观察60min,较闭塞即刻增加不明显[(0.83±0.24) cm/s比(0.85±0.25) cm/s,P＞0.05];白藜三醇组及硝酸甘油组给药后,闭塞血管远端血流呈反向或双向,APV的绝对值[分别为(9.22±0.80) cm/s和(8.93±1.28)cm/s]明显高于闭塞即刻[分别为(0.84±0.21 )cm/s和(0.86±0.26) cm/s]及对照组[(0.86±0.22)cm/s](P均＜0.05),达峰值后数据绝对值逐渐减小,重复给药后数值再次增加;但2个给药组间比较差异无统计学意义;而白藜三醇组APV增高持续时间明显长于硝酸甘油组[2次给药总时间分别为(58.83±6.15) min比(21.80±5.79) min,P＜0.05].结论 猪急性闭塞冠状动脉自身侧支循环建立明显不足.白藜三醇能够显著促进猪急性闭塞冠状动脉侧支循环的开放,且维持时间长于硝酸甘油.     

Pravastatin promotes coronary collateral circulation in patients with coronary artery disease

BACKGROUND: Previous studies suggested that hydroxymethylglutaryl coenzyme A reductase inhibitor (statin) promotes collateral circulation in ischemic limbs of rabbits. The present study was designed to determine the association between treatment with pravastatin and the development of coronary collateral circulation as assessed by the Rentrop Score in patients with coronary artery disease (CAD) in a case-control study. DESIGN: The study included patients who had one (1-V), two (2-V) or three (3-V) significantly stenosed vessels. Patients who did and did not receive pravastatin were defined as case participants (n = 42) and control participants (n = 100), respectively. RESULTS: The case participants included a higher percentage of 3-V patients with a Rentrop Score 1 compared to the control participants but there was no difference among 1-V and 2-V patients, suggesting that pravastatin was associated with coronary collateral circulation independent of the number of stenosed vessels. Patients with 3-V disease who were treated with pravastatin were most likely [odds ratio (confidence interval), 17.4 (4.4-115)] to develop collateral circulation, as assessed by multiple logistic regression analysis. CONCLUSIONS: Treatment with pravastatin was associated with the development of collateral circulation in patients with CAD, suggesting that such action constitutes part of the pleiotropic effects of statin.     

Reduced collateral circulation to the infarct-related artery in elderly patients with acute myocardial infarction

OBJECTIVES: The purpose of this study was to investigate the hypothesis that circulation via collateral vessels to an infarct-related artery (IRA) is impaired with aging in patients with acute myocardial infarction (AMI). BACKGROUND: Animal experiments have shown that advanced age blunts the development of new vessels in response to angiogenic cytokines. METHODS: Of 3,573 consecutive patients with AMI, 1,934 patients who fulfilled the following criteria were enrolled in this study: 1) coronary angiograms were obtained within 72 h after the onset of AMI; and 2) IRA showed complete occlusion (Thrombolysis In Myocardial Infarction [TIMI] flow grade 0 or 1). Collaterals to the IRA were angiographically evaluated using the Rentrop score. Rentrop scores 1 to 3 were defined as demonstrating significant collaterals. RESULTS: The prevalence of collaterals decreased with age, from 47.9%, 45.8%, 43.4%, to 34.0% in patients <50 years, 50 to 59 years, 60 to 69 years, > or =70 years, respectively (p < 0.001). Advanced age was an independent factor predicting the absence of collateral circulation to the IRA. In contrast, time to catheterization, history of angina pectoris, and preinfarction angina were independent predictors for the presence of collaterals. Multivariate analysis showed that the absence of collaterals was an independent predictor of in-hospital mortality in elderly patients > or =70 years (odds ratio, 15.6; 95% confidence interval, 3.5 to 69.6), although this finding was not significant in patients <70 years. CONCLUSIONS: Advanced age is associated with decreased angiographic presence of collaterals to the IRA in patients with AMI. This abnormality may contribute to the poor prognosis of elderly patients with AMI.     

Coronary collateral circulation: clinical significance and influence on survival in patients with coronary artery occlusion

In a consecutive series of 96 patients with coronary artery occlusion, 67 had good and 29 had no or poor collateral circulation. Patients with good collaterals had the severest degree of coronary artery disease. Good collaterals are associated with a higher incidence of angina pectoris and normal electrocardiogram and with lower incidence of Q-waves, positive exercise tests, heart failure, previous myocardial infarction, and dyskinesia at ventriculography. Survival rates after 10 years were (1) 51.5% with good and 34.5% with poor collaterals (p less than 0.1), (2) 59.4% with angina pectoris and good collaterals and 41.2% with angina pectoris and poor collaterals (p less than 0.05), (3) 64.8% without and 24.4% with heart failure and good collaterals (p less than 0.001), and (4) 58.3% without and 16.1% with heart failure and poor collaterals (p less than 0.01). Good collaterals protect the myocardium by prevention of acute myocardial infarction and heart failure and thus improve survival.     

冠状动脉侧支循环与前驱心绞痛对急性心肌梗死的影响

目的 :探讨侧支循环 (CR)和前驱心绞痛对急性心肌梗死 (AMI)患者梗死范围和心功能的影响及其可能的机制。方法 :119例首次AMI患者行选择性冠状动脉造影和左心室造影 ,分析冠状动脉CR及前驱心绞痛与AMI时肌酸激酶 (CK)峰值浓度和左室功能改变等的关系。结果 :①全组共 119例患者 ,兼有CR和前驱心绞痛者 (A组 ) 5 3例 ;有CR无前驱心绞痛者 (B组 ) 2 1例 ;仅有前驱心绞痛者 (C组 ) 2 6例 ;既无CR又无前驱心绞痛者 (D组 ) 19例。②心肌酶学改变 :A组CK峰值浓度显著低于D组 (P <0 .0 5 ) ,其CK同工酶 (CK MB)的峰值浓度显著低于D组和B组 (分别P <0 .0 1和 <0 .0 5 ) ;而且B组和C组的CK MB峰值浓度均低于D组 (均P <0 .0 5 )。③各组患者的心肌梗死部位、病变血管支数无统计学差异 ,但非Q波心肌梗死的比例A组显著高于D组(36 %对 2 1% ,P <0 .0 5 )。④心功能情况 :A组左室射血分数 (LVEF)显著高于其他各组 ,而且B组和C组的LVEF均高于D组 (P <0 .0 5 )。而室壁运动Cortina计分则A组明显低于其他各组 ,B组和C组均显著低于D组 (P <0 .0 5 )。结论 :冠状动脉CR和前驱心绞痛所致的缺血预适应对AMI患者的心肌均有重要的保护作用 ,而且二者可协同发挥作用     

冠状动脉侧支循环影响因素的探讨

目的探讨冠状动脉侧支循环形成的相关影响因素。方法选择冠状动脉闭塞病变的患者106例,用单因素和多因素回归分析方法分析了患者年龄、性别、体重指数、血压、血脂、尿酸、血糖、胰岛素水平以及冠状动脉闭塞程度、病变特点等与侧支循环的关系。结果血糖水平和冠状动脉闭塞程度与冠状动脉侧支循环形成之间的回归系数达显著水平(P<0.01)。结论血糖水平和冠状动脉闭塞程度是影响冠状动脉侧支循环形成的重要因素。