急性心肌梗死合并左心室附壁血栓患者经皮冠状动脉介入术后的抗栓治疗

目的分析急性心肌梗死（AMI）并发左心室附壁血栓（LvT）行经皮冠脉介入治疗（PCI）患者的临床特征及抗栓治疗。方法收集煤炭总医院2005年8月至2012年2月确诊为急性心肌梗死并发左室附壁血栓并行PCI治疗的12例患者的临床资料,对其进行回顾性分析。结果广泛前壁心肌梗死、前壁心肌梗死9例（75％）,左室射血分数低于40％共7例（58％）,冠脉造影检查三支及以上血管病变7例（58％）。6例给予华法林、阿司匹林、氯吡格雷三联抗栓,2例给予西洛他唑、阿司匹林及氯吡格雷三联抗血小板治疗,随访期间血栓均消失。4例双联抗血小板治疗者l例发生脑梗死后加用华法林,3例患者血栓消失,1例血栓机化。12例患者均未出现严重出血现象。结论急性心肌梗死并发左心室附壁血栓并接受PCI治疗患者,充分衡量获益及出血风险,按照个体化原则给予抗栓治疗安全有效。     

Determinants of left ventricular thrombus formation after primary percutaneous coronary intervention for anterior wall myocardial infarction

Previous studies have reported that left ventricular (LV) thrombus is a complication in 10–56% of ST-segment elevation acute anterior wall myocardial infarctions (AWMI). Data suggest that changes in acute myocardial infarction management such as early anticoagulation, thrombolysis, and most recently, primary percutaneous coronary intervention (PCI), may decrease thrombus occurrence. Early time to reperfusion has been shown to decrease mortality and improve LV function recovery. To determine if door-to-balloon time (DTBT) affects the incidence of LV thrombus, we retrospectively analyzed data on 43 consecutive patients who underwent successful PCI of a primary acute ST-segment elevation AWMI. Transthoracic echocardiography was performed for detecting LV thrombus and measuring LV ejection fraction (EF) within 5 days on all patients (average time: 2.17 days post event). Nineteen patients underwent PCI within 2 h of arrival to the Emergency Department (Group A, average 88 min) and 24 patients underwent PCI with DTBT of more than 2 h (Group B, average 193 min). Clinically significant LV thrombus was detected in 35% of all patients. The incidence of LV thrombus formation in Group A was not significantly different from that in Group B (42.1% vs. 29.0%, respectively; P = 0.52). The risk of LV thrombus was independent of in-hospital anticoagulation and medical management, peak enzyme levels, and LVEF but did relate to age (odds ratio = 1.96, 95% CI 1.03–3.73, P = 0.04 per decade). No embolic events in hospital were observed (average hospital stay 9.2 days). We conclude that the incidence of LV thrombus remains high despite PCI. Also, we find that DTBT in patients presenting with an ST-segment elevation AWMI does not affect the incidence of LV thrombus formation. Increased age, however, does appear to increase the risk of LV thrombus development.     

糖尿病合并急性心肌梗塞病人心功能的临床评价

对６７例急性心肌梗塞（ＡＭＩ）合并Ⅱ糖尿病人（ＤＭ－ＡＭＩ组），和按其一般情况及梗塞部位配对的无ＤＭ和ＡＭＩ病人６７例（ＮＤＭ－ＡＭＩ组）进行比较研究，结果显示：两组的肌酸磷酸激酶（ＣＰＫ）峰值、心电国科ＱＲＳ记分均无显著性差异，但ＤＭ－ＡＭＩ组住院期间的死亡率及严重心脏事件的发生率均高于ＮＤＭ－ＡＭＩ组，梗塞后４周和５个月时的左室舒张末容量（ＬＶＥＤＶ）及收缩末容量（ＬＶＥＳＶ）显著高于ＮＤＭ－     

