优化直接经皮冠状动脉介入治疗流程对ST段心肌梗死患者预后的影响

目的探讨优化直接经皮冠状动脉介入治疗（PPCI）流程对门．球囊时间（DtoB）及sT段抬高心肌梗死（STEMI）患者预后的影响。方法回顾性分析2009年1月—2010年6月在台州医院心内科成功行PPCI的STEMI患者的临床资料。按不同导管室启动模式分为A组和B组。A组：急救中心医生初步诊断STEMI后通知心内科医生会诊,后者确认后再通过导管室负责人启动导管室;B组：急救中心医生初步诊断STEMI后直接通知导管室负责人,后者派心内科医生会诊的同时启动导管室。主要分析指标为PPCI相关时间：D to B时间;门-心电图（DtoE）时间;心电图．导管室（E to L）时间;导管室-球囊（L to B）时间。次要分析指标为临床结果：肌酸激酶同工酶MB（CK—MB）、肌钙蛋白I（TnI）峰值;住院期间及出院后30天累计死亡率,主要不良心脏事件（MACE）发生率。结果两组共入选患者124例,A组54例,B组70例,两组患者基础临床情况相近。B组与A组比较DtoB时间为（91．3±14．0）min比（103．3±14;1）min（6=4．72,P〈0．01）。DtoB时间的缩短主要得益于EtoL时间的缩短（65．4±14．5）rain比（75．9±14．5）min（t=4．01,P〈0．01）;B组CK-MB、cTnI峰值较A组均有明显降低,分别为（2574-205）U／L比（392±292）U／L（t=2．90,P〈0．01）、（43．4±29．5）比（56．3±32．3）ng／ml（t=2．31,P〈0．01）。两组住院期间及出院后30天总死亡率、MACE发生率差异无统计学意义（X^2=1．66、0．01、0．57、0．06,P〉0．05）。结论急救中心医生直接通过导管室负责人预先启动导管室较传统呼叫心内科医生会诊后启动导管室能明显缩短DtoB时间,使CK-MB、cTnI峰值明显降低。     

优化急性ST段抬高型心肌梗死的直接经皮冠状动脉介入治疗

对ST段抬高型心肌梗死实施直接经皮冠状动脉介入治疗不应只是为获得TIMI 3级血流,而应是良好的心肌灌注。可通过上游使用血小板膜糖蛋白Ⅱb/Ⅲa受体拮抗剂、他汀类调脂药,个体化正确使用血栓抽吸装置,必要时延迟支架植入等手段,优化直接经皮冠状动脉介入治疗术的效果。     

急性ST段抬高性心肌梗死患者直接经皮冠状动脉介入治疗再灌注时间对ST段回落的影响

目的探讨直接经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗中症状发作-球囊扩张时间(symptom-onset-to-balloon,SOTB)对再灌注后心电图ST段的回落、住院期间左心室射血分数、6个月内总的主要心血管事件(包括心绞痛、再发心肌梗死、因心血管事件再入院、心力衰竭和死亡等)发生率的影响。方法回顾性分析2005年1月至2006年7月于北京大学深圳医院行直接PCI治疗的ST段抬高性心肌梗死(ST-elevation myocardial infarction,STEMI)患者225例的基线资料、心电图资料以及随访资料,比较不同时间SOTB(>3 h及≤3 h)术前、术后1 h ST段抬高总和恢复百分比(sumSTR)%、住院期间超声心动图所测的左心室射血分数、随访6个月的主要心血管事件发生率。结果SOTB≤3 h组PCI治疗后1 h ST段完全回落≥70%的患者比例明显高于SOTB>3 h组,差异有统计学意义(57.4%vs.43.2%,P=0.005);住院期间左心室射血分数高于SOTB>3 h组,差异有统计学意义(57.69%±7.64%vs.53.80%±9.03%,P=0.014);6个月主要心血管事件发生率低与SOTB>3 h组,差异有统计学意义(14.9%vs.35.4%,P=0.001)。结论 STEMI患者PCI治疗中SOTB短,ST段回落就迅速而完全,住院期间的左心室射血分数高,6个月主要心血管事件发生率低。     

