我国部分医院ST段抬高急性冠状动脉综合征再灌注治疗登记研究

目的了解目前我国ST段抬高急性冠状动脉综合征(ACS)再灌注治疗实施状况及近期预后。方法入选来自5个地区不同级别(从中心城市的三级医院到县级医院)20个中心的ST段抬高ACS或怀疑为新出现的左束支传导阻滞的患者共518例,对其临床特点,再灌注治疗情况及预后进行评价,并进行3个月随访。其中男371例,女147例,平均年龄(65±11)岁。随访率为99．6％。结果患者自症状开始到就诊的中位数时间为4 h,20％的患者在症状出现12 h以上就诊。292例(56％,292／518)ST段抬高ACS患者接受了再灌注治疗,其中134例(46％,134／292)接受了急诊冠状动脉介入(PCI)治疗,158例(54％,158／292)为溶栓治疗,溶栓治疗中尿激酶的应用占67％。从就诊到开始PCI的中位数时间(door-to-cath)为110 min,从患者就诊到开始溶栓的中位数时间为65 min。多因素回归分析显示,高龄(≥75岁,P<0．01)、有心肌梗死病史(P<0．01)及心力衰竭病史(P< 0．05)是未接受再灌注治疗的预测因素。非再灌注治疗组出院(P<0．01)和3个月病死率(P< O．01)、出院(P<0．01)和3个月心力衰竭发生率(P<0．01),以及3个月死亡或再梗死和死亡或再梗死或卒中的联合事件发生率(均P<0．01)均明显高于再灌注治疗组,但不同的再灌注治疗方法对近期预后无明显影响。相似的结果也见于症状出现12 h以内就诊患者的亚组分析。结论再灌注治疗是改善ST段抬高ACS患者预后的关键措施。我国ST段抬高ACS再灌注治疗有待于进一步提高,不仅要提高再灌注治疗率,更应缩短就诊和再灌注治疗前的延误时间,并加强高危患者的再灌注治疗。     

中国多省市急性冠状动脉综合征住院患者高胆固醇血症患病现况

目的 了解中国多省市急性冠状动脉综合征(ACS)住院患者高肌固醇血症的患病、知晓及治疗现状.方法 以2751例住院诊断的ACS患者为研究对象.2006年在中国31个省市自治区选择32家三级医院和32家二级医院,每家医院以研究启动时点起连续选择50例经住院诊断的ACS患者.为避免研究可能带来的干预影响,采用回顾形式收集已出院患者的病历,填写统一表格,分析患者高胆同醇血症的患病、院前知晓及治疗情况.结果 (1)在调查的2751例ACS住院患者中,男性占68.8%(1893例),女性占31.2%(858例),平均年龄(65±11)岁;其中心电图ST段抬高心肌梗死占39.4%,非sT段抬高心肌梗死8.8%,不稳定性心绞痛占51.8%;既往有ACS病史者27.3%.(2)2751例ACS住院患者中19.6%伴有高胆固醇血症,女性(25.5%)高于男性(16.9%,P＜0.01);按地理区域分为7个地区(华北、华东、华南、华中、东北、西北和西南),其中华东地区患者高胆固醇血症患病率最高(24.7%),华中地区最低(10.0%),各地区间的差异具有统计学意义(P＜0.01).(3)在540例高胆同醇血症患者中,人院前知晓率为12.2%,各地区间知晓率的差异具有统计学意义(P＜0.05);入院前高胆固醇血症的治疗率为8.2%,知晓者的治疗率为66.7%;治疗率最高的是华南地区(83.3%),最低是西南地区(0%).(4)既往有ACS史的患者中高胆固醇血症的患病率为22.1%,知晓率为18.1%,治疗率为76.7%,上述三率均高于既往无ACS病史者(18.7%、9.7%、58.3%);其中仅有21.2%的患者胆固醇控制达标.结论 ACS住院患者中近20%伴有高胆固醇血症;入院前高胆同醇血症知晓率为12.2%;治疗率为66.7%.既往有ACS史的高胆固醇血症患者仅有1/5控制达标,这在冠心病二级预防中应当引起重视.     

