ST段早期恢复反映急性心肌梗死溶栓治疗后心肌再灌注

目的 比较溶栓再通后早期ST段恢复与未恢复者住院期间临床结局的差异，探讨ST段早期恢复在心肌再灌注中的作用。方法 108例溶栓经酶学等指标临床判定再通的急性心肌梗死（AMI）患者，按照有无早期（溶栓后2h)ST段恢复分为两组。连续测定血清肌酸激酶（CK）水平，了解心肌酶峰出现时间及峰值；放射性核素评估左心室功能。观察4周住院期间充血性心力衰竭（CHF）、室壁瘤、心肌梗死后心绞痛发生情况及病死率。结果 无论是前壁MI还是下壁MI，ST段早期恢复组左心室射血分数均高于未恢复组（P＜0．05）；CK峰值则低于未恢复组（P＜0．05）。住院期间ST段恢复组核素心肌显像充盈缺损、CHF及室壁瘤发生率低，心肌梗死后心绞痛发生率高（P值均小于0.05)。结论 同ST段未恢复组相比，溶栓再通后ST段早期恢复者临床预后好。心电图模式可以反映再灌注程度。     

The effect of preinfarction angina on clinical reperfusion time in patients with acute myocardial infarction receiving successful thrombolytic therapy

BACKGROUND: Preinfarction angina (PA) and early reperfusion of infarct-related arteries have been shown to reduce infarct size in patients with acute myocardial infarction (AMI). The beneficial effects of PA on infarct size have been attributed to the development of ischemic preconditioning and faster coronary recanalization in patients treated with thrombolytic therapy (TT). OBJECTIVE: To evaluate the effect of PA on clinical coronary reperfusion time in patients with AMI receiving successful TT. METHODS: Seventy-five patients presenting with AMI (within 6 h after the initial onset of symptoms) were studied. All patients received TT and were evaluated with coronary angiography (CA) at predischarge. The patients were divided into two groups: group 1 (PA-positive) comprised those who experienced a new onset of prodromal angina within 72 h before the onset of AMI. Group 2 (PA-negative) comprised those who had a sudden onset of AMI without the preceding angina. The successful myocardial reperfusion criteria after TT were ST segment resolution of 50% or greater, the appearance of reperfusion arrhythmias and the resolution of chest pain. The time of reperfusion criteria was recorded after TT. CA was performed in all patients at predischarge. Patients with no patent infarct-related arteries on CA and clinical failure of reperfusion were excluded from the study. RESULTS: Clinical characteristics, risk factors and angiographic findings did not differ significantly between the groups. The time interval from the start of continuous chest pain to TT was also similar between the groups. The left ventricular ejection fraction was higher and there were less frequent ventricular arrhythmias in patients with PA than in those without PA (47.9+/-7.4 versus 44.4+/-8.1, P=0.041, and 17.1% versus 37.5%, P=0.043, respectively). The clinical reperfusion time was significantly shorter in the patients with PA than in those without PA (68.2+/-24.5 min versus 81.4+/-19.3, P=0.012). The clinical reperfusion time was positively correlated with age and the time interval from the start of continuous chest pain to TT but inversely related to the presence of PA. CONCLUSIONS: In patients with AMI preceded by PA, TT resulted in more rapid clinical reperfusion than in patients without PA. Thus, earlier myocardial reperfusion may account for smaller infarct size and better prognosis in patients with PA.     

急性心肌梗塞溶栓后神经肽γ、一氧化氮、超氧化物歧化酶、丙二醛含量的变化

目的:探讨急性心肌梗塞(AMI)患者溶栓前、后血清神经肽γ(NPY)、一氧化氮(NO)、超氧化物歧化酶(SOD)、丙二醛(MDA)的含量变化及临床意义。方法:测定108例健康人和171例AMI患者溶栓前及溶栓后1、2、3、24、48和72 h血清中NPY、NO、SOD和MDA的含量。结果:与健康人比较,溶栓前患者NPY和MDA含量升高,NO和SOD含量降低(P<0.05)。溶栓后1~3 h的再通组与溶栓前及未通组比较,NPY和MDA含量更高,而NO和SOD含量更低(P<0.01)。再通组的NPY和MDA高峰和NO和SOD的低谷均出现在溶栓后2 h。溶栓24 h后再通组NPY和MDA含量下降,而NO和SOD含量升高(P<0.05),其变化幅度大于未通组(P<0.01)。结论:AMI溶栓1~3 h内NPY和MDA明显升高,NO和SOD明显下降,可能与溶栓后早期内皮功能损伤有关。     

