年轻急性心肌梗死患者临床及冠状动脉病变特征分析

目的 探讨年轻急性心肌梗死（AMI）患者临床及冠状动脉病变特征.方法 从我院2005年1月至2010年9月期间收治的AMI患者中,选取年龄＜40岁有完整冠脉造影资料的AMI患者48例作为年轻组,选取同期年龄＞60岁有完整冠脉造影资料的AMI患者52例作为对照组.比较两组的临床资料及冠脉造影结果.结果 两组患者均为男性占优势,而年轻组这一优势更加显著（91.7%比57.7%,P＜0.05）.年轻组中有冠心病家族史、长期大量吸烟、肥胖、血脂异常及ST段抬高型心肌梗死（STEMI）的比例均高于对照组（分别为27.1%比 9.2%,81.3%比 40.4%,47.9%比26.9%,29.2%比19.2%,89.6%比65.4%,P均＜0.05）,而高血压、糖尿病、既往劳累性心绞痛及非ST段抬高型心肌梗死（NSTEMI）的比例均低于对照组（分别为33.3%比51.9%,16.7%比32.7%,12.5%比38.5%,10.4%比34.6%,P值均＜0.05）.年轻组TG高于对照组[（179.6±32.5）mg/dl比（138.5±27.3） mg/dl,P＜0.05],HDL-C低于对照组[（36.7±16.8）mg/dl比 （43.2±13.7）mg/dl,P＜0.05],而TC及LDL-C均与对照组相当[分别为（191.9±45.3）mg/dl比（187.4±42.8）mg/dl,P＞0.05;（118.4±30.5）mg/dl比（115.7±36.6）mg/dl,P＞0.05].年轻组中就诊时有典型胸痛的比例高于对照组（70.8%比28.8%,P＜0.05）.年轻组罪犯血管在左主干者占2.1%,前降支者占56.3%,回旋支者为8.3%,右冠状动脉者占33.3%,和对照组相比,差异无统计学意义.年轻组单支血管病变所占比例明显高于对照组（56.3%比26.9%,P＜0.05）,而多支血管病变所占比例明显低于对照组（37.3%比71.2%,P＜0.05）.结论 长期大量吸烟、冠心病家族史、肥胖、血脂异常是年轻人患AMI的主要危险因素.年轻AMI患者发病时症状典型,多表现为STEMI,且多为单支血管病变.     

Riskfactors and coronary morphology in 218 patients with myocardial infarction under 40 years of age (author's transl)

With 218 postinfarction patients under 40 years of age who all underwent coronary angiography, the question in priority is: Can myocardial infarction in young age be characterized by special constellation of risk factors and by specific coronary morphology? Compared with results from literature the risk factors hypertension and diabetes seem to be of less importance than in older patients, smoking on the other hand seems to be more significant: 90.5% of postinfarction patients under 40 years of age were smoking regularly. Coronary angiography proved a pre-domination of 1-vessel disease: 72% showed 1-vessel, 17.9% 2-vessel and 10.1% 3-vessel disease. These findings and those from literature show that the majority of patients with myocardial infarction in young age have the following characteristics: In connection with the risk factor smoking the sclerotic coronary vessel process is developing rapidly, very often at a single spot. Since no longterm gradual occlusion process occurs, no prolonged period of angina pectoris precedes the infarction. There is no time for the development of an adequate collateral circulation; it follows that the infarction is a large one. After the acute infarction there is no angina pectoris.     

