急性冠状动脉综合征与昼夜节律

为观察急性冠状动脉综合征与昼夜节律的关系，本语文分析了我院１２２例急性冠状动脉综合征的患者的发病时间，发现５４例发病分布于上午６－１２时，６２例不稳定心绞痛患者中，２６例（４１．９％）分布于此间期；４９例急性心肌梗经死患者中，２３例分布于此间期；１１例心性猝死患者中，５例分布于此间期，上午６－１２时的急性冠状动脉综合征事件发生率是显著高于其他间期     

青壮年男性急性心肌梗死患者危险因素及临床特征分析

目的：探讨青壮年男性急性心肌梗死患者的危险因素及临床特征。方法：比较青壮年（103例）与老年（238例）男性急性心肌梗死患者的危险因素、临床特点及治疗。结果：青壮年组和老年组比较，吸烟、糖尿病、高脂血症、动脉硬化家族史、代谢综合征的比例分别为78．6％ vs 55％、22．3％ vs 39．1％、63．1％ vs 38．7％、12．6％ vs 4．6％、19．4％ vs 8％（P〈0．001），高血压比例为55.3％ vs 47．5％（P〉0．05）；既往心绞痛发作史、发病时呈典型临床表现和发生急性左心衰竭（Kill ip分级）的比例分别为49．6％ vs 61．8％、78．6％ vs 61．8％、14．5％ vs 42．9％（P〈0．05）；左室射血分数分别为63．06±13．64和45．39±14．54（P〈0．05）；心律失常、梗死部位、室壁运动异常在两组间无显著性差异；两组患者行冠状动脉旁路移植术分别为6．7％vs 37．8％（P〈0．05）。结论：青壮年男性急性心肌梗死患者往往有明确的危险因素，如吸烟、高脂血症、动脉硬化家族史和代谢综合征，其临床特征包括既往多无心绞痛发作史、发病时多有典型临床症状、急性左心衰发生率低和预后较好。     

新生儿G^—杆菌败血症88例临床分析

新生儿G－（革兰氏阴性）杆菌败血症近几年报导较少，为了提高认识，合理选用抗生素，提高治愈率，降低死亡率，现将我院1990年～1994年收治的资料完整的G一杆菌败血症做一分析。临床资料1．一般资料：男66例，女28例，男女比例约2：l；3天以内发病者15例（17．0％），4～7天发病33例（37．5％），7～28天发病者38例（45．5％）；体重小于25O0923例（21．6％），大于2500965例（7．9％）；舱龄小于37周12例（13．6％），足月76例问6．4％）；有窒息史26例（29．5％）；早胶水9例（10．2％）；有脐部、皮肤、粘膜感染者71例（80．l％）。症…     

2004～2009年我院ICU急性呼吸窘迫综合征的发病及死因分析

目的调查晋城煤业集团总医院ICU中急性呼吸窘迫综合征（ARDS）的发病情况、原发病、病死率及其影响因素。方法根据中华医学会重症医学分会急性肺损伤／急性呼吸窘迫综合征诊断和治疗指南（2006）中诊断标准，沿用1994年欧美ARDS联席会议制定的ARDS诊断标准，回顾性调查2004～2009年晋城煤业集团总医院ICU中ARDS患者的原发病、逐年发病情况、病死情况及其影响因素。结果2004年1月至2009年12月年晋城煤业集团总院ICU共收治危重病患者1714例，其中60例符合ARDS诊断标准，占同期ICU收治的各类危重患者的3．5％。肺内疾病致ARDS（肺内型ARDS）共16例，（占26．7％），死亡10例，病死率62．5％。肺外疾病致ARDS（肺外型ARDS）共44例（占73．3％），死亡21例，病死率47．1％。肺内型ARDS病死率明显高于肺外型（X^2=13．261，P〈0．01）。原发病为脓毒症13例（占21．7％）及肺炎10例（占16．7％），其他为大手术、重症胰腺炎（5％）、多发性创伤（25％）等。60例ARDS患者中死亡31例，其中肺内疾病死亡10例（占32．3％），肺外疾病死亡21例（占67．7％）。ARDS总病死率为51．67％。6年间病死率无明显变化。脓毒性休克是主要的死亡原因。结论①6年间ARDS平均发病率为3．5％，2007年最低（2．97％），从2004年（3．17％）到2009年（4．06％），呈缓慢上升趋势；②6年间总病死率达51．67％；肺内型ARDS病死率明显高于肺外型ARDS，6年间病死率无明显变化；③危重病患者并非死于单纯的ARDS；ARDS患者多数死于感染性休克；④发生感染性休克或多脏器功能衰竭（MOF）时，则病死率明显增加。     