急诊PCI对急性心肌梗死合并新发右束支传导阻滞患者左室重构的影响

目的探讨急诊经皮冠状动脉介入治疗（PCI）对急性心肌梗死合并新发右束支传导阻滞患者左室重构的影响。方法86例新发右束支传导阻滞的AMI患者随机分为急诊PCI治疗组（45例，观察组）及静脉溶栓治疗组（41例，对照组），分别于人院后24h、I周、1个月及3月行超声心动图检查，测量左心室舒张末期容积指数、左心室收缩末期容积指数和左心室射血分数。结果急诊PCI组与静脉溶栓治疗组于术后1个月及3个月左心室容积均减小，左心室射血分数升高；术后3个月两组左心室舒张期末容积指数[（63．4±5．8）ml／m^2比（67．3±6．4）ml／m^2]、左心室收缩期末容积指数[（30．5±3．4）ml/m^2比（34．6±4．0）ml／m^2]和左心室射血分数[（0．53±0．04）％比（0．50±0．02）％]，差异有统计学意义。结论急诊PCI治疗可明显抑制新发右束支传导阻滞的急性心肌梗死患者左室重构，改善左心室功能。     

Assessment of potentially salvageable myocardium during acute myocardial infarction: use of postextrasystolic potentiation

Twenty-three patients with evolving acute myocardial infarction (AMI) undergoing catheterization for thrombolytic therapy had interventional contrast ventriculography using programmed atrial stimulation. Postextrasystolic (PES) potentiation was present in 67% of infarct-related segments up to 9 hours after the onset of AMI. The presence of segmental potentiation was not related to time from onset of pain to ventriculography, initial ejection fraction, presence of collaterals, left ventricular end-diastolic pressure or the PES delay. In 18 patients reperfusion was successful using intracoronary streptokinase an average of 6.2 hours after the onset of AMI; in these patients repeat contrast ventriculography was performed an average of 11 days after AMI. Improved chronic segmental ventricular function was predicted by the presence of collaterals to the infarct-related artery at the time of acute catheterization (p = 0.02), but was best predicted by analysis of acute PES potentiation (p less than 0.0001). The predictive value of PES analysis was highest in segments without collaterals. Thus, atrial stimulation is safe during AMI and analysis of segmental ventricular function shows potentially viable myocardium up to 9 hours after the onset of AMI. In addition, analysis of PES segmental function can predict chronic function if reperfusion is successful, especially in segments without collaterals. PES ventriculographic analysis may allow prospective determination of which patients during AMI are most likely to benefit from acute thrombolytic therapy.     

急性心肌梗死早期溶栓治疗对QT离散度及恶性室性心律失常的影响

研究急性心肌梗死（ＡＭＩ）后溶栓治疗对ＱＴ离散度（ＱＴｄ）及恶性室性心律失常（ＭＶＡ）事件的影响。回顾性选择分析ＡＭＩ患者７５例（溶栓治疗组４３例、未溶栓组３２例）,通过测量入院时及入院后２４ｈ常规心电图计算ＱＴｄ、校正ＱＴｃ（ＱＴｃｄ）,并在入院后一周内心电监护观察ＭＶＡ事件发生情况。溶栓再通组ＱＴｄ、ＱＴｃｄ较溶栓前显著缩短（４２．６±１４．３ｍｓｖｓ７１．７±１６．９ｍｓ,４５．９±１７．４ｍｓｖｓ７４．８±１８．５ｍｓ,Ｐ均＜０．０１）;溶栓未通组、未溶栓组入院２４ｈ期间ＱＴｄ、ＱＴｃｄ无明显变化（Ｐ＞０．０５）。ＱＴｄ、ＱＴｃｄ≥９０ｍｓ者ＭＶＡ事件明显高于＜９０ｍｓ者（７０．６％ｖｓ１０．２％,Ｐ＜０．０１）,溶栓再通组ＭＶＡ事件与溶栓未通组比较趋于减少（１１％ｖｓ２８％）。结论：ＡＭＩ后成功的溶栓治疗可以缩短心室复极的ＱＴｄ,从而可能减少ＡＭＩ后早期ＭＶＡ的发生;无效的溶栓治疗对ＡＭＩ近期预后无任何影响。     

