冠状动脉内应用维拉帕米对急性心肌梗死急诊介入治疗后冠状动脉灌注、心肌灌注和临床预后的影响

目的探讨急性ST段抬高性心肌梗死（STEMI）急诊经皮冠状动脉介入治疗（PCI）时冠状动脉内应用维拉帕米对冠状动脉灌注、心肌灌注及临床预后的影响。方法本研究为前瞻性、随机、双盲、对照性临床研究。连续性入选99例STEMI拟行急诊PCI的患者,随机分为维拉帕米组与对照组。在支架释放后即刻,维拉帕米组在靶血管内注入维拉帕米200μg,对照组在靶血管内注入肝素生理盐水,比较两组PCI术前、术后和冠状动脉内注药后的冠状动脉灌注和心肌灌注的差别。冠状动脉灌注以心外膜TIMI血流（TFG）和校正的TIMI血流帧数计数（CTFC）来评价。心肌灌注以TIMI心肌灌注分级（TMPG）和心肌灌注显影（MBG）来评价。并比较两组在PCI术后1周心脏彩色超声结果、住院期间以及随访期间主要心脏不良事件（MACE）发生率上的差别。结果最终91例患者有完整资料,其中维拉帕米组47例,对照组44例,两组临床基本特征和造影特征相仿。维拉帕米组和对照组在术前和支架释放后即刻冠状动脉灌注和心肌灌注各指标差异均无统计学意义（P〉0.05）。冠状动脉内注入维拉帕米后,维拉帕米组的CTFC、TFG、MBG、TMPG均较对照组有显著改善,分别为CTFC：27.1±14.2比39.0±23.8,P=0.011;TFG≥2级：100%比90.9%,P=0.035;MBG≥2级：91.5%%比75.5%,P=0.034;TMPG≥2级：89.4%比72.7%,P=0.042。维拉帕米组和对照组PCI术后1周时左室射血分数（63.4%±8.2%比63.5%±10.3%,P=0.578）、院内MACE发生率（4.3%比9.1%,P=0.613）和3个月MACE发生率（23.9%比22.7%,P=0.894）差异均无统计学意义。结论STEMI患者急诊行PCI治疗时,冠状动脉内应用维拉帕米可显著改善冠状动脉灌注和心肌灌注水平,但未观察到其对急诊PCI术后心室重构和短期临床预后的显著影响。     

冠脉内注射尿激酶原对AMI患者急诊PCI术后心肌微循环的影响

目的:探讨冠脉内注射重组人尿激酶原(rhPro-UK)对急性心肌梗死(AMI)患者急诊经皮冠脉介入治疗(PCI)术后心肌微循环的影响。方法:2016年7月~2017年12月我院的90例行PCI治疗的AMI患者被随机均分为PCI对照组(单纯急诊PCI)和联合治疗组(先冠脉内注射rhPro-UK,再行急诊PCI)。比较两组PCI术后即刻TIMI血流分级、校正的TIMI血流帧数(CTFC)、TIMI心肌灌注分级(TMPG),及PCI术前、24h后外周血肌酸激酶同工酶(CK-MB)、心肌肌钙蛋白I(cTnI)水平,并记录两组30d内主要不良心血管事件(MACE)及出血事件发生情况。结果:术后即刻,与PCI对照组比较,联合治疗组TIMI 3级比例(75.56%比91.11%)、TMPG 3级比例(71.11%比93.33%)均显著升高,CTFC[(30.62±4.94)帧比(24.84±5.29)帧]显著降低,P<0.05或<0.01。两组术后24h外周血CK-MB、cTnI水平均显著升高;与PCI对照组比较,联合治疗组术后24h CK-MB[(34.26±5.64)ng/ml比(29.68±4.49)ng/ml]、cTnI[(9.85±2.36)ng/ml比(8.25±2.13)ng/ml]水平显著降低,P均=0.001。联合治疗组30d内MACE发生率显著低于PCI对照组(15.56%比35.56%),P=0.030;两组30d内出血事件发生率无显著差异,P=0.535。结论:冠脉内注射尿激酶原能够显著改善AMI患者急诊PCI术后心肌微循环灌注,减轻心肌损伤,降低30d内MACE发生率,且不显著增加出血风险。     