合肥地区医院急性冠脉综合征住院患者临床特征及治疗探讨

目的 探讨合肥市近3年来急性r冠脉综合征(ACS)住院患者的临床特征及治疗现状.方法 回顾性分析合肥地区三所省级医院和三所市级医院2004年1月-2007年7月ACS住院患者病历.结果 在209例接受调查的患者中,男性占80.4%,年龄38～96(平均72.2±11.3)岁,急性心肌梗死早期再灌注治疗率为27.8%,其中25.7%接受急诊经皮冠状动脉介入治疗(PCI),1.1%接受溶栓治疗.阿司匹林的使用率93.4%、氯吡格雷62.8%、血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂(71.5%)、调酯类(63.2%),市级医院上述用药比率低于省级医院;两组医院β受体阻滞剂使用率差别不大,均达到55%.二级预防药物应用率40.1%～97.9%.结论 ACS多发于老年,男性多于女性,且发病率随增龄而增加,2004～2007年合肥市ACS患者治疗状况与2007年ACC/AHA治疗指南的要求存在一定差距;二级预防用药率较低,应引起临床重视.     

中国省、市和县级医院急性ST段抬高型心肌梗死住院患者再灌注治疗和二级预防用药分析

目的:比较我国省级、市级及县级三个级别医院针对ST段抬高型急性心肌梗死(STEMI)患者进行再灌注治疗和住院期间二级预防药物的使用情况。方法:中国急性心肌梗死注册(CAMI)研究在2013-01-01至2014-09-30期间共登记覆盖全国31个省市、自治区和直辖市107家医院收治的18967例在发病7天内的STEMI患者,其中223例患者因住院结局等关键数据缺失而被排除,分析省、市和县级三个级别医院收治患者的人口统计学信息、再灌注治疗[包括急诊冠状动脉介入治疗(PCI)和溶栓治疗]和二级预防用药[包括阿司匹林、P2Y12抑制剂、他汀类药物、β受体阻滞剂、血管紧张素转化酶抑制剂(ACEI)/血管紧张素Ⅱ受体拮抗剂(ARB)]的使用情况。结果:在分析的18744例STEMI患者中,9885例(52.7%)接受了再灌注治疗,其中8038例(42.9%)接受了急诊PCI,1847例(9.9%)接受了溶栓治疗。省级医院再灌注治疗率明显高于地市级医院和县级医院,分别为4041例(61.8%)、4728例(49.1%)和1116例(43.2%),差异有统计学意义(P0.001);三个级别医院的再灌注治疗方式也存在明显差别,省级医院:急诊PCI 3840例(58.7%),溶栓201例(3.1%);市级医院:急诊PCI 3753例(39.0%),溶栓975例(10.1%);县级医院:急诊PCI 445例(17.2%),溶栓671例(26.0%)。发病12小时内到达医院的12502例患者中有8856例(70.8%)接受再灌注治疗,其中急诊PCI 7089例(56.7%),溶栓1746例(14.1%),省级医院3537例(80.0%),市级医院4274例(67.5%),县级医院1045例(59.8%),三个级别的医院依然差别明显(P0.001)。在住院期间有16575例(90.9%)使用他汀、17963例(96.8%)使用阿司匹林,17922例(96.5%)例应用P2Y12抑制剂,12657例(68.2%)使用β受体阻滞剂,10541例(56.8%)使用ACEI/ARB。三个级别医院在应用上述几种二级预防用药比例相似。结论:CAMI研究中,在发病12小时内到达医院的患者中,有70.8%接受再灌注治疗。县级医院的再灌注治疗率明显较低。三个级别医院的二级预防用药情况相似,但β受体阻滞剂和ACEI/ARB使用比例偏低。     