Levels of tumor necrosis factor (TNF-alpha) and interleukin 6 (IL-6) in serum of patients with acute myocardial infarction

In acute myocardial infarction may increase the synthesis of cytokines, which can enlarge the myocardial lesion owing to their direct toxic action on myocytes or induction of inflammatory changes that lead to myocardiofibrosis. All this may quickening the appearance of congestive heart failure after myocardial infarction. The aim of the study was examination of tumor necrosis factor (TNF-alpha) and interleukin 6 (IL-6) plasma levels in patients with acute myocardial infarction and analysis of correlation between concentrations of these cytokines and myocardial lesions during infarction. The study was made in 94 patients admitted to the Department of Cardiology with acute myocardial infarction (AMI). Of these, 40 were women aged from 41 to 85 (mean 67 years) and 54 were men aged from 39 to 86 (mean 63 years). Anterior AMI was diagnosed in 40 patients, inferior AMI was diagnosed in 54 patients. 63 patients underwent the thrombolytic therapy, reperfusion appeared in 45 patients, 24 patients were excluded from the thrombolytic therapy. Control group consisted of 28 healthy persons aged from 35 to 76 (mean 61 years). Blood samples for determination of TNF-alpha and IL-6 plasma levels were taken just after admission prior to the treatment. Then patients were taken streptokinase or tissue-type plasminogen activator with typical doses. Blood samples for determination of cytokines were obtained in 3. and 7. day after treatment. TNF-alpha and IL-6 plasma levels were determined with radioimmunological assay. Creatine kinase activity were monitored in patients with AMI as well as ejection fraction was checked in echocardiography in 3. and 7. day after treatment. We showed increased plasma levels of TNF-alpha and IL-6 in patients with AMI with maximum in 3. day of infarction. Concentrations of cytokines were higher in patients with anterior AMI than in patients with inferior AMI. In anterior infarction concentrations of cytokines were significantly lower after thrombolytic therapy with reperfusion than after treatment without reperfusion. There is a correlation between infarct size and concentrations of TNF-alpha and IL-6.     

Effect of delayed coronary angioplasty after thrombolytic therapy on outcome of acute myocardial infarction

Patients with acute myocardial infarction (n=161) were in random order divided into 2 groups: (1) those who received thrombolytic therapy (TT), (n=126), (2) those who received TT, optimized coronary angioplasty (TT+CA) on days 2-7 (n=35). During hospital period we assessed systolic and diastolic left ventricular (LV) function, content of cytokine tumor necrosis factor a (TNF a) and its soluble receptor type I (sTNF alphaR-I). Outcomes were registered after 1 year. By the end of hospital period group 2 had significantly higher LV ejection fraction, smaller left atrial dimensions, and lower pulmonary artery pressure. Zones of disturbances of local contractility were more rarely registered in this group. No significant differences were revealed between groups 1 and 2 in parameters of LV diastolic function, levels of TNF alpha and sTNF alphaR-I were revealed by the end of hospital period. After 1 year end point (cardiac death/reinfarction/revascularization) was noted in 47.5% of patients of group 1 and only in 20% of patients in group 2 (relative risk 0.48; 95% confidence interval 0.21-0.84, p=0.0035). Thus delayed CA after TT in acute myocardial infarction is an effective method of reperfusion therapy.     

