Underuse of Thrombolytic Therapy in Acute Myocardial Infarction and Left Bundle Branch Block

Thrombolytic therapy reduces mortality in patients with acute myocardial infarction (AMI) and left bundle branch block (LBBB). The difficulty in accurately diagnosing AMI in patients with LBBB, however, might result in their undertreatment. Among 3,890 patients hospitalized with chest pain, 241 (6.2%) had LBBB at presentation. The only variable independently associated with AMI among patients with LBBB was in‐hospital left ventricular failure (odds ratio [OR]: 4.32, 95% confidence interval [CI]: 1.95–9.57, p < 0.0005). Only 16 (29%) of the LBBB patients with AMI received thrombolytic therapy compared with 583 (78%) of the 747 patients with ST‐elevation AMI (p < 0.0005). A further 19 (10%) LBBB patients without AMI also received thrombolysis. Difficulty in making an accurate early diagnosis in patients with LBBB ensures that the majority of those with AMI fail to receive thrombolytic therapy while others without AMI are treated inappropriately. Improved diagnostic and therapeutic strategies are needed for patients with acute coronary syndromes and LBBB. Copyright © 2010 Wiley Periodicals, Inc.     

急性心肌梗死溶栓药物疗效的循证医学评价

根据大量临床试验结果对治疗急性心肌梗死(AMI)的溶栓药物从疗效、并发症等进行了比较,发现溶栓药物从第1代到第3代在纤维蛋白选择性、半衰期、给药方式等方面有了较大的改进,使AMI的病死率降至7%~8%,但新型溶栓药物在有效率方面并没有明显超过组织型纤溶酶原激活剂,仍存在着颅内出血并发症、价格昂贵等缺点。因此,积极联用抗栓药物和经皮冠状动脉介入术治疗AMI,乃是降低病死率的倡用办法。     

急性心肌梗死常见并发症的防治进展

随着生活水平的提高,冠心病的发病率呈逐年上升趋势。急性心肌梗死（AMI）为冠心病的严重类型,具有发病急、病情凶险、病死率高等特点,可出现心力衰竭、心源性休克、心律失常及心脏破裂等多种并发症,这些并发症是导致心肌梗死死亡的主要原因。尽管溶栓、冠脉介入治疗的广泛应用使得AMI住院病死率显著降低,但AMI并发症严重影响着冠心病患者的远期预后及生活质量。因此通过早期预测因素风险评估,积极采取预防措施,尽早防治严重并发症是降低AMI病死率的关键。     

急性心肌梗死的早期诊断生化标志物

急性心肌梗死(AM I)一直是临床关注的重症疾患之一,它的早期诊断至关重要。血清生化标志物凭借其特异性及敏感性,在AM I的早期诊断中具有重要的地位,现就国内外有关方面的实验研究报道作一综述。     

AMI患者尿激酶与组织型纤溶酶原激活剂治疗结果的对比

比较31例尿激酶(UK)及14例组织型纤溶酶原激活剂(t-PA)静脉溶栓辅以阿斯匹林及肝素治疗急性心肌梗塞(AMI)的疗效.t-PA组与UK组相比较:血管再通率分别为78.6%与58.1%(P>0.05);脑、消化道及呼吸道出血并发症在t-PA组稍多,而UK组以局部皮肤出血较多.血管再通组心力衰竭、严重性心律失常、室壁瘤及梗塞后心绞痛的发生率较低,但两组间均无显著性差异;再通组病人心脏破裂的发生明显低于未再通组(0与17.6%P<0.05).本研究提示静脉t-PA溶栓治疗血管再通率高于静脉UK,有条件者可以首选t-PA.溶栓再通可以减少心力衰竭、室壁瘤、心梗后再缺血的发生,特别是心脏破裂的发生,从而改善病人的预后.     

Routine Coronary Arteriography Following Thrombolytic Therapy for Acute Myocardial Infarction: An Unsettled Controversy

Although coronary artery disease remains the leading cause of death in industrialized countries, the management of patients recovering from acute myocardial infarction varies significantly. The issue of routine arteriography and revascularization following thrombolytic therapy remains controversial despite substantial evidence associating infarct-related artery patency with improved cardiac function and survival. Randomized trials of routine intervention after myocardial infarction have generally failed to demonstrate advantages of this invasive approach but methodological problems limit their application to current practice. High-risk patients should be referred for arteriography. While awaiting definitive trials addressing the influence of routine arteriography on patient survival and its cost effectiveness, the management of other patient groups must be individualized.     