急性心肌梗死后左室重构临床研究

目的　探讨溶栓治疗对急性心肌梗死后左室结构和功能的影响。方法　对 36例首发急性心肌梗死患者于梗死后 4周和 12周进行超声心动图观察。分别测定左室舒张末期容积指数 (LVEDVI)、左室收缩末期容积指数 (LVESVI)、射血分数 (EF) ,作为反映左室结构和功能变化的指标。结果　急性心肌梗死后LVEDVI、LVESVI均明显增高 (分别为P <0 0 1,P <0 0 5 )。 4周和 12周检查发现 ,溶栓组LVEDVI、LVESVI无明显差异 (分别P>0 0 5 ,P >0 0 5 ) ,EF值明显增大 (P <0 0 5 ) ;未溶栓组LVEDVI、LVESVI明显增大 (分别为P <0 0 5 ,P <0 0 5 ) ,EF值无明显变化 (P >0 0 5 ) ;对 4周和 12周的检查结果作组间比较发现 ,溶栓组LVEDVI、LVESVI均小于未溶栓组 (P <0 0 5 ) ,EF值溶栓组高于未溶栓组 (P <0 0 5 )。结论　溶栓治疗能有效地抑制急性心肌梗死后左室重构 ,改善心功能。     

Clinical manifestation of early phase left ventricular rupture complicating acute myocardial infarction in the primary PCI era

ObjectiveBefore reperfusion therapy was introduced, the incidence of ventricular septal and left ventricular free wall rupture complicating acute myocardial infarction (AMI) was 1–3%. Primary percutaneous coronary intervention (PCI) was expected to reduce the incidence of such mechanical complications.MethodsWe retrospectively analysed 1290 AMI patients referred to our institute from January 2005 to January 2011. Primary PCI was done in 1002 cases of the study patients (77.7%).ResultsVentricular septal rupture (VSR) occurred in 19 cases (1.5%) and left ventricular free wall rupture (LVFR) in 17 cases (1.3%). Mean observation periods from onset to VSR and LVFR were 2.6 days. We demonstrated that risk factors for LV rupture were advanced age, female sex, absence of history of angina or myocardial infarction, lack of previous PCI, and absence of previous hypertension. Coronary angiography revealed that the culprit lesions of the left anterior descending artery or single vessel disease were the risk factors for LV rupture. Furthermore, in the present observation, 9 patients (47.4%) with VSR and 8 patients (47.1%) with LVFR developed LV rupture within 24 h after symptoms onset (early rupture). The early rupture demonstrated extremely poor outcome compared with late rupture (in-hospital mortality was 88.2% in early rupture and 63.1% in late rupture).ConclusionEven in the patients’ cohort with higher prevalence of primary PCI, LV rupture cases were not decreased in contrast to our expectations. More attention should be paid to early LV rupture cases within 24 h from symptom onset in those cases.     

急性心肌梗死与左室重构

急性心肌梗死(AMI)后左室发生细胞学,分子学及细胞间质的变化,进而引起左室在大小、形态、组织结构和功能状态的改变,此即目前许多研究所提及的AMI后的左室重构.AMI后左室的重构贯穿于整个病程的始终,成为影响AMI患者近远期预后的主要原因之一.     

卡维地洛对心肌梗死后左室重塑的影响

目的：观察卡维地洛对急性心肌梗死（AMI）左室重塑的影响。方法：将80例AMI患随机分为常规治疗组（n=20)，依那普利组（n=30)及卡维地洛组（n=30)在AMI后1周，24周用超声心动图分别测定3组病人的左房内径（LA），左室舒张末期内径（LVDd)，左室收缩末期内径（LVDs)，室间膈舒张末期厚度（IVSd)，左室后壁舒张末期厚度（LVPWd)，计算左室重量（LWM），左室重量质数（LVMI）及左室射血分数（LVEF）。结果：AMI后24周，卡维地洛组和依那普利组与常规治疗组比较LA，LVDd,IVDs均明显缩小，IVSd,LVPWd,LVM及LVMI明显减小，而LVEF明显升高（P＜0．01），以上指标卡维地洛组与依那普利组比较无显性差异（P＞0．05），结论：卡维地洛可以防治AMI后左室重塑，改善心功能，其作用与依那普利相同。     