急性冠状动脉综合征43例诊治体会

目的总结急性冠状动脉综合征（ACS）内科治疗的临床经验。方法回顾性分析2004年1月至2006年5月43例ACS患者的冠状动脉造影结果和药物治疗、介入治疗的临床资料。结果本组院内死亡5例（11．6％），均为急性心肌梗死患者，均未行冠状动脉介入治疗和（或）溶栓治疗；好转出院38例（88．4％）。结论ACS的冠状动脉病变特点与临床之间存在较好的相关性，采用抗血小板、抗凝血酶及溶栓治疗、冠状动脉介入治疗为主的综合治疗措施能有效提高救治率。     

女性冠心病误诊134例分析

目的：选择以往临床诊断为冠心病的女性患者134例，于200106～2006—12通过行冠状动脉造影明确既往诊断误诊率并分析其原因，以便为今后女性患者冠心病的诊断提供参考。方法：以往诊断为冠心病的女性患者134例均行冠状动脉造影。结果：冠状动脉造影提示134例患者中冠状动脉正常者69例（51．5％）；轻度狭窄者23例（17．2％o）；中度狭窄者11例（8．2％）；重度狭窄者31例（23．1％）。结论：女性冠心病实际发生率较既往临床诊断低。     

老年急性心肌梗死尿激酶溶栓治疗56例疗效观察及护理

目的：探讨老年急性心肌梗死尿激酶溶栓治疗的疗效及护理方法。方法：将56例老年急性心肌梗死患者入院后给予尿激酶100～150万U加入生理盐水100ml，静脉滴注，30min内滴完。溶栓12h后，根据情况给予低分子肝素钙0．4ml，皮下注射，2次／d，连用5—7d。治疗期间密切观察病情并加强护理。结果：56例中血管再通39例，再通率69．64％。其中，发病2h内溶栓13例，再通13例（100％）；2～6h内溶栓29例，再通20例（68．97％）；6～12h内溶栓14例，再通6例（42．86％）；死亡6例，病死率10．71％。结论：尿激酶溶栓治疗老年急性心肌梗死安全有效．加强护理可提高疗效。     

青壮年男性急性心肌梗死患者冠状动脉造影特点分析

目的探讨青壮年男性急性心肌梗死患者的冠状动脉造影特点。方法比较青壮年组（103例）与老年组（238例）男性急性心肌梗死患者的冠状动脉造影特点及治疗方式。结果青壮年组平均年龄（41．80±13．69）岁，老年组平均年龄（66．96±5．52）岁；单支病变为74．7％vs32．8％，双支及三支病变为12．6％vs31．5％，11．7％vs35．7％，P〈0．001；侧支循环（0级、1级、2级、3级）为80．5％vs49．6％、12．7％vs26．05％、6．8％vs18．05％、0vs6．3％，P〈0．05，有统计学意义；梗死相关血管：左前降支右冠状动脉、回旋支分别为，57．8％vs63．0％、28．4％vs30．7％、13．8％vs6．3％，P=0．331，无统计学意义。青壮年组、老年组行“冠状动脉旁路移植术”治疗的比例为6．7％vs37．8％，P〈0．05。结论青壮年病人以单支偏心无钙化的局限型病变为主，侧支循环不明显；梗死相关血管无统计学差异，且病人预后好，行冠状动脉旁路移植术比率低。     

非ST段抬高急性冠状动脉综合征患者早期介入治疗前应用替罗非班近期预后的临床观察

目的观察非ST段抬高急性冠状动脉综合征（ACS）患者早期介入治疗前使用替罗非班的疗效。方法99例高危非ST段抬高ACS患者在进行12～48h药物治疗后，随机分为观察组（48例）和对照组（51例），行早期冠状动脉介入治疗（PCI）。观察组于PCI前30～60min加用替罗非班，比较2组的治疗效果。结果观察组PCI术后30d复合心血管事件（心绞痛复发＋再次心肌梗死＋死亡）发生率明显低于对照组．分别为6．3％与23．5％（P〈0．05）；观察组术后血小板聚集率明显降低，疗效优于对照组（P〈0．01）；2组的主要不良反应为轻度出血，观察组有增加趋势，但与对照组比较差异无统计学意义（P〉0．05）。结论非ST段抬高ACS早期介入治疗前使用替罗非班可改善患者的近期预后且不增加出血风险。     