Prophylactic Furosemide Treatment in Acute Myocardial Infarction

ABSTRACT. Prophylactic diuretic theraphy in acute myocardial infarction (AMI) was evaluated in 83 consecutive patients without severe left ventricular failure (LVF) on admission. A high dose group (HDG) received 120–160 mg and a low dose group (LDG) 20–40 mg furosemide daily for six weeks. Mortality and reinfarction rates did not differ between the groups. One HDG patient and five LDG patients developed severe LVF. Four HDG patients developed severe dehydration. Serum enzyme activities and electrolytes were similar in both groups. The increased diuresis in the HDG was accompanied by a 4 % hemoconcentration, smaller radiological heart volumes, higher heart rates, a higher demand for nitroglycerin and higher ratings of thirst. Exercise tests yielded similar results in both groups. Later blood volumes and transthoracic electrical impedance were similar in both groups. It is concluded that liberal prophylactic furosemide treatment in AMI offers no major clinical advantage.     

Changes in Autonomic Tone Following Thrombolytic Therapy for Acute Myocardial Infarction:

Heart Rate Variability in Acute MI. Introduction: Little data are available on changes in autonomic tone during the first 24 hours of acute infarction in patients undergoing thromholytic therapy. Particularly, the association of changes in autonomic tone to reperfusion of the infarctrelated artery has not been evaluated in man. Heart rate variability (HRV) is a noninvasive tool to assess cardiac autonomic tone, which carries prognostic information in postinfarction patients. Methods and Results: To assess changes in autonomic tone with ungiographically assessed success of thrombolysis in patients with acute infarction, the proportion of adjacent RR intervals different by greater than 50 msec (pNN50) was analyzed from 24-hour Holler monitoring initiated before the start of thrombolytic therapy in 103 consecutive patients. Mean heart rate (HR) and pNN50 were available in 95 of 103 patients and were separately analyzed for the first hour after initiation of thrombolysis (reperfusion phase) and the first 24 hours. As assessed by coronary angiography 90 minutes after start of thrombolysis, 74 patients (78%) had successful coronary artery reperfusion. HR averaged 72 ± 13/min for the first hour in all 95 patients and 74 ± 13/min for the first 24 hours. The respective values for pNN50 were 11±2%± 11±7% for the first hour and 9±7%± 9±2% for the first 24 hours. Patients with inferior myocardial infarction (MI) had a lower mean HR of 72 ± 12/min versus 76 ± 13/min (P = 0±11) and a higher pNN50 (11±2%± 9±8% versus 7±6%± 8±3%, P = 0±01) compared to patients with anterior MI. The mean HR correlated weakly with pNN50 (r = -0±33, P < 0±01). For patients with coronary artery patency after 90 minutes, mean HR was 70 ± 12/min for the first hour compared to 80 ± 13/min for patients without (P = 0±003). For the first 24 hours, these values were 72 ± 12/min compared to 80 ± 14/min (P = 0±02). For the first hour, pNN50 averaged 12±6%± 12±4% for patients with successful reperfusion compared to 6±6%± 7±3% for patients without (P = 0±024). For the first 24 hours, these values were 9±2%± 8±5% compared to 11±5%± 11±3% (P = NS). Patients with inhospital ventricular fibrillation (n = 8) had a higher mean HR throughout the first 24 hours (88 ±16/min vs 73 ± 12/min, P = 0±008) compared to patients with an uneventful course. Additionally, there was a trend toward a lower HRV in patients with ventricular fibrillation. Conclusion: Thrombolysis-induced reperfusion of the infarct-related artery results in a higher vagal tone during the early hours of MI as compared to failed reperfusion. This finding is independent from intfarct location and associated with a trend toward a lower incidence of ventricular fibrillation during the acute phase of infarction.     