12小时内就诊的急性心肌梗死患者治疗现状分析

目的　分析评价我国目前存在急性ST段抬高的心肌梗死患者的治疗现状。方法　分析我国近三年 1 2所医院注册的 5 1 8例于发病后 1 2h内就诊的急性ST段抬高心肌梗死患者的治疗现状 ,包括 :再灌注治疗 ,阿司匹林、血管紧张素转换酶抑制剂 (ACEI)、β 受体阻滞剂、调脂药治疗等。 结果　 (1 )近 1 / 3的患者未接受任何形式的再灌注治疗 ,1 / 2的患者接受了直接经皮冠状动脉介入治疗(PCI) ,1 / 5的患者接受了溶栓治疗 ;(2 )年龄 >75岁、合并糖尿病是患者未能接受再灌注治疗的预测因子 ;(3)阿司匹林的使用率接近 1 0 0 %;仍能进一步提高 β 受体阻滞剂 (6 5 2 %～ 71 4 %)、ACEI(5 2 1 %～ 6 0 4 %)、调脂药 (6 9 8%～ 73 5 %)的使用率 ;(4)接受直接PCI治疗的患者总住院时间最短 ;(5 )直接PCI治疗在住院期间的疗效优于溶栓治疗和单纯药物治疗。结论　 (1 )除外就诊时间长 (>1 2h)以及医院因素 (能否开展再灌注治疗 )以外 ,年龄 >75岁、合并糖尿病等是影响患者接受再灌注治疗的因素 ;(2 )即使急诊PCI开始治疗的时间晚于溶栓治疗 ,其疗效仍然优于溶栓治疗 ;(3)我国需要接受经循证医学证实有效的治疗 (再灌注治疗 ,ACEI、β 受体阻滞剂、调脂药治疗 )的患者为数众多。     

经皮冠状动脉介入治疗术后肌钙蛋白I变化与心肌再灌注的关系

目的:探讨高危非ST段抬高的急性冠状动脉综合征(ACS)患者经皮冠状动脉介入治疗术(PCI)后肌钙蛋白I的变化与心肌再灌注的关系。方法:高危非ST段抬高的ACS的患者42例,运用TIMI血流分级、校正的TIMI帧计数及TIMI心肌灌注分级(TMPG)评价肌钙蛋白I升高与心肌再灌注的关系。结果:14例患者PCI后肌钙蛋白I升高,28例患者没有升高。PCI后肌钙蛋白I升高患者的TIMI心肌灌注分级为0/1级的比例(43%)远远高于PCI后肌钙蛋白I没有升高患者的比例(7%)(P<0.05)。TMPG分级为0/1级患者肌钙蛋白I的水平(5.3±2.7)mg/L远远高于TMPG分级为2/3级患者肌钙蛋白I的水平(1.5±1.3)mg/L(P<0.01)。结论:高危非ST段的ACS患者PCI后肌钙蛋白I升高提示心肌灌注不良。     

经皮冠状动脉介入治疗术后肌钙蛋白Ⅰ变化与心肌再灌注的关系

目的:探讨高危非ST段抬高的急性冠状动脉综合征(ACS)患者经皮冠状动脉介人治疗术(PCI)后肌钙蛋白Ⅰ的变化与心肌再灌注的关系.方法:高危非ST段抬高的ACS的患者42例,运用TIMI血流分级、校正的TIMI帧计数及TIMI心肌灌注分级(TMPG)评价肌钙蛋白Ⅰ升高与心肌再灌注的关系.结果:14例患者PCI后肌钙蛋白Ⅰ升高,28例患者没有升高.PCI后肌钙蛋白Ⅰ升高患者的TIMI心肌灌注分级为0/1级的比例(43%)远远高于PCI后肌钙蛋白Ⅰ没有升高患者的比例(7%)(P＜0.05).TMPG分级为0/1级患者肌钙蛋白Ⅰ的水平(5.3±2.7)mg/L远远高于TMPG分级为2/3级患者肌钙蛋白Ⅰ的水平(1.5±1.3)mg/L(P＜0.01).结论:高危非ST段的ACS患者PCI后肌钙蛋白Ⅰ升高提示心肌灌注不良.     