急诊冠状动脉介入术强化阿托伐他汀治疗的临床疗效

目的:探讨急性ST段抬高心肌梗死(STEMI)急诊经皮冠状动脉介入治疗(PCI)术前单次口服大剂量阿托伐他汀和术后强化阿托伐他汀治疗的临床疗效。方法:选择STEMI并行急诊PCI治疗的118患者,随机分为2组:强化组(61例)术前阿托伐他汀80mg口服,术后40mg/d;常规组(57例)仅于术后给予阿托伐他汀20mg/d。两组均给予常规冠心病二级预防治疗。主要研究终点是术后30d主要心脏不良事件(MACE)发生率,次要研究终点包括心肌灌注TMPG分级、术后即刻和术后6hST段回降率(STR)和阿托伐他汀治疗前、后生化指标的变化。结果:PCI术后强化组CK-MB峰值明显低于常规组[(230.20±128.84)U/L∶(285.28±149.55)U/L,P<0.05]。PCI术后6h强化组STR≥50%的比例明显高于常规组(86.9%∶71.9%,P<0.05)。与常规组相比,强化组治疗30d后LDL-C、高敏C反应蛋白(hs-CRP)明显下降(P<0.05)。结论:STEMI急诊PCI术前大剂量阿托伐他汀80mg口服和术后40mg/d治疗安全有效,能够明显改善PCI术后6hSTR,降低CK-MB峰值和术后30d的LDL-C和hs-CRP。     

急性心肌梗死的延迟冠状动脉介入治疗

目的 探讨延迟冠状动脉介入治疗的疗效及安全性。方法 回顾性分析我院2003年4月～2006年3月发病超过12h 110例急性ST段抬高心肌梗死病人的临床资料。根据其是否接受冠状动脉介入治疗分为：延迟冠脉介入治疗组42例及药物治疗组68例。记录并分析两组住院及随访期间主要心脏事件的发生情况。结果 两组的基本情况除介入治疗组病人的年龄较药物治疗组偏小外．其他临床特征差异无统计学意义（P〉0．05）。介入治疗手术成功率：95％（40／42）。导丝无法通过病变手术失败1例,术后并发蛛网膜下腔出血1例,术中无死亡病例。两组住院及随访期间主要心脏事件发生情况：介入治疗组累计死亡1例（3．1％）;药物治疗组累计死亡7例（10．3％）,介入治疗组明显低于药物治疗组（P〈0．001）。主要心脏事件发生率,住院期间介入治疗组为34．5％,药物治疗组为50．0％;随访期间介入治疗组为37．5％,药物治疗组为60．3％。两组差异有统计学意义（P〈0．001）。结论 与常规药物治疗相比,延迟冠状动脉介入治疗安全有效,能明显改善急性心肌梗死的预后。     

Data feedback reduces door-to-balloon time in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Current guidelines recommend a goal of door-to-balloon (D2B) time < 90 min for patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). We aim to prospectively determine the effect of data feedback on D2B time and its seven individual components in primary PCI. From December 7, 2007, to June 2, 2009, 116 consecutive patients with STEMI who received PCI within 12 h of symptom onset were enrolled, including 56 patients before and 60 patients after the implementation of data feedback on July 28, 2008. The proportion of patients treated within 90 min increased from 26.8 to 55.0% (p = 0.002). On multivariable analyses, data feedback (OR 5.3, p = 0.003), known coronary artery disease (OR 5.6, p = 0.043), regular hours presentation (OR 3.3, p = 0.048), and arrival by transfer (OR 14.0, p = 0.003) were independent predictors of a D2B time less than 90 min. Median D2B time decreased from 112 min before data feedback to 87 min after data feedback (p < 0.001). The most significant decrease occurred in median door-to-ECG (11 vs. 3 min, p < 0.001), consult-to-cardiologist (5 vs. 3 min, p < 0.001), and puncture-to-balloon (21 vs. 17 min, p = 0.004) time. Data feedback to the emergency department and catheterization laboratory staff decreases D2B time in primary PCI. This simple approach may be the best first step to decrease D2B time in hospitals that are still striving to achieve the goal of D2B time < 90 min.     

