非ST段抬高急性冠状动脉综合征的危险因素分析及早期干预

目的　探讨非ST段抬高急性冠状动脉综合征(ACS)的临床高危因素及早期有创干预的价值。方法　在 2001年 10月至 2003年 10月期间连续入院的非ST段抬高的ACS患者共 545例,随机分成早期保守治疗组与早期有创干预组;随访 30天与 6个月患者的复合心血管事件 (包括心脏性死亡、非致命性心肌梗死、非致命性心力衰竭、因反复缺血性心绞痛发作住院 )发生率,将患者一般临床特征及辅助检查指标对复合心血管事件做多变量回归分析,筛查主要的高危因素;评价早期保守治疗与早期有创干预对患者预后的影响。结果　随访 513例患者, 30天与 6个月的复合心血管事件发生率分别为 14 0%与 25 7%;多变量Logistic回归分析,显示ST段压低、肌钙蛋白Ⅰ (TnI)水平升高、高敏C反应蛋白(hs CRP)增高、左室射血分数(LVEF)值下降以及心肌梗死溶栓疗法(TIMI)危险评分高分者与 6个月的复合心血管事件增高密切相关,它们分别是患者复合心血管事件危险性增加的独立预测因子;与早期保守治疗组比较,早期有创干预组随访 30天时反复心绞痛发作住院率减少,复合心血管事件减少;随访 6个月时复合心血管事件也减少 (P均 <0 05)。结论　ST段压低、TnI水平升高、hs CRP增高、LVEF值下降或TIMI危险评分增高是非ST段抬高ACS患者的高危因素,早期有创干预能     

肌钙蛋白I对非ST段抬高急性冠状动脉综合征临床转归的预测价值

目的　前瞻、多中心、随机对照研究肌钙蛋白(Tn)I阳性的非ST段抬高急性冠状动脉综合征病人(NSTEACS)发生心血管事件的危险程度,探讨TnI对其临床预后的预测价值。方法在10个医院入选起病后24h内就诊的NSTEACS患者,随机接受早期介入或保守治疗。随访30d和6个月,观察终点为心血管事件,包括心脏性死亡、非致命性心肌梗死、非致命性心力衰竭、因反复心绞痛发作住院。结果　6个月时,TnI阳性组患者因反复心绞痛住院及复合心血管事件明显增多,与TnI阴性组比较,差异有统计学意义(P<0 01)。早期介入干预可明显降低TnI阳性患者30d及6个月的复合心血管事件发生率(P值均<0 01)。结论　TnI阳性患者6个月心血管事件较TnI阴性者明显增加,TnI阳性是NSTEACS患者的预后预测因素。早期介入干预治疗能减少TnI阳性患者随访期内心血管事件的发生,不能使TnI阴性患者从中受益。     

低分子肝素钙治疗非ST段抬高急性冠状动脉综合征疗效观察

目的:观察低分子肝素钙治疗肌钙蛋白Ⅰ(TnI)阳性和TnI阴性非ST段抬高急性冠状动脉综合征(NSTE ACS)的疗效及价值。方法:NSTE ACS160例住院患者,TnI阳性者和TnI阴性者分别随机分为治疗组和对照组,治疗组常规治疗同时加低分子肝素钙,对照组仅接受常规治疗。随访30d、6个月,观察心血管事件发生率。结果:TnI阳性治疗组患者因反复心绞痛住院及复合心血管事件发生率均显著低于对照组(P<0.05);而TnI阴性患者中治疗组与对照组无显著性差异(P>0.05)。结论:早期低分子肝素钙干预治疗能减少TnI阳性患者随访期内心血管事件发生率,但不能使TnI阴性患者从中受益。     