心电图aVR导联ST段抬高对急性冠脉综合征患者长期预后的评估价值研究

目的探讨心电图a VR导联ST段抬高对急性冠脉综合征(ACS)患者长期预后的评估价值,为提高ACS的诊治水平提供参考依据。方法选取2011年10月—2012年12月解放军第一零五医院收治的ACS患者185例,根据心电图a VR导联ST段变化分为ST段抬高组(n=112)和非ST段抬高组(n=73)。收集入选ACS患者的临床资料和随访资料,主要包括年龄、性别、既往史、吸烟史、心率、收缩压、心功能分级、生化指标〔超敏C反应蛋白(hs-CRP)、肌酸激酶同工酶(CK-MB)、血肌酐及心肌肌钙蛋白T(cTnT)阳性率〕、冠状动脉病变情况、治疗情况〔经皮冠状动脉介入术(PCI)治疗和冠状动脉旁路移植术(CABG)治疗〕及心血管事件发生情况、随访时间、3年无心血管事件生存率,并采用多元Cox比例风险回归模型筛选影响ACS患者长期预后的相关因素。结果两组患者年龄、心率、收缩压、血肌酐、男性所占比例、既往史(高血压、糖尿病、心肌梗死)阳性率、吸烟史阳性率、心功能分级Ⅱ～Ⅳ级者所占比例、三支病变发生率、PCI治疗率和CABG治疗率比较,差异无统计学意义(P0.05);两组患者hs-CRP水平、CK-MB水平、全球急性冠状动脉事件注册(GRACE)评分、cTnT阳性率、左主干病变发生率和左主干+三支病变发生率比较,差异有统计学意义(P0.05)。ST段抬高组患者再发心肌梗死、新发心力衰竭、心源性猝死发生率均高于非ST段抬高组(P0.05)。ST段抬高组患者中82例发生心血管事件,随访时间为0～36个月,3年无心血管事件生存率为26.8%;非ST段抬高组患者中26例发生心血管事件,随访时间为2～36个月,3年无心血管事件生存率为64.3%。非ST段抬高组患者3年无心血管事件生存率高于ST段抬高组(log-rankχ~2=25.711,P0.001)。多元Cox比例风险回归分析结果显示,aVR导联ST段抬高〔HR=3.79,95%CI(1.81,7.90)〕是ACS患者长期预后的独立危险因素。结论心电图aVR导联ST段抬高的ACS患者长期预后劣于非ST段抬高的ACS患者;心电图aVR导联ST段抬高是ACS患者长期预后的独立预测因子。     

急性冠状动脉综合征患者住院治疗现状分析

目的评价我国目前急性冠状动脉综合征(ACS)患者接受经循证医学证实有效的治疗措施应用现状.方法来自全国12家医院注册、共1301例ACS患者住院期间接受不同的治疗措施,分析不同ACS患者接受再灌注现状及阿司匹林、ACEI、β-受体阻滞剂、低分子肝素、他汀类调脂药物的临床应用情况.结果①STEMI患者不同时期药物使用情况阿司匹林(95.9%～100%)、ACEI(72%～88.4%)、β-受体阻滞剂(62.7%-74.5%)、低分子肝素(84.7%～100%)、调脂药(72.5%～93%);②非ST段抬高ACS患者阿司匹林(100%)、低分子肝素在NSTEMI中的应用率(84.2%～100%)、UAP中(65.1%～87.2%);③STEMI患者中有28.8%的患者未接受任何形式的再灌注治疗、12%的患者接受了单纯溶栓治疗、7.5%的患者接受了溶栓+PCI治疗、48.9%的患者接受了PCI治疗④50%的NSTEACS患者接受了PCI治疗.结论在我国医疗水平较高的地区,经循证医学证实有效的治疗ACS措施在临床中的实际应用情况优于国外报告结果,但仍有较大的提升空间.     