地尔硫卓治疗直接经皮冠状动脉介入术无复流的临床研究

目的探讨冠状动脉内注射地尔硫卓治疗直接经皮冠状动脉介入术（PCI）无复流的疗效。方法对23例直接PCI无复流患者给予梗死相关冠脉（IRA）内推注地尔硫卓2-4mg,分别于推注地尔硫卓前及推注后5min,用校正的心肌梗死溶栓治疗临床实验（TIMI）帧数（Corrected TIMI FrameCount,CTFC）评价IRA血流情况。结果23例无复流患者于IRA内注入地尔硫卓后CTFC由（60.45±12.10）帧降至（30.03±8.20）帧（P〈0.001）,其中17例（复流组）IRA血流恢复至TIMI3级,6例（无复流组）IRA血流未恢复,有效率73.91%。结论冠脉内注射地尔硫卓治疗直接PCI无复流能有效地恢复患者IRA血流,可作为治疗无复流的一种方法。     

替罗非班在老年人急诊经皮冠状动脉介入治疗中预防无复流的临床观察

目的观察老年人急诊PCI术中冠状动脉内注射替罗非班对术后无复流的影响。方法选择急性心肌梗死行急诊PCI患者163例,随机分为替罗非班组(83例)和对照组(80例)。替罗非班组在导丝通过病变后经导管冠状动脉内注射替罗非班10μg/kg,之后予替罗非班0.15μg/(kg·min)持续静脉滴注24 h。对照组给予常规治疗。观察2组患者TIMI、心肌灌注分级(TMPG),入院后30 d LVEF和左心室舒张末内径,心血管事件及出血并发症。结果替罗非班组TIMI血流3级和TMPG 2～3级比例较对照组明显升高,TIMI血流0～2级和TMPG 0～1级比例较对照组明显降低,差异有统计学意义(P<0.05)。替罗非班组LVEF较对照组明显改善,主要心血管事件较对照组明显降低,差异有统计学意义(P<0.05)。结论急诊PCI术中冠状动脉内注射替罗非班减少无复流,改善心肌灌注和心功能,且不增加心血管事件和并发症。     

急性心肌梗死经皮冠状动脉介入治疗后心肌灌注的方法评价

目的　联合应用TIMI心肌灌注分级 (TMP)、校正的TIMI画面记帧 (CTFC)、心电图ST段变化 (sumSTR)方法评价急性心肌梗死 (AMI)急诊经皮冠状动脉介入治疗 (PCI)后心肌灌注程度 ,探讨心肌灌注程度对临床预后的影响。方法　 77例AMI患者PCI后即刻采用TMP CTFC、TMP sumSTR、CTFC sumSTR三种联合方法评价心肌灌注程度 ,PCI术后 1个月检查双核素心肌灌注显像 ,记录 6个月心脏事件。结果　评价心肌灌注程度 ,与双核素心肌灌注显像对比 ,TMP sumSTR敏感性 86 7%、特异性 85 7%、准确性 86 2 % ;TMP CTFC敏感性 80 %、特异性 77 1%、准确性 78 5 % ;多变量回归分析TMP 0 / 1级 sumSTR <30 %为 6个月心脏事件的独立危险因子 (OR=2 1 5 ,95 %可信区间 2 7～ 6 5 7,P =0 0 0 3) ;Kaplan Meier分析曲线显示TMP sumSTR方法评价的心肌灌注不良组 6个月心脏事件高于心肌灌注良好组 (P <0 0 5 )。结论　TMP sumSTR、TMP CTFC能更好的评价心肌灌注程度 ;TMP sumSTR可预测 6个月心脏事件。     

Relation of hyperemic epicardial flow to outcomes among patients with ST-segment elevation myocardial infarction receiving fibrinolytic therapy