血浆脑钠素在非ST段抬高急性冠脉综合征中的变化及其意义

目的探讨血浆脑钠素(BNP)在非ST段抬高急性冠脉综合征(ACS)患者中的变化,并分析其判断预后及指导治疗的价值。方法在2004年6月至2005年5月间连续入院的非ST段抬高的ACS患者共65例,入院时检测血浆BNP水平。并随机分为保守治疗组和有创干预组,随访6个月复合心血管事件发生,评价BNP在判断预后中的价值。结果非ST段抬高ACS患者及健康对照组的血浆BNP水平分别是(139.6±112.7)pg/ml、(20.1±9.1)pg/ml,两者差异有统计学意义(P<0.01)。多因素logistic回归分析显示,BNP是患者复合心血管事件危险性的独立预测因子(OR=2.96,95%CI:2.62～11.32,P<0.01)。有创干预可以降低BNP水平减少6个月复合心血管事件发生率。结论非ST段抬高ACS患者血浆BNP水平在早期即明显升高,是患者复合心血管事件危险性的独立预测因子,有创干预能明显减少非ST段抬高ACS患者的复合心血管事件。     

心肌梗死溶栓试验危险评分对无ST段抬高急性冠状动脉综合征患者不同干预策略的影响

目的探讨心肌梗死溶栓试验（TIMI）危险评分对无ST段抬高急性冠状动脉综合征（ACS）患者不同干预策略的影响。方法将2001年10月至2003年10月期间连续入院的无ST段抬高ACS患者共545例,随机分成早期保守治疗组（284例）与早期有创干预组（261例）,并根据TIMI危险评分分为低分组、中分组和高分组,随访30天与6个月的复合心血管事件（包括心脏性死亡、非致命性心肌梗死、非致命性心力衰竭、反复缺血性心绞痛发作住院事件）,评价不同TIMI危险评分对两种干预策略疗效的影响。结果早期有创干预组的随访30天反复心绞痛发作住院事件[3．5％（9／261）]及30天与6个月复合心血管事件[分别为10．0％（26／261）,21．1％（55／261）]低于随访同时期的早期保守治疗组[分别为8．1％（23／284）、16．9％（48／284）和28．2％（80／284）,均P〈0．05];早期有创干预组随访30天TIMI危险评分高分组[12．2％（5／41）]和随访6个月的高分组及中分组患者的复合心血管事件发生率[22．0％（9／41）,12．7％（20／158）]明显低于随访同时期保守治疗组[随访30天高分组37．3％（19／51）;随访6个月高分组74．5％（38／51）,中分组30．4％（49／161）;均P〈0．01];在TIMI危险评分低分组中两种治疗对策对心血管事件的影响差异无统计学意义。结论在TIMI危险评分高及中分组无ST段抬高ACS患者中,早期有创干预较早期保守治疗策略能明显降低复合心血管事件、改善预后;对TIMI危险评分低分组者,两种干预策略的疗效无明显著别。     

非ST段抬高的急性冠状动脉综合征患者早期介入治疗与单纯药物治疗对预后的影响

目的探讨非ST段抬高急性冠状动脉综合征(ACS)患者早期介入治疗与单纯药物治疗对预后的影响。方法收集2005年9月至2007年11月入院的非ST段抬高ACS患者共181例临床资料,分成单纯药物治疗组和介入治疗组,随访患者发病30d和6个月心血管不良事件的发生率。结果与早期单纯药物治疗相比,早期介入治疗能够降低30d和6个月时心血管不良事件(P<0.05)。经随访,中危患者早期介入治疗组与药物治疗组30d时心血管不良事件发生率分别为8.1%和9.5%,6个月随访时分别为11.7%和15.0%,差异均无统计学意义(P>0.05);高危患者心血管不良事件30 d时的发生率分别为14.6%和43.4%,6个月时发生率分别为25.8%和86.9%,差异均有统计学意义(P<0.05)。结论对于中危患者早期介入治疗和药物保守治疗对心脏事件的影响差异无统计学意义,而对于高危患者早期介入治疗可显著降低近期和远期的心脏事件的发生率。     