脑室引流治疗破入脑室的高血压脑出血

1992年5月～1996年10月我们采用脑室引流治疗破入脑室的高血压脑出血35例，获得较好的疗效，并与同期保守治疗的41例对比分析。1资料与方法1．1一般资料脑室引流组（手术组）35例，男20例，女15例；年龄37～75岁，平均627岁。保守治疗组门E手术组）41例，男24例，女17例；年龄36～77岁，平均63．2岁。全部患者均有高血压病史。发病时舒张压均＞12．6kPa。入院时意识状态按格拉斯哥昏迷评分（GCS）：手术组3～5分7例（ZO．0％），6～8分15例（42．9％），9～IS分I3例（3TI％）；非手术组分别为8例（I｝5％）、17例（41．5％）、16例（3…     

Coronary surgery for acute coronary syndrome: which determinants of outcome remain?

BACKGROUND: The mortality risk associated with coronary artery bypass grafting (CABG) after acute myocardial infarction remains controversial. The objective of the present study was therefore to analyze the outcome and predictors of in-hospital mortality in patients (pts) referred to CABG with acute coronary syndrome (ACS). PATIENTS AND METHODS: Between January 2003 and May 2005, a total of 3,127 pts underwent primary isolated CABG at our institution, including 220 pts with ACS. Out of these, unstable angina pectoris was present in 88 pts (group I), 97 pts (group II) had non-ST-elevation infarction, whereas 35 pts (group III) had ST-elevation infarction. Clinical data, in-hospital morbidity and mortality were recorded and studied retrospectively. RESULTS: Overall in-hospital mortality was 6.4% (n = 14) in the complete cohort, being 2.2% in group I (n = 2), 9.2% in group II (n = 9) and 8.5% (n = 3) in group III (P < 0.05). Logistic regression and receiver operating characteristic analyses identified age, NYHA, ejection fraction < 45%, catecholamine support, cardiogenic shock, renal disease and the additive EuroSCORE > 10 (P < 0.0001) as significant predictors related to in-hospital mortality. The mean time from the onset of symptoms to revascularization differed significantly between survivors (5.1 +/- 2.7 h) and no survivors (11.4 +/- 3.2 h) (P < 0.0007) in the STEMI group. Preoperative cTnI did not provide any prognostic information. CONCLUSION: CABG in pts with ACS can be performed with good clinical results. The clinical outcome is particular depending on the different groups of ACS. Therefore an individual risk stratification of each pts in ACS is necessary. The time interval of 6 h seems to be crucial as prognostic variable in the STEMI-group.     

氟伐他汀对急性冠状动脉综合征患者基质金属蛋白酶-9及组织因子的影响

目的 观察急性冠状动脉综合征(ACS)患者血清基质金属蛋白酶-9(MMP-9)、血浆组织因子(TF)及血脂的水平;探讨氟伐他汀对ACS患者血清MMP-9、血浆TF及血脂水平的影响,进一步了解氟伐他汀稳定斑块抑制血栓形成的作用.方法 选取ACS患者40例,其中不稳定型心绞痛(UAP)20例,心肌梗死(AMI)20例;稳定型心绞痛(SAP)20例;正常对照13例(对照组).测定入院时血清MMP-9、血浆TF及血脂的水平.再将40例ACS患者随机分成氟伐他汀治疗组20例和常规治疗组20例,2周后再次测定用药后上述指标.血清MMP-9、血浆TF用酶联免疫吸附法测定.结果 ACS患者(AMI组和UAP组)血清MMP-9及血浆TF水平明显高于SAP组和正常对照组,差异有统计学意义(P<0.001,P<0.05);AMI组与UAP组比较血清MMP-9及血浆TF水平明显升高(P<0.05).氟伐他汀组治疗后血清MMP-9及血浆TF、胆固醇、低密度脂蛋白均明显降低.与治疗前比较差异均有统计学意义(均P<0.05);对照组治疗前后各项指标差异均无统计学意义(均P>0.05);氟伐他汀治疗组MMP-9、TF的变化与血脂均无相关性(均P>0.05).结论 ACS患者血清MMP-9及血浆TF水平明显升高,氟伐他汀治疗ACS患者2周可使血清MMP-9及血浆TF水平明显降低,可能有利于稳定动脉粥样斑块和抑制血栓的形成,且这种作用与调脂作用无关.     