Adverse effect of warfarin in acute myocardial infarction: increased left ventricular thrombus formation in patients not treated with high-dose heparin

In a prospective non-randomized study, 229 patients with a verfiedfirst acute anterior myocardial infarction (AAMI) underwentechocardiography before discharge in order to study left ventricular(LV) thrombus formation. Antithrombotic therapy was given accordingto the routine of each centre. Patients receiving high-dose heparin had few LV thrombi, irrespectiveof warfarin therapy (6/32 vs 3/25, P ns). In patients not givenheparin, however, a significantly higher prevalence of LV thrombiwas found in a subgroup of patients treated with warfarin ascompared to those who did not receive warfarin (8/13 vs 17/68,P 0.02). A similar, but non-significant difference was observedin patients given low-dose heparin (42% vs 27%, P ns). Withinthe non-heparin and low-dose heparin groups, age, infarct size,occurrence of Q-wave infarction, congestive heart failure andLV wall motion impairment did not differ between those treatedor not treated with warfarin. In conclusion, high-dose heparin seems effective in the preventionof LV thrombosis irrespective of warfarin therapy after AAMI.The start of warfarin therapy in patients not receiving heparinwas, however, associated with an increased prevalence of LVthrombosis.     

Left ventricular thrombus following acute myocardial infarction: A prospective serial echocardiographic study of 96 patients

In a prospective serial study of 96 patients with acute myocardialinfarction, two dimensional echocardiography identified leftventricular thrombus in 18 patients. The majority of thrombi(15) developed within the first 4 days after admission. In threepatients thrombi were identified for the first time 4 monthsafter the acute episode. All 18 patients had received therapeuticanticoagulants on admission and had large anterior wall infarctionscomplicated by serve pump failure and motion abnormalities echocardiographically.None of the patients had systemic embolisation during the studyperiod. Thus, left ventricular thrombus is a not uncommon thoughsilent complication of acute anterior wall infarction even whenpatients receive therapeutic anticoagulants.     

Predictors of left ventricular thrombus formation in acute myocardial infarction treated with successful primary angioplasty with stenting

BACKGROUND: There are limited data referring to the incidence of left ventricle (LV) thrombus formation after successful primary percutaneous coronary intervention (PCI) with stenting, which is now the treatment of choice in patients with acute myocardial infarction (AMI). Previously reported results were often based on low or heterogeneous patient populations. METHODS: To evaluate the prevalence of LV thrombus in the early period of AMI, 2,911 patients who had undergone successful primary stenting were retrospectively studied. Baseline demographic characteristics, angiographic findings, and antiplatelet treatment were analyzed to find predictors of thrombus formation. LV thrombus was diagnosed by 2-dimensional echocardiography within 3 to 5 days after PCI. RESULTS: This complication was detected in 73 patients (2.5%). Patients with thrombus and patients without it were at the same age and had diabetes mellitus, prior myocardial infarction, and lipid disorders at the same frequency. The extent of coronary artery disease was similar in both groups. The incidence of LV thrombi was similar in patients treated with and without glycoprotein IIb/IIIa inhibitors (2.02% vs 2.9%, NS). According to results of multiple log-regression analysis, the presence of LV thrombus was strongly associated with anterior AMI, ejection fraction <40%, and previous hypertension. CONCLUSIONS: The incidence of left ventricular thrombus early after AMI is very low if primary PCI with stenting is successful, probably due to the salvage of myocardium at risk. Localization of AMI and the size of myocardium damage remain the most important independent predictors of LV thrombus formation irrespective of various treatments.     