中国多中心急性冠脉综合征患者高血压控制现况

背景 冠状动脉疾病(CAD)是目前世界范围内危害人类健康的主要疾病,降低CAD的发病率进而减轻相关的疾病负担成为心血管疾病防治领域的重点,有效地实施冠心病二级预防的指南已成为许多国家改善心脏病临床实践的主要目标.中国冠心病二级预防架桥工程(BRIG)研究基线调查旨在全面如实地反映中国CAD诊疗及二级预防现状,发现、确定当前中国CAD二级预防在临床实践中存在的问题、障碍和主要影响因素.目的 了解中国多省市急性冠脉综合征(ACS)患者危险因素控制现况-高血压的治疗、控制情况.方法 以3223例急性冠脉综合征住院病人为研究对象.2006年在中国31个省市自治区选择32家三级医院和32家二级医院.本研究主要分析患者入院前的高血压患病、治疗及控制情况.结果 1)在3223例ACS患者中,男性占67.7%(2183例),女性占32.3%(1040例),年龄(65±11)岁;其中ST段抬高心肌梗死占39.8%,非ST段抬高心肌梗死9.2%,不稳定心绞痛占51.0%;既往有ACS病史者27.1%.2)ACS患者中既往有高血压病史者52.7%,女性(57.8%)高于男性(50.3%,P＜0.01);按地理位置分为7个地区(华北、华东、华南、华中、东北、西北和西南),其中东北地区既往有高血压病史者比例最高(61.7%),华南地区最低(43.0%),各地区间的差异具有非常显著意义(P＜0.01).3)既往有高血压病史者,其治疗率为85.4%,治疗率最高的是华南地区(90.0%),最低是西南地区(78.3%);在治疗者中控制率为38.5%,其中控制率最高的是西南地区(46.7%),最低是东北地区(28.2%).4)既往有ACS的患者中高血压的患病率为58.1%,治疗率为90.0%,治疗者的控制率为42.2%,上述三率均高于既往无ACS病史者(50.8%、83.5%、36.8%).结论 急性冠脉综合征患者中近55%伴有高血压病史;高血压治疗率、控制率存在地区间差异;虽然高血压治疗率较高,但控制率仍处于较低水平,这在冠心病二级预防中应当引起重视.     

Impact of on-site cardiac interventional facilities on management and outcome of patients with acute coronary syndromes

OBJECTIVES: To investigate the impact of on-site cardiac interventional facilities on the management and outcome of patients with versus those without ST elevation acute coronary syndromes (ACS) in the Canadian-American Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIb population. METHODS: Data from 4605 patients were analyzed in relation to the admitting hospital's capability to perform coronary procedures (noninvasive, angiography-capable and interventional hospitals). Differences in medication use, revascularization rate and patient outcome were determined. RESULTS: Whereas medication use during hospitalization and at discharge differed between non-ST elevation ACS patients treated in the three groups, these were generally more comparable among ST elevation ACS patients. In both ST segment cohorts, patients treated in interventional hospitals underwent coronary procedures more often (angiography rate greater than 70% versus 40% for noninvasive hospitals) and sooner (median two to three days versus four days in noninvasive hospitals) than those treated in other hospitals. Recurrent ischemia was significantly less common in non-ST elevation ACS patients treated in interventional hospitals (32% versus 36% in angiography-capable and 40% in noninvasive hospitals, P<0.001) and tended to be less common among ST elevation ACS patients treated in interventional hospitals. Patients treated in interventional hospitals tended to have lower mortality in the non-ST elevation ACS cohort but significantly fewer died in the ST elevation ACS during hospitalization and at 30 days, six months and one year (8.8% versus 11% in angiography-capable and 15% in noninvasive hospitals, P=0.015). These differences in mortality persisted after adjustment for key baseline covariates. Separate analysis of Canadian and American patients revealed similar mortality patterns, as to the total population, in both ST segment cohorts. CONCLUSIONS: Presence of an on-site cardiac interventional facility favourably affected the management and outcome of ACS patients in both non-ST and ST elevation cohorts.     