In patients with ST-segment elevation myocardial infarction (STEMI), the restoration of normal epicardial flow following fibrinolytic administration is associated with improved clinical outcomes. The goal of this analysis was to examine the relation between hyperemic flow and outcomes following fibrinolytic administration for STEMI. In Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis In Myocardial Infarction 28 (CLARITY-TIMI 28), patients with STEMI (n=3,491) treated with fibrinolytic therapy were scheduled to undergo angiography 48 to 192 hours after randomization. Corrected TIMI frame count (CTFC) and TIMI myocardial perfusion grade (TMPG) were assessed, and their associations with outcomes at 30 days were evaluated. When evaluating initial angiography of the infarct-related artery, there was a nearly linear relation between CTFC and 30-day mortality, with faster flow (lower CTFC) associated with improved outcomes. Conversely, in patients who underwent percutaneous coronary intervention (PCI), very fast flow (CTFC<14) after intervention was associated with worse outcomes. Post-PCI hyperemic flow (CTFC<14) was associated with a higher incidence of mortality (p=0.056), recurrent myocardial infarction (p=0.011), and a composite of death or myocardial infarction (p<0.001) compared with normal flow (CTFC 14 to 28). When post-PCI CTFC was further stratified by TMPG, there was a U-shaped relation between mortality and CTFC in patients with poor myocardial perfusion (TMPG 0 or 1). This relation appeared to be linear in patients with TMPG 2 or 3. In conclusion, in patients who undergo PCI after fibrinolytic therapy for STEMI, hyperemic flow on coronary angiography is associated with an increased incidence of adverse outcomes. Hyperemic flow with associated impaired myocardial perfusion may be a marker of more extensive downstream microembolization.     

Relation of corrected thrombolysis in myocardial infarction frame count and ST‐segment resolution to myocardial tissue perfusion after acute myocardial infarction

Objectives : To evaluate myocardial tissue perfusion by corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC) and ST‐segment resolution after successful percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). Background : Early and sustained potency of infarct‐related artery (IRA) has become the main goal of reperfusion therapy in patients with AMI. However, myocardial tissue perfusion may remain impaired even after the achievement of TIMI grade 3 flow of the epicardial artery without residual stenosis. Methods : CTFC was measured after successful PCI in 63 patients with first AMI. The extent of ST‐segment resolution was recorded 1 hr after reperfusion therapy. The wall motion score index (WMSI) was assessed before and 1 month after PCI. Then we studied the correlation between CTFC, ST‐segment resolution, and WMSI. Results : According to CTFC, the patients with TIMI grade 3 flow after PCI were divided into two groups: CTFC fast group and CTFC slow group. CTFC fast group had higher percentage of complete ST resolution (54.1% vs. 25.0%, P < 0.05) and lower percentage of no ST resolution (2.6% vs. 29.2%, P < 0.05). Improvement of WMSI in the CTFC fast group was significantly greater than that of the CTFC slow group (1.30 ± 0.41 vs. 0.64 ± 0.30, P < 0.05). CTFC had a significant negative correlation with the change in WMSI (r = ?0.75, P < 0.01). Conclusions : Combined with ST‐segment resolution, CTFC could predict risk for patients with successful reperfusion therapy after AMI and provide evidence for additional adjunctive treatment. © 2008 Wiley‐Liss, Inc.     

Reperfusion after primary angioplasty for ST-elevation myocardial infarction: predictors of success and relationship to clinical outcomes in the APEX-AMI angiographic study.

