急性心肌梗死猝死患者心肌细胞凋亡的研究

目的 :探讨细胞凋亡在急性心肌梗死时心肌细胞死亡中的意义。方法 :用末端原位标记 (TU NEL )法、DNA电泳和电镜 3种方法检测急性心肌梗死猝死患者和心脏正常的车祸死亡者心肌细胞的凋亡。结果 :TU NEL 法发现 ,猝死者梗死区的心肌细胞凋亡数 (5 5 7.95± 1 4 4.1 0 )× 1 0 - 3明显高于正常对照组 (34 .30±2 0 .6 8)× 1 0 - 3(P=0 .0 0 0 0 ) ;心肌细胞凋亡数在冠脉 1支病变者为 (5 0 6 .38± 1 75 .88)× 1 0 - 3<2支病变者为(5 5 4.38± 92 .1 5 )× 1 0 - 3<3支病变者为 (6 6 8.2 5± 1 2 7.1 9)× 1 0 - 3,虽然均明显高于正常对照组 (P均 <0 .0 5 ) ,但 3组之间比较则无统计学差别 (P均 >0 .0 5 ) ;冠脉 2～ 3支病变者梗死区的心肌细胞 DNA电泳可见相差约1 80～ 2 0 0 bp的阶梯片段 ;电镜发现猝死者梗死区内的心肌细胞核膜完整、染色质浓集、电子密度增加的凋亡特征 ,有的则出现核膜破裂、染色质溶解成碎屑的坏死现象。结论 :细胞凋亡在急性心肌梗死猝死者的心肌细胞死亡中起重要作用。     

急性心肌梗死发生猝死心脏复苏的临床分析

目的探讨急性心肌梗死患者发生猝死的临床特征以及预后。方法对2002～2006年合江镇中心卫生院收治的急性心肌梗死患者315例,其中发生猝死的133例,心脏复苏成功61例,失败72例患者的临床资料进行整理统计,比较其临床特征以及预后。结果与复苏失败组比较,心脏复苏的成功与良好的心功能基础、抢救时间、电复律方法、快速静脉用药相关;对心脏复苏成功患者随访（1.9±0.6）年,死亡4例,心脏复苏成活率93.44%。结论成功的心脏复苏与尽早的抢救、不间断的心脏按压、尽早的心脏电除颤,以及良好的静脉通路、患者良好的心功能有关,心脏复苏患者预后良好。     

青年女性自发冠状动脉夹层导致急性心肌梗死1例并文献复习

目的 探讨自发性冠状动脉夹层的临床特点,以期提高对该病的诊治与认识。方法 回顾性分析1例青年女性自发性冠状动脉夹层导致急性心肌梗死患者的临床资料,并以“自发性冠状动脉夹层”、“急性心肌梗死”以及“青年女性”等关键词,通过检索中国知网、PubMed及万方数据库,筛选公开发表的相关中英文文献,以分析自发性冠状动脉夹层的临床特点。结果 本例为青年女性,35岁,因间断胸痛就诊,心电图检查提示I、aVL及V2-V5导联ST段抬高,肌钙蛋白T升高(>2 000 ng/L),冠状动脉造影结果示左主干(LM)自开口可见夹层,延伸至左前降支(LAD)远段及回旋支(LCX)中段,管腔全程受压,近段血管部分不能显影,经血管内超声(intravenous ultrasound, IVUS)指导下行经皮冠状动脉介入(percutaneous coronary intervention, PCI)治疗,随访1个月并复查冠状动脉造影(coronary angiography, CAG)患者治疗效果良好。结论 自发性冠状动脉夹层是导致急性冠脉综合征的罕见病因,其疾病特点及治疗方法与冠状动脉粥样硬化不同,诊断具有...     

心肌Heidenhain染色在诊断冠心病猝死中的应用价值

目的探讨心肌铁矾苏木素伊红染色(Heidenhain染色)诊断冠心病猝死(CAD-SD)的临床价值。方法选取134例冠心病心肌梗死患者(CAD-MI组)、119例高血压心脏病患者(HHD组)、97例失血性休克患者(HS组)、75例心脏病合并失血性休克患者(HD-HS组)、64例一氧化碳中毒患者(COP组)以及同期体检科确诊的60例健康个体(对照组)。所有研究对象均接受心肌Heidenhain染色检查,分析各组心肌Heidenhain染色检测结果。结果 6组研究对象心肌Heidenhain染色阳性强度相比差异有统计学意义(P0.05)。以心肌Heidenhain染色检查结果强阳性(2+)作为CAD-SD的诊断标准,心肌Heidenhain染色诊断CAD-SD的灵敏度、特异度、阳性预测值、阴性预测值、诊断准确度分别为94.8%、99.5%、98.4%、98.3%、98.4%。结论心肌Heidenhain染色诊断CAD-SD具有较高的灵敏度与特异性。     