急性心肌梗塞静脉溶栓治疗改善左心室功能的作用

为评价急性心肌梗塞（ＡＭＩ）静脉溶栓再灌注对左心室功能及重塑的影响，应用二维超声心动图（２ＤＥ）对６１例ＡＭＩ接受静脉溶栓治疗的患者，分别在急性期及６个月后随访时测量并计算左心室容积（ＥＳＶ和ＥＤＶ），射血分数（ＥＦ），左心室内膜弧长（ＡＳＬ和ＰＳＬ）以及室壁运动指数（ＧＷ－ＭＩ和ＲＷＭＩ）。结果显示，以上各项指标急性期时两组比较差异均无显著性，在６个月后的随访中，再通组ＥＦ值明显高于未通组，再通组左室容量减小、变形减轻。急性期两组的心功能无差异，随访时再通组心功能较未通组显著改善。提示溶栓再灌注能明显减轻左心室的扩张及抑制左心室重塑，改善患者的心功能和预后。     

Viable Myocardium Impact on Left Ventricular Function after Late Revascularization of Infarct-related Artery in Acute Myocardial Infarction

Objectives The long-term benefit of late reperfusion of infarct-related artery (IRA) after acute myocardial infarction (AMI) is controversial, and the benefit mechanisms remain uncertain. Low dose dobutamine stress echocardiography (LDSE) can identify viable myocardium and predict improvement of wall motion after revascularization. Methods Sixty-nine patients with first AMI who did not received early reperfusion therapy were studied by LDSE at 5 to 10 days after AMI. Wall motion abnormality and left ventricular size were measured at the same time. Successful PCI were done in all patients at 10 to 21 days after AMI onset. Patients were divided in two groups based on the presence or absence of viable myocardium. Echocardiography was repeated six months later. Results There were 157 motion abnormality segments. 89 segments (57%) were viable during LDSE. 26 patients (38%) with viability and 43 (62%) without. In viable group, left ventricular ejection fraction (LVEF) was increased (P < 0.05), and left ventricular end systolic volume index (LVESVI) and wall motion score (WMS) were decreased (P < 0.05 and P < 0.01) significantly at 6 months compared with baseline. But in patients without viability, LVEF was decreased (P < 0.01), and LVESVI and left ventricular end diastolic volume index (LVEDVI) were increased (P<0.05) significantly after 6 months, and the WMS did not changed (P > 0.05). LVEF increased (P< 0.05) and WMS decreased (P < 0.05) on LDSE during acute phase in patients with viability, but they were not changed in the nonviable group. Conclusions Late revascularization of IRA in patients with presence of viable myocardium after AMI is associated with long-term preservation left ventricular function and less ventricular remodeling. Improvement of left ventricular systolic function on LDSE indicates late phase recovery of left ventricular function after late revascularization.     

Serial analyses of ventricular late potentials in patients with reciprocal ST segment changes during acute myocardial infarction

The aim of this study was to determine whether successful reperfusion may alter substrate that is responsible for late potentials in the presence or absence of reciprocal ST segment changes (RC). The study population consisted of 50 patients (27 with RC and 23 without RC) with anterior acute myocardial infarction (AMI) undergoing successful thrombolytic therapy (TT). The presence of reciprocal changes was defined as ST-segment depression >1 mm, measured 80 ms after the J point in at least 2 leads other than those reflecting the infarct on admission ECG. All patients were evaluated with coronary angiography at predischarge. Signal averaged ECG (SAECG) recordings were obtained before and 10 days after TT. Baseline characteristics, SAECG findings, and angiographic data were similar between the groups. The only different baseline finding was the time from symptom onset to TT (204 +/- 150 minutes for patients with RC vs 312 +/- 174 minutes for patients without RC. P = 0.021). After TT, RMS values improved in patients with RC (from 35 +/- 17 microV to 43 +/- 14 microV, P = 0.038) and LAS and RMS were significantly better in this group. However, patients without RC did not show any changes in SAECG parameters after TT. LV ejection fraction (10th day) was better in patients with RC (45 +/- 11% vs 39 +/- 6%, P = 0.014). The frequency of ventricular arrhythmias during the hospitalization period was also similar between the groups. Reciprocal ST depression that regresses simultaneously with the infarction related ECG changes after TT in anterior AMI seems to be related to the time that has elapsed since the symptom onset. The improvement in SAECG parameters after TT in these patients is probably the result of earlier reperfusion leading to less myocardial damage.     