AIMS: We studied the clinical, demographic, and angiographic factors associated with successful reperfusion and the relationship between angiographic indices and clinical outcomes in a subset of the APEX-AMI trial, which tested the efficacy of pexelizumab in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: Among 5745 patients enrolled in the trial, 1018 underwent independent quantitative angiographic evaluation by a core laboratory. Successful epicardial reperfusion was defined as TIMI (thrombolysis in myocardial infarction) flow grade 3 or corrected TIMI frame count (cTFC) <28 frames, and successful myocardial reperfusion as TIMI myocardial perfusion grade (TMPG) 2 or 3. TIMI 3 flow after PCI occurred in 85%, cTFC < 28 in 58% (mean cTFC was 27 +/- 20), and TMPG 2 or 3 in 91%. Overall 90 day clinical outcomes were 2.7% for mortality and 8.2% for the composite of death, congestive heart failure (CHF), or shock. After adjustment for baseline characteristics, TMPG 2/3 after PCI was associated with younger age [odds ratio (OR) for 10 year increase 0.75, 95% confidence interval (CI) 0.59-0.96, P = 0.023], pre-PCI TIMI flow 2/3 (OR 3.5, 95% CI 1.7-7.1, P = 0.001), and ischaemic time [for every hour, OR 0.81 (0.69-0.96), P = 0.015]. TMPG 2/3 after PCI was significantly associated with 90 day mortality (adjusted hazard ratio 0.26, 95% CI 0.09-0.78, P = 0.013). Neither post-PCI TMPG nor TIMI flow grade was significantly associated with 90 day death/CHF/shock. CONCLUSION: Younger age, patent infarct-related artery at presentation, and ischaemic time predicted higher likelihood of successful myocardial perfusion, which was associated with improved survival.     

Early administration of abciximab bolus in the emergency department improves angiographic outcome after primary PCI as assessed by TIMI frame count: results of the early ReoPro administration in myocardial infarction (ERAMI) trial.

OBJECTIVES: We assessed the safety and efficacy of early administration of abciximab prior to percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) patients. BACKGROUND: Research suggests that platelet glycoprotein IIb/IIIa receptor inhibitors, e.g. abciximab, may improve myocardial perfusion. In particular, early administration in the emergency department, prior to PCI, may result in more effective reperfusion. METHODS: Eighty AMI patients with planned PCI were randomized in a double-blind fashion to receive a 0.25 mg/kg abciximab bolus either "early" in the emergency department or "late" in the catheterization laboratory after angiographic assessment. In total, 74 patients underwent PCI after diagnostic angiography, all of which then received an abciximab infusion of 0.125 microg/kg/min for 12 hr. RESULTS: Prior to PCI, no significant differences were observed between the two groups regarding the angiographic endpoints or ST-segment resolution. After PCI, thrombolysis in MI (TIMI) frame count (TFC) was significantly improved in patients treated early rather than in those treated late (23 +/- 10 vs. 41 +/- 35; P = 0.02). Consistent trends, also favoring early treatment, were observed for TIMI flow grade 3 (TFG 3), corrected TFC (CTFC), and TIMI myocardial perfusion grade 3 (TMPG 3). Nine deaths (4 early, 5 late) and six significant bleeds (4 early, 2 late) were observed at 30 days after randomization. CONCLUSIONS: Early administration of abciximab is both feasible and safe in patients planned for primary PCI, increasing coronary flow and myocardial reperfusion after PCI, as demonstrated by significantly decreased TFC scores and trends toward improvements in TFG, CTFC, and TMPG.     

老年急性冠状动脉综合征患者替罗非班冠状动脉和静脉用药的疗效比较

目的 分析老年急性冠状动脉(冠脉)综合征(ACS)患者替罗非班不同负荷和不同用药途径对心肌灌注和30 d主要不良心血管事件(MACE)的影响,探讨替罗非班的负荷用药最佳途径.方法 2009年7月至2010年7月,连续入选120例老年ACS患者,均行经皮冠状动脉介入术(PCI),术前开始用替罗非班.根据负荷给药途径不同分为两组:冠脉内用药组和静脉用药组,各60例.观察两组患者PCI后冠脉血流、心肌灌注及PCI术后30 d的MACE.结果 冠脉内用药组病变冠脉的急性心肌梗死溶栓试验(TIMI)血流分级3级、TIMI心肌灌注分级(TMPG)3级率明显高于静脉用药组[分别为53例(88.3%)、38例(63.3%)和40例(66.7%)],两两比较,均P＜0.05,但两组患者院内和PCI后30 d的MACE[分别为1(1.7%)和0,3(5.0%)和5(8.3%)]及不同程度出血和血小板减少症发生率比较差异均无统计学意义.结论 老年ACS患者PCI前冠脉内使用负荷剂量替罗非班与静脉内用药途径比较,能更有效地增加冠状动脉血流及心肌水平的灌注.