The clinical implications of increased OX40 ligand expression in patients with acute coronary syndrome

BACKGROUND: Increasing evidence show that OX40 ligand (OX40L), also known as tumor necrosis factor superfamily member 4 (TNFSF4), plays an important role in the pathogenesis of atherosclerosis. We investigated whether expression levels of soluble OX40L in serum and of membrane OX40L on platelets were related to serum concentrations of matrix metalloproteinases (MMPs) and stability of coronary atherosclerotic plaque in patients with acute coronary syndrome (ACS). METHODS: We included healthy controls (n=30), patients with stable angina (SA) (n=40) and patients with ACS, including unstable angina (UA) (n=70) and acute myocardial infarction (AMI) (n=40). The expression of OX40L on platelets (pOX40L) was analyzed with flow cytometry whereas serum concentrations of soluble OX40L (sOX40L), MMP-9 and MMP-3 were determined with ELISA. All coronary stenoses with >/=30% diameter reduction were assessed by angiographic coronary stenosis morphology. RESULTS: The expression of OX40L on platelets were significantly higher in patients with ACS (61.5+/-11.5) compared with healthy controls (28.9+/-7.4) or with the group of patients with SA (31.2+/-8.1) (mean fluorescence intensity+/-SD) (p<0.001). Similarly, we observed higher sOX40L concentrations in patients with ACS (34.6+/-9.3) compared with controls (10.2+/-4.7) or patients with SA (11.4+/-5.8) (ng/ml+/-SD) (p<0.001). Serum MMP-3 and MMP-9 levels in patients were two times greater than those in the control group. A positive correlation was observed between OX40L expression on platelets and MMP-9 and MMP-3 serum concentrations. OX40L expression on platelets were furthermore correlated with soluble OX40L in serum and with complex coronary stenoses (r1=0.61, r2=0.57, p<0.001). CONCLUSION: Patients with ACS show increased OX40L system (pOX40L and sOX40L) expression which may create a proinflammatory milieu for aggravating the development of atherosclerosis, and may be a valuable marker for predicting the severity of ACS.     

奥扎格雷对急性冠脉综合征患者血浆血管性血友病因子含量及金属蛋白酶-9水平的影响

目的研究奥扎格雷对急性冠脉综合征(ACS)患者血浆血管性血友病因子(vWF)含量及基质金属蛋白酶-9(MMP-9)水平的影响。方法选择84例ACS患者,随机分为对照组(常规治疗,n=42)和治疗组(常规治疗加奥扎格雷,n=42),测定治疗前后患者血浆vWF含量及MMP-9水平,同时比较治疗前后心电图改善情况,并进行统计分析。结果 2组患者治疗后的血浆vWF及MMP-9水平均呈显著下降的趋势,其中治疗组血浆vWF及MMP-9水平下降的幅度均显著大于对照组。结论采用奥扎格雷治疗ACS患者,可显著降低血浆vWF含量及MMP-9水平。     

Anti-(apolipoprotein A-1) IgGs are associated with high levels of oxidized low-density lipoprotein in acute coronary syndrome

