急性心肌梗死患者的直接经皮腔内冠状动脉成形术与溶栓治疗疗效比较

为探讨急性心肌梗死直接经皮腔内冠状动脉成形术的安全性及临床疗效 ,选择 6 2例未经静脉和冠状动脉内溶栓治疗的急性心肌梗死患者 ,在紧急冠状动脉造影后即行直接经皮腔内冠状动脉成形术 ;另外选择 5 9例急性心肌梗死患者 ,采用溶栓治疗 ,溶栓治疗后不再接受介入治疗和外科冠状动脉搭桥 ,然后比较直接经皮腔内冠状动脉成形术和溶栓治疗的疗效、安全性及预后。结果发现 ,直接经皮腔内冠状动脉成形术组 6 0例再灌注成功 ,成功率为 96 .7% ,其中 4例合并心源性休克的患者均再灌注成功 ,血压回升 ,急性上消化道出血 1例 ,死亡率为 0 ;溶栓治疗组 38例再灌注成功 ,成功率为 6 4 .4 % ,住院期间死亡 5例 ,出院 6月内死亡 2例 ,急性上消化道出血 1例 ,血尿 1例 ,溶栓治疗后心源性休克 5例 ,死亡率为 1 1 .9%。直接经皮腔内冠状动脉成形术再灌注成功率明显高于溶栓治疗 ,死亡率和主要心脏事件的发生率明显低于溶栓治疗 (P <0 .0 1 )。结果提示 ,急性心肌梗死的直接经皮腔内冠状动脉成形术治疗安全有效 ,再灌注成功率明显高于溶栓治疗 ,疗效及预后优于溶栓治疗     

急性心肌梗死早期再灌注性心室颤动

目的　探讨再灌注性心室颤动 ( RVF)易发因素、治疗及预后。方法　 35 8例接受再灌注疗法的急性心肌梗死 ,其中静脉溶栓 32 2例 ,急症 PTCA36例 ,临床再通者 2 2 1例 ,其中溶栓组 186例 ,急症 PT-CA组 35例 ,临床再通者有 7例发生 RVF,其中溶栓组 6例 ,急症 PTCA组 1例。结果　 7例 RVF平均年龄为 41.6± 2 .8岁 ,胸痛至再灌注时间为 3.2± 0 .8小时 ,RVF发生前多无恶性心律失常等先兆 ,闭塞部位于冠状动脉近端 ,开通后残余轻 ,随访 2 3.3月无心室颤动复发。结论　心肌梗死时缺血范围大 ,再灌注时间早 ,再灌注流量大 ,是 RVF的易发因素 ,电转复是有效的治疗方法。随访期间无心室颤动复发 ,预后良好     

急性心肌梗死直接冠状动脉成形术后再灌注心律失常分析

目的 分析急性心肌梗死直接冠脉成形术后严重再灌注心律失常发生的状况，探讨其预防和紧急治疗方法。方法 行直接经皮冠状动脉成形术的急性心肌梗死患者245例，根据梗死相关动脉分成三组，LAD组：126例；RCA组：97例；LCX组：22例。统计各组经皮冠状动脉成形术后再灌注心律失常发生的状况。结果 共151例患者发生严重的再灌注心律失常，发生率为61．6％；加速性室性自主心律发生率最高(22．0％)，与梗死相关动脉无关；其次是室性早搏(19．2％)，以LAD组最高(27．8％)。RCA组缓慢性心律失常(窦缓、窦性停搏、高度房室传导阻滞)发生率(35．1％)显著高于LAD组(3．9％)和ICX组(22．7％)：LCX组各种再灌注心律失常发生率界于LAD组和RCA组之间。结论 急性心肌梗死直接冠脉成形术后严重心律失常总的发生率较高，心律失常的类型与梗死相关动脉有明确的相关性。     

