急性ST段抬高性心肌梗死直接经皮穿刺冠状动脉成形术后早期ST段变化的意义

目的探讨急性ST段抬高性心肌梗死(STEMI)直接经皮穿刺冠状动脉成形术(PCI)术后梗死相关动脉(IRA)完全开通、前向血流恢复后,早期ST段变化的临床意义。方法回顾性分析2001-01~12北京朝阳医院心脏中心收治的216例直接PCI后、IRA完全开通、前向血流恢复正常病人的临床、冠脉造影和心电图资料。直接PCI术后,ST段抬高指数≥50%的病人41例,为病例组。从其余175例ST段抬高指数<50%的病人中随机抽取50例,为对照组。结果两组病人的ST段抬高指数、Q波计数、室壁运动积分和平均肌酸激酶值差异有显著性意义(P<0·05);术后2周,ST段早期恢复较ST段持续抬高病人的室壁运动改善,左室射血分数(LVEF)、心排指数(CI)、每搏指数(SVI)增加(P<0·05)。ST段早期恢复合并心功能不全的病人,术后2周室壁运动增强,LVEF、CI、SVI增加(P<0·05),左室舒张末容积、左室收缩末容积减少(P<0·01)。结论STEMI直接PCI后IRA完全开通、前向血流恢复正常而ST段持续抬高病人的梗死范围扩大,左室舒缩功能不全严重,可能与心肌组织没有有效地恢复血流灌注或无复流有关。     

Risk stratification for ST segment elevation myocardial infarction in the era of primary percutaneous coronary intervention

Acute coronary syndromes presenting with ST elevation are usually treated with emergency reperfusion/revascularisation therapy. In contrast current evidence and national guidelines recommend risk stratification for non ST segment elevation myocardial infarction(NSTEMI) with the decision on revascularisation dependent on perceived clinical risk. Risk stratification for STEMI has no recommendation. Statistical risk scoring techniques in NSTEMI have been demonstrated to improve outcomes however their uptake has been poor perhaps due to questions over their discrimination and concern for application to individuals who may not have been adequately represented in clinical trials. STEMI is perceived to carry sufficient risk to warrant emergency coronary intervention [by primary percutaneous coronary intervention(PPCI)] even if this results in a delay to reperfusion with immediate thrombolysis. Immediate thrombolysis may be as effective in patients presenting early, or at low risk, but physicians are poor at assessing clinical and procedural risks and currently are not required to consider this. Inadequate data on risk stratification in STEMI inhibits the option of immediate fibrinolysis, which may be cost-effective. Currently the mode of reperfusion for STEMI defaults to emergency angiography and percutaneous coronary intervention ignoring alternative strategies. This review article examines the current risk scores and evidence base for risk stratification for STEMI patients. The requirements for an ideal STEMI risk score are discussed.     

急性ST段抬高型心肌梗死直接冠脉成形术ST段变化的临床价值

目的探讨急性ST段抬高型心肌梗死患者行直接冠脉成形术,术前和术后ST段变化对远期心血管事件的临床预测价值。方法对54例ST段抬高型心肌梗死患者行直接冠脉成形术,观察术前和术后1h心电图ST段变化,计算ST段回落指数。对所有患者随访12个月,观察12个月内心血管事件（猝死、心肌梗死、再狭窄、再次血管重建、慢性心衰）发生情况。对ST段回落指数和随访心血管事件行ROC分析,并通过COX比例风险模型多因素回归分析ST段回落指数对12个月终点事件的独立预测价值。结果在12个月的随访中,发生心源性死亡2例,再发心绞痛4例,慢性心衰7例。ST段回落指数临界点取63％时,对目标心脏事件预测的ROC曲线下面积0．843,灵敏度76．9％,特异度78．0％。COX比例风险模型多因素回归分析显示ST段回落指数对目标终点事件具有独立预测价值。结论急性ST段抬高型心肌梗死患者行直接PCI术,术前和术后ST段的变化即ST段回落指数对术后12个月预后具有独立预测价值。     

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。     

The MI SYNTAX score for risk stratification in patients undergoing primary percutaneous coronary intervention for treatment of acute myocardial infarction: A substudy of the COMFORTABLE AMI trial

Background

To investigate the performance of the MI Sxscore in a multicentre randomised trial of patients undergoing primary percutaneous coronary intervention (PPCI).

