他汀类药物对急性心肌梗死患者应激性高血糖的影响

目的探讨他汀类药物对于急性心肌梗死(AMI)患者应激性高血糖的影响。方法纳入2009年1月至2012年12月间,发生AMI的非糖尿病患者,分别调查血糖、血脂、肝肾功能、合并疾病以及口服药物,分析入院后出现应激性高血糖的相关的危险因素。结果 316例非糖尿病AMI患者符合入选标准,其中男性183例,女性133例,年龄47~89(67±12.8)岁。33.23%(105例)患者发生了应激性高血糖。二分类Logistic回归分析提示年龄(OR=2.992,95%CI:1.045~8.565,P=0.041),以及他汀类药物使用(OR=2.852,95%CI:1.051~7.741,P=0.040)为AMI患者应激性高血糖发生的危险因素。结论他汀类药物的使用促进AMI患者应激性高血糖的发生。     

Left ventricular remodeling in patients with stress hyperglycemia after acute myocardial infarction

Background To investigate the association between left ventricular remodeling and stress hyperglycemia (SH) inpatients with acute anterior wall myocardial Infarction. Methods Patients with acute anterior myocardial infarction and a successful primary percutaneous coronary intervention (PCI) were enrolled and divided into two groups according to the presence or absence of SH. Patients with diabetes mellitus were excluded. Echocardiographic studies were performed on discharge and at 6 month follow-up. Left ventricular (LV) ejection fractions (EF), LV end-diastolic volume (EDV) and LV end-systolic volume (ESV) were obtained at baseline and at 6 month. Differences between changes of ESV (ΔESV) and changes of EDV (ΔEDV) in the two groups as well as EF improvement rate (ΔEF %) over six month were obtained. Correlation between SH and LV remodeling was investigated. Results (1) At baseline, the level of hemoglobin A1c was significantly higher in SH group (6.9±1.4 vs 6.2±0.8 P=0.04). Other baseline characteristics, including peak serum creatine kinase MB and LV function, were similar between two groups; (2) EF increased significantly over 6 months in both group with SH((41.1±7.2)% vs (52.7±8.4)%, P=0.02) and group without SH. ((43.6±8.7)% vs (54.5±9.3)%, P=0.03) (3) Only in SH group, EDV increased significantly at 6 month (139.6±26.7 vs 126.1±26.7 P=0.04); (4) There was a weak correlation between ΔEDV and the level of fasting plasma glucose on admission.(Pearson's r=0.35, P0.01). Conclusions (1) Previous glucose metabolism disorder is at least partially responsible for hyperglycemia on admission; (2) Given successful primary PCI within recommended time interval, left ventricular function improved regardless of whether SH is present or not; (3) The degree of glucose metabolic dysfunction on admission is weakly associated with the remodeling process in 6 months     

Neurohumoral response and stress hyperglycemia in myocardial infarction

BackgroundHyperglycemia is associated with an increased risk for death in acute coronary syndromes. This could be related to underlying glucose metabolism abnormalities or be caused by a counter-regulatory stress response. However, there is a paucity of data on the relationship between stress hormones, hyperglycemia, and clinical outcomes in myocardial infarction.MethodsSingle-center, prospective, observational study. Patients admitted to the coronary care unit with a diagnosis of myocardial infarction were included. On admission, blood samples were obtained to measure serum glucose, cortisol, and catecholamines. A second sample was obtained at 8 AM after 48 h from admission.ResultsThere was a mild and positive correlation between serum cortisol and glucose (Spearman's rho = 0.24, p = 0.005), and no significant correlation was found between glucose and catecholamines. A similar correlation between cortisol and glucose among diabetics and non-diabetics was observed. Significantly higher serum cortisol and glucose levels were present in patients who developed heart failure or died during hospitalization. The association between glycemia and mortality lost significance in multivariate analysis, with a significant interaction term with cortisol (p = 0.003).ConclusionCortisol is a key responsible for stress hyperglycemia, and its deleterious effects on the cardiovascular system could be the cause for worst outcomes associated with hyperglycemia in ACS. Further research is warranted to ascertain this relationship and to investigate potential therapeutic targets.     