Abstract：

Objective To analyze the therapeutic effect of intracoronary versus intravenous bolus tirofiban on myocardial perfusion and major cardiovascular events (MACE) in elderly patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and explore the optimal route of tirofiban application. Methods From July 2009 to July 2010, 120 NSTE-ACS patients undergoing percutaneous coronary intervention (PCI ) were consecutively enrolled in this study. They were randomly divided into two groups: intracoronary (60 cases) versus intravenous (60 cases) bolus tirofiban. Thrombolysis in myocardial infarction (TIMI) flow, TIMI myocardial perfusion grade (TMPG) and MACE 30 days after PCI were observed. Results The incidence of TIMI flow and TMPG 3 grade in intracoronary group were higher than in intravenous group [53(88.3%) vs. 38(63.3%); 53(88.3%) vs. 40(66.7%), respectively, both P＜0.05]. However, MACE incidence and bleeding complications during hospital 30 days after PCI had no significant difference between the two groups [1 (1.7%) vs. 0; 3(5.0%) vs. 5(8.3%)], which were not statistically significant (P＞0.05). Conclusions Intracoronary bolus tirofiban before PCI more effectively increases coronary blood flow and myocardium blush than intravenous route in elderly NSTE-ACS patients.     

Pretreatment with intragraft verapamil prior to percutaneous coronary intervention of saphenous vein graft lesions: results of the randomized,controlled vasodilator prevention on no-reflow (VAPOR) trial

BACKGROUND: Intragraft verapamil is effective in treating no-reflow during saphenous vein graft (SVG) percutaneous coronary intervention (PCI). In this study, we assessed the use of intragraft verapamil given pre-PCI to prevent no-reflow. METHODS: Patients undergoing SVG PCI were randomized to receive intragraft 200 g verapamil or no verapamil immediately prior to PCI. Pre- and post-PCI, vessel flow was assessed using TIMI flow grade and TIMI frame count by blinded angiographic readers. Tissue level perfusion in the graft territory was assessed using the TIMI myocardial perfusion grade (TMPG). CK-MB or troponin I levels were measured 6 12 hours post-PCI. RESULTS: Ten patients were randomized to the verapamil group and 12 were assigned to the placebo group. No-reflow occurred in 33.3% of the placebo group, compared to none of the verapamil patients (p = 0.10). The use of intragraft verapamil prior to SVG PCI increased flow rate in the vessel as assessed by TIMI frame count (53.3 22.4% faster in the verapamil group versus 11.5 38.9% in the placebo group; p = 0.016). There was a trend toward improved myocardial perfusion as assessed by TMPG. There was no difference in the incidence of cardiac biomarker release following PCI. CONCLUSIONS: Intragraft administration of verapamil prior to saphenous vein graft PCI reduces no-reflow and is associated with a trend toward improved myocardial perfusion.     

校正的TIMI帧数评价急性心肌梗死血管成形术后心肌组织灌注

目的观察急性心肌梗死患者经皮冠状动脉介入(PCI)治疗成功后,即TIMI血流达到3级时,用校正的TIMI帧数(CTFC)评价心肌组织水平灌注的可行性.方法选取急性心肌梗死患者急症PCI治疗后血流达TIMI 3级者63例,其中男45例,女18例.测定患者的CTFC,并在术前及术后1个月分别测定室壁运动记分(WMSI).观察CTFC与WMSI之间的相关性.结果按照CTFC将TIMI血流3级者分为快、慢两组,1个月后快CTFC组的WMSI改善程度明显优于慢CTFC组,CTFC与术前、术后WMSI的差值有明显的负相关;快CTFC组患者从发病到接受PCI治疗的时间明显短于慢CTFC组.结论较低的CTFC预示着良好的心功能恢复及临床预后,它是一种定量、客观、简单、经济、重复性好的方法,用其评价心肌循环灌注情况可为临床提供是否需要进一步辅助治疗的证据.     