Methods and results

The MI Sxscore was prospectively determined among 1132 STEMI patients enrolled into the COMFORTABLE AMI trial, which randomised patients to treatment with bare-metal (BMS) or biolimus-eluting (BES) stents. Patient- (death, myocardial infarction, any revascularisation) and device-oriented (cardiac death, target-vessel MI, target lesion revascularisation) major adverse cardiac events (MACEs) were compared across MI Sxscore tertiles and according to stent type.The median MI SXscore was 14 (IQR: 9–21). Patients were divided into tertiles of Sxscore_low (≤ 10), Sxscore_intermediate (11–18) and Sxscore_high (≥ 19). At 1 year, patient-oriented MACE occurred in 15% of the Sxscore_high, 9% of the Sxscore_intermediate and 5% of the Sxscore_low tertiles (p < 0.001), whereas device-oriented MACE occurred in 8% of the Sxscore_high, 6% of the Sxscore_intermediate and 4% of the Sxscore_low tertiles (p = 0.03). Addition of the MI Sxscore to the TIMI risk score improved prediction of patient- (c-statistic value increase from 0.63 to 0.69) and device-oriented MACEs (c-statistic value increase from 0.65 to 0.70). Differences in the risk for device-oriented MACE between BMS and BES were evident among Sxscore_high (13% vs. 4% HR 0.33 (0.15–0.74), p = 0.007 rather than those in Sxscore_low: 4% vs. 3% HR 0.68 (0.24–1.97), p = 0.48) tertiles.

Conclusions

The MI Sxscore allows risk stratification of patient- and device-oriented MACEs among patients undergoing PPCI. The addition of the MI Sxscore to the TIMI risk score is of incremental prognostic value among patients undergoing PPCI for treatment of STEMI.     

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。     

不同临床途径直接冠状动脉介入治疗对急性ST段抬高心肌梗死预后的影响

目的:比较急诊室-导管室与急诊室-CCU(病房)-导管室这2种临床途径直接经皮冠状动脉介入治疗(PCI)对急性ST段抬高心肌梗死(STEMI)患者住院期和远期预后的影响。方法:分析12 h内接受直接PCI治疗的连续228例STEMI患者冠状动脉病变及干预情况,记录手术成功率、平均住院日、院内死亡率及随访期间终点事件发生率,并多因素回归分析心血管事件相关危险因素。结果:急诊室-导管室组(甲组)与急诊室-CCU-导管室组(乙组)临床特征、冠状动脉病变、PCI成功率及平均住院日相似。与乙组相比,甲组的就诊-球囊时间延迟缩短(P<0.01),住院期和随访期(32.3个月)死亡率及复合终点事件发生率显著减低(均P<0.05)。多因素回归分析表明,就诊-球囊时间(OR=1.01,P<0.05)和年龄(OR=1.06,P<0.05)与心血管事件发生率显著相关。结论:STEMI患者到达急诊室后,直接送导管室行PCI治疗可显著缩短就诊-球囊时间延迟,改善近期和远期临床预后。     

不同冠状动脉重建术治疗非ST段抬高急性心肌梗死的效果

目的比较经皮冠状动脉介入治疗(PCI)和冠状动脉旁路移植术(CABG)治疗非ST段抬高急性心肌梗死(NSTEAMI)的临床效果。方法98例NSTEAMI患者入院后行PCI和CABG治疗,进行12个月的随访,比较两组患者的一般临床资料、冠状动脉造影血管病变情况及心源性病死率、再发心绞痛以及再入院率和再次血运重建术率。结果CABG组三支和完全闭塞冠状动脉病变例数明显高于PCI组(87.23%vs.47.06%,87.23%vs.23.53%,P<0.05),随访12个月两组患者在心源性病死率、合并心律失常和再次血管重建术发生率(P>0.05)差异无统计学意义。而在心绞痛复发和再次住院率经皮冠状动脉成形术组高于CABG组(21.57%vs.6.38%,23.52%vs.6.38%,P<0.05)。结论对NSTEAMI患者入院后行PCI与CABG治疗是安全的血运重建的重要手段,应根据患者的具体情况采用合理的血运重建方式,以达到最佳重建冠状动脉血流的结果,改善患者的预后。     