心电图变化及肌钙蛋白水平对无ST段抬高的急性冠状动脉综合征患者的危险分层与预后预测的价值

目的　探讨心电图变化及肌钙蛋白水平对无ST段抬高的急性冠状动脉综合征患者的危险分层与预后预测的价值。方法　自 2 0 0 0年 7月～ 2 0 0 1年 6月 ,在急诊室因急性胸痛拟诊不稳定性心绞痛及无ST段抬高心肌梗死而收入住院且记录资料完整的连续 2 56例患者。入急诊室后仔细询问病史、查体 ,并在 10min内完成常规 18导联心电图检查 ,将患者入院时心电图的改变分为ST段压低组 (包括伴有T波倒置者 )、单纯T波倒置组、尚不能诊断的心电图组及正常心电图组 ,同时床旁抽静脉血做肌钙蛋白I(TnI)检测。并据TnI水平将患者分成TnI阳性组 (TnI定量检测≥ 0 1μg/L)和TnI阴性组 (TnI <0 1μg/L )。观察各组住院期主要心血管事件 (心脏性死亡、非致命性心肌梗死、反复缺血性心绞痛发作 ) ,并随访 1～ 12 (7 2± 3 8)个月主要心血管事件变化。结果　与正常心电图组比较 ,ST段压低组的反复心绞痛发作及复合心血管事件明显增多。 3 2 1%的不稳定性心绞痛及所有无ST段抬高心肌梗死患者的TnI阳性 ,TnI阳性组有明确冠心病诊断者较TnI阴性组多 ,TnI阳性组较TnI阴性组的住院期非致命性心肌梗死发生率增高 ,住院期与随访期反复心绞痛发作增加 ,总心脏性病死率也上升 ,且复合心血管事件显著增多。对复合心血管事件的预测 ,T     

肌钙蛋白Ⅰ及肌红蛋白对非ST段抬高急性冠状动脉综合征的预后评价

目的探讨肌钙蛋白(troponinI,TnI)、肌红蛋白(myoglobin,Mb)对非ST段抬高急性冠状动脉综合征病人预后的预测价值。方法因急性胸痛拟诊非ST段抬高急性冠状动脉综合征病人而连续收入院的120例病人,入院后仔细询问病史、检查体格,并在10min内完成常规12导联心电图检查,同时测定静脉血TnI、Mb。以血TnI1.0μg/L将病人分成TnI阳性组和TnI阴性组;Mb70μg/L分为Mb阳性组和阴性组。随访各组6个月主要心血管事件发生率。结果TnI阳性组及Mb阳性组的随访期因反复心绞痛住院及复合心管事件显著增多。多因素Logistic回归分析显示,TnI阳性较Mb阳性及ST段压低因素对病人随访期复合心血管事件有独立预测价值。结论TnI及Mb水平对非ST段抬高ACS病人的危险分层及心血管事件预测有重要价值。     

血氨基末端脑钠素前体对急性冠状动脉综合征远期预后的评估价值

目的:观察血氨基末端脑钠素前体(NT-proBNP)对急性冠状动脉综合征(ACS)患者的远期预测价值。方法:将85例发病24h以内的ACS患者,分为ST段抬高的急性心肌梗死、非ST段抬高的急性心肌梗死和不稳定型心绞痛3组。所有病例既往均无明显心功能不全。于入院即刻、24h及1周测NT-proBNP,高敏C反应蛋白(hs-CRP),7～10d查超声心动图,记录随访1年的病死率和心血管事件住院率。结果:所有ACS患者的NT-proBNP峰值均高于正常,高峰见于入院24h。随访中病死率、所有心血管事件住院率和心力衰竭住院率分别为5.9%、17.6%、和10.6%。多因素回归分析显示hs-CRP峰值、肌酸激酶-同工酶、恶性心律失常、左室射血分数及NT-proBNP峰值是远期心血管死亡的主要危险因子,而后两者又是心力衰竭事件的预测因子。结论:NT-proBNP峰值是ACS的独立危险因子,它对ACS的远期预测价值可能要优于hs-CRP。     

C反应蛋白和B型尿钠肽对ACS患者的预后探讨

目的反映心肌损伤的生物标志如高敏-C反应蛋白(hs-CRP),B型尿钠肽(BNP)和肌钙蛋白-I(Tn-I)的升高和急性冠脉综合征(ACS)患者的预后相关,本文旨在探讨这些生物标记对ACS危险分层的临床预后价值。方法共收集215例ACS患者(140男性,65±46岁),入院时即查hs-CRP,BNP和Tn-I,其中ST段抬高心肌梗死(STEMI)56例,非ST段抬高心肌梗死(NSTEMI)98例,不稳定心绞痛(UA)61例。结果平均随访246天,期间一共有24件心血管事件发生,STEMI:1例,NSTEMI:6例,UA:6例,慢性心力衰竭:1例,死亡:10例。在这些发生心血管事件的患者中,hs-CRP和BNP比那些没有发生心血管事件的患者要高。在排除其他影响因素的作用后,hs-CRP和BNP对ACS患者具有独立的预测心血管事件发生的作用。当hs-CRP>3.5mg/L和BNP>500pg/ml比hs-CRP≤3.5mg/L和BNP≤500pg/ml的患者发生心血管事件的风险要高11倍。结论联合hs-CRP和BNP这两个生物标记对ACS患者的危险分层有临床预后价值。     