急性心肌梗死突发猝死20例抢救及护理观察

目的：探讨急性心肌梗死突发猝死的护理措施。方法：对20例急性心肌梗死患者实施及时的抢救并给予严密的病情观察及护理。结果：20例急性心肌梗死患者均抢救成功。结论：做好急性心肌梗死患者的现场救治和护理,能有效地减少并发症的发生,对挽救患者生命,促进患者早日康复具有重要临床意义。     

QT间期离散度增加与急性心肌梗塞预后的关系

对７８例急性心肌梗塞（ＡＭＩ）患者的ＱＴ间期离散度（ＱＴｄ）进行分析，以探讨其对ＡＭＩ近期预后的预测价值。结果显示：室性心动过速（ＶＴ）、心室颤动（Ｖｆ）及猝死者的ＱＴｄ明显长于无ＶＴ、Ｖｆ及非猝死者（Ｐ＜０．０１），且前壁梗塞组ＱＴｄ明显长于下后壁梗塞组（Ｐ＜０．０１或＜０．０５）。说明ＱＴｄ是预测ＡＭＩ近期预后的一项敏感指标。     

The clinical challenge of preventing sudden cardiac death immediately after acute ST-elevation myocardial infarction

Unfortunately, of all patients experiencing acute myocardial infarction (MI), usually in the form of ST-elevation MI, 25–35% will die of sudden cardiac death (SCD) before receiving medical attention, most often from ventricular fibrillation. For patients who reach the hospital, prognosis is considerably better and has improved over the years. Reperfusion therapy, best attained with primary percutaneous coronary intervention compared to thrombolysis, has made a big difference in reducing the risk of SCD early and late after ST-elevation MI. In-hospital SCD due to ventricular tachyarrhythmias is manageable, with either preventive measures or drugs or electrical cardioversion. There is general agreement for secondary prevention of SCD post-MI with implantation of a cardioverter defibrillator (ICD) when malignant ventricular arrhythmias occur late (>48 h) after an MI, and are not due to reversible or correctable causes. The major challenge remains that of primary prevention, that is, how to prevent SCD during the first 1–3 months after ST-elevation MI for patients who have low left ventricular ejection fraction and are not candidates for an ICD according to current guidelines, due to the results of two studies, which did not show any benefits of early (<40 days after an MI) ICD implantation. Two recent documents may provide direction as to how to bridge the gap for this early post-MI period. Both recommend an electrophysiology study to guide implantation of an ICD, at least for those developing syncope or non-sustained ventricular tachycardia, who have an inducible sustained ventricular tachycardia at the electrophysiology study. An ICD is also recommended for patients with indication for a permanent pacemaker due to bradyarrhythmias, who also meet primary prevention criteria for SCD.     

Cardiac malignant tumor as a rare cause of acute myocardial infarction

Acute myocardial infarction is predominantly caused by coronary artery atherosclerotic plaque rupture and subsequent occlusive thrombus formation. The recognition of less common causes of acute myocardial infarction is important because they may require a different treatment strategy. We report a patient with acute myocardial infarction without any angiographic evidence of coronary atherosclerosis and a left atrial mass detected on echocardiography. Therefore, coronary embolism from intracardiac thrombus or tumor was suspected. No additional manifestations of a potential tumor were found on thoracic, abdominal and cranial computed tomography. During subsequent cardiac surgery, a large tumor could be in toto resected and was diagnosed as a highly malignant leiomyosarcoma on histopathological evaluation.     