Electrocardiographic correlates of hyperglycemia in acute myocardial infarction

Clinical, biochemical and electrocardiographic parameters were studied in 10 patients with uncomplicated acute myocardial infarction with hyperglycemia (but normal glycosylated hemoglobin), and 15 age- and sex-matched patients with uncomplicated acute myocardial infarction without hyperglycemia. The magnitude of hyperglycemia correlated with the site and extent of the infarct, the magnitude of ST-segment elevation and the levels of 17-ketosteroids in the urine.     

血浆脑钠肽水平对非糖尿病急性心肌梗死并发应激性高血糖患者近期预后评价

目的:观察非糖尿病急性心肌梗死(AMI)并发应激性高血糖患者血浆脑钠肽(BNP)水平变化,探讨血浆BNP在非糖尿病AMI并发应激性高血糖患者近期预后评估中的作用。方法:将60例AMI患者根据空腹血糖值分为2组,非糖尿病AMI并发应激性高血糖组(试验组)(血糖≥7.0mmol/L)36例,AMI未并发应激性高血糖组(对照组)(血糖<7.0mmol/L)24例,对AMI患者在发病后24h时测定血浆BNP水平。所有入选患者入院后2周行心脏彩超检查,测定和计算左室舒张末期内径(LVDd)、左室收缩末期内径(LVSd)、左室射血分数(LVEF);同时行24h动态心电图检测,记录2组患者心律失常发生率;并观察住院2周内心绞痛、心力衰竭、心源性休克、心源性猝死等主要不良心血管事件(MACE)发生率。结果:①发病后24h血浆BNP浓度试验组明显高于对照组[(671.87±631.71)ng/L∶(299.53±455.67)ng/L,P<0.01]。②试验组LVDd、LVSd均高于对照组[(53.01±4.00)mm∶(50.50±3.20)mm,(45.32±5.92)mm∶(42.52±3.27)mm,均P<0.05],LVEF低于对照组[(52.86±5.79)%∶(61.00±7.54)%,P<0.05]。③试验组室性心律失常、室上性心律失常、严重窦性心动过缓和房室传导阻滞发生率均高于对照组(分别为66.67%∶41.67%,63.89%∶37.50%,47.22%∶20.83%,均P<0.05)。④试验组与对照组住院2周内MACE发生率,包括心力衰竭(36.11%∶12.50%)、心源性休克(16.67%∶0.00%)、梗死后心绞痛(25.00%∶4.17%)均差异有统计学意义(均P<0.05);死亡率(2.78%∶0.00%)差异无统计学意义(P>0.05)。结论:非糖尿病AMI并发应激性高血糖患者近期预后差,血浆BNP水平升高更为明显。     

Acute hyperglycemia in patients with acute myocardial infarction

Acute hyperglycemia is a common feature during the early phase after acute myocardial infarction (AMI), regardless of diabetes status. Numerous studies have demonstrated that patients with AMI and hyperglycemia on admission have high rates of mortality. It has been reported that there is a linear positive relation between admission blood glucose levels and mortality after AMI. However, recent studies showed that the relationship is U-shaped in patients with a history of diabetes. Diabetic patients with moderate hyperglycemia (glucose 9-11 mmol/L) had the lowest mortality and not only severe hyperglycemia (glucose ≥ 11 mmol/L) but also euglycemia (glucose < 7 mmol/L) was associated with higher mortality. Although it has been debated whether acute hyperglycemia is causally related to adverse outcomes after AMI or is simply an epiphenomenon of severely damaged myocardium, multiple physiological studies have demonstrated that hyperglycemia has a direct detrimental effect on ischemic myocardium through several mechanisms, including oxidative stress, inflammation, apoptosis, endothelial dysfunction, hypercoagulation, platelet aggregation and impairment of ischemic preconditioning. Current guidelines recommend the use of an insulin-based regimen to achieve and maintain glucose levels < 10.0 mmol/dl, and emphasize the avoidance of hypoglycemia. However, the optimal management goal of glucose levels for patients with acute hyperglycemia remains uncertain. Further studies are warranted into the appropriate management in patients with AMI and acute hyperglycemia.     