Door-to-balloon time in radial versus femoral approach for primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction

Primary percutaneous coronary intervention (pPCI) is considered the preferred reperfusion strategy for patients presenting with ST-segment elevation myocardial infarction (STEMI). This study compares the door-to-balloon (D2B) time between transradial vs. the transfemoral approach in patients presenting with STEMI.MethodsA retrospectively collected catheterization laboratory database was reviewed for the consecutive patients presenting with a STEMI. Specific time parameters were recorded, and our composite end points were time to revascularization, angiographic success, short term clinical success, and procedural vascular complications.ResultsRadial PCI (r-PCI) was performed in 33 patients (67.3%) and in 16 patients (32.7%) PCI was done through femoral artery (f-PCI). No significant difference was observed in the pre-catheter and catheter laboratory times. Mean times from emergency room door-to-catheter laboratory time for r-PCI vs. f-PCI were 82.48 ± 37.42 and 76.29 ± 34.32 min, respectively (P = 0.636). The mean time from patient arrival to the cardiac catheter laboratory-to-balloon inflation was 34.56 ± 14.2 in the r-PCI group vs. 33.12 ± 12.56 min with the f-PCI group (P = 0.215). The total D2B time was not significantly different between r-PCI vs. f-PCI groups (100.32 ± 36.3 vs. 97.31 ± 30.37 min, respectively, P = 0.522). Angiographic success rates were observed in 92.1% of the patients for r-PCI, and in 87.5% for f-PCI (P = 0.712). There were no vascular complications in both groups.ConclusionsPatients presenting with STEMI can undergo successful pPCI via radial artery without compromising patient care.     

Anticoagulation with bivalirudin during percutaneous coronary intervention for ST-segment elevation myocardial infarction

OBJECTIVE: The objective of this retrospective analysis of high-risk patients treated with bivalirudin during primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) was to evaluate the safety and feasibility of direct thrombin inhibitor (DTI) without concomitant glycoprotein (GP) IIb/IIIa inhibition. BACKGROUND: Reperfusion by PCI is the treatment of choice for patients with STEMI. In patients with stable or unstable angina without ST-segment elevation undergoing PCI, bivalirudin was at least as effective as heparin plus GPIIb/IIIa inhibitors in reducing ischemic events and more effective in preventing bleeding. There are no published studies detailing the use of bivalirudin in patients with STEMI. METHODS: From 09/02 to 05/03 at the Heart Care Centers of Illinois, Blue Island, Illinois. Ninety-one consecutive patients with STEMI underwent PCI with or without stent placement. Bivalirudin was administered as a bolus dose (0.75 mg/kg) followed by infusion (1.75 mg/kg/hr) for the duration of the procedure. Outcomes were recorded over a 30-day follow-up period. RESULTS: Patients (n = 91) had several high-risk characteristics (40% female, 30% diabetes mellitus, 21% previous MI and 18% cardiogenic shock). PCI procedures utilized balloons, stents, or a combination of both. Intraaortic balloon pumps were used for 41% and closure devices for 24% of patients. CONCLUSIONS: This evaluation demonstrates excellent TIMI flow without the addition of GPIIb/IIIa inhibitors. The low mortality and complication rates suggest anticoagulation with bivalirudin in patients with STEMI undergoing PCI is feasible and warrants further study in larger controlled trials to evaluate the effectiveness of bivalirudin in this patient population.     

急性ST段抬高心肌梗死患者急诊经皮冠状动脉介入治疗无复流现象相关因素分析

目的探讨急性ST段抬高心肌梗死（STEMI）患者急诊经皮冠状动脉介入治疗（PCI）中出现无复流的相关危险因素。方法选取发病在12h内的1059例STEMI患者给予急诊PCI,收集患者的临床、造影和介入治疗资料。PCI术后,根据心肌梗死溶栓（TIMI）分级和校正TIMI帧数将患者分为正常血流组和无复流组。比较两组患者的基本临床资料、造影结果和手术相关资料的差异,分析STEMI患者急诊PCI术中出现无复流的原因。结果急诊PCI术中无复流组患者118例。正常血流组941例,无复流发生率为11．14％。研究共纳入63个指标,通过单变量分析发现,年龄、症状至PCI时间、谷草转氨酶、氯吡格雷使用情况、干预病变数、狭窄程度及血栓负荷与急诊PCI术中发生无复流具有相关性（P〈0．05）。多变量Logistic回归模型认为,年龄（OR=1．04,95％CI：1．02—1．06）与血栓负荷（OR=1．72,95％CI：1．07～2．76）可作为预测急诊PCI术中无复流发生的独立危险因素。结论年龄与血栓负荷可作为预测急性STEMI患者急诊PCI术中发生无复流的独立危险因素,而糖尿病、高血压、高血脂、吸烟等冠心病的传统危险因素与无复流未见相关性。     