冠心病猝死者心肌细胞凋亡与Bcl-2和Bax 基因蛋白表达及其临床意义

目的：探讨Bcl-2和Bax基因蛋白在冠心病心脏性猝死者心肌细胞凋亡中的作用，为冠心病生物治疗提供理论依据。方法；用凋亡原位末端标记检测（TUNEL）法检测16例冠心病心性猝死者和10例心脏正常其他原因死亡者心肌细胞凋亡，用免疫组化法检测Bcl-2和Bax基因蛋白在心肌细胞中表达水平，并探讨其相互关系。结果：（1）冠心病心性猝死者梗死区心肌细胞凋亡数与Bax蛋白表达阳性细胞数均明显高于正常对照组（P〈0．05）；且于梗死区心肌细胞凋亡数及冠状动脉病变支数成明显正相关性。Bcl-2基因蛋白表达则与之相反，梗死区心肌细胞Bcl-2基因蛋白表达明显低于对照组（P〈0．05），且与梗死心区肌细胞凋亡数、冠状动脉病变支数成明显的负相关性。结论：冠心病心性猝死者梗死心肌细胞存在明显的凋亡现象，且受Bax蛋白与Bcl-2基因蛋白下调影响，Bax蛋白与Bcl-2蛋白共同调节心肌细胞凋亡，诱导心肌细胞表达Bcl-2将可能成为探索心肌生物治疗措施的新途径。     

急性心肌梗塞溶栓疗法对室壁瘤形成的影响

目的：探讨溶栓疗法对室壁瘤形成的影响。方法：溶栓组１７例采用链激酶１５０万单位或尿激酶２００万单位静滴，于３０分钟内滴完后继用硝酸甘油２０μｇ／ｍｉｎ持续静滴４８小时。非溶栓组１７例采用硝酸甘油２０μｇ／ｍｉｎ持续静滴４８小时。平均治疗３周时对所有患者进行超声心动检查及心血池扫描显像检查，分别计算两组室壁瘤的发生率及左心室射血分数均值，并对其差异的显著性进行χ２检验和ｔ检验。结果：溶栓组室壁瘤发生率（１７．６％）低于非溶栓组（５２．９％），两者有显著性差异（Ｐ＜０．０５）。溶栓组左室射血分数均值（０．４５±０．０９）高于非溶栓组（０．３６±０．１４），两者有显著性差异（Ｐ＜０．０５）。结论：溶栓疗法可降低室壁瘤的发生率，提高左室射血分数。     

急性无Q波心肌梗死和Q波心肌梗死早期冠状动脉造影的比较

目的　探讨急性无Q波心肌梗死 (ANQMI)和急性Q波心肌梗死 (AQMI)在发病最初 6h内冠状动脉病变的性质、血栓及侧支循环形成情况的不同 ,为进一步治疗提供理论基础。方法　对 5 2例AN QMI患者和 130例AQMI患者在发病 6h内进行选择性冠状动脉造影 ,比较两组在冠状动脉造影所见中的不同特点 ,并对他们的发病年龄、临床症状、心肌酶变化特点等情况进行。结果　与AQMI比较 ,ANQMI发病年龄较高 ,临床中常缺乏特征性的胸痛症状。冠状动脉造影所见中 ,相关的冠状动脉完全性闭塞在ANQ MI组为 2 8 9% (15 / 5 2 ) ,在AQMI组为 86 9% (113/ 130 ) ;ANQMI组血栓存在为 15 1% (8/ 5 2 ) ,AQMI组为73 9% (96 / 130 ) ;ANQMI组侧支循环形成 4 0 4 % (2 1/ 5 2 ) ,AQMI组 13 9% (18/ 130 ) ;ANQMI组多支病变为 5 1 9% (2 7/ 5 2 ) ,AQMI组为 4 0 0 % (5 2 / 130 )。以上 P<0 0 5。结论　与AQMI组比较 ,ANQMI在发病最初 6h内完全性闭塞发生率低 ,血栓存在率低 ,侧支循环较丰富 ,多支病变发生率较高。因此 ,对于ANQ MI早期溶栓治疗可能不会收到理想的效果 ,而应尽早采用其他冠脉介入性治疗     

Vertebral artery dissecting aneurysm treated by internal trapping via the contralateral vertebral artery: A case report

A 42-year-old man with a history of sudden onset of severe headache followed by consciousness disturbance was brought to our hospital. Radiological examinations revealed subarachnoid hemorrhage, associated with rupture of a left vertebral artery dissecting aneurysm. Initially, internal trapping was attempted via the ipsilateral vertebral artery. However, the microcatheter could not be navigated through the true lumen to the distal side of the vertebral artery. Subsequently, therefore, the guiding catheter was placed in the right vertebral artery, and the microcatheter was retrogradely navigated successfully through the lesion to the proximal side of the left vertebral artery. Finally, the lesion was completely embolized with electrodetachable coils without complications. However, the patient died after the operation because of deterioration of the general condition. The postmortem examination revealed how an intimal flap had interfered with the antegrade navigation of the microcatheter in the lesion. The present case showed that endovascular treatment for a vertebral artery dissecting aneurysm via the contralateral vertebral artery may be a useful option in cases where antegrade navigation of the microcatheter via the ipsilateral vertebral artery is found to be difficult.     