Prognostic implications of stress hyperglycemia in acute ST elevation myocardial infarction. Prospective observational study

Introduction and objectives

In patients with acute myocardial infarction, elevation of plasma glucose levels is associated with worse outcomes. The aim of this study was to evaluate the association between stress hyperglycemia and in-hospital mortality in patients with acute myocardial infarction with ST-segment elevation (STEMI).

Methods

We analyzed 834 consecutive patients admitted for STEMI to the Coronary Care Unit of our center. Association between admission glucose and mortality was assessed with Cox regression analysis. Discriminative accuracy of the multivariate model was assessed by Harrell's C statistic.

Results

Eighty-nine (10.7%) patients died during hospitalization. Optimal threshold glycemia level of 140 mg/dl on admission to predict mortality was obtained by ROC curves. Those who presented glucose ≥140 mg/dl showed higher rates of malignant ventricular tachyarrhythmias (28% vs. 18%, P = .001), complicative bundle branch block (5% vs. 2%, P = .005), new atrioventricular block (9% vs. 5%, P = .05) and in-hospital mortality (15% vs. 5%, P < .001). Multivariate analysis showed that those with glycemia ≥140 mg/dl exhibited a 2-fold increase of in-hospital mortality risk (95% CI: 1.2-3.5, P = .008) irrespective of diabetes mellitus status (P-value for interaction = 0.487 and 0.653, respectively).

Conclusions

Stress hyperglycemia on admission is a predictor of mortality and arrhythmias in patients with STEMI and could be used in the stratification of risk in these patients.Full English text available from: www.revespcardiol.org     

Dipyridamole echocardiography test during the acute phase of lower myocardial infarction

Two-dimensional echocardiography with intravenous injection of dipyridamole (0.56 mg/kg) was performed in 33 consecutive patients with acute (2 +/- 2 days) postero-inferior myocardial infarction for semiquantitative segmental wall motion analysis. The results were compared with those of coronary angiography which was carried out during the hospital period. After a second evaluation of the recordings the following results were obtained: feasibility: 94 per cent with 85 per cent of segments analysed. Residual ischaemia in the first days of myocardial necrosis was common (70%). The ischaemia was often clinically silent including during the investigation (61%). When pain occurred, it always followed changes in regional wall motion. The dipyridamole test suggested multivessel disease with a sensitivity of 72 per cent and a specificity of 90 per cent, and residual arterial stenosis with a sensitivity of 75 per cent ans specificity of 80 per cent the secondary effects were minor. The main limitation of the test is related to the distinction between pharmacological and physiologic ischaemia. A positive test was associated with lesions justifying myocardial revascularisation (coronary bypass or angioplasty) in 19 out of 23 cases but with a very poor correlation with the topography of the coronary lesions. A negative test indicated arterial occlusion, residual stenosis with extensive myocardial damage or a normal coronary angiogram. Therefore, the dipyridamole echocardiography test may help identify a group of patients with little or no myocardial ischaemia in whom invasive investigations could be deferred; these patients contrast with the group with a positive test indicating residual ischaemia in which the coronary lesions should be documented by coronary angiography.     

应激性高血糖对急性ST段抬高型心肌梗死患者远期预后的影响

目的探讨急性sT段抬高型心肌梗死（STEMI）患者发生应激性高血糖的相关危险因素,并评估应激性高血糖对STEMI患者远期预后的影响。方法白求恩国际和平医院2009年8月至2010年4月92例初次发生STEMI的非糖尿病住院患者,根据入院后测定的空腹血糖或随机血糖分A组（应激性高血糖组）41例和B组（血糖正常组）51例。平均随访1．5年。结果应激性高血糖的发生率是44．6％（41／92）。A和B组间经logistic回归分析提示女性（OR=8．952,P=0．013）、心功Killip分级越高（OR=3．530,P=0．048）、肌酸激酶同工酶（CK．MB）峰值越高（OR=9．408,P〈0．001）均是应激性高血糖发生的相关危险因素。Cox回归对A和B组患者1～2年内发生的死亡风险进行分析,提示应激性高血糖是远期死亡（RR1．532,95％CI1．004--2．337,P=0．048）的独立预测因子。高甘油三酯血症患者远期死亡风险是正常者1．557倍（P=0．041）。结论女性、Killip分级、CK．MB增高是应激性高血糖发生的相关危险因素。应激性高血糖可能是STEMI患者远期预后不良的独立预测因子和危险因素。高甘油三酯血症可能加重患者的死亡风险。     

Heart rate variability during the acute phase of myocardial infarction.