急性心肌梗死患者早期血浆脑钠素与左室重塑的关系

目的　探讨急性心肌梗死 (AMI)早期血浆脑钠素与左室重塑的关系。方法　 44例AMI患者分为依那普利组及常规治疗组 ,采用放射免疫法测定入院后 14d内血浆脑钠素水平 ;超声心动图测定同期及 3个月左室舒张末容积指数 (LVEDVI)、左室收缩末容积指数 (LVESVI)及左室射血分数 (LVEF)。结果　常规治疗组入院后即刻血浆脑钠素水平较健康对照组明显升高 (P <0 .0 1) ,5、14d较入院即刻进一步升高 (P <0 .0 5 )。AMI患者 5、14d血浆脑钠素水平与同期及 3个月LVEDVI、LVESVI正相关 (P <0 .0 5 ,0 .0 1)。与常规治疗组相比 ,依那普利组脑钠素与心室容积指数一致性下降。结论　AMI后早期血浆脑钠素升高与左室重塑密切相关。     

重组人脑钠肽对急性心肌梗死冠脉未通患者左室重塑和心功能的影响

目的研究重组人脑钠肽（rhBNP）对急性心肌梗死（AMI）冠脉未通患者左室重塑和心功能的影响。方法将103例AMI冠脉未通患者随机分为常规治疗组23例、地高辛组40例、rhBNP治疗组40例,并于AMI后1周、12周、24周分别进行超声心动图分析,测定左室心肌重量,左室收缩功能、舒张功能,了解rhBNP对AMI后左室重塑的阻抑作用。结果①AMI后24周时rhBNP组与常规治疗组和地高辛组比较,室间隔厚度、左室后壁厚度、左室舒张末内径和左室心肌重量指数均明显降低。地高辛组与常规治疗组各项指标比较差异无统计学意义。②AMI后1周时,地高辛组和rhBNP组左室收缩末期容积较常规治疗组降低（P〈0．01）,左室射血分数较常规治疗组升高（P〈0．05）,两组间差异无统计学意义（P〉0．05）。治疗后12周、24周时,rhBNP组左室舒张末期容积和收缩末期容积较同时间点常规治疗组和地高辛组均显著降低（P〈0．05）,而左室射血分数、E／A则显著升高（P〈0．05）。结论rhBNP能明显减轻心肌梗死后心肌肥厚和左室重塑,阻抑左室重塑过程,改善左室功能。     

Long-term outcome of primary percutaneous transluminal coronary angioplasty for low-risk acute myocardial infarction in patients older than 80 years: a single-center, open, randomized trial

Background Although coronary reperfusion therapy with thrombolytic agents or percutaneous transluminal coronary angioplasty (PTCA) immediately after acute myocardial infarction (AMI) has survival benefits for younger patients, the effect of coronary reperfusion therapy for very elderly (aged 80 years and older) patients with AMI remains controversial. Methods and Results We studied 120 patients aged 80 years and older at relatively low risk with AMI. The patients were randomized into a primary PTCA group (n = 61) or a “conservative” no-PTCA group (n = 59). Long-term follow-up examination was conducted with regard to endpoints, which included all causes of death, cardiac death, nonfatal re-MI, the development of congestive heart failure, and cerebral vascular accident. End-diastolic volume index and end-systolic volume index were significantly increased in both groups at follow-up examination 6 months after AMI. However, left ventricular ejection fraction, end-diastolic volume index, and end-systolic volume index were similar between both groups. With endpoints of all causes of death, cardiac death, reinfarction, congestive heart failure, and cerebral vascular accident, a 3-year Kaplan-Meier event-free survival rate analysis revealed no significant benefits in the PTCA group. Anteroseptal MI, multivessel disease, and left ventricular ejection fraction were significantly associated with the combined events with multivariate Cox proportional hazards analysis results. Conclusion First, primary PTCA for very elderly patients with AMI appears to have few beneficial effects on combined events during a 3-year period. Second, early PTCA did not prevent left ventricle remodeling after AMI in patients with AMI at relatively low risk. (Am Heart J 2002;143:497-505.)     

The state of lipid peroxidation and antioxidants following thrombolytic therapy with rt-PA and streptokinase in acute myocardial infarction.