静脉溶栓治疗急性心肌梗死患者对其室壁瘤形成的影响

目的：探讨静脉溶栓治疗急性心肌梗死（ＡＭＩ）患者对其室壁瘤形成的影响。方法：对４８例首次ＡＭＩ患者接受静脉溶栓治疗后３周～４周进行左室造影检查。结果：获得梗死相关冠状动脉（冠脉）再通组与未通组分别为２５例和２３例，冠脉再通组发生室壁瘤３例（发生率为１２．０％），冠脉未通组发生室壁瘤１０例（发生率为４３．５％），２组比较差异显著（Ｐ＜０．０５）。再通组左心功能改善，左室射血分数（０．６１±０．１１）明显优于未通组（０．５１±０．１２），Ｐ＜０．０５。室性心律失常发生率再通组（２８．０％）低于未通组（５６．５％）。结论：ＡＭＩ静脉溶栓治疗后梗死相关冠脉再通可显著降低室壁瘤的发生率，改善患者的心功能和预后。     

Early out-of-hospital lidocaine administration decreases the incidence of primary ventricular fibrillation in acute myocardial infarction

This study was designed to assess the effectiveness of early prehospital intravenous administration of lidocaine in preventing primary ventricular fibrillation (PVF) in patients with suspected acute myocardial infarction (AMI). Sixty patients with suspected AMI, seen by the Mobile Coronary Care Unit (MCCU) of Florence, were randomly allocated at home to treatment with lidocaine (bolus IV of 1 mg/kg, followed by an infusion of 4 mg/min) or placebo (infusion of saline at a rate of 1 mL/min), respectively.

The lidocaine group (27 patients) and the control group (33 patients) were not significantly different in age, clinical condition, or time of randomization. The diagnosis of AMI was confirmed in all 60 patients during the hospital stay. Ventricular fibrillation (VF) occurred in 5 patients in the control group in comparison to none in the lidocaine group (P < 0.05). Three patients experienced VF at home and were successfully resuscitated by an MCCU cardiologist. In another two patients, VF occurred during the first 4 hours after onset of symptoms. No major side effects were observed after the infusion of lidocaine. Our findings support the effectiveness of the prophylactic administration of lidocaine in preventing PVF in the prehospital phase of AMI and suggest that the drug can be safely administered in this setting by prehospital personnel.     

冠状动脉造影正常的急性心肌梗死的临床特点

目的探讨冠状动脉造影正常的急性心肌梗死(AMI)患者的临床特点及相关病因和可能的发病机制。方法对419例临床诊断为AMI患者进行冠状动脉造影,冠状动脉造影正常的AMI为观察组,冠状动脉造影异常者为对照组。观察冠状动脉造影正常的AMI患者的易患因素、临床特点及可能的发病机制。结果419例AMI患者中,21例冠状动脉造影显示正常(占5.01%),观察组年龄明显低于对照组(P<0.05),吸烟、过度悲伤较对照组明显增多(P<0.05),过敏和免疫系统疾病较对照组增多(P<0.01),而高血压、高血脂及糖尿病较对照组明显降低(P<0.001),同时观察组左室功能较好且梗死部位以下壁者居多(P<0.05)。结论约有5.01%的AMI患者冠状动脉造影正常。此类患者既往多无高血压、糖尿病及高血脂病史,以年龄轻、吸烟和过度悲伤、患有过敏和免疫系统疾病、梗死部位多为下壁、心功能较好为临床特点。发病机制可能是冠状动脉病变较轻,由于冠状动脉发生痉挛或微小斑块破裂形成血栓,继而发生血栓自溶而致造影无异常。     