不同性别急性冠脉综合征住院患者的临床特征及治疗现状

目的评价中国不同性别急性冠脉综合征（ACS）住院患者的临床特点及住院治疗现状。方法中国急性冠脉事件注册研究人选12家三级甲等医院,从2001年1月起截止到2003年10月,总共1301例ACS患者人选该研究。结果（1）患者年龄为27-93（63．13±10．89）岁,包括318（例）女性和983（例）男性患者;女性平均年龄显著高于男性（67．23岁比61．80岁）。（2）女性患者心绞痛、心力衰竭、糖尿病和高血压病史显著高于男性（分别为73．6％比62．3％,8．2％比5．7％,30．8％比18．6％,和66．4％比56．8％）,但女性患者吸烟比例显著低于男性（6．6％比66．2％）;（3）患者ST段抬高心肌梗死（STEMI）的男性患者比例显著高于女性（48．5％比39％）。（4）除B受体阻滞剂以外,ACS患者住院期间阿司匹林、血管紧张素转换酶抑制剂、调脂药及低分子肝素的应用在两性之间无显著性差异;对于非ST段抬高ACS（NSTE-ACS）患者,女性住院期间使用8受体阻滞剂的比例显著低于男性（63．4％比75．1％）。（5）所有女性ACS患者住院期间未接受再灌注治疗的比例显著高于男性（STEMI：37．1％比26．8％;NSTE-ACS：53．6％比37．2％）。（6）女性住院期间再发心绞痛、充血性心力衰竭的发生率显著高于男性ACS患者。（7）住院期间,女性ACS患者的死亡率与男性比较没有显著差异（STEMI：5．6％比7．1％,NSTE-ACS：2．1％比1．4％）。结论我国治疗水平较高地区ACS患者女性年龄要显著高于男性,女性合并更多的危险因素（高血压、糖尿病等）,女性ACS患者住院期间接受再灌注治疗的比例低于男性ACS患者,但住院期间两性之间死亡率并无显著差异。     

A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin; the Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS).

AIMS: To better delineate the characteristics, treatments, and outcomes of patients with acute coronary syndromes (ACS) in representative countries across Europe and the Mediterranean basin, and to examine adherence to current guidelines. METHODS AND RESULTS: We performed a prospective survey (103 hospitals, 25 countries) of 10484 patients with a discharge diagnosis of acute coronary syndromes. The initial diagnosis was ST elevation ACS in 42.3%, non-ST elevation ACS in 51.2%, and undetermined electrocardiogram ACS in 6.5%. The discharge diagnosis was Q wave myocardial infarction in 32.8%, non-Q wave myocardial infarction in 25.3%, and unstable angina in 41.9%. The use of aspirin, beta-blockers, angiotensin converting enzyme inhibitors, and heparins for patients with ST elevation ACS were 93.0%, 77.8%, 62.1%, and 86.8%, respectively, with corresponding rates of 88.5%, 76.6%, 55.8%, and 83.9% for non-ST elevation ACS patients. Coronary angiography, percutaneous coronary interventions, and coronary bypass surgery were performed in 56.3%, 40.4%, and 3.4% of ST elevation ACS patients, respectively, with corresponding rates of 52.0%, 25.4%, and 5.4% for non-ST elevation ACS patients. Among patients with ST elevation ACS, 55.8% received reperfusion treatment; 35.1% fibrinolytic therapy and 20.7% primary percutaneous coronary interventions. The in-hospital mortality of patients with ST elevation ACS was 7.0%, for non-ST elevation ACS 2.4%, and for undetermined electrocardiogram ACS 11.8%. At 30 days, mortality was 8.4%, 3.5%, and 13.3%, respectively. CONCLUSIONS: This survey demonstrates the discordance between existing guidelines for ACS and current practice across a broad region in Europe and the Mediterranean basin and more extensively reflects the outcomes of ACS in real practice in this region.     