ApoA-1 (apolipoprotein A-1) is the main component of HDL (high-density lipoprotein) and stabilizes PON-1 (paraoxonase-1), which prevents lipid peroxidation and oxLDL (oxidized low-density lipoprotein) formation. Autoantibodies against apoA-1 [anti-(apoA-1) IgG] have been found in antiphospholipid syndrome and systemic lupus erythematosous, two diseases with an increased risk of thrombotic events, as well as in ACS (acute coronary syndrome). OxLDL levels are also elevated in these diseases. Whether anti-(apoA-1) IgGs exist in other prothrombotic conditions, such as APE (acute pulmonary embolism) and stroke, has not been studied and their potential association with oxLDL and PON-1 activity is not known. In the present study, we determined prospectively the prevalence of anti-(apoA-1) IgG in patients with ACS (n=127), APE (n=58) and stroke (n=34), and, when present, we tested their association with oxLDL levels. The prevalance of anti-(apoA-1) IgG was 11% in the ACS group, 2% in the control group and 0% in the APE and stroke groups. The ACS group had significantly higher median anti-(apoA-1) IgG titres than the other groups of patients. Patients with ACS positive for anti-(apoA-1) IgG had significantly higher median oxLDL values than those who tested negative (226.5 compared with 47.7 units/l; P<0.00001) and controls. The Spearman ranked test revealed a significant correlation between anti-(apoA-1) IgG titres and serum oxLDL levels (r=0.28, P<0.05). No association was found between PON-1 activity and oxLDL or anti-(apoA-1) IgG levels. In conclusion, anti-(apoA-1) IgG levels are positive in ACS, but not in stroke or APE. In ACS, their presence is associated with higher levels of oxLDL and is directly proportional to the serum concentration of oxLDL. These results emphasize the role of humoral autoimmunity as a mediator of inflammation and coronary atherogenesis.     

急性冠脉综合征患者血清胆红素测定的临床意义

目的探讨急性冠脉综合征（ACS）病人血清胆红素变化的临床意义。方法108例ACS病人分为ST段抬高的心肌梗死组（STEMI组,40例）,非ST段抬高的心肌梗死组（NSTEMI组,30例）,不稳定型心绞痛组（UAP组,38例）,对照组45例为健康查体人员。108例病人中66例行冠状动脉造影后分为单支病变组（26例）,双支病变组22例,三支病变组（18例）,选择同期冠状动脉造影正常的30例非冠心病病人作为对照组。以上各组均测定血清总胆红素、直接胆红素等临床指标。结果对照组总胆红素、直接胆红素均高于其他各组（P〈0．05）;其中UAP组高于STEMI组（P〈0．05）。造影正常组血清胆红素也高于其他三组（P〈0．05）,单支病变组高于多支病变组（P〈0．05）。结论ACS病人血清胆红素低于正常人,低血清胆红素水平可能与ACS患者病情严重程度有关。     

冠心病患者冠状动脉重构效应初步探讨

目的使用血管内超声(IVUS)初步探讨冠心病患者的冠状动脉重构效应。方法28例行IVUS检查的冠心病患者随机分为急性冠脉综合征(ACS)组(18例)和稳定性心绞痛组(对照组,10例),分别测定两组患者的斑块面积、血管外弹力膜(EEM)面积、斑块负荷、重构指数(RI)等指标,同时采用酶联免疫吸附法测定患者血浆高敏C反应蛋白(hs-CRP)、金属基质蛋白酶(MMP,包括MMP-2、MMP-9)、CD40配体(CD40L)和妊娠相关蛋白A(PAPP-A)水平。结果ACS组患者的"罪犯"病变斑块面积(P=0.000)、EEM面积(P=0.003)和斑块负荷(P=0.037)均大于对照组,高危斑块发生率(P=0.028)和RI(P=0.015)也升高。正重构多见于ACS组(P=0.040),负重构多见于对照组(P=0.039)。高危斑块组患者的血浆MMP-2(P=0.011)、MMP-9(P=0.001)和CD40L(P=0.034)水平高于非高危斑块组。与负重构组和无重构组比较,正重构组血浆hs-CRP(P=0.190)、MMP-2(P=0.255)、MMP-9(P=0.574)、CD40L(P=0.342)和PAPP-A(P=0.403)水平,以及高危斑块发生率(P=0.566)等均无显著性差异。以RI为因变量、以分组和炎症介质水平等为自变量的回归方程为RI=0.179-0.131group(group代表分组),其中分组变量的回归系数具有显著性意义(P<0.05)。结论冠心病的表现类型可能是预测冠状动脉重构的独立变量。     