The role of reactive oxygen products in myocardial damage caused by ischemia-reperfusion has been established in a number of studies performed in animals models. However, studies showing the development of increased free radicals following effective myocardial reperfusion in humans are scarce. In the present study, both the increase of lipid peroxidation (LPO) following early stage thrombolytic therapy which is the current treatment issue performed after acute myocardial infarct (AMI) and the plasma levels of vitamin E and C (chain braker antioxidants) were investigated parallel to time. Forty patients with AMI who were admitted to hospital within six hours from the beginning of symptoms were included in the study and divided into two groups; group 1 (recombinant tissue-Plasminogen Activator, rt-PA group) and group 2 (streptokinase group). Serial serum specimens were drawn before and 30, 90 minutes and 24 hours after thrombolytic therapy for the investigation of LPO, vitamin E and C levels. Echocardiographic examination was performed on the tenth day to evaluate the functions of the left ventricle. Plasma levels of lipid peroxides (LPO) were found to increase 90 minutes after thrombolytic therapy in each group, while the levels of vitamins E and C showed significant decreases. The difference between the two groups was not significant. Similar to this finding, no significant difference in the ejection fraction values was observed between the groups. Further, no correlation was observed between the ejection fraction and LPO values at the 90th minute which is considered to be the time of successful thrombolysis. In conclusion, the occurrence of a series of biochemical changes confirming an increase in free radical development of peripheral blood was observed. Although the decrease in vitamin E and C levels suggests the need for supplementation of these vitamins along with the thrombolytic therapy, the fact that at least a week is needed for an increase of tissue levels of vitamin E confirms the opinion that the daily prophylactic doses of these vitamins is suitable for the decrease of AMI risk.     

早期补镁对心肌梗死再灌注时心肌顿抑的影响

目的:评价急性心肌梗死(AMI)早期补给硫酸镁对再灌注时心肌顿抑及梗死后左室收缩功能的影响。方法:将82例AMI患者随机分为硫酸镁干预组(n=42)和对照组(n=40),干预组在接受再灌注治疗前30min静脉给予25％硫酸镁20ml,两组均接受静脉溶栓或直接经皮冠脉介入治疗术(PCI)。再灌注成功的病例采用低剂量多巴酚丁胺超声负荷试验(LDDE)检测顿抑心肌的发生,并测定梗死后左室射血分数(LVEF)及左室收缩末期容量(LVESV)。结果:与对照组相比,硫酸镁干预组的顿抑心肌节段和梗死心肌节段较少(P<0.05),左室收缩功能优于对照组(P<0.05)。结论:AMI再灌注治疗同时早期补镁作为一种辅助治疗手段具有重要的意义。     

急诊血运重建对急性心肌梗死左心室功能的影响

目的应用二维超声心动图及多普勒组织成像（Doppler tissue imaging，DTI）评价急诊血运重建（包括静脉溶栓或者急诊冠状动脉支架置入术）对急性心肌梗死（acute myocardial infarction，AMI）左心室收缩和舒张功能的影响。方法入院后根据AMI患者治疗方法分为常规组和治疗组。常规组30例给予内科常规治疗；治疗组20例在内科常规治疗基础上实施静脉溶栓或急诊冠状动脉支架置入术。应用DTI检测左心室射血分数、二尖瓣血流舒张早期流速峰值（peak velocity at early diastole，VE）和舒张晚期流速峰值（peak velocity at late diastole，VA）比值（VE／VA），DTI成像模式检测二尖瓣环后间隔、侧壁、前壁、下壁、前间隔和后壁6个节段的收缩期运动速度峰值（peak velocity during systole，Sa）、舒张早期运动速度峰值（peak velocity at early diastole，Ea）和心房收缩期流速峰值（peak velocitv at atrial contraction，Aa），并计算Ea／Aa比值。各取6个节段的平均值。结果所有AMI患者于发病后1周、3月末左心室射血分数、VE／VA、Sa、Ea和Ea／Aa均较对照组降低；予急诊血运重建的AMI患者于AMI发病后3个月S。和E。较本组发病后1周增高，并较未行急诊血运重建干预组（常规组）发病后3个月增高。结论AMI后左心室收缩和舒张功能受损，实施急诊血运重建可以有效改善心脏功能．应用DTI技术检测二尖瓣环运动速度可以精确反映AMI患者局部节段性心功能的恢复。     