How should patients with unstable angina and non-ST-segment elevation myocardial infarction be managed? A meta-analysis of randomized trials

PURPOSE: Patients with unstable angina or non-ST-segment elevation myocardial infarction (MI) may be managed with either an "invasive" or "conservative" strategy. It is unclear which of these strategies is superior. METHODS: We identified studies with MEDLINE and EMBASE searches (1966-September 2003) and by reviewing reference lists. Studies were included if they were randomized controlled trials comparing management strategies for patients in the early post-unstable angina/non-ST-segment elevation MI period and had follow-up data for at least 3 months. RESULTS: Seven trials that randomized a total of 9212 patients were included. The pooled odds ratio (OR) for all-cause mortality was 0.96 (95% confidence interval [CI]: 0.72 to 1.27). The occurrence of fatal or nonfatal re-infarction was reduced with an invasive strategy (OR 0.73; 95% CI: 0.61 to 0.88) as was readmission to hospital (OR 0.67; 95% CI: 0.48 to 0.94). The endpoints of nonfatal MI and the composite of death or nonfatal MI showed nonsignificant trends favoring an invasive strategy. Trials that included a higher proportion of patients with ST-segment depression on admission and trials in which a larger proportion of patients underwent revascularization showed a greater magnitude of benefit for an invasive strategy. CONCLUSION: For patients with unstable angina/non-ST-segment elevation MI, an invasive strategy reduces rates of fatal or nonfatal re-infarction and hospital readmission, but not all-cause mortality, when compared with a noninvasive strategy. These results suggest that an invasive management strategy should be considered for all patients with unstable angina/non-ST-segment elevation MI and perhaps in particular those with ST-segment depression.     

早期介入治疗对高危非ST段抬高型心肌梗死患者短期预后的影响

目的 比较早期与择期介入治疗对高危非ST段抬高型心肌梗死（NSTEMI）患者短期预后的影响。方法 纳入西京医院心血管内科行介入治疗的高危NSTEMI患者,根据手术实施时间分为早期介入组（入院24 h内）和择期介入组（24~48 h）。比较两组患者围手术期并发症、住院期间死亡、PCI成功率、住院时间以及费用,对患者随访6个月,观察再发心绞痛、因冠心病再住院 、主要心血管不良事件（MACE）的发生和左心室射血分数（LVEF）改善的情况。结果 与择期介入组比较,早期介入组围手术期并发症、住院期间死亡、PCI成功率与MACE发生率差异无统计学意义,早期介入组住院时间、住院费用、再发心绞痛及因冠心病再住院率低于择期介入组,两组LVEF均明显提高,早期介入组高于择期介入组。结论 高危NSTEMI患者早期介入治疗的短期预后优于择期介入治疗。     