The impact of introduction of Code-STEMI program on the reduction of door-to-balloon time in acute ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention: A single-center study in Saudi Arabia

Objectives

This study was conducted to evaluate the effect of direct emergency department activation of the catheterization lab on door-to-balloon time (D2BT) and outcomes of acute ST-elevation myocardial infarction (STEMI) patients at a major tertiary care hospital in Riyadh, Saudi Arabia.

急诊经桡动脉与股动脉入路介入治疗ST段抬高急性心肌梗死对比研究

目的观察经桡动脉入路行急诊ST段抬高急性心肌梗死直接经皮冠状动脉介入(PCI)治疗的有效性和安全性。方法选择沈阳军区总医院2005年1月至2006年10月连续607例ST段抬高性急性心肌梗死(STEMI)住院患者,分别接受经桡动脉入路(273例)或经股动脉入路(334例)途径行PCI治疗,观察两组手术成功率和并发症发生率。结果两组患者PCI成功率差异无统计学意义(97.07%对95.81%,P>0.05)。经桡动脉入路组局部血肿、假性动脉瘤、迷走反射发生率显著低于经股动脉入路组。结论行PCI治疗的STEMI患者经桡动脉入路途径是安全、有效和可行的方法,与经股动脉比较,经桡动脉途径可减少并发症的发生。     

早期应用替罗非班对急性ST段抬高型心肌梗死急诊介入治疗的有效性及安全性分析

目的评价在急性ST段抬高型心肌梗死经皮冠状动脉介入治疗（PCI）中早期应用血小板膜糖蛋白Ⅱb／Ⅲa受体拮抗剂替罗非班的有效性和安全性。方法将80例急性ST段抬高型心肌梗死患者随机分为替罗非班组（替罗非班＋直接PCI,40例）和对照组（直接PCI,40例）。比较两组患者梗死相关动脉PCI后即刻TIMI血流、术后90min心电图ST段回落百分比、术后7d左室射血分数、术后30d内主要不良心脏事件（心绞痛、心肌梗死、死亡）、出血和血小板减少的发生率。结果替罗非班组PCI后慢复流发生率及主要不良心脏事件的发生率均低于对照组（P〈0．05）,出血并发症的发生与对照组比较差异无统计学意义（P〉0．05）。结论早期应用替罗非班能改善急性ST段抬高型心肌梗死患者PCI后梗死相关血管的TIMI血流,减少PCI后主要不良心脏事件的发生率,临床应用安全有效。     

Clinical outcomes of elderly South-East Asian patients in primary percutaneous coronary intervention for ST-elevation myocardial infarction

Objective To evaluate the clinical characteristics and in-hospital outcomes of elderly South-East Asian patients undergoing primary percutaneous coronary intervention (PPCI). Methods From January 2009 to December 2012, 1268 patients (86.4% male, mean age of 58.4 ± 12.2 years) presented to our hospital for ST-elevation myocardial infarction (STEMI) and underwent PPCI. They were divided into two groups: elderly group defined as age > 70 years and non-elderly group defined as age < 70 years. Data were collected retrospectively on baseline clinical characteristics, door-to-balloon (D2B) time, angiographic findings, therapeutic modality and hospital course. Results The elderly group constituted 19% of the study population with mean age 76.6 ± 5.0 years. There was a higher proportion of female gender and ethnic Chinese patients in the elderly group when compared with the non-elderly group. The former was less likely to be smokers and have a significantly higher prevalence of hypertension. The mean D2B time was significantly longer in the elderly group. They also had a significantly higher incidence of triple vessel disease and obstructive left main disease. The use of radial artery access, glycoprotein 2b/3a inhibitors and drug-eluting stents during PPCI were also significantly lower. In-hospital mortality was significantly higher in the elderly group. The rate of cardiogenic shock and inhospital complications were also significantly higher. Conclusions Our registry showed that in-hospital mortality rate in elderly South-East Asian patients undergoing PPCI for STEMI was high. Further studies into the optimal STEMI management strategy for these elderly patients are warranted.     