急性ST段抬高型心肌梗死经皮冠状动脉介入治疗术中再灌注心律失常的临床特点

目的观察急性sT段抬高型心肌梗死行经皮冠状动脉介入治疗（PCI）术中再灌注心律失常发生特点,提高救治成功率。方法对188例急性sT段抬高型心肌梗死患者在12小时内行急诊PCI,根据梗死相关动脉,分为前降支组、回旋支组及右冠状动脉组,观察3组再灌注心律失常发生情况,分析再灌注心律失常与梗死相关动脉的关系,了解冠脉再通时间对再灌注心律失常的影响。结果185例患者中185例成功植入支架。其中完全闭塞156例,次全闭塞或部分再通者32例,共发生再灌注心律失常75例,右冠状动脉组缓慢心律失常发生率高于前降支组和回旋支组,而快速心律失常发生率低于前降支组、回旋支组,但无统计学差异。开通时间越早,再灌注心律失常发生率越高,〈4小时组的快速心律失常发生率、缓慢心律失常发生率均大于4～8小时组、〉8小时组。结论直接PCI治疗开通梗死相关血管率高,是治疗急性心肌梗死的有效方法;随着血管的开通,可以发生再灌注心律失常,4小时内开通者发生再灌注心律失常高,右冠状动脉心肌梗死更容易发生缓慢性心律失常,只要及时处理,再灌注心律失常预后良好。     

无复流现象的预防与治疗

急性心肌梗死（AMI）治疗的关键是尽早给予冠状动脉（冠脉）血管重建，包括药物溶栓、经皮冠状动脉腔内成形术（PTCA）、支架及冠状动脉搭桥等，使梗死相关动脉再通，恢复心肌灌注。然而在临床实践中，某些心外膜血管在再灌注治疗期间已解除机械性梗阻，但相应心肌组织并没有完全有效地恢复血流灌注，即无复流现象。Abbo指出无复流作为一种并发症，使住院死亡和MI发生率增加5～10倍。无复流本身虽不是危险区心肌梗死（MI）的最初原因，但无复流是继续缺血、梗死延展、心室重构、心功能恢复障碍及MI急性期高死亡率的预测指标，也是严重心肌和微血管损伤的标记。无复流是评估现代再灌注治疗成功与否的主要指标之一，因此成为近年来研究的焦点。     

女性急性心肌梗死患者再灌注治疗的疗效观察

<正> 当今急性心肌梗死(AMI)再灌注治疗的主要手段包括溶栓治疗和直接经皮冠状动脉腔内成形术(PTCA+支架术).它们是近年来广泛应用于临床的肯定疗法.国内外几个大规模临床试验显示尽管其年龄、性别等因素不同,其临床预后均显著改善,即病死率降低,心功能改善.但AMI患者因性别不同,在接受再灌注治疗后可能会存在某些差异.本文旨在回顾性分析我院4年内AMI患者接受溶栓治疗和直接PTCA+支架术的疗效,以观察男女性别之间再灌注治疗的差别.     

急性心肌梗死患者静脉溶栓失败后补救性介入治疗的疗效观察

目的:探讨溶栓失败后即刻补救性介入治疗术(PCI)——经皮腔内冠状动脉成形术(PTCA)或支架置入术(STENT)治疗急性心肌梗死(AMI)的安全性及近期疗效。方法:将59例AMI患者分为直接PCI组(A组)、补救性PCI组(B组)2组。A组31例,直接行PCI;B组28例,静脉溶栓后120min时,依冠状动脉开通临床标准进行判定,若溶栓失败立即行PCI。2组患者均于PCI前及PCI后即刻行冠状动脉造影观察再通率。治疗后3周用超声心动图测量并计算左室射血分数、住院期间再发心肌缺血事件发生率、病死率、出血并发症及住院天数。结果:2组患者梗死相关血管的再通率、住院期间死亡率、支架置入成功率、住院期间再梗死率、平均住院天数、出血并发症及心功能均差异无统计学意义。结论:补救性PCI成功率高,具有较好的临床效果,并未增加出血并发症,可以在临床推广应用。     