高敏C反应蛋白结合血脂可以更好预测急性冠脉综合征患者的长期预后

目的: 评价高敏C反应蛋白（hs-CRP）及其联合血脂对急性冠脉综合征（ACS）患者长期预后的预测价值。方法: 连续入选ACS患者246名,测定其入院时的hs-CRP和肌钙蛋白T（cTnT）水平以及基线的血清总胆固醇、低密度脂蛋白胆固醇（LDL-C）、高密度脂蛋白胆固醇（HDL-C）等指标。观察住院及随访期间（40±6）个月主要心血管事件的发生情况,据此将患者分为事件组和对照组。根据两组中有显著差异的临床指标,筛选对终点事件有独立预测价值的指标。依据所筛选独立预测指标的不同水平,对患者进行危险分层,观察不同危险组患者的主要心血管事件发生率。所有资料均采用SPSS13.0软件进行分析。结果: 完成随访241例,失访率2.0%,其中121例发生心血管事件。事件组和对照组患者的年龄、白细胞计数、hs-CRP、LDL-C/HDL-C和cTnT阳性率均有显著差异（P<0.05）,行Logistic回归分析后只有hs-CRP和LDL-C/HDL-C进入回归方程（P<0.01）。分别根据hs-CRP和LDL-C/HDL-C的三分位数对患者进行危险分层,发现随着hs-CRP和LDL-C/HDL-C的升高,患者的心血管事件发生率均呈上升趋势（均P＜0.05）。对于LDL-C/HDL-C<2.75的患者,hs-CRP可进一步分层,识别出危险性相对较高者。结论: hs-CRP可以独立预测ACS患者长期再发心血管事件的危险;结合血脂,其危险分层作用更强。     

Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials.

OBJECTIVES: This study sought to systematically determine whether early invasive therapy improves survival and reduces adverse cardiovascular events in the management of non-ST-segment elevation acute coronary syndromes. BACKGROUND: Although early invasive therapy reduces recurrent unstable angina, the magnitude of benefit on other important adverse outcomes is unknown. METHODS: Clinical trials that randomized non-ST-segment elevation acute coronary syndrome patients to early invasive therapy versus a more conservative approach were included for analysis. RESULTS: In all there were 7 trials with 8,375 patients available for analysis. At a mean follow-up of 2 years, the incidence of all-cause mortality was 4.9% in the early invasive group, compared with 6.5% in the conservative group (risk ratio [RR] = 0.75, 95% confidence interval [CI] 0.63 to 0.90, p = 0.001), and at 1 month (RR = 0.82, 95% CI 0.50 to 1.34, p = 0.43). At 2 years of follow-up, the incidence of nonfatal myocardial infarction was 7.6% in the invasive group, versus 9.1% in the conservative group (RR = 0.83, 95% CI 0.72 to 0.96, p = 0.012), and at 1 month (RR = 0.93, 95% CI 0.73 to 1.19, p = 0.57). At a mean of 13 months of follow-up, there was a reduction in rehospitalization for unstable angina (RR = 0.69, 95% CI 0.65 to 0.74, p < 0.0001). CONCLUSIONS: Managing non-ST-segment elevation acute coronary syndromes by early invasive therapy improves long-term survival and reduces late myocardial infarction and rehospitalization for unstable angina.     

Use of the early invasive approach in the management of acute coronary syndromes

Large randomized clinical trials of early invasive versus conservative strategy in patients with non-ST-elevation acute coronary syndromes (NSTE ACS) have been published recently. These studies have clearly shown that intermediate and high-risk patients presenting with NSTE ACS have better outcomes when referred early to cardiac catheterization. Patients who are referred early to cardiac catheterization have a reduction of death, myocardial infarction, and recurrent ischemia, and also have shorter hospital stays. Guidelines recommend referral to cardiac catheterization for intermediate and high-risk NSTE ACS patients within the first 48 hours of presentation. Despite these recommendations, data from a large nationwide registry show that the majority of high-risk patients with NSTE ACS are not being managed with an early invasive strategy.     

血浆高敏C反应蛋白对冠状动脉介入术后早期并发症及再狭窄的预测价值

目的　探讨心绞痛患者行经皮冠状动脉介入治疗 (PCI)前 ,高敏C 反应蛋白 (hs CRP)水平对早期并发症及术后再狭窄的预测价值。方法　对 12 0例心绞痛的患者 (5 2例稳定型心绞痛 ,6 8例不稳定型心绞痛 )入院时测定血浆hs CRP水平 ,然后行单支血管的经皮冠状动脉腔内成形术(PTCA) ,随访 1年 ,观察早期并发症及晚期再狭窄发生率 ,对其进行分析。结果　 12 0例患者中 ,血浆hs CRP升高者 6 8人 ,早期并发症均发生在高hs CRP水平者。再狭窄发生率为 4 6 % ,其中血浆hs CRP正常者 14例 ,占 2 7% ;血浆hs CRP升高者 37例 ,占 6 3% (P <0 0 0 1)。经多因素回归分析显示 ,术前CRP水平增高 (r=11 7,P <0 0 0 1)、高血压 (r=4 3,P =0 0 3)、女性 (r=4 1,P =0 0 13)是预测早期并发症的独立危险因素 ,而高CRP(r=6 7,P <0 0 0 1)及术后残余狭窄 (r=3 2 ,P =0 0 0 7)是预测再狭窄的独立危险因素。结论　血浆hs CRP水平可作为炎症标志物反映冠状动脉炎症情况 ,对PTCA早期并发症及术后再狭窄有一定的预测价值。     