校正TIMI帧数与ST段回落评价老年急性心肌梗死患者支架成形术后心肌组织灌注

目的　观察老年急性心肌梗死 (AMI)患者冠状动脉介入 (PCI)治疗成功后 ,校正的 TIMI帧数 (CTFC)与心电图 ST段回落联合评价心肌组织水平灌注的可行性。方法　选取接受 PCI治疗后血流达 TIMI3级的老年 AMI患者 42例 ,测定 CTFC,并在术前及术后 1月分别测定室壁运动记分 (WMSI)。观察 CTFC与 WMSI之间的相关性 ,同时检查术前及术后 1 h心电图 ST段回落情况。结果　按照 CTFC将 TIMI血流 3级者分为快、慢两组 ,快 CTFC组 ST段回落程度明显优于慢 CTFC组 ;一个月后快 CTFC组的 WMSI改善程度明显优于慢 CTFC组 ,CTFC与术前、术后WMSI的差值有明显的负相关 ;快 CTFC组患者从发病到接受 PCI治疗的时间明显短于慢 CTFC组。结论　 CTFC作为一种定量、客观、简单、经济、重复性好的方法评价心肌微循环灌注情况 ,较低的 CTFC及心电图 ST段回落完全预示着良好的心功能恢复及临床预后 ,可为临床提供是否需要进一步辅助治疗的依据。     

急性冠状动脉支架成形术后心肌组织灌注的临床研究

目的 观察急性心肌梗死患者冠状动脉介入(PCI)治疗成功后，校正的TIMI帧数(CTFC)与心电图ST段回落联合评价心肌组织水平灌注的可行性。方法 测定PCI治疗后血流达。TIMI3级患者的CTFC，并在术前及术后1个月分别测定室壁运动记分(WMSI)。观察CTFC与WMSI之间的相关性，同时检查术前及术后1小时心电图ST段回落情况。结果 按照CTFC将，TIMI血流3级者分为快、慢两组，快CTFC组患者ST段回落程度明显优于慢CTFC组；1个月后快CTFC组患者的室壁运动记分改善程度明显优于慢CTFC组，CTFC与术前、术后WMSI的差值有明显的负相关；快CTFC组患者从发病到接受PCI治疗的时间明显短于慢CTFC组。结论 CTFC作为一种定量、客观、简单、经济、重复性好的方法评价心肌微循环灌注情况，较低的CTFC及心电图ST段回落完全预示着良好的心功能恢复，可为临床提供是否需要进一步辅助治疗的证据。     

Meta-analysis of randomized controlled trials comparing intracoronary and intravenous administration of glycoprotein IIb/IIIa inhibitors in patients with ST-elevation myocardial infarction

Glycoprotein IIb/IIIa receptor inhibitors (GPIs) have been widely adopted as an adjuvant regimen during primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction, but whether intracoronary administration of these potent antiplatelet agents conveys better efficacy and safety over the intravenous route has not been well addressed. A meta-analysis was performed by a systematic search of the published research for randomized controlled trials comparing intracoronary versus intravenous administration of GPIs in patients with ST-segment elevation myocardial infarction. Eight studies involving 686 patients in the intracoronary arm and 660 in the intravenous arm met the inclusion criteria. Postprocedural Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.08 to 1.98, p <0.05) and myocardial reperfusion grade 2 or 3 (OR 1.78, 95% CI 1.29 to 2.46, p <0.001) were markedly more often achieved in patients who received intracoronary boluses of GPIs than those receiving the intravenous strategy. Intracoronary administration resulted in a reduced incidence of mortality (OR 0.44, 95% CI 0.21 to 0.92, p <0.05), target vessel revascularization (OR 0.53, 95% CI 0.29 to 0.99, p <0.05), and the composite end point of major adverse cardiac events (OR 0.48, 95% CI 0.31 to 0.76, p <0.005) at 30-day follow-up. No significant difference was found in terms of major or minor bleeding (OR 1.14, p = 0.71, and OR 0.86, p = 0.47 respectively). In conclusion, intracoronary administration of GPIs yielded favorable outcomes in postprocedural blood flow restoration and 30-day clinical prognosis in patients with ST-segment elevation myocardial infarction. The intracoronary use of GPIs can be recommended as a preferred regimen during primary percutaneous coronary intervention.     