高龄急性ST段抬高型心肌梗死患者临床特征及冠脉造影分析

【摘要】 目的 探讨高龄急性ST段抬高型心肌梗死( STEMI) 患者的临床特征及冠状动脉造影特点。方法 将临床确诊为STEMI年龄≥75 岁的97例患者( 高龄组) 与＜75岁的92例患者( 非高龄组) 进行对照研究,分析其临床特征和冠状动脉造影特点。结果 高龄组的STEMI 危险因素中合并高血压、糖尿病、高血脂、陈旧性心肌梗死、脑卒中史及肺功能减退的比例高于非高龄组,而吸烟史和AMI 阳性家族史低,但差异无统计学意义。高龄患者既往经皮冠状动脉介入治疗（PCI）、肾功能减退（肾小球滤过率降低）较对照组多, 分别是(24.7% VS 10.9%;52.1 4.2 VS 63.7 2.3ml/min.1.73 m2,P<0.05 )。高龄组不典型胸痛更多见,约占34.1%,主要表现为呼吸困难（16.5% VS 6.5%,P<0.05）。其他症状,如消化道症状及晕厥,未达到统计学差异 （13.4% VS 5.4%, P>0.05;5.2% VS 5.4%, P>0.05）。心功能KillipⅠ级在高龄组低于对照组(51.5% VS 71.7%,P<0.01),而KillipⅡ-Ⅲ级则高于对照组(38.2% VS 22.9%,P<0.05),均具有统计学意义。高龄组冠脉多支病变、侧支建立、复杂病变明显高于对照组,分别是（81.4% VS 65.2%,P<0.05;82.5% VS 68.5%,P<0.01;61.1% VS 47.8%,P<0.05）,差别具有统计学意义。结论 高龄STEMI患者既往PCI、肾功能减退、不典型胸痛更多见,冠状动脉多支病变、侧支建立、复杂病变的发生率显著增高。     

Acute myocardial infarction in subjects under 40 years of age. Coronary risk factors

Myocardial infarction in the under-40s is rare. A series of 19 patients, 3.07% of a two-year series of coronary cases, is presented with a view to evaluating the incidence of risk factors, with special attention to familial factors and dyslipoproteinaemia. Risk factors are discussed together with the statistical importance of family aspects in two previous generations. Family factors and the abnormal lipoprotein profile are statistically important while other risk factors such as arterial hypertension, obesity and the use of oral contraceptive are insignificant. Cigarette smoking was a factor in more than 50% of cases and this strengthens the effects of other factors (obesity and hypertension) which, alone, do not appear to have any inductive importance in the genesis of coronary disease in this particular age segment.     

Clinical and angiographic features in patients under 35 years with a first Q wave acute myocardial infarction.

Sixty patients less than 35 years with a first Q wave acute myocardial infarction were prospectively studied to evaluate their features, risk factors and evidence of any viral infection. Typical chest pain was present in 98.3% with Q waves and ST segment elevation in all. None had hypotension or cardiogenic shock. Smoking was the most common risk factor (81.7%). Mean total cholesterol was 5.74 (+/-1.42) mmol/l. History of a viral illness was present in 28.3%, severe emotional stress in 21.7% and exhausting physical activity in 18.3%. Mean left ventricular diastolic and end systolic volumes were increased (90.11+/-22.5 ml/m2) and (46.62+/-20.46 ml/m2), respectively. The ejection fraction was depressed (49.71+/-1.6%). Triple vessel disease was seen only in 6.8 and 26.7% had insignificant or no coronary artery disease. Left anterior descending artery was most frequently involved (66%). None had left main involvement. Coronary ectasia was present in 11.7%, intracoronary thrombus in 28.3% and 40% had collaterals. Patients with no significant disease had no diabetes, a smaller number had a raised total cholesterol or smoked and had a lower ejection fraction. Patients from the Indian subcontinent who had fewer conventional risk factors, had more severe disease than those from the Arab world suggesting that other etiological factors need investigation.     

Myocardial infarction in the young. Angiographic features and risk factor analysis of patients with myocardial infarction at or before the age of 35 years

We reviewed the records of 2,400 consecutive patients undergoing cardiac catheterization at USAF Medical Center Keesler between 1978 and 1984 and found 35 patients (1.5 percent of all cardiac catheterizations) aged 35 years or less (mean age, 32 years) who underwent cardiac catheterization after myocardial infarction. These 35 patients (group 1) were compared to a randomly selected group of 100 patients (group 2) aged 55 years or greater who underwent cardiac catheterization for evaluation of coronary artery disease during the same period. The two groups were compared in terms of angiographic features and risk factors for coronary artery disease. The patients in group 1 had a higher proportion of normal coronary arteries (14 percent [5 patients] vs 0; p less than 0.01) and single-vessel disease compared to group 2, while the incidence of three-vessel disease was much less (14 percent [5] vs 47 percent; p less than 0.001). Involvement of the left main coronary artery was uncommon in group 1 (3 percent [1] vs 15 percent in group 2; p less than 0.01). Risk factor analysis revealed smoking to be the most common risk factor in both groups (89 percent [31] in group 1 and 91 percent in group 2). Hypertension (28 percent [10] vs 48 percent; p less than 0.05) and diabetes (3 percent [1] vs 23 percent; p less than 0.01) were more common in group 2. Importantly, of 19 patients in group 1 who underwent cardiac catheterization for prognosis despite being asymptomatic and able to reach at least stage 4 on a Bruce protocol exercise test, none was found to have residual surgically correctable disease.     