SYNTAX评分预测急性ST段抬高型心肌梗死介入后无复流

目的：评价急性ST段抬高型心肌梗死（ST segment elevation myocardial infarction,STEMI）患者诊断性冠状动脉造影获得的SYNTAX评分,与经皮冠状动脉介入治疗（percutaneous coronary intervention,PCI）后无复流现象的相关性。方法：入选在发病后12h内行PCI治疗的397例STEMI患者,进行回顾性分析。根据单纯冠状动脉病变心脏外科与介入治疗狭窄冠状动脉研究（Synergy between percutaneous coronary intervention with TAXUS and cardiac surgery,SYNTAX）评分的中位数,将患者分为高分组和低分组。将冠状动脉造影结果作为无复流的判断标准。采用多元Logistic回归分析,评价SYNTAX评分与急诊PCI后无复流现象的的相关性。结果：PCI术后发生无复流现象的患者共79例（19.9%）,其中SYNTAX评分高分组无复流发生率显著高于低分组。多元Logistic回归分析显示,年龄≥55岁（OR=2.46,95%CI=1.72～3.41;P〈0.001）、入院前服用β阻滞剂（OR=0.62,95%CI=0.41～0.92;P=0.021）、术前Killip分级（4级,OR=3.78,95%CI=2.14～6.48;P〈0.001）、再灌注时间（≥2h,OR=1.37,95%CI=1.02～1.79;P=0.036）、及SYNTAX评分≥15.75（OR=1.16,95%CI=1.01～2.45;P〈0.001）是直接PCI术无复流现象的独立预测因素。结论：STEMI患者急诊PCI前通过冠状动脉造影获得的SYNTAX评分对于预测STEMI患者PCI后无复流现象并进行危险分层具有一定参考价值。     

老年急性心肌梗死患者直接PCI的治疗评价

目的观察直接经皮冠状动脉介入治疗(PCI)对高龄ST段抬高的急性心肌梗死(STEMI)患者治疗的安全性、可行性及治疗现状。方法62例急性STEMI患者分成两组(≥70岁和<70岁)并予梗死相关血管(IRA)给予直接PCI治疗。比较各组患者心血管事件的发生。结果≥70岁组与<70岁组血管再通率、术中及术后24h内死亡和恶性心律失常及心源性休克不良心血管事件的发生及两组患者接受直接PCI治疗的比例差异无显著性。结论年龄≥70岁的STEMI患者可以安全接受直接PCI治疗,并且有较好疗效。     

Prognosis and high-risk complication identification in unselected patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention

Abstract

Aims: The aim of this study was to evaluate treatment with primary percutaneous coronary intervention (PCI) in unselected patients with ST-segment elevation myocardial infarction (STEMI). Methods: We registered complication and mortality rates in all patients with STEMI admitted for primary PCI at a high-volume center over a two-year period (2004 to 2006). Results: We included 1022 consecutive patients (mean age 64 years; 69% men). In-hospital and one-year mortality were 8% and 12%, respectively. Cardiac arrest, cardiogenic shock, left ventricular ejection fraction ≤40% and atrioventricular block significantly predicted increased one-year mortality in univariate analysis (P < 0.001 for all) and were considered high-risk complications. 65% of patients had no high-risk complications. One-year mortality for patients without high-risk complications was 4% compared with 28% for those with high-risk complications (P < 0.001). Conclusion: Unselected patients with STEMI treated with primary PCI have mortality rates corresponding to those reported in randomized clinical studies including transport of patients. Mortality is strongly related to high-risk complications developed during admission. Thus, patients with high-risk complications should receive special attention. The majority of patients (65%) without high-risk complications have an excellent short- and long-term prognosis following primary PCI.     