超选择性冠脉内注射硝普钠对急性心肌梗死急诊冠状动脉介入治疗中无再流现象的作用

目的:评价超选择性冠状动脉内注射硝普钠对急性心肌梗死(AMI)患者急诊经皮冠状动脉介入(PCI)治疗中梗死相关动脉(IRA)无复流现象的作用。方法:选择AMI急诊PCI后再通的IRA存在无复流现象者43例。21例患者经血栓抽吸导管超选择性梗死相关冠状动脉内注射法,22例患者采用常规指引导管内注射方法。药物均采用硝普钠100μg,2 s内"弹丸式"快速注射完毕。10 min后复查冠状动脉造影,评定冠状动脉血流TIMI分级及校正TIMI帧数(cTFC)。结果:两组均可明显改善急诊PCI后的无再流现象,超选择组所有患者梗死相关血管IRA血流恢复TIMIⅢ级,cTFC帧数由用药前的(84±7)帧降至(26±6)帧,与常规组相比较差异有统计学意义(P0.01)。结论:超选择性IRA内快速注射硝普钠100μg能更有效地改善AMI急诊PCI中无再流现象。     

Prediction of clinical outcome after mechanical revascularization in acute myocardial infarction by markers of myocardial reperfusion

OBJECTIVES: We sought to evaluate and compare recently suggested parameters of reperfusion after angioplasty in acute myocardial infarction (AMI) for risk stratification during long-term follow-up. BACKGROUND: Abnormal myocardial perfusion has a detrimental impact on survival. Several parameters of reperfusion have been evaluated in controlled study populations for risk stratification. METHODS: In 253 consecutive patients undergoing intervention in AMI on a native coronary vessel, angiographic myocardial blush grade (MBG), corrected TIMI (thrombolysis in myocardial infarction) frame count (CTFC) and persistent ST-segment elevation (STE) were determined to evaluate reperfusion. This was a high-risk population, including referral for treatment failure at a primary center in 29.2%, failed thrombolysis in 22.1% and cardiogenic shock in 13.4% of cases. RESULTS: In addition to age, patient referral, LBBB and heart rate on admission, MBG 0 to 1 (odds ratio [OR] = 3.23, p < 0.001), CTFC (OR = 1.01, p = 0.015) and persistent STE >2 leads (OR = 3.46, p = 0.010) were univariate predictors of mortality during a 22.1 +/- 15.6 months follow-up. Myocardial blush grade 0 to 1 (OR = 2.17, p = 0.033) and persistent STE (OR = 3.61, p = 0.017) persisted as independent predictors of mortality, whereas CTFC failed. Differences in mortality between reperfusion groups at 30 days remained throughout the complete follow-up. In sequential Cox models, the predictive power of clinical data alone for mortality (model chi-squared 55.8) was strengthened by adding MBG (model chi-squared 64.2) and ECG postintervention (model chi-squared 69.2). CONCLUSIONS: Myocardial blush grade 0 to 1 and persistent STE are independent predictors for long-term mortality after angioplasty in AMI. Corrected TIMI frame count is a less powerful predictor. Combining both parameters to consider quality of reperfusion in the myocardium at risk and extent of the infarct zone increases the predictive power.     