阿托伐他汀在急性冠脉综合征血脂正常患者中的早期应用

目的:观察阿托伐他汀对血脂正常急性冠状动脉综合征(ACS)患者早期炎症因子和心脑血管事件的干预效果。方法:122例血脂正常的ACS患者随机分为阿托伐他汀治疗组和常规治疗对照组(各61例),另选择同期40例健康者作为健康对照组,分析比较组间及阿托伐他汀治疗(10mg/日×6月)前和治疗后2、4周血清白介素-6(IL-6)、高敏C反应蛋白(hs-CRP)和血脂水平的变化,同时观察ACS患者住院和半年随访期间主要心脑血管事件发生情况。结果:两组ACS患者血脂水平与健康对照组无显著差别,但其IL-6和hs-CRP水平显著高于健康对照组(P均<0.01);阿托伐他汀治疗2周后,仅IL-6、hs-CRP显著降低(P均<0.01),治疗4周后血胆固醇(TC)、低密度脂蛋白-胆固醇(LDL-C)及IL-6、hs-CRP均显著降低(P均<0.01)且均低于常规治疗对照组(P均<0.05);阿托伐他汀治疗组住院期间复发性心绞痛、心力衰竭、心律失常及半年随访期间复发性心绞痛、非致死性心肌梗塞、心力衰竭、心律失常、需再住院治疗等均较常规治疗组显著降低(P均<0.05)。结论:血脂正常的ACS患者存在炎症反应,阿托伐他汀早期治疗能够抑制炎症因子,降低住院期间和半年随访期间主要心血管事件发生率。     

Peripheral arterial disease, acute coronary syndromes, and early invasive management: the TACTICS TIMI 18 trial

BACKGROUND: Patients with peripheral arterial disease (PAD) represent a high-risk patient subset in the setting of non-ST-segment elevation acute coronary syndromes (NSTE ACS). The efficacy and safety of early invasive management for such patients remains unclear. Hypothesis: Early invasive management would be well tolerated and effective among patients with NSTE ACS and PAD. METHODS: Patients from the Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction (TACTICS-TIMI) 18 trial were stratified by the presence or absence of PAD and assessed with respect to baseline clinical factors. The outcomes of patients with PAD and NSTE ACS were examined with respect to treatment assignment to either early invasive therapy or conservative treatment of NSTE ACS. Finally, the bleeding and stroke rates of patients with PAD managed invasively were compared with patients with PAD managed conservatively. RESULTS: Of 2219 patients with NSTE ACS overall, 166 (7.5%) had concomitant PAD. Compared with those patients without PAD, those with PAD were older (75 vs. 62 years, p < 0.001) and were more likely to have high-risk clinical features, including prior histories of bypass surgery (39 vs. 20%, p < 0.001) or diabetes mellitus (38 vs. 27%, p = 0.002), and more ST-segment depression on their 12-lead electrocardiogram (43 vs. 29%, p < 0.001). Among such patients, early invasive management was associated with significant reductions in the risk of myocardial infarction (MI) at 30 days (11.4 vs. 2.3%, p = 0.03). At 180 days, compared with early conservative management, early invasive treatment for patients with PAD and NSTE ACS was associated with similar reductions in MI (12.7 vs. 3.5%, p = 0.04), and was also accompanied by significant reductions in risk of death (10.1 vs. 2.3%, p = 0.05). No excess in bleeding or stroke rates was noted among patients with PAD managed invasively. CONCLUSIONS: Among patients with NSTE ACS and a history of PAD, early invasive management is well tolerated and accompanied by significant reductions in morbidity and mortality when compared with a more conservative, ischemia-driven approach.