Fever after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction is associated with adverse outcomes

Background

Fever is a common finding after primary percutaneous coronary intervention (PPCI) in patients with ST-segment elevation myocardial infarction (STEMI). However, its prognostic value is not validated yet.

Objectives

This study sought to evaluate the impact of fever after PPCI in STEMI on adverse clinical outcomes.

Methods

Five hundred fourteen consecutive patients who underwent PPCI due to STEMI were enrolled. Body temperature (BT) was checked every 6 h for 5 days after PPCI. Patients were divided into two groups according to the highest quartile of peak BT; peak BT ≤ 37.6 °C (control group) and peak BT > 37.6 °C (fever group). Rates of 1-year major adverse cardiovascular events (MACE; death, myocardial infarction, any revascularization) were compared.

Results

The prevalence of fever group (peak BT > 37.6 °C) was 24.7% (127/514). White blood cell count, highly sensitive C-reactive protein and serum cardiac troponin I level were higher in fever group than control group (12,162 ± 4199/μL vs. 10,614 ± 3773/μL, p < 0.001; 22.9 ± 49.4 mg/L vs. 7.4 ± 2.5 mg/L, p = 0.001, 16.7 ± 36.9 ng/dl vs. 8.70 ± 26.2 ng/dl, p = 0.027, respectively). The frequency of a history of previous myocardial infarction and left ventricular ejection fraction was lower in fever group (0.0% vs. 4.7%, p = 0.010; 47 ± 8 % vs. 49 ± 9 %, p = 0.002, respectively). There was no significant difference in angiographic characteristics between 2 groups. 1-year MACE rates were higher in fever group (11.0% vs. 4.7%, p = 0.010). Multivariate analysis revealed fever (OR 2.358, 95% CI 1.113–4.998, p = 0.025), diabetes mellitus as risk factor (2.227, 1.031–4.812, 0.042), and left anterior descending artery as infarct related artery (2.443, 1.114–5.361, 0.026) as independent predictors for 1-year MACE.

Conclusions

Fever after PPCI in patients with STEMI is frequently developed and it can predict adverse clinical outcome.     

Predictors of no-reflow phenomenon following percutaneous coronary intervention for ST-segment elevation myocardial infarction

ObjectivesNo reflow during percutaneous coronary intervention (PCI) is a complex issue with serious outcomes. Multiple studies have studied predictors of no-reflow during primary PCI, but data on patients with the late presentation is sparse, which constitutes the majority of patients in peripheral centers. This study aimed to determine predictors of no-reflow during PCI in patients with ST-segment elevation myocardial infarction (STEMI) in 7 days.MethodsIt was a single-center prospective case-control study performed at a tertiary care center and included 958 patients with STEMI who underwent PCI within 7 days of symptom onset. Baseline and angiographic data of patients undergoing PCI were recorded and patients divided into reflow and no-reflow group.ResultsOf 958 who underwent PCI, 182 (18.9%) showed no-reflow by myocardial blush grade (MBG) < 2. No-reflow group had a higher mean age (66.46 ± 10.71 vs. 61.36 ± 9.94 years), lower systolic blood pressure (SBP) on admission (100.61 ± 26.66 vs. 112.23 ± 24.35, P < 0.0001), a higher level of peak Troponin I level (9.37 ± 2.81 vs. 7.66 ± 3.11 ng/dL, P < 0.0001), low left ventricular ejection fraction (36.71 ± 3.89 vs. 39.58 ± 4.28% respectively P < 0.0001). Among angiographic data and procedural features, multivariable logistic regression analysis identified that advanced age, reperfusion time > 6 hours, SBP < 100 mmHg on admission, functional status of Killip class for heart failure ≥ 3, lower EF (≤ 35%), low initial myocardial blush grade (≤ 1) before PCI, long target lesion length, larger reference diameter of vessel (> 3.5 mm) and high thrombus burden on angiography were found to be independent predictors of no-reflow (P < 0.05).ConclusionNo-reflow phenomenon after PCI for STEMI is complex and multifactorial and can be identified by simple clinical, angiographic, and procedural features. Preprocedural characters of the lesion and early perfusion decides the fate of the outcome.     