Association of peripheral neutrophilia with adverse angiographic outcomes in ST-elevation myocardial infarction

We hypothesized that absolute and relative neutrophilia would be associated with adverse angiographic outcomes in the 394 patient Limitation of Myocardial Infarction Following Thrombolysis in Acute Myocardial Infarction (LIMIT) Acute Myocardial Infarction (AMI) trial of fibrinolysis in ST-elevation myocardial infarction. The mean neutrophil count was 7.9 x 10(9)/L, with a mean neutrophil percentage of 72%. Patients with time from symptom onset to fibrinolytic treatment more than the median (2.7 hours) had a higher neutrophil count and percentage of neutrophils than patients with shorter time to treatment. Patients with a closed infarct-related artery at 90 minutes (Thrombolysis In Myocardial Infarction [TIMI] grade 0/1 flow) had higher neutrophil counts (8.8 +/- 3.8 vs 7.6 +/- 3.0, p = 0.02) but no difference in the percentage of neutrophils than patients with an open artery. Higher neutrophil counts were also mildly correlated with longer corrected TIMI frame counts (CTFC) in the infarct-related artery (r = 0.14, p = 0.02). Patients with impaired myocardial perfusion by TIMI myocardial perfusion grade (TMPG) had a greater percentage of neutrophils (73.2 +/- 10.7% for TMPG 0/1 vs 69.9 +/- 12.6% for TMPG 2/3, p = 0.047) but no detectable difference in neutrophil counts (8.2 +/- 3.3 vs 7.7 +/- 2.9, p = 0.24). There were no significant associations between other indexes in the cell differential and angiographic or clinical outcomes. Higher neutrophil counts remained independently associated with both closed arteries and CTFC in multivariable models controlling for age, left anterior descending artery infarct location, time to treatment, and pulse and blood pressure on admission. A greater percentage of neutrophils remained independently associated with impaired microvascular perfusion in a similar multivariable model. In patients with ST-elevation myocardial infarction, absolute and relative neutrophilia were associated with impaired epicardial and microvascular perfusion.     

冠状动脉内注射乌拉地尔对急性心肌梗死心肌灌注和心功能的影响

目的:探讨乌拉地尔对急性心肌梗死(AMI)急诊经皮冠状动脉介入治疗(PCI)患者心肌灌注和心功能的影响。方法:对经急诊PCI治疗的AMI患者54例,随机分为乌拉地尔组、硝酸甘油组和对照组。分别于经皮腔内冠状动脉成形术前冠状动脉内注射乌拉地尔、硝酸甘油、生理盐水。观察PCI术前、术后心肌梗死溶栓试验(TIMI)血流、校正的TIMI帧计数(cTFC)、心肌充血分级(MBG)、ST段回落、心肌坏死指标、左心室射血分数(LVEF)及住院期间主要心血管不良事件(MACE)。结果:乌拉地尔组与硝酸甘油组和对照组相比,PCI后cTFC降低、MBG增加、ST段回落增加、LVEF增加、CK和TnT峰值降低(P均<0.01)。结论:乌拉地尔可改善AMI急诊PCI患者冠状动脉血流、心肌灌注和左心室收缩功能,减少梗死面积,不增加住院期间MACE。     

心电图ST段回落结合校正TIMI帧数对心肌微血管灌注的评价

目的 :探讨急性心肌梗死 (AMI)患者血管再通后心肌组织灌注的评价方法。方法 :AMI患者接受成功的冠状动脉内介入治疗后 ,检查术前及术后 1h心电图ST段回落情况 ,并在术后检测校正的TIMI帧数(CTFC) ,观察两者之间的关系。结果 :根据ST段回落程度将患者分为 3组 ,ST段完全回落组的CTFC较低 ,术后 1个月检查射血分数恢复较好 ;无ST段回落组CTFC较高 ,射血分数值较低 ;ST段部分回落组介于两者之间。结论 :CTFC是目前临床上较理想的评价心肌微血管灌注的指标之一 ,它联合心电图ST段回落可更好地预测AMI患者的危险度 ,为是否需要进一步治疗提供可靠的依据