Histopathology of aspirated thrombus and its association with ST‐segment recovery in patients undergoing primary percutaneous coronary intervention with routine thrombus aspiration

Background : In patients with ST‐segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) with thrombus aspiration, the histopathology of aspirated thrombus was previously related to long‐term mortality. In this study, we sought to investigate the association between histopathology of aspirated thrombus and ST‐segment recovery, a marker of microvascular dysfunction, immediately at the end of the PCI procedure. Methods : We included 892 STEMI patients who underwent primary PCI with routine thrombus aspiration and for whom combined data on histopathology of aspirated thrombus and ST‐segment recovery were available. Patients were categorized according to histopathology of aspirated thrombus: fresh only (<1 day), older (>1 day), or no material aspirated. ST‐segment recovery was defined as incomplete if <50%. Results : Incomplete ST‐segment recovery occurred in 134 of 363 patients (37%) with fresh thrombus, in 104 of 238 patients (44%) with older thrombus, and in 142 of 291 patients (49%) with no material. Unadjusted odds ratios for incomplete ST‐segment recovery of patients with older thrombus and no material, when compared with patients with fresh thrombus, were 1.33 (95% CI, 0.95–1.85; P = 0.097) and 1.63 (95% CI 1.19–2.23; P = 0.002), respectively. Both associations were unchanged after multivariable adjustment for clinical predictors of ST‐segment recovery. ST‐segment recovery was a strong predictor of long‐term mortality, independent of the histopathology of aspirated thrombus. Conclusions : This study shows that ST‐segment recovery immediately at the end of the PCI procedure was a significant prognosticator, independent of the histopathology of aspirated thrombus. We found that the histopathology of aspirated thrombus (fresh, older, no material) was associated with ST‐segment recovery in STEMI patients undergoing primary PCI with thrombus aspiration. © 2010 Wiley‐Liss, Inc.     

老年急性心肌梗死患者急诊经皮冠状动脉介入治疗术中无复流临床影响因素分析

目的探讨老年急性ST段抬高心肌梗死(ST-segment elevation acute myocardial infarction,STEAMI)患者行急诊经皮冠状动脉介入治疗(PCI)术中发生无复流的临床因素。方法因STEAMI行急诊PCI治疗老年患者68例,分为正常复流组(54例)和无复流组(14例),通过比较2组患者的临床资料来阐明老年STEAMI患者无复流发生的相关影响因素。结果行急诊PCI后无复流发生率为20.6%(14/68),无复流组与正常复流组相比,2组之间入院收缩压(SBP)、2型糖尿病患病数、发病-再灌注时间、球囊扩张次数和靶血管植入支架数量差异均有统计学意义(P0.05);经多因素Logistic回归分析显示入院SBP100 mmHg、合并糖尿病、球囊扩张次数和发病-再灌注时间是老年患者急诊PCI术后无复流发生的危险因素。结论老年STEAMI患者行急诊PCI后无复流发生与入院SBP100 mmHg、合并糖尿病、球囊扩张次数及发病-再灌注时间等临床因素具有相关性。     

Relation of troponin T release kinetics to long-term clinical outcome in patients with acute ST segment elevation myocardial infarction treated with a percutaneous intervention.

The purpose of this study was to determine the relation of troponin T release kinetics to long-term clinical outcome in patients with an acute ST segment elevation myocardial infarction treated with a primary percutaneous intervention. One hundred and four patients with typical ischemic chest pain and > 1.5 mm ST segment elevation in > 2 contiguous leads underwent primary stenting (n = 60) or primary percutaneous transluminal coronary angioplasty (n = 44). Serum troponin T concentrations were obtained prior to and serially postintervention for 72 hr. Mean time to peak serum troponin T concentration was significantly longer in patients with cardiac death (P = 0.02), reinfarction (P = 0.007), target lesion reintervention (P = 0.03), and the composite of these events (13.2 +/- 5.3 vs. 9.3 +/- 4.0 hr; P < 0.0005). Multivariate analysis identified age, Killip class > 2, and time to peak serum troponin T concentration as independent predictors of long-term cardiac event-free survival. Thus, time to peak serum troponin T concentration independently predicts long-term cardiac event-free survival in patients with acute ST segment elevation myocardial infarction treated with a primary percutaneous intervention.