实验性急性心肌梗塞心肌细胞凋亡的研究

目的　为探讨细胞凋亡在急性心肌梗塞时心肌细胞中的意义。方法　用末端原位标记 (TUNEL)法、DNA电泳和电镜三种方法检测兔急性心梗模型中梗塞区心肌细胞的凋亡。结果　TUNEL法发现 :兔急性心梗模型中梗塞区心肌细胞凋亡千分率在冠脉结扎前 (0h)和结扎后 1h、2h、3h、4h、6h、8h、12h的改变如下 :0h组 (31 0 0± 14 0 0‰ )和 12h组 (6 8 0 0±31 72‰ ) <1h组 (142 33± 5 3 5 2‰ ) <2h组 (370 83± 6 6 0 1‰和 8h组 (32 1 17± 86 43‰ ) <3h组 (5 86 83± 5 5 0 2‰ ) <4h组(836 17± 43 73‰ ) (P均 <0 0 5 ) ,即急性心梗心肌细胞凋亡数在冠脉结扎后 1h时开始逐渐增多 ,到 4h时达高峰 ,其后逐渐下降 ,到 12h时已逐渐降至正常。DNA梯形电泳显示在兔冠脉结扎后 3h、4h、6h时梗塞区的心肌细胞均出现相差约 180～2 0 0bp的DNA阶梯 (Ladder) ,而其它各时间点的心肌细胞未见有相差约 180～ 2 0 0bp的DNA条带。电镜观察显示在兔冠脉结扎后梗塞区内的心肌细胞核膜完整、染色质浓集、电子密度增加的凋亡特征 ,有的则出现核膜破裂、染色质溶解成碎屑的坏死现象。结论　兔冠脉在结扎 3～ 6h时梗塞的心肌细胞凋亡特征最明显 ,细胞凋亡在急性心梗心肌细胞死亡中起重要作用。     

Fatality of myocardial infarction in relation to the coronary anatomy: role of culprit lesion location

OBJECTIVE. We set out to study the effect of the location of the culprit coronary lesion on myocardial infarction (MI) fatality by combining data from MI survivors in the coronary care unit (CCU) and autopsied patients with pre‐hospital fatal MI.

DESIGN. We studied two simultaneous series of men under 70 years with fatal pre‐hospital MI ( n ?=?36) and men admitted for acute ST‐elevation‐MI ( n ?=?92). The culprit lesion was identified by the presence of thrombus at autopsy and by coronary angiography in patients admitted to the CCU.

RESULTS. The culprit lesion was located in the right coronary artery (RCA) in 22 (61%) of 36 men with fatal MI compared to 30 (33%) of 92 men with non‐fatal MI (P ?=?0.01). Seventy‐three percent of fatal RCA occlusions were proximal as opposed to only 30% of non‐fatal RCA occlusions (P?<?0.001). Forty‐four percent of all fatal MI were due to proximal RCA occlusion as opposed to only 10% of non‐fatal MI (P?<?0.005).

CONCLUSIONS. Proximal RCA occlusions were very often found among men with fatal pre‐hospital MI, whereas left‐sided coronary occlusions were significantly more frequent in hospital‐admitted survivors of MI. Left‐sided coronary occlusions may be associated with a more favourable pre‐hospital phase of acute MI compared to proximal RCA occlusions.     

Dissecting aneurysm of the basilar artery as a cause of orgasmic headache

A 39-year-old woman experienced recurrent, severe bursting headache which was abruptly developed at the time of orgasm. Both magnetic resonance angiography and conventional angiogram of the brain confirmed dissecting aneurysm of the basilar artery. After the neuroradiological intervention using a stent was performed, she has been totally free of the orgasmic headache during the follow-up period for about one year.     

Respiratory sinus arrhythmia as a predictor of sudden cardiac death after myocardial infarction

Background. Measurement of high-frequency (HF) spectral power of heart rate (HR) variability has not been able to identify the patients at risk of sudden cardiac death (SCD) despite the experimental evidence of protective role of vagal activity for fatal arrhythmias.

Aim. We developed a novel respiratory sinus arrhythmia (RSA) analysis method and tested its ability to predict SCD after an acute myocardial infarction.

Method. The RSA analysis method was developed in 13 subjects from simultaneous recordings of respiration and R-R intervals. An adaptive threshold was computed based on the zero-phase forward and reverse digital filtering in the analysis of RSA. With this method, only respiration-related R-R interval fluctuations are included. The prognostic power of RSA, analyzed from 24-hour electrocardiographic recordings, was subsequently assessed in a large postinfarction population including 1631 patients with mean follow-up of 40±17 months.

Results. Depressed RSA was a strong predictor of SCD (hazard ratio 7.4; 95% CI 3.6–15.1; P <0.0001) but only a weak predictor of non-SCD. The RSA index remained an independent predictor of SCD after adjustments for ejection fraction and other clinical risk variables (RR 4.7; 95% CI 2.28–9.85).

Conclusions. Reduced respiratory-related HR dynamics, detected by RSA index, are a specific marker of an increased risk of SCD among postinfarction patients.