急性心肌梗死介入再灌注治疗的进展

急性心肌梗死 (ＡＭＩ)发病后 6～ 12ｈ内给予静脉溶栓治疗 ,可以降低住院病死率 ,改善患者的预后 ,但静脉溶栓治疗临床再通率为 6 0 %～ 70 % ,90ｍｉｎ冠状动脉 (冠脉 )造影心肌梗死血流分级 (ＴＩＭＩ) 3级者仅 5 0 %左右 ,早期再闭塞率约 5 %～ 10 % ,晚期再闭塞率 30 % ,颅内出血及卒中等并发症限制了溶栓治疗的使用。直接经皮冠脉介入 (ＰＣＩ)治疗ＡＭＩ是对胸痛症状发作 6～ 12ｈ内的患者直接进行冠状动脉造影 ,通过经皮穿刺冠脉血管成形术 (ＰＴＣＡ)或同时置入支架将闭塞的冠脉开通 ,恢复血流灌注 ,初步临床研究结果令人满意 ,它…     

入院血糖水平与急性心肌梗死相关性的临床研究

目的：评价经再灌注治疗成功的初发ST段抬高急性心肌梗死（STEMI）患者入院血糖水平与住院期间临床事件发生的相关性。方法：将135例经急诊经皮冠状动脉介入治疗（PCI）或溶栓治疗再通的初发STEMI患者按入院血糖水平高低分为3组,分析各组在危险因素、住院期间临床事件特征、心肌梗死部位及范围、梗死相关动脉部位及冠状动脉病变累及支数之间的关系。结果：随着血糖水平的增高,合并2型糖尿病的患者增多,住院期间的心血管事件发生率增高,患者冠状动脉病变累及支数更多,3组间均有显著性差异（P值均〈0．05）。结论：STEMI入院血糖增高更多见于合并2型糖尿病的患者;高血糖是经再灌注治疗的sTEMI患者住院期间心血管事件发生的危险因素,且冠状动脉造影示病变累及的范围更广。     

入院血糖水平与急性心肌梗死相关性的临床研究

目的：评价经再灌注治疗成功的初发ST段抬高急性心肌梗死（STEMI）患者入院血糖水平与住院期间临床事件发生的相关性。方法：将135例经急诊经皮冠状动脉介入治疗（PCI）或溶栓治疗再通的初发STEMI患者按入院血糖水平高低分为3组,分析各组在危险因素、住院期间临床事件特征、心肌梗死部位及范围、梗死相关动脉部位及冠状动脉病变累及支数之间的关系。结果：随着血糖水平的增高,合并2型糖尿病的患者增多,住院期间的心血管事件发生率增高,患者冠状动脉病变累及支数更多,3组间均有显著性差异（P值均〈0．05）。结论：STEMI入院血糖增高更多见于合并2型糖尿病的患者;高血糖是经再灌注治疗的sTEMI患者住院期间心血管事件发生的危险因素,且冠状动脉造影示病变累及的范围更广。     

经皮冠状动脉介入治疗急性心肌梗死伴心力衰竭、心源性休克的疗效分析

目的观察ST段抬高的急性心肌梗死(AMI)伴心力衰竭(心衰)、心源性休克患者经皮冠状动脉介入(PCI)治疗的近期和中期疗效。方法206例ST抬高AMI患者,伴心衰和(或)休克90例。对心衰和(或)心源性休克患者行PCI58例、药物溶栓20例、一般治疗12例(未行再灌注组);比较PCI组和溶栓组的住院时间、住院及随访期间不良心血管事件发生率、心功能恢复情况,观察PCI组血管开通时间、TIMI血流与预后的关系。结果PCI组、溶栓组血管开通率分别为98.3%和65.0%(P<0.01),平均住院时间分别为15.3天±3.5天和20.5天±4.4天,住院及随访期间死亡率PCI组6.9%,溶栓组25%(P<0.05)。PCI组两亚组术后心功能恢复均好于溶栓组(P<0.01和P<0.05)。结论PCI与溶栓相比,能及时开通血管且开通率高,术后心功能恢复较好,安全有效,可作为首选。     