Coronary artery bypass grafting in young patients under 36 years of age

Results of coronary artery bypass graft (CABG) surgery in patients under age 36 who were operated upon between 1970 and 1980 at two large medical centers were compared to matched control patients, age 45 to 59 years, and 60 years and over. Patient follow-up ranged from one to 13 years (average five years). Event-free survival was significantly worse in the young group (37 percent) vs the middle aged group (61 percent, p less than 0.01) and vs the elderly group (59 percent, p less than 0.02). Failure of the operation was due to failure to improve or worsening of Canadian Cardiovascular Society anginal class, need for reoperation, subsequent myocardial infarction, or death due to cardiac causes. Risk of failure of CABG surgery in young patients was increased with the presence of cardiac risk factors. Because of the high rate of long-term failure of CABG surgery in young patients, its use in this group needs to be reevaluated relative to current aggressive medical therapy for angina.     

小于50岁急性心肌梗死患者的临床特点

目的:探讨年龄50岁急性心肌梗死(AMI)患者的临床特点。方法:以246例临床确诊的初发AMI患者为研究对象,按年龄分为50岁组与50岁组,比较两组的临床资料。结果:年龄50岁AMI患者的男性比例、吸烟率、饮酒率、血清胆固醇水平、左室射血分数、广泛前壁心梗发生率、单支病变率、介入治疗率均显著高于50岁组患者;而左室舒张末期内径、急性左心衰发生率、室壁瘤发生率及住院期间病死率显著低于50岁组患者(P0.05)。结论:年龄50岁的AMI患者的临床特点与50岁患者有诸多不同。     

Safety of coronary stenting early after thrombolysis in patients with acute myocardial infarction: one- and six-month clinical and angiographic evolution.

To determine the feasibility and safety of early posthrombolysis coronary stenting and the incidence of further reocclusion, we followed 99 consecutive patients with acute myocardial infarction thrombolyzed with rt-PA 2.0 +/- 0.8 hr after onset. Culprit artery was stented 14.0 +/- 7.0 hr after thrombolysis. All patients underwent clinical and angiographic follow-up at 1 and 6 months. Angiographic success was achieved in 99% of cases. Neither major cardiac events nor bleeding or vascular complications occurred during hospital stay. At 30 days, no events occurred and normal flow persisted in all stented arteries. At 6 months, only one artery reoccluded (1%), resulting in a nonfatal reinfarction. Restenosis rate was 21%. Contribution of the infarcted area to left ventricular function significantly increased from baseline to 30-day and to 6-month evaluations. Thus, early posthrombolysis stenting is a safe strategy with a low reocclusion rate, which seems to allow functional recovery of the infarcted area. Further studies are necessary to define its impact on survival and cost-effectiveness.     

青年急性心肌梗死患者血尿酸、血脂及冠脉病变特点

目的:探讨40岁以下急性心肌梗死(AMI)患者血尿酸、血脂及冠状动脉病变特点。方法: 回顾分析2007年12月~2010年12月就诊于北京友谊医院，并确诊为AMI的40岁及以下患者（青年组）42例，与40岁以上的AMI患者380例（中老年组）进行对照研究，分析其血尿酸、血脂等危险因素以及冠脉病变程度的不同特点。结果: 青年组患者血尿酸水平、低密度脂蛋白胆固醇（LDL-C）、三酰甘油（TG）、体质量指数(BMI)、男性及吸烟者比例显著高于中老年患者，具有统计学差异；冠脉造影显示青年组单支血管病变明显多于老年组，而双支与多支病变则显著少于中老年组。通过多元相关分析，AMI患者血尿酸与性别、BMI、TG、糖化血红蛋白(HbA1c)相关，与年龄无明显相关。消除BMI、TG、HbA1c影响，两组患者血尿酸仍有统计学差异。结论: 与中老年组比较，青年组AMI患者血尿酸水平、脂代谢异常及BMI明显升高，冠脉病变以单支血管病变较常见；男性患者为主。 在IABP中应用LMWH可以达到应用UFH相同的抗凝、预防血栓形成的效果，同时并发症无增加，而费用减少。     

Correlation of reciprocal ST-segment depression after acute myocardial infarction with coronary angiographic findings.