C-Reactive protein as a risk factor for left ventricular thrombus in patients with acute myocardial infarction

BACKGROUND: Elevated C-reactive protein (CRP) has been found to correlate with higher risk for cardiac events in patients with acute myocardial infarction (AMI). It has been suggested that CRP may be involved in initiation process of coagulation; however, the role of CRP level in the formation of left ventricular (LV) thrombus has not been studied. HYPOTHESIS: This study investigated whether CRP is a risk factor for LV thrombus in patients with AMI. METHODS: Clinical, echocardiographic, and biochemical data were analyzed in 141 consecutive patients (aged 57 +/- 13 years; 33 women) with first anterior AMI. Two-dimensional and Doppler echocardiographic examinations were performed on Days 1, 3, 7, 15, and 30. Blood samples were obtained every day during hospitalization. Serum CRP concentrations were measured by an ultrasensitive immunonephelometry method. RESULTS: Left ventricular thrombus was detected in 33 (23.4%) patients. Univariate analysis showed that patients with LV thrombus had a higher peak creatine kinase (CK) level (2,879 +/- 742 vs. 1,693 +/- 1,210 I/U, p = 0.001), higher peak CRP level (14.9 +/- 7.1 vs. 9.2 +/- 6.8 mg/dl, p = 0.001), higher wall motion score index (1.8 +/- 0.2 vs. 1.5 +/- 0.3, p = 0.002), higher apical wall motion score index (2.35 +/- 0.72 vs. 2.07 +/- 0.70, p = 0.001), larger end-diastolic volume (145.2 +/- 43.7 vs. 116.5 +/- 44.2 ml, p = 0.002), larger end-systolic volume (85.4 +/- 37.2 vs. 62.9 +/- 31.6 ml, p = 0.003), and lower ejection fraction (42.1 +/- 12 vs. 47.3 +/- 13, p = 0.04). In multivariate analyses, only peak CK level (p = 0.0001), LV apical wall motion score index (p = 0.001), and CRP levels (p = 0.001) were independent predictors of LV thrombus formation. CONCLUSIONS: These results suggest that CRP is a risk factor for LV thrombus in patients with AMI.     

多普勒超声心动图评价急性心肌梗塞后左室重构及心功能改变

应用多普勒超声心动图对56例不同部位急性心肌梗塞（AMI）后患者及40例正常人左室结构（LVR）、收缩舒张功能参数进行对比分析研究。结果显示AMI后患者左室舒张及收缩末期内径、左心室舒张末期容积、左心室收缩末期容积、左室射血前期与射血时间比、舒张晚期峰值血流速度、A峰面积增大；射血分数、短轴缩短率、舒张早期峰值血流速度、E峰／A峰面积则降低，两组间比较有极显著性差异（P＜0．01）。认为AMI后患者心脏不同程度的发生了LVR及收缩舒张功能减退。     

老年急性心肌梗塞溶栓治疗对左心室功能的改善作用

目的 :评价链激酶溶栓治疗老年急性心肌梗塞 (AMI)对左心室功能的影响。方法 :应用二维超声心动图对 2 9例 AMI接受链激酶溶栓治疗和 2 1例未溶栓的 AMI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 (EDV和 ESV) ,射血分数 (EF)等参数。结果 :急性各组心功能无差异。随访期再通组 EF值明显增加 ,且明显高于未通组和未溶栓组。结论 :链激酶溶栓能明显减轻老 AMI患者的左心室扩张 ,改善左心室功能和长期预后     

Thrombolytic therapy reduces the incidence of left ventricular thrombus after anterior myocardial infarction: Relationship to vessel patency and infarct size