急性冠状动脉综合征患者血浆五聚素3水平研究

目的 通过分别检测急性冠状动脉综合征(ACS)患者、稳定型心绞痛(SAP)患者及对照者的血浆五聚素3(PTX3)水平及血清超敏C-反应蛋白(hs-CRP)水平,探讨血浆PTX3水平在各组间的差异以及血浆PTX3水平与ACS的相关性是否强于血清hs-CRP水平.方法入选经冠状动脉造影确诊为正常的20例患者为对照组;经冠状动脉造影确诊为冠心病58例,其中SAP 22例(SAP组),ACS 36例(ACS组).分别检测各组患者入院第2天的血浆PTX3、血清hs-CRP水平及各项常规血生化检查.血浆PTX3水平取对数后服从正态分布.应用SPSS 10.0统计软件对所得数据进行单因素方差分析和Logistic回归分析.结果ACS组患者的血浆PTX3对数水平高于SAP组和对照组,差异具有统计学意义(均P<0.05);SAP组与对照组之间差异无统计学意义(P>0.05).以组别为因变量,血浆PTX3对数水平和血清hs-CRP水平为协变量进行多分类变量Logistic回归分析显示血浆PTX3对数的参数估计值B=2.32(P<0.05),血清hs-CRP的估计值B=0.447(P>0.05).结论ACS患者血浆PTX3水平明显高于对照组和SAP组,主要表达于脉管系统的血浆PTX3与ACS的相关性优于血清hs-CRP.     

Prognostic value of admission glucose and glycosylated haemoglobin levels in acute coronary syndromes

BACKGROUND: Admission hyperglycaemia is associated with poorer prognosis in patients with an acute coronary syndrome (ACS). Whether hyperglycaemia is more important than prior long-term glucose metabolism, is unknown. AIM: To investigate the prognostic value of admission glucose and HbA(1c) levels in patients with ACS. METHODS: We measured glucose and HbA(1c) at admission in 521 consecutive patients with suspected ACS. Glucose was categorized as <7.8 (n = 305), 7.8-11.0 (n = 138) or > or =11.1 mmol/l (n = 78); HbA(1c) as <6.2% (n = 420) or > or =6.2% (n = 101). Mean follow-up was 1.6 +/- 0.5 years. RESULTS: The diagnosis of ACS was confirmed in 332 patients (64%), leaving 189 (36%) with atypical chest pain. In ACS patients, mortality by glucose category (<7.8, 7.8-11.0 or > or =11.1 mmol) was 9%, 8% and 25%, respectively (p = 0.001); mortality by HbA(1c) category (<6.2% vs. > or =6.2%) was 10% vs. 17%, respectively (p = 0.14). On multivariate analysis, glucose category was significantly associated with mortality (HR 3.0, 95% CI 1.1-8.3), but HbA(1c) category was not (HR 1.5, 95%CI 0.6-4.2). DISCUSSION: Elevated admission glucose appears more important than prior long-term abnormal glucose metabolism in predicting mortality in patients with suspected ACS.     

Management and outcomes of acute coronary syndrome with minimal myocardial necrosis: analysis of a large prospective registry from a non-interventional centre

The aim of this study was to assess the clinical risk of minimal myonecrosis below the cut-off for acute myocardial infarction (MI) in comparison with other grades of acute coronary syndrome (ACS). One-thousand four hundred and sixty seven consecutive patients with ACS admitted between May 2001 and April 2002 were studied in a non-interventional centre. Patients were divided into unstable angina (UA) (cTnT < 0.01 microg/l), non-ST elevation ACS with minimal myonecrosis (0.01 or= 0.1 microg/L) and ST elevation myocardial infarction (STEMI). UA (n = 638) was associated with the fewest events at 6 months (2% cardiac death or MI). Patients with any myonecrosis (n = 829) had worse outcomes (6-month cardiac death or MI 18.3-23.3%). Compared with ACS patients with minimal myonecrosis, UA patients were at significantly lower risk (OR 0.21, 95% CI 0.12-0.45, p < 0.001), NSTEMI patients were at similar risk (OR 1.45, 95% CI 0.89-2.35, p = 0.13), and STEMI patients were at higher risk (OR 2.12 95% CI 1.26-3.85, p = 0.008) in adjusted analyses. Nearly 85% of cardiac deaths occurred within 6 months. The risk of adverse events was higher among patients managed by non-cardiologists (OR 1.66, 95% CI 1-2.75, p = 0.049). Patients with non-ST elevation ACS and minimal myonecrosis are a high-risk group more comparable with NSTEMI and clearly distinguishable from patients with UA.