We studied 266 consecutive patients with acute myocardial infarction to assess the significance of electrocardiographic "mirror images". Ninety-four (group A) had anterior wall and 132 (group B) had inferior wall infarction. Thirty-one group A patients had stenosis of the right coronary artery greater than 85% in diameter (subgroup A1), and 63 either had a normal right coronary artery or less than 85% stenosis (subgroup A2). Of group B patients 62 had greater than 85% stenosis of the left anterior descending (subgroup B1) and 70 had a left anterior descending or less than 85% stenosis (subgroup B2). ST-segment depression was significantly greater in depth and duration in subgroup A1 than A2 (p = 0.02) and in subgroup B1 than B2 (p = 0.02, p = 0.01, respectively). Left ventricular ejection fraction was lower in subgroup A1 than A2 (p less than 0.001) and in B1 than B2 (p less than 0.001). There was a strongly positive correlation between depth and duration of ST-segment depression and the Gensini index (r = 0.78, 0.84) for anterior and inferior infarction, respectively. In conclusion, increased depth and duration of ST-segment depression opposite the infarct are indicative of ischemia, and are related to the extent of coronary artery disease, the degree of stenosis of the vessels supplying the opposite wall and of left ventricular dysfunction.     

Comparison of traditional risk factors, natural history and angiographic findings between coronary heart disease patients with age <40 and >or=40 years old.

OBJECTIVE: In this study we aimed to examine the angiographic findings, traditional risk factors and natural history of Turkish patients <40 and >or=40 years old with coronary heart disease (CHD). METHODS: The records of 491 patients with stable angina pectoris or acute coronary syndrome (ACS), who had undergone coronary angiography (CAG) were reviewed. The patients <40 years (group 1) and >or=40 years (group 2) were compared. RESULTS: The study population was classified as group 1 with 240 patients (mean age 35.7+/-3.4 years) and group 2 with 251 patients (mean age 61.0+/-9.7 years). Smoking, family history, hypercholesterolemia, hypertriglyceridemia and low levels of high-density lipoprotein cholesterol were more prevalent in group 1 while diabetes mellitus, hypertension was higher in group 2. The common presentation among <40 years patients was ACS whereas stable angina was the most common presentation in patients >or=40 years old. Patients in group 1 showed a preponderance of single-vessel disease whereas patients of group 2 showed dominance of multivessel disease. Early clinical course of patients with ACS in group 1 was better than in group 2. CONCLUSION: Our study shows a significantly different clinical, angiographic and biochemical profile in <40 years patients with CHD compared with >or=40 years patients. Dominance of smoking and dyslipidemias that are the preventable risk factors in premature CHD patients is an important threat for our community health. Healthy life styles should be encouraged beginning from young ages and new precautions about smoking must be taken.     

Myocardial infarction before the age of 40 years is associated with insulin resistance

Insulin resistance is associated with atherosclerosis, and hyperinsulinemia is predictive of coronary heart disease. However, a quantitative estimation of in vivo insulin sensitivity in juvenile myocardial infarction is still lacking and the mechanism of hyperinsulinemia is unknown. We estimated insulin sensitivity, beta-cell secretion, and hepatic insulin extraction using the minimal model analysis of a frequently sampled intravenous glucose tolerance test (FSIGT) in 25 normal-weight subjects without glucose intolerance and hypertension who had an acute myocardial infarction before the age of 40 years, and 10 control subjects comparable for age, sex, body mass index, and blood pressure. All patients underwent a coronary angiography. Insulin sensitivity was significantly lower in patients than in control subjects (mean +/- SEM, 4.6 +/- 0.6 v8.5 +/- 1.2 10(-4). min(-1)(microU/mL), P = .002). The basal C-peptide secretion rate (P = .02), total C-peptide secretion (P = .005), area under the curve (AUC) of insulin (P = .04) and C-peptide (P = .01), and hepatic insulin extraction (P = .04) were higher in patients versus control subjects. In conclusion, insulin resistance is evident in subjects with early myocardial infarction accurately selected to avoid the influence of other factors known to reduce insulin sensitivity, and hyperinsulinemia is due to an increase in beta-cell secretion rather than a decrease in hepatic insulin extraction.