老年ST段抬高急性心肌梗死患者急诊介入与溶栓治疗比较

目的急性心肌梗死（AMI）后尽早恢复梗死相关动脉的再灌注是治疗中的首要问题。本研究旨在评价老年急性ST段抬高性心肌梗死（STEMI）分别接受直接经皮冠状动脉介入（PCI）治疗和溶栓治疗住院及随访期间的临床疗效差别。方法109例65岁以上老年STEMI患者,59例行直接PCI治疗,50例行溶栓治疗。比较2组梗死相关动脉（IRA）再通率、左室功能指标、病死率及主要心血管事件发生率的差别。结果PCI组IRA开通率明显高于溶栓治疗组,住院病死率明显低于溶栓治疗组,左室功能指标明显优于溶栓治疗组（左室射血分数更高、左室舒张末径较小、室壁运动障碍率较低。随访期间比较,PCI组再次血运重建率和心血管病死率明显低于溶栓治疗组。结论老年AMI患者行直接PCI治疗能够显著提高IRA再灌注成功率,保护心功能,减少再次血运重建,并且在降低病死率及心血管事件上也总体优于溶栓治疗。     

冠状动脉介入治疗再灌注时间对急性前壁心肌梗死左室重构及远期预后的影响

目的评价冠状动脉介入治疗(PCI)再灌注时间对急性前壁心肌梗死左室重构及远期预后的影响。方法选择113例首次急性前壁心肌梗死患者,冠状动脉造影证实梗死相关动脉(IRA)完全闭塞(TIMI0～1级)。依据PCI再灌注时间分为3组,A组35例,6h内IRA成功再灌注;B组40例,6～12h内IRA成功再灌注;C组38例,12～24h内IRA成功再灌注。分别于术后即刻和6个月行冠状动脉造影及左心室造影,对比分析3组左心室造影的心功能指标:左心室舒张末容积、左心室收缩末容积、左心室射血分数、每分输出量、心脏指数,并观察1年内主要不良心脏事件(MACE)的发生情况。结果成功再灌注即刻,3组之间各项心功能参数无显著性差异。6个月时A组和B组各项心功能参数较即刻有改善趋势;C组较前下降,但均无统计学意义。1年随访期间,A、B组无死亡及再次心肌梗死事件发生。心绞痛的发生在3组中无差别。C组心力衰竭及死亡的发生均明显高于A、B组。结论前壁心肌梗死后尽早行PCI,开通IRA,可阻抑左室重构,改善心功能,减少死亡等MACE的发生,从而改善预后。     

急性心肌梗死急诊介入治疗与溶栓治疗的疗效比较

目的比较急性ST段抬高性心肌梗死(STEMI)患者分别接受直接经皮冠状动脉介入(PCI)治疗和溶栓治疗住院及随访期间的临床疗效差别。方法108例STEMI患者,66例行直接PCI治疗(PCI组),42例行溶栓治疗(UK组)。比较2组梗死相关动脉(IRA)再通率、左室功能指标、病死率及主要心血管事件发生率的差别。结果PCI组IRA开通率高于UK组(P<0.01),住院病死率低于UK组(P<0.05),左室功能指标优于UK组(左室射血分数更高、左室舒张末径较小、室壁运动障碍率较低,P<0.05)。随访期间比较PCI组再次血运重建率低于UK组(P<0.01),心血管病死率低于UK组(P<0.05)。结论与溶栓治疗相比,PCI治疗能及时有效地开通梗死相关血管,改善左室功能,降低病死率和再次血运重建率。     