The effect of high plasma levels of angiotensin-converting enzyme (ACE) and plasminogen activator inhibitor (PAI-1) on the reperfusion after thrombolytic therapy in patients presented with acute myocardial infarction

The resistance to thrombolytic agents and delays in reperfusion occur in more than 30% after acute myocardial infarction. This may play an important role in the unsuccessful recanalization after thrombolytic therapy. The aim of this study is to assess the clinical and biochemical markers of reperfusion after different types of thrombolytic therapy and to find out the relationship between PAI-1 and ACE serum levels and the short-term outcome. Pretreatment ACE and PAI-1 plasma levels of 184 patients with acute myocardial infarction, treated with thrombolytic therapy were determined. Failure of thrombolysis was considered when reperfusion was delayed as assessed by noninvasive reperfusion criteria, reinfarction, and impaired left ventricular function. High plasma level of ACE (> 50 U/L), PAI-1 (> 43 ng/ml) and both was found in 57, 108 and 32 patients respectively. Subjects with high ACE plasma levels were characterized by impaired LV systolic function (79.0% vs. 75.0%), new Q-wave (88.4% vs. 74.2%), less reperfusion arrhythmia (19.3% vs. 22.8%) and prolonged hospitalization (70% vs. 66%) but no statistical significance was observed. High enzymes levels of PAI-1 were observed with higher incidence of anterior myocardial infarction (50.0% vs. 41.0%), lesser ST segment resolution (65.6% vs. 58.8%), reinfarction (6.3% vs. 5.9%), and impaired LV systolic function (90.6% vs. 76.0%), and prolonged hospitalization (70.4% vs. 63.4). There was a statistically significant difference between thrombolytic agents in the presence of high ACE regarding hospital overstay (p = 0.02). While the presence of high PAI-1 was significantly affect the degree of ST-segment resolution (p = 0.03). Conclusion: High plasma ACE and/or PAI-1 plays a considerable role in the higher incidence of unsuccessful reperfusion and impaired left ventricular function after thrombolytic therapy. A rapid diagnostic tool that enables physician of detecting those enzymes before giving thrombolytic therapy may change the strategy of treatment to offer another effective revascularization method.     

急性前壁心肌梗死患者相关血管再通后血液中成熟型肾上腺髓质素变化研究

目的探讨急性心肌梗死(AMI)再灌注后,有活性的成熟型肾上腺髓质素(AM)在冠状窦-主动脉差值是否有变化。方法对146例首次发生急性前壁心肌梗死患者和51例冠状动脉造影阴性作对照。入选的心肌梗死患者症状出现后24 h内完成冠状动脉腔内成形术(PICA)的再灌注治疗。再灌注后取主动脉和冠状窦血,测定血浆AM的两种分子形态(AM-m和AM-Gly)。结果AMI患者主动脉和冠状窦血浆AM-m,AM-Gly水平明显高于对照组[(1．7±1．4)pmol／L比(0．4±0．3)pmoL／L,P<0．01]。AMI患者血浆AM-m水平的冠状窦-主动脉差值明显高于对照组,而AM- Gly在两组之间差异无统计学意义(P=0．30)。AM-m的冠状窦-主动脉差值,在伴有左心室功能障碍的AMI患者(n=49)明显高于不伴有左心室功能障碍的AMI患者(n=97)。主动脉和冠状窦的血浆AM-m水平与左室射血分数呈负相关(r=-0．50,r=-0．48,P<0．01)。结论AMI再灌注后,尤其伴有严重左心室功能障碍的患者冠状动脉循环血液中AM的有活性的成熟型(AM-m)合成加速,提示AMI再通后AM经自分泌和(或)旁分泌可能对心血管起保护作用。     

急性心肌梗死冠状动脉再通后ST段回落缓慢的意义

５４例急性心肌梗死患者溶栓或经皮冠状动脉腔内成形术后梗死相关冠状动脉再通，９０分钟时ＳＴ段上移总和回落，≥５０％为乙组。与乙组比较，甲组溶栓距发病时间及肌酸激酶峰值距发病时间延长。住院期间心脏事件发生率甲组显著高于乙组，而且出院前超声心动图检查显示，甲组收缩末期容量较乙组增大，射血分数减低。