急性冠脉综合征的院前急救（附158例分析）

急性冠脉综合征（acute coronary syndrome，ACS）是严重危害人类健康的重要疾病之一，它包括不稳定性心绞痛、非ST段抬高的心肌梗塞和ST段抬高的心肌梗塞是院前急救最常见的内科疾病，对其中的心肌梗死患者，目前约1／3病人没有症状，仅体检时发现；1／3的病人在院前死亡，没有机会见到医生；仅有1／3病人既有症状，又有机会到达医院接受治疗。     

南疆地区汉族与维吾尔族人群冠状动脉粥样硬化多层螺旋CT表现对比分析

目的 探讨新疆南疆地区汉族及维吾尔族健康体检人群多层螺旋CT冠状动脉血管成像(CCTA)中冠状动脉粥样硬化的检出率、斑块性质及管腔狭窄程度的差异。方法 回顾性分析2016年6月—2017年1月喀什地区第一人民医院3 565例维吾尔族及汉族健康人群CCTA资料。3 565例中,男2 271例、女1 294例,年龄25~79(48.13±10.60)岁。其中维吾尔族2 041例,年龄25~79(48.42±10.58)岁,男1 299例、女742例;汉族1 524例,年龄28~75(47.91±10.62)岁,男972例、女552例。对冠状动脉进行曲面重建(CPR)、最大强度投影(MIP)及容积再现(VR),比较汉族及维吾尔族人群冠状动脉粥样硬化的检出率及其所致管腔狭窄程度,以及斑块性质的差异。结果 3 565例健康人群中,冠状动脉粥样硬化CCTA检出率为33.44%(1192/3 565),其中汉族人群检出率为28.41%(433/1 524),维吾尔族人群检出率为37.19%(759/2 041)。共检出不同性质斑块2 657个:汉族人群检出不同性质斑块802个,占总数30.19%(802/2 657),其中钙化斑块551个、混合斑块140个、软斑块111个;维吾尔族人群检出不同性质斑块1 855个,占总数69.81%(1 855/2 657),其中钙化斑块1313个、混合斑块311人、软斑块231个。动脉粥样硬化所致斑块狭窄程度:汉族人群组轻度狭窄者占71.83%(311/433),中度占12.47%(54/433),重度占3.23%(14/433);维吾尔族人群组狭窄程度分别为轻度占58.24%(442/759),中度占20.42%(155/759),重度占3.69%(28/759)。两组冠状动脉粥样硬化检出率、狭窄度差异均有统计学意义(χ²=30.190, Z=-11.396, P值均＜0.05),冠状动脉粥样硬化斑块性质差异无统计学意义(χ²=1.340, P＞0.05 )。结论 新疆南疆地区维吾尔族与汉族健康成人CCTA对冠状动脉粥样硬化的检出率及其所致狭窄度存在差别,动脉粥样硬化斑块性质无明显差异。     

腹部B超、16排CT和1.5T磁共振胰胆管成像检查诊断胆囊结石合并肝外胆总管结石的对比（附157例分析）

目的评价超声、腹部16排CT和1.5T磁共振胰胆管成像（MRCP）三种非侵入性检查方法在肝外胆管结石确诊中的应用价值。方法选择2008年1月～2010年1月在我院腹部外科手术确诊的胆囊结石合并肝外胆管结石的患者157例,并比较B超,16排CT和1.5TMRCP检查对肝外胆管结石的显示率并进行统计学分析。结果手术证实的结石患者157例,B超、16排CT和1.5TMRCP检查对肝外胆管结石的显示率分别为42.8%、75.3%和89.7%。两两比较有显著性差异（P〈0.05）;B超检查肝外胆总管〈0.8cm的胆总管结石患者共有65例,B超、16排CT和1.5TMRCP检查对胆总管无扩张的胆总管结石的显示率分别为33%、45%和67%;B超与CT比较无显著性差异（P〉0.05）,与MRCP比较有显著性差异（P〈0.01）。结论诊断肝外胆管结石时,MRCP明显优于CT和B超检查,尤其肝外胆管无扩张的患者,B超和CT检查有一定局限性。     

Green tea extract protects rats against myocardial infarction associated with left anterior descending coronary artery ligation

There is increasing evidence that green tea polyphenols can protect against myocardial damage. Recently, we showed that they bind to cardiac troponin C and alter myofilament Ca²⁺ sensitivity in cardiac muscle. In the present study, we examined whether green tea extract (GTE) could prevent the progressive remodeling seen in ischemic myocardium and improve cardiac function by modulation of the contractile apparatus utilizing a myocardial infarction (MI) model in the rat involving ligation of the left anterior descending branch. Using this model, severe myocardial injury was found, including altered cardiac performance and the appearance of extensive fibrosis and left ventricular (LV) enlargement. Supplementation with 400 mg/kg/day of GTE for 4, 18, or 46 days had beneficial effects in preventing the hemodynamic changes. Histopathological studies showed that GTE attenuated the progressive remodeling seen after myocardial injury. Echocardiography confirmed that GTE prevented LV enlargement and improved LV performance in post-MI rats. In addition, we showed that GTE supplementation for 18 or 46 days increased the myofilament Ca²⁺ sensitivity of the ischemic myocardium in post-MI rats. These results validate the novel action of green tea polyphenols in protecting against myocardial damage and enhancing cardiac contractility by modulating myofilament Ca²⁺ sensitivity in post-MI rats.     

A case of anomalous origin of the left coronary artery presenting with acute myocardial infarction and cardiovascular collapse

Background

Though a rare clinical entity, anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) a common cause of myocardial infarction in children. Unrecognized and untreated it leads to progressive left ventricular dilatation and systolic dysfunction. In settings of high infectious burden, ALCAPA may erroneously be diagnosed as myocarditis, dilated cardiomyopathy or other common childhood disorders.