BACKGROUND. After acute myocardial infarction (AMI), several abnormalities of the autonomic control to the heart have been described. Heart rate (HR) variability has been used to explore the neural control to the heart. A low HR variability count measured 7-13 days after AMI is significantly related to a poor outcome. Little information is available on HR variability early after AMI and its relation to clinical and hemodynamic data. METHODS AND RESULTS. We studied 54 consecutive patients (42 men and 12 women; mean age, 60.4 +/- 11 years) with evidence of AMI by collecting the 24-hour HR SD from Holter tapes recorded on day 2 or 3. We also measured HR variability in 15 patients with unstable angina and in 35 age-matched normal subjects. HR variability was lower in AMI than in unstable angina patients (57.6 +/- 21.3 versus 92 +/- 19 msec; p less than 0.001) and controls (105 +/- 12 msec; p less than 0.001). Also, HR variability was greater in non-Q-wave than in Q-wave AMI (p less than 0.0001) and in recombinant tissue-type plasminogen activator-treated patients with respect to the rest of the group (p less than 0.02). No difference was found for infarct site. HR variability was significantly related to mean 24-hour HR, peak creatine kinase-MB, and left ventricular ejection fraction (all p less than 0.0001). Patients belonging to Killip class greater than I or who required the use of diuretics or digitalis had lower counts (p less than 0.004, p less than 0.001, and p less than 0.024, respectively). Six patients died within 20 days after admission to the hospital. In these patients, HR variability was lower than in survivors (31.2 +/- 12 versus 60.9 +/- 20 msec; p less than 0.001), and a value less than 50 msec was significantly associated with mortality (p less than 0.025). CONCLUSIONS. HR variability during the early phase of AMI is decreased and is significantly related to clinical and hemodynamic indexes of severity. The causes for the observed changes in HR variability during AMI may be reduced vagal and/or increased sympathetic outflow to the heart. It is suggested that early measurements of HR variability during AMI may offer important clinical information and contribute to the early risk stratification of patients.     

Prognostic impact of stress hyperglycemia ratio in acute myocardial infarction patients with and without diabetes mellitus

Background and aimsStress hyperglycemia ratio (SHR) is associated with increased in-hospital morbidity and mortality in patients with acute myocardial infarction (AMI). We aimed to investigate the impact of stress “hyperglycemia” on long-term mortality after AMI in patients with and without diabetes mellitus (DM).Methods and resultsWe included 2089 patients with AMI between February 2014 and March 2018. SHR was measured with the fasting glucose divided by the estimated average glucose derived from glycosylated hemoglobin (HbA1c). The primary endpoint was all-cause death. Of 2 089 patients (mean age: 65.7 ± 12.4, 76.7% were men) analyzed, 796 (38.1%) had DM. Over a median follow-up of 2.7 years, 141 (6.7%) and 150 (7.2%) all-cause deaths occurred in the diabetic and nondiabetic cohorts, respectively. Compared with participants with low SHR (<1.24 in DM; <1.14 in non-DM), the hazard ratios and 95% confidence intervals for those with high SHR (≥1.24 in DM; ≥1.14 in non-DM) for all-cause mortality were 2.23 (1.54–3.23) and 1.79 (1.15–2.78); for cardiovascular mortality were 2.42 (1.63–3.59) and 2.10 (1.32–3.35) in DM and non-DM subjects, respectively. The mortality prediction was improved in the diabetic individuals with the incorporation of SHR into the Global Registry of Acute Coronary Events (GRACE) score, showing an increase in a continuous net reclassification index of 0.184 (95%CI: 0.003–0.365) and an absolute integrated discrimination improvement of 0.014 (95%CI: 0.002–0.025).ConclusionThe improvement in the prediction of long-term mortality beyond the GRACE score indicates the potential of SHR as a biomarker for post-MI risk stratification among patients with DM.Registration number for clinical trialsNCT03533543.     