Bolus Administration of Saruplase in Europe (BASE), a Pilot Study in Patients with Acute Myocardial Infarction

To study the safety and efficacy of the thrombolytic agent saruplase as a bolus, the angiographic and clinical outcomes of three bolus regimens were investigated in a pilot study conducted in 192 patients with an acute myocardial infarction and were compared with the standard regimen. Fifty-two patients received a double bolus of 40 mg and 40 mg after 30 minutes, 51 patients a bolus of 80 mg, and 36 patients a bolus of 60 mg. Fifty-three patients received the standard regimen (a bolus of 20 mg and 60 mg IV infusion over 1 hour). At 60 minutes TIMI 2 and 3 flow were, respectively, 9.6% and 61.5% with the 40/40-mg bolus, 15.7% and 51.0% with the 80-mg bolus, 16.7% and 30.6% with the 60-mg bolus, and 7.5% and 54.7% with the standard 20/60-mg infusion. At 90 minutes TIMI 2 and 3 flow improved to 9.6% and 73.1%, 15.7% and 56.9%, 13.9% and 36.1%, and 5.7% and 71.7%, respectively. The primary endpoint, persistent patency (TIMI 2 + 3) at 24–45 hours, was seen in 69.2%, 64.7%, 44.4%, and 67.9% of patients who had no rescue PTCA, respectively. Inclusion in the 60-mg bolus group was prematurely stopped because of their low patency rates. The 40/40-mg bolus group had the highest mortality rate (13.5%), whereas the 60-mg bolus group had no deaths. Other adverse event rates were similar in the four groups. This clinical outcome is highly influenced by rescue PTCA of patients with insufficient TIMI flow. This pilot study indicates that in patients with an acute myocardial infarction, a double bolus of 40/40 mg resulted in the highest patency but also had the highest complication rate. The 80-mg single bolus is an attractive alternative for further evaluation because of its acceptable patency and event profile, and its easy form of administration.     

新型冠状病毒肺炎疫情对急性心肌梗死诊治的影响

新型冠状病毒肺炎成为世界卫生体系的严峻挑战,国内外均采取了前所未有的严格防控措施,肺炎疫情对急性心肌梗死的急诊救治流程产生了深刻的影响,国内外制定了一系列的相关文件以指导疫情期间急性心肌梗死的救治工作,本文对此进行综述。     

急性心肌梗死经皮冠状动脉介入治疗研究进展

急性心肌梗死的治疗主要涉及药物和介入治疗两个方面。及时有效的经皮冠状动脉介入治疗能迅速开通阻塞的冠状动脉、挽救濒死心肌,降低急性心肌梗死病人的病死率和病残率。现就有关急性心肌梗死的经皮冠状动脉介入治疗研究进展作一综述。     

急性心肌梗死不同时间段溶栓治疗的效果观察

目的观察急性心肌梗死不同时间段溶栓效果。方法选取50例不同时间段急性心肌梗死者给予溶栓治疗,同时对血管再通等进行观察与相关数据统计分析。结果血管再通率≤3h者占81.25%、3～6h者占71.43%、6～12h者占46.15%,且溶栓时间越早患者恢复越快（P〈0.05）。结论溶栓治疗急性心肌梗死效果明显,且溶栓越早血管再通率越高、心肌梗死面积越小、患者预后越好。     

易化的经皮冠脉介入治疗——急性心肌梗死治疗新策略

急性心肌梗死再灌注治疗的方法主要包括溶栓和紧急经皮冠脉介入治疗,其中溶栓治疗简单易行,但再灌注不充分,并且再闭塞率高;而直接经皮冠脉介入治疗,可以恢复心外膜血管的血流,血管的开通率高,但是只有在有条件的医院才能进行,而对于急性心肌梗死来讲,血管开通的时间是最重要的,因此,人们试图通过将溶栓治疗和经皮冠脉介入治疗联合应用来发挥各自的优势,尽量减少缺陷来尽快恢复心脏血流供给,也就是采用易化经皮冠脉介入治疗的方法来治疗急性ST段抬高心肌梗死,从而获得梗死相关动脉更早的开通和更高的开通率。     

急性心肌梗塞溶栓治疗后D-二聚体动态变化的意义

在22例符合溶栓条件的急性心肌梗塞患者，应用尿激酶溶栓治疗前后，用乳胶颗粒凝集法检测了血清D-二聚体的动态变化和对照组比较，D-二聚体含量在梗塞相关动脉（IRA）再通者明显升高（P＜0．01），而IRA未再通者仅稍有升高（P＞0．05）。结果表明，D-二聚体水平和IRA再通与否之间有良好的相关性，且方法简便，易于推广。     

Acute Myocardial Infarction During Transesophageal Echocardiography

We describe the occurrence of acute myocardial infarction during transesophageal echocardiography (TEE) in a patient with atrial fibrillation and underestimated angina. Such a case has not been previously reported in the literature. This case illustrates one of the possible complications of TEE, leading us to suggest systematic sedation in patients with angina in whom TEE is envisaged.     