Clinical case

We present the case of a 10 weeks old male infant who presented to the inpatient unit with marked restlessness and irritability. He was inconsolable, had marked respiratory distress, cool extremities, central and peripheral cyanosis oxygen. The radial and brachial pulses were absent. The mean arterial pressure was 65mmHg, Heart rate of 160 beats per minute with a third heart sound. The liver was enlarged 4cm below the costal margin and tender, with a splenomegaly. He had an elevated Creatinine Kinase-MB of 112.5 u/L. ECG revealed deep Q waves in leads I, aVL, V5, V6 with ST elevation in the anterolateral leads. Echo showed a dilated left ventricle LVEDd of 40mm, with paradoxical interventricular septal motion, severe LV systolic dysfunction (FS=15%, EF=28%), LV anterolateral wall echo brightness and flow reversal in the Left coronary artery with its origin from the pulmonary trunk. He was admitted to the coronary care unit as a case of acute myocardial infarction with cardiovascular collapse. He received fluid resuscitation, inotropic support and standard management of heart failure. Six days later he was discharged home with a plan to refer abroad. He died at home after one week.

Conclusion

A combination of a high index of suspicion, typical ECG and echocardiographic findings in a young infant presenting with LV dysfunction could lead to an earlier diagnosis of ALCAPA.     

Spontaneous coronary artery dissection presenting as acute myocardial infarction

Spontaneous coronary artery dissection is a rare entity being increasingly diagnosed as a cause of acute myocardial infarction, especially in cases of low cardiac risk female patients. This is one such case report of a black female patient, who suffered an acute anterior wall myocardial infarction due to an idiopathic spontaneous coronary artery dissection of the left anterior descending artery. She was treated with a thrombolytic agent in the acute phase, uneventfully. An urgent coronary angiogram demonstrated an intimal tear with a dissection of the left anterior descending artery. She survived the acute event and her subsequent hospital course was uncomplicated. Hence she was treated medically for her ischemic event and left ventricular systolic dysfunction with a favorable outcome. This case is yet another report of a survivor treated with a thrombolytic agent for the acute myocardial infarction due to spontaneous coronary artery dissection.     

Superdominant right coronary artery with absent left circumflex artery

Noninvasive imaging of coronary artery disease is rapidly replacing angiography as the first line of investigation. Multislice CT is the non-invasive modality of choice for imaging coronary artery disease and provides high speed with good spatial resolution. CT coronary angiography in addition to detecting and characterising atherosclerotic coronary artery disease is also a good imaging tool for evaluating anomalies of coronary arteries. Superdominant right coronary artery with absent left circumflex artery is one such rare coronary artery anomaly which is well evaluated with multislice CT angiography. The authors report one such case of superdominant right coronary artery with absent left circumflex artery imaged with 64-slice MDCT.     

Cellular response of the evolving myocardial infarction after therapeutic coronary artery reperfusion

This study describes the cellular response of the evolving myocardial infarction in humans after early coronary artery reperfusion by one or more of the following therapies: streptokinase, percutaneous transluminal coronary angioplasty, tissue plasminogen activator, and/or coronary artery bypass graft surgery. Postmortem histologic changes were compared in two groups (n = 43 pairs) of human hearts with acute myocardial infarction matched for clinical age and left ventricular location of the infarct. The treatment group received one or more of the forms of reperfusion therapy. The control group received conventional therapy. The treatment group was judged to have an older histologic age infarct, P less than 0.002, compared with documented clinical age. For example, infarcts that were clinically 4 days old or less were judged histologically to be 1 day older. The treatment group had a higher Cellular Response Index, P less than 0.017; more hemorrhage within the infarct, P less than 0.001; a greater extent of selective myocardial cell necrosis, and a lesser extent of coagulation necrosis, P less than 0.05; more patchy, nontransmural distribution of necrosis, P less than 0.04; and a more florid cellular response, specifically more macrophages, P less than 0.034, and reactive stromal cells, P less than 0.05. In infarcts less than 3 days old clinically, the treatment group had hemorrhage and a cellular response which were wide-spread throughout the lesion, P less than 0.05, n = 18 pairs. In infarcts 3 to 4 days old clinically, the treatment group had a florid cellular response due to more macrophages, P less than 0.05, n = 9 pairs. In infarcts 5 to 10 days old, the treatment group had more macrophages, P less than 0.01; and more phagocytosis, P less than 0.003. In infarcts 10 to 40 days old clinically, the treatment group had scar formation that was patchy, P less than 0.05. In conclusion, this study demonstrates that early therapeutic coronary artery reperfusion after an acute myocardial infarction alters the pattern of injury and the cellular response to the evolving myocardial infarction so that the classical criteria for infarcts need to be modified.     

Atresia of left coronary ostium and left main coronary artery

An uncommon coronary anomaly incidentally found at autopsy of a 76-year-old woman is reported. There was no history of cardiovascular symptoms or clinical signs of ischemic heart disease. The autopsy disclosed that the patient had no left coronary ostium and that the left main coronary artery was atretic. However, the rest of the left coronary system, including the left anterior descending coronary artery and the left circumflex coronary artery, were intact in their normal positions. Arterial flow to the left coronary system was supplied by a dilated collateral vessel that originated from the right main coronary artery and coursed between the right ventricular infundibulum and the aorta. Our case suggests that atresia of the left coronary ostium and the left main coronary artery, often associated with death at an early age, may also be compatible with symptom-free longevity. Moreover, attention is focused on the nomenclature of single coronary anomalies.