BACKGROUND: Controversial evidence exists as to whether thrombolytic therapyreduces the incidence of left ventricular thrombus in acutemyocardial infarction and, if so, how this relates to successfulreperfusion. METHODS: Four hundred and eighteen consecutive patients underwent echocardiographyand coronary angiography within 3 weeks of an acute myocardialinfarction. A dyssynergic score was calculated by analysingregional wall motion in 18 left ventricular segments. The infarct-relatedartery was considered patent if TIMI grade 2 or 3 flow and lessthan 90% stenosis were present. Retrograde perfusion by Rentrop'sgrade 2 or 3 collaterals was considered significant. RESULTS: Large anterior myocardial infarctions were associated with thehighest prevalence (39%) of left ventricular thrombosis. Thrombuswas also very frequent if the left anterior descending coronaryartery was occluded and no collaterals to the infarct area wereseen (75%). Anticoagulant therapy reduced the prevalence ofleft ventricular thrombus, regardless of whether the infarct-relatedvessel was patent or not. Conversely, in patients undergoingthrombolysis the incidence of left ventricular thrombosis waslower when the left anterior descending coronary artery waspatent, and especially when an early creatine kinase peak, suggestiveof reperfusion, was recorded (7%). Finally, the presence ofleft ventricular thrombosis was inversely related to the asynergyscore. CONCLUSION: These observations suggest that the presence of left ventricularthrombus is related to the extent of myocardial damage. Thrombolytictherapy reduces thrombus probably by salvaging myocardium atrisk. (Eur Heart J 1996; 17: 421–428)     

心肌梗死后室壁瘤形成伴严重二尖瓣返流对左室附壁血栓形成的影响

目的:探讨心肌梗死后室壁瘤形成伴严重二尖瓣返流对左室附壁血栓形成的影响。方法: 回顾性分析340例心肌梗死后室壁瘤形成患者的临床资料,根据是否并发严重二尖瓣返流分为严重二尖瓣返流组与非严重二尖瓣返流组,严重二尖瓣返流组84例,二尖瓣返流较轻或无返流256例,归为非严重二尖瓣返流组,比较两组左房直径、左室舒张末期直径、左室收缩末期直径、室间隔及左室后壁厚度、左室射血分数及左室附壁血栓发生率。结果: 分析结果显示,严重二尖瓣返流组的左室附壁血栓发生率明显低于非严重二尖瓣返流组(11% vs. 22%,P<0.05)。严重二尖瓣返流组的左房直径、左室舒张末期直径、左室收缩末期直径均大于非严重二尖瓣返流组（均P<0.01)。严重二尖瓣返流组的左室射血分数低于非严重二尖瓣返流组。左室舒张期室间隔厚度及后壁厚度两组无显著差异。结论: 心肌梗死后室壁瘤形成伴严重二尖瓣返流时可能有降低左室附壁血栓形成的作用。     

急性心肌梗死患者心室血栓与血小板体积和数量的相关性

目的分析急性心肌梗死(AMI)患者并发左心室血栓与平均血小板体积(MPV)和血小板计数(PLT)的相关性。方法回顾性分析2007年1月至2011年4月在阜外心血管病医院住院治疗的69例AMI并心室血栓形成患者,及138例与之年龄匹配(1∶2)的无心室血栓形成的AMI患者。比较两组患者入院时和入院后第6～8天两个时间点的MPV和PLT变化特点,以及分析MPV和PLT的相关性。结果两组患者入院时MPV差异无统计学意义[(10.3±1.0)fl比(10.3±0.8)fl,P=0.854],入院后第6～8天心室血栓组患者的MPV明显高于无心室血栓组[(11.1±1.7)fl比(10.7±0.7)fl,P=0.029]。入院时和入院后第6～8天PLT在两组间差异均无统计学意义(P=0.587、0.807)。入院后第6～8天患者MPV与PLT的关联表现为线性关系。结论 AMI患者MPV增大可能与心室血栓形成相关。     

年龄对急性ST段抬高型心肌梗死患者左室射血分数的影响

目的:分析年龄对急性ST段抬高型心肌梗死患者(STEMI)左室射血分数(LVEF)的影响.方法:收集急性STEMI患者245例,根据年龄分为5组:≤50岁组(49例)、51～60岁组(70例)、61～70岁组(62例)、71～ 79岁组(50例)、≥80岁组(14例);对临床基线资料(包括年龄、性别、高血压、糖尿病、高血脂、吸烟史、超急性期及急性期ST段抬高导联数、入院时及入院12～72 h肌钙蛋白、Killip分级、LVEF、是否接受冠状动脉介入治疗(PCI)和住院期间死亡等)进行比较分析.结果:多元线性回归分析显示,LVEF与年龄(P＜0 05)和肌钙蛋白(P＜0.05)呈负相关,随着年龄增长,LVEF降低;随着肌钙蛋白的增加,LVEF降低.在≤50岁组LVEF显著高于其余各年龄组(均P＜ 0.05),而≥80岁组LVEF则显著低于其余各组(均P＜0.05).≥80岁组KilliP分级≥Ⅱ级者显著高于其余各组(均P＜0.05).≥80岁组患者的住院期间病死率显著高于≤50岁组、51～60岁组、61～ 70岁组(均P＜0.05).结论:年龄可作为影响急性STEMI患者心功能的独立危险因素.     