Value of lead aVR in the detection of significant left main coronary artery stenosis in acute coronary syndrome

BACKGROUND: Electrocardiographic lead aVR is usually ignored in patients with chest pain. ST segment elevation in aVR may have diagnostic value in patients with acute coronary syndrome (ACS) and significant stenosis or obstruction of the left main coronary artery (LMCAS), especially when accompanied by ST segment elevation in lead V(1). AIM: To asses the value of lead aVR and V1 for the detection of LMCAS in patients with ACS. METHODS: The study group consisted of 150 patients (mean age 60.6+/-9.5 years, range 33-78 years) with ACS, including 46 with LMCAS and 104 without LMCAS. ECG recordings obtained on admission were compared between these two groups. RESULTS: In patients with LMCAS, ST segment elevation in lead aVR was two times more frequent than in remaining patients (69.6% vs 34.6% p=0.0001) whereas there were no differences in lead V(1). Sensitivity of ST elevation in aVR in detection of LMCAS was 69.6%, specificity - 65.4%, positive predictive value - 47.1%, and negative predictive value - 82.9%. In patients with LMCAS, ST segment depression was significantly more often present in ECG leads other than aVR (45.6% vs 23.1% p<0.01). Patients with LMCAS more often had hypertension (95.6% vs 77.9% p<0.05) and three-vessel disease (78.3% vs 31.8%, p<0.0001). CONCLUSIONS: The assessment of lead aVR in patients with ACS may indicate LMCAS. Additional analysis of lead V(1) does not improve diagnostic accuracy.     

The outcome of coronary artery bypass grafting surgery among patients hospitalized with acute coronary syndrome: the Euro Heart Survey of acute coronary syndrome experience

AIM: To determine the frequency and outcomes of coronary artery bypass graft (CABG) surgery in patients with a wide spectrum of acute coronary syndromes (ACS). METHODS AND RESULTS: We prospectively enrolled 10,484 ACS patients from 103 hospitals in 25 countries across Europe and the Mediterranean basin. Of the 10,204 patients with complete data, 460 (4.5%) underwent CABG while in hospital; 3.4% had ST elevation ACS, 5.4% had non-ST elevation ACS, and 4.4% had undetermined ECG ACS (p=0.001 for non-ST elevation ACS vs. others). In general, patients who underwent CABG were more likely to be males, to have diabetes mellitus, hyperlipidemia, a positive family history of premature coronary disease, and prior angina pectoris, but had less often prior heart failure. While in hospital, all CABG patients underwent coronary angiography and 15.2% also underwent percutaneous revascularization, as compared with 51.3 and 33.1% in the remaining patients, respectively. The in-hospital mortality was 3.7% for ACS patients who underwent CABG and 4.8% for non-CABG ACS patients (p=nonsignificant) with an adjusted odds ratio of in-hospital death for CABG patients of 1.00 (95% CI 0.59-1.61). CONCLUSIONS: Approximately 4.5% of ACS patients underwent CABG during their initial hospitalization, with a greater likelihood among non-ST elevation ACS patients. Of the CABG patients, 15.2% also underwent percutaneous revascularization. The outcome of CABG patients was as good as non-CABG patients, indicating that CABG remains an effective and safe means to achieve revascularization among ACS patients in current clinical practice.     

Improved adherence to practice guidelines yields better outcome in high-risk patients with acute coronary syndrome without ST elevation: findings from nationwide FINACS studies