直接PCI治疗高龄急性ST段抬高性心肌梗死

目的评价高龄急性ST段抬高性心肌梗死（ST-segment elevation myocardial infarction,STEMI）患者行直接经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗的安全性和有效性。方法对比分析46例高龄STEMI患者（高龄组）和64例年轻STEMI患者（年轻组）冠状动脉造影特征、直接PCI治疗的情况．即刻手术成功率、住院及随访期间主要心血管事件的发生情况。结果高龄组与年轻组比较,冠状动脉病变多为多支病变（73．9％比28．1％,P〈0．01）;2组手术即刻成功率无明显差异;2组术后达到心肌梗塞溶栓（thrombolysis inmyoxardial infarction,TIMI）3级血流患者比率无明显差异;高龄组手术操作时间较年轻组长[（64．4±25．4）min比（49．7±21．8）min,P〈0．05];高龄组住院期间、随访期间累计总的主要心血管事件发生率明显高于年轻组。随访期间,高龄组1例术后4个月猝死,死亡原因不明,1例术后1年死于脑出血：年轻组无死亡病例。结论对高龄STEMI患者行直接PCI治疗是比较安全而有效的再灌注手段。     

In hospital observation of patients with acute coronary syndrome without ST elevation and multivessels coronary artery disease treated with early invasive strategy. Comparison of results of percutaneous coronary intervention and coronary artery by-pass grafting

Acute coronary syndromes (ACS) without persistent ST-segment elevation are the main cause of hospitalization, morbidity and mortality. The objective of this study was to compare clinical and angiographic parameters as well as in-hospital results of treating 307 consecutive patients with ACS without persistent ST-segment elevation with either PCI or CABG. Inclusion criteria were: rest angina within the last 24 hours, ST-segment depression (> 0.5 mm), T-wave inversion (> 1 mm) in at least two leads, positive serum cardiac markers. PCI was performed in 75.9% of patients and 24.1% of patients underwent CABG. Both groups did not differ as to age, sex, history of diabetes, arterial hypertension, heart failure, smoking and ejection fraction. Positive troponin was significantly more frequent in the PCI group. 51% of PCI patients and 80% of CABG patients had complete revascularization (p = 0.00001). Independent predictors of in-hospital death in the CABG group were: inability to determine culprit vessel during coronary angiography due to lesions' severity (OR 13.65; 95% CI 9.40-15.20; p = 0.007) and heart failure (OR 15.58; 95% CI 12.29-18.01; p = 0.003). In the PCI group these independent predictors were: Braunwald's IIIC unstable angina (OR 5.48; 95% CI 3.10-7.17; p = 0.04) and diabetes (OR 2.22; 95% CI 1.07-3.90; p = 0.003). In-hospital mortality rate was significantly higher in the CABG group (8.1% vs 1.7% p < 0.01). Patients with multivessel coronary artery disease and ACS without ST-segment elevation treated with PCI have better in-hospital outcome than patients assigned to CABG, but the rate of complete revascularization is lower.     

Predictors of long-term outcomes following direct percutaneous coronary intervention for acute myocardial infarction.

To determine predictors of a long-term major adverse cardiac event (MACE) in unselected patients undergoing direct percutaneous coronary intervention (PCI), 274 consecutive patients presenting within 12 hours of ST-segment elevation acute myocardial infarction (AMI) were evaluated. No patient with ST-segment elevation AMI received intravenous thrombolytic drugs. Chest pain to balloon time was 3.8 hours (range 2.5 to 6.9). percutaneous transluminal coronary angioplasty was successful in 95% of patients. Abciximab was administered to 69% of patients, stents were deployed in 53%, and 17% underwent only catheterization. In-hospital events were death (7%), abrupt closure (2%), emergent coronary artery bypass grafting (CABG) (5%), repeat PCI (3%), and recurrent myocardial infarction (1%). In patients undergoing direct PCI (n = 227), the in-hospital event rate was death 5.3%, abrupt closure 2.2%, emergency CABG 0.9%, repeat PCI 3.1%, and repeat myocardial infarction 1.3%. Median time to last follow-up or death was 20 months (range 11 to 34), and to any event, 0.3 months (range 0.03 to 24.0). Postdischarge MACE included death (5%), AMI (4%), repeat PCI (8%), CABG (9%), and stroke (0.7%). Among those undergoing direct PCI (n = 227), 10% died, 3.5% had a repeat AMI, 9% had a repeat PCI, 5% had CABG, and 1% had a stroke at long-term follow-up. At long-term follow-up, 75% were event free. Multivariate predictors were (hazard ratio [95% confidence interval (CI)]): abciximab use 0.6 (95% CI 0.43 to 0.95), Killip class 2.2 (95% CI 1.1 to 4.4), and number of narrowed coronary arteries 1.7 (95% CI 1.4 to 2.2). In this unselected consecutive series of patients presenting with ST-segment elevation AMI, direct PCI was associated with sustained long-term efficacy. Outcomes were predicted by cardiac impairment at presentation and number of narrowed coronary arteries. MACE is not related to device selection but is significantly improved with abciximab.     