Primary percutaneous coronary intervention for patients presenting with ST-segment elevation myocardial infarction: process improvement in a rural ST-segment elevation myocardial infarction receiving center

Background

Rural ST-segment elevation myocardial infarction (STEMI) care networks may be particularly disadvantaged in achieving a door-to-balloon time (D2B) of less than or equal to 90 minutes recommended in current guidelines.

ST-Elevation Myocardial Infarction Process Upgrade Project

A multidisciplinary STEMI process upgrade group at a rural percutaneous coronary intervention center implemented evidence-based strategies to reduce time to electrocardiogram (ECG) and D2B, including catheterization laboratory activation triggered by either a prehospital ECG demonstrating STEMI or an emergency department physician diagnosing STEMI, single-call catheterization laboratory activation, catheterization laboratory response time less than or equal to 30 minutes, and prompt data feedback.

Evaluating success

An ongoing regional STEMI registry was used to collect process time intervals, including time to ECG and D2B, in a consecutive series of STEMI patients presenting before (group 1) and after (group 2) strategy implementation. Significant reductions in time to first ECG in the emergency department and D2B were seen in group 2 compared with group 1.

Conclusions

Important improvement in the process of acute STEMI patient care was accomplished in the rural percutaneous coronary intervention center setting by implementing evidence-based strategies.     

血清肌酐水平对ST段抬高性心肌梗死急诊PCI治疗患者预后的影响

目的探讨血清肌酐水平对ST段抬高性心肌梗死（STEMI）急诊经皮冠状动脉介入治疗（PCI）患者预后的影响。方法接受急诊PCI治疗的495例STEMI患者,根据入院即刻肌酐水平分为肌酐正常组409例和肌酐升高组86例,随诊1 a,比较两组患者院内和1 a时的病死率及主要不良心脏事件（MACE,包括死亡、心肌梗死、需要血运重建的心绞痛）的发生情况。结果入院肌酐升高组患者与正常组比较,年龄大,高血压患者发病率及既往心肌梗死发病率高,心功能差,院内病死率和随访1 a时病死率、MACE发生率均较高,差异有统计学意义（P均〈0.05）。多变量回归分析显示,入院肌酐水平与STEMI接受急诊PCI治疗患者1 a病死率密切相关（RR=1.41,95%CI：1.24-2.69,P=0.02）。结论STEMI接受急诊PCI治疗患者入院时的肌酐水平对预测患者预后有重要意义。     

Impact of thrombus aspiration during primary percutaneous coronary intervention in cardiogenic shock complicating ST-segment elevation myocardial infarction

AimTo assess the impact on in-hospital and long-term survival of thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS).Methods and ResultsFrom September 2001 to May 2010 we collected data from 155 patients affected with STEMI complicated by CS undergoing PPCI (12.4% of all PPCI) including 70 patients (45.2%) in TA group and 85 patients (54.8%) in conventional PCI group. Patients in TA group were more likely to have right ventricular infarction (24.3% vs 5.9%, p = 0.002), higher mean left ventricular ejection fraction (40% ± 9% vs 35% ± 7%, p < 0.0001) and lower left main coronary artery occlusion (2.8% vs 21.2%, p = 0.002). TA was associated with a lower rate of in-hospital and long-term mortality (31.4% vs 48.2%, p = 0.05 and 42.8% vs 64.7%, p = 0.01 respectively) at a mean follow-up time of 6.1 ± 2.1 years. At multivariate analysis the only independent predictor of in-hospital and long-term survival was the procedural success (HR 0.18 95% CI 0.025–0.31, p = 0.03 and HR 0.46 95% CI 0.09–0.74, p = 0.034 respectively).ConclusionsIn this retrospective study TA, performed during PPCI for STEMI complicated by CS, was not an independent predictor of in-hospital and long-term survival.