OBJECTIVES: Treatment options for acute coronary syndrome (ACS) without ST elevation have evolved rapidly during the recent years, but the successful implementation of practice guidelines incorporating new treatments into practice has been challenging. In this study, we evaluate whether targeted educational intervention could improve adherence to treatment guidelines of ACS without ST elevation. DESIGN, SETTING AND SUBJECTS: A previous study, FINACS I, evaluated the treatment and outcome of 501 consecutive non-ST elevation ACS patients that were referred in early 2001 to nine hospitals, covering nearly half of the Finnish population. That study revealed poor adherence to ESC guidelines, so targeted educational intervention on optimal practice was arranged before the second study (FINACS II), which was performed in the same hospitals using the same protocol as FINACS I. FINACS II, undertaken in early 2003, evaluated 540 consecutive patients. Interventions. Targeted educational programmes on optimal practice. MAIN OUTCOME MEASURES: The use of evidence-based therapies in non-ST elevation ACS patients. In-hospital event-free (death, new myocardial infarction, refractory angina, readmission with unstable angina and transient cerebral ischaemia/stroke) survival, and event-free survival at 6 months. RESULTS: Baseline characteristics and risk markers were similar in both studies, and no significant changes in resources were seen. In 2003, the in-hospital use of statins, ACE-inhibitors, clopidogrel and glycoprotein (GP) IIb/IIIa receptor antagonists increased significantly, and in-hospital angiography was performed more often, especially in high-risk patients (59% vs. 45%, P < 0.05); waiting time also shortened (4.2 +/- 5.5 vs. 5.8 +/- 4.7 days, P < 0.01). Overall no significant change was seen in the frequency of death either in-hospital (2% vs. 4%, P = NS) or at 6 months (7% vs. 10%, P = NS) in FINACS II. However, the survival of high-risk patients improved both in-hospital (95% vs. 90%, P = 0.05) and at 6 months (89% vs. 78%, P = 0.05). CONCLUSION: In patients with non-ST elevation ACS-targeted educational interventions appeared to be associated with improved adherence to practical guidelines, which yielded a better outcome in high-risk ACS patients.     

北京市急性ST段抬高心肌梗死患者转诊现况调查

目的 了解北京市急性ST段抬高心肌梗死(STEMI)患者的转诊现况以及对再灌注治疗和近期预后的影响.方法 入选2006年1月1日至12月31日期间就诊于北京市19所具备急诊经皮冠状动脉介入治疗(PCI)能力的医院并于发病后24 h内到院的STEMI患者.根据到院前是否经历转诊,将患者分为转诊组和非转诊组.通过调查问卷及查阅病历收集资料.结果 789例STEMI患者中,236例(29.9%)经历过转诊.由3级以下级别医院向3级医院转诊者占76.7%(181/236),由3级医院向3级医院转诊者占22.9%(54/236).由非直接PCI中心向直接PCI中心转诊者占67.4%(159/236),由直接PCI中心向直接PCI中心转诊者占32.6%(77/236).转诊组与非转诊组的直接PCI率(62.7%比66.4%,P=0.328)和进门-球囊扩张时间(132 min比135 min,P=0.473)差异无统计学意义.转诊组的发病-球囊扩张时间显著长于非转诊组(397 min比246 min,P<0.001).转诊组与非转诊组的住院病死率差异无统计学意义(4.7%比5.8%,P=0.609).结论 北京市急性STEMI患者的转诊情况复杂,转诊对近期预后无影响,有必要建立规范的STEMI转诊网络.     

Multicenter HP ACS Registry

BackgroundNo population representative data on characteristics, treatment, and outcome were available in acute coronary syndrome (ACS) patients.MethodsThe clinical characteristics, treatment, and in-hospital outcome of 5180 ACS patients registered in multicenter ACS Registry across 33 hospitals in the state since January 2012 to December 2014 are reported. ACS was diagnosed using standard criteria.Result70.8% were men; mean age was 60.9 ± 12.1. NSTEMI was more frequent than STEMI (54.5% vs. 45.5%). 83.3% of the ACS population were from rural area. Pre-hospital delay was long, with a median of 780 min. 35.6% of STEMI patients received thrombolytic therapy. Evidence-based treatment was prescribed in more than 80% of ACS patients, and the treatment was similar in men and women across all types of health care centers. In-hospital mortality was 7.6%, and was more frequent in STEMI than in NSTEMI (10.8% vs. 5.0%, p < 0.001).InterpretationPre-hospital delay was long, and use of reperfusion therapy was significantly lower. The in-hospital death rates are higher.