急性心肌梗死后左心室重构及其防治

本文简述了急性心肌梗死后左心室重构的发生机制、时间、后果、影响因素及防治措施等     

Coronary collaterals and left ventricular function early after acute transmural myocardial infarction

The coronary collateral circulation and ventricular function,segmental wall motion and infarct size, were investigated fromhemodynamic and angiographic data in 126 patients with acutetransmural myocardial infarction and complete obstruction ofa major coronary vessel. The patients were divided into twogroups: 74 with obstruction of the right coronary artery and52 with obstruction of the left anterior descending artery.The collateral circulation was rated as absent, poor, fair oradequate: two weeks after infarction, collateral vessels wereobserved in only 27% (poor 15.4%, fair 5.8%, adequate 5.8%)of the patients with an anterior myocardial infarction and inonly 35% (poor 13.5%, fair 16.4%, adequate 4.5%) of the patientswith an inferior myocardial infarction. In both groups of patients, the presence of collateral vesselshad no significant influence on the following parameters: leftventricular performance (left ventricular end-diastolic pressure,left ventricular enddiastolic volume, ejection fraction andmean velocity of fiber shortening), extent of abnormally contractingsegment and segmental wall motion. After anterior myocardialinfarction, there was an insignificant trend to lesser myocardialdamage in patients with coronary collaterals. Thus, coronary collaterals are infrequent in patients with acutetransmural myocardial infarction and total obstruction of acoronary vessel; in these patients we conclude that the collateralshave no effect either on left ventricular function or on thesize of the infarction.     

Two-dimensional echocardiographic assessment of anticoagulant therapy in left ventricular thrombosis early after acute myocardial infarction

This study was designed to assess, by two-dimensional echocardiography,the effects of anticoagulant therapy on left ventricular thrombosisdetected after acute myocardial infarction. Thirty-eight patientswith left ventricular thrombi detected by two-dimensional echocardiologywithin 5 weeks (mean 4) of the onset of infarction were randomlyassigned to the following groups: group A consisted of 19 patientswho received oral anticoagulants (acenocoumarin 1.6 mg dailyregulated to keep prothrombin time within the range of 25 to35%) and group B which consisted of 19 non-treated control patients.Seventeen patients from both groups were restudied 15 days,3 months and one year later to evaluate the changes in sizeof thrombi. Echocardiographic examinations were read blindly;a significant decrease in ventricular thrombus size was takenas a 5 mm reduction of thickness in the apical views. In Group A, 9 patients showed a complete resolution of thrombusat the 15 day study; at one year, thrombus had resolved in 15and persisted unchanged in size in 2 patients. The mean dimensionof thrombi in patients of group A was 18±6.6 mm at thescreening examination and decreased to 6.6mm, 3.8mm and 2.2mm,respectively, at 15 days, 3 months and one year follow-up studies.Among 17 patients of group B at the 15 day study, two had resolutionof thrombus and 15 were unchanged; at the one year examinationthrombus was resolved in 4, decreased in size in 4 and persistedunchanged in 9 patients. Analysis of variance of the dimensionalchanges of thrombi in the two groups of patients confirmed asignificant efficacy of anticoagulant therapy (P<0.001). On the basis of our results we conclude that full-dose anticoagulanttherapy, started early (within 5 weeks) after acute myocardialinfarction, is effective in the resolution of left ventricularthrombosis.