Accentuation of myocardial ischemia during coronary recanalization in the acute phase of myocardial infarction

Coronary recanalisation during the acute phase of myocardial infarction, especially by in situ infusion of thrombolytic agents, is accompanied in most cases by rapid regression of chest pain and a reduction in the degree of ST elevation. However, a multicentre retrospective study of 104 attempts at recanalisation, including 78 successful procedures, showed in 10 cases (12.8 p. 100), an apparently paradoxical accentuation of the chest pain with or without increased ST elevation, at the time of angiographically demonstrable recanalisation. This phenomenon may be interpreted as being the result of aggravation of the ischaemia of the border zone, the objective of therapy. Several pathogenic hypotheses, all with experimental proof, may be suggested to explain these observations (haemorrhagic infarction, non reperfusion, ischaemic contraction due to massive intracellular flow of calcium, etc.). It is usually associated with arrhythmias and may be considered to be a reliable sign of recanalisation. It may also explain certain cases of persistence of chest pain and ECG changes despite the demonstration of a permeable epicardial artery on initial coronary angiography.     

Ultrasonic diagnosis of biventricular thrombus during the acute phase of myocardial infarction

The occurrence of a left ventricular thrombus is a classic complication of acute myocardial infarction. On the contrary, this is much less frequent in the right ventricle. The authors report the case of a patient presenting a biventricular thrombus resulting as a complication of an anterior myocardial infarction, diagnosed by bidimensional ultrasonography. The course is characterized by the occurrence of a cerebral vascular accident. The sonogram following this neurological accident shows that the left ventricular thrombus has disappeared, confirming its migration. On the contrary, the right ventricular thrombus regressed under appropriate heparin treatment, without any embolic complication.     

Influence of emotional stress and behavior during acute myocardial infarction on prognosis

Seventeen cases of acute myocardial infarction (AMI) with emotional stress (group A) and 54 cases with basically stable emotion (group B) were compared with respect to three major complications (arrhythmia, cardiac insufficiency of grade 3 and 4 and cardiogenic shock) and therapeutic effect. The results showed that the incidences of the three complications in group A were significantly higher than those in group B (P less than 0.05), and the clinical condition was more serious in the former group. Response to narcotics showed that number of patients requiring more than 3 injections of either dolantine 50 mg or morphine 5 mg was significantly greater in group A than in group B (P less than 0.001). Sigma ST was not found to be significantly different between the two groups. However, the duration of elevation of ST segment was significantly longer in group A than in group B (P less than 0.01). It is suggested that relief of myocardial ischemia is slow in group A. There were five patients in group A with extended infarct size and died during the acute stage. None in the group B showed extension of infarction. The mortality rate in group A significantly higher than that in group B (53% VS 3.7%, P less than 0.001) and it bears no relation with sex, age and the site of infarction on admission. The greater the emotional upheaval the more unfavorable the prognosis. It is shown that excessive emotional stress is an important risk factor of AMI and aggressive measures are required to prevent worsening of the condition.     

急性心肌梗死甘油三酯/高密度脂蛋白胆固醇比值变化及意义

目的　探讨急性心肌梗死血脂的变化。　方法　以临床确诊急性心肌梗死 38例作为观察组 ,32例健康体检者为对照组。以酶法测定其空腹血清TG ,TC ,HDL C ,并计算TG HDL C的比值。　结果　急性心肌梗死TG ,TG HDL C比值高于对照组 ( P <0 0 1) ,HDL C低于对照组 ( P<0 0 1) ,TC ,LDL C则无统计学意义 ( P >0 0 5 )。　结论　TG HDL C比值增高对急性心肌梗死的诊断价值较TC及LDL C增高更有意义