Acute Myocardial Infarction with Hyperoxemic Therapy (AMIHOT): a prospective, randomized trial of intracoronary hyperoxemic reperfusion after percutaneous coronary intervention.

OBJECTIVES: This study sought to determine whether hyperoxemic reperfusion with aqueous oxygen (AO) improves recovery of ventricular function after percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). BACKGROUND: Hyperbaric oxygen reduces myocardial injury and improves ventricular function when administered during ischemia-reperfusion. METHODS: In a prospective, multicenter study, 269 patients with acute anterior or large inferior AMI undergoing primary or rescue PCI (<24 h from symptom onset) were randomly assigned after successful PCI to receive hyperoxemic reperfusion (treatment group) or normoxemic blood autoreperfusion (control group). Hyperoxemic reperfusion was performed for 90 min using intracoronary AO. The primary end points were final infarct size at 14 days, ST-segment resolution, and delta regional wall motion score index of the infarct zone at 3 months. RESULTS: At 30 days, the incidence of major adverse cardiac events was similar between the control and AO groups (5.2% vs. 6.7%, p = 0.62). There was no significant difference in the incidence of the primary end points between the study groups. In post-hoc analysis, anterior AMI patients reperfused <6 h who were treated with AO had a greater improvement in regional wall motion (delta wall motion score index = 0.54 in control group vs. 0.75 in AO group, p = 0.03), smaller infarct size (23% of left ventricle in control group vs. 9% of left ventricle in AO group, p = 0.04), and improved ST-segment resolution compared with normoxemic controls. CONCLUSIONS: Intracoronary hyperoxemic reperfusion was safe and well tolerated after PCI for AMI, but did not improve regional wall motion, ST-segment resolution, or final infarct size. A possible treatment effect was observed in anterior AMI patients reperfused <6 h of symptom onset.     

Primary versus rescue percutaneous coronary intervention in patients with acute myocardial infarction

OBJECTIVE: To compare angiographic and clinical outcomes of patients with acute myocardial infarction (AMI) who underwent primary percutaneous coronary intervention (PCI) versus rescue PCI following failed thrombolysis. BACKGROUND: Patients presenting with AMI are treated either with primary PCI or with thrombolysis. When thrombolysis fails, rescue PCI is performed. METHODS AND RESULTS: We compared the outcome of 105 consecutive patients with AMI who underwent either primary PCI (60 patients) or rescue PCI (45 patients) between January 1997 and January 1999. The patients were followed for up to 6 months. Time delay to reperfusion was significantly longer in the rescue PCI group (354 vs. 189 min; p < 0.001). The majority of patients received a stent (93%). Glycoprotein (GP) IIb/IIIa inhibitors were used in 53% of patients in the primary PCI group and in 22% in the rescue group. TIMI grade 3 flow was achieved in 93.3% of patients in the primary PCI group and in 88.8% in the rescue group (p = 0.08). Post-procedure ejection fraction was 53% in the primary PCI group and 47% in the rescue group (p = 0.014). A composite endpoint of death, recurrent MI, repeat PCI, coronary artery bypass grafting (CABG) and recurrent angina at 6 months occurred in 35% of the patients in the primary PCI group and 26.7% in the rescue group (p = 0.36). CONCLUSION: Despite a significant delay to reperfusion and a lower immediate post-procedure ejection fraction, the clinical outcome of patients treated with rescue PCI following failed thrombolysis appears to be similar to that of patients treated with primary PCI at 6 months.     

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.