Intravenous Amiodarone Decreases the Duration of Atrial Fibrillation Associated with Acute Myocardial Infarction

Purpose: Atrial fibrillation (AF) is a fairly common complication of acute myocardial infarction (AMI). The aim of this study was to examine the safety and efficacy of intravenous amiodarone in converting AF associated with AMI. Methods: Seventy patients with AMI complicated with AF were prospectively divided into 3 groups: a) In group D (n = 26), 0.75 mg digoxin was administered intravenously and thereafter as needed, b) In group AM (n = 16), 300 mg of amiodarone was infused over 2 hours followed by 44 mg/hour for up to 60 hours or until sinus rhythm was restored, c) In group D + AM (n = 28), 0.75 mg of digoxin was administered (as in group D) for the initial 2 hours followed by amiodarone infusion as in group AM. Results: Sinus rhythm was restored: a) by the end of the 2nd hour in 9/26 patients from group D, 4/16 from group AM, and 10/28 from group D + AM (p = NS), b) by the end of the 96th hour, in 18/26 patients from group D, and in all patients from group AM and groupd D + AM. The corresponding duration of AF was 51 ± 34 hours, 17 ± 15 hours and 9 ± 13 hours, respectively (F = 15.4, p < 0.001). AF recurred in 9/26, 5/16 and 1/28 patients of groups D, AM and D + AM, respectively (p = 0.026). The required dosage of amiodarone was lower in the D + AM group than in the AM group (603 ± 563 mg versus 1058 ± 680 mg, p = 0.037). Conclusions: Intravenous amiodarone was well tolerated in patients with AMI complicated by AF and was effective in decreasing the duration of AF. However, the combination of amiodarone and digoxin was superior to amiodarone alone in restoring sinus rhythm faster, maintaining sinus rhythm longer, and allowing the use of a lower cumulative amount of amiodarone.     

急性心肌梗死与高血糖

无论有无糖尿病病史,急性心肌梗死患者常伴有高血糖。急性血糖升高可对心血管造成许多有害影响,并可加重患者的不良转归。强化高血糖控制措施可改善急性心肌梗死患者的预后。因此,提高对急性心肌梗死与高血糖之间相关关系、产生机制及其防治的认识,具有重要的意义。     

急性心肌梗死生化标志物的研究进展

急性心肌梗死是临床常见的危重疾病,血液中生化标志物的测定是反映心肌损伤的重要手段之一。生化标志物凭其高度的敏感性及特异性,在急性心肌梗死的诊断、危险分层及评估预后中发挥了非常重要的作用。目前已有越来越多的心肌梗死生化标志物在临床中得到应用。现就急性心肌梗死损伤生化标志物的最新研究进展做一综述。     

Coronary Angioplasty or Intravenous Thrombolysis: The Dilemma of Optimal Reperfusion in Acute Myocardial Infarction: A Critical Review of the Literature.

Thrombolytic therapy in acute myocardial infarction reduces infarct size and prolongs survival. Coronary reperfusion can also be achieved by direct (primary) percutaneous transluminal coronary angioplasty (PTCA). Whereas thrombolysis has the benefits of simplicity and ease of administration, PTCA achieves high reperfusion rates at a relatively low risk of bleeding and is less frequently contraindicated. These two strategies were evaluated in randomized trials as well as in a number of large registries. In most of the randomized trials, PTCA was found to yield better results than thrombolysis, although the largest randomized trial found only a modest and transient benefit. The registries, on the other hand, found no difference between the two treatment strategies. We analyze the available data and discuss the possible causes for the discrepant results in different studies. PTCA seems to be a better strategy to open occluded coronary arteries, but its clinical benefit is critically dependent on operator experience and on the time to treatment. It is the treatment of choice if the culprit lesion can be crossed within 1 hour of presentation. Home thrombolysis offers the chance of very early reperfusion and may be the most cost-effective way of improving the overall results of reperfusion therapy in the community. Coronary stenting and more effective platelet inhibition may improve the results of medical and interventional reperfusion, and further comparisons of these two strategies will be required.     

急性心肌梗死溶栓疗法临床分析

目的 分析溶栓疗法治疗急性心肌梗死的疗效.方法 选择发病在12h内的急性心肌梗死患者30例,在对症治疗的同时立即给予静脉滴注尿激酶100万U,分析患者的冠状动脉再通率情况.结果 30例患者中26例再通,再通率为86.67%,没有发生严重的不良反应.结论 心肌梗死后早期采用静滴尿激酶进行溶栓安全、有效,值得临床推广应用.