昼夜节律对急性ST段抬高型心肌梗死患者院内心血管事件的影响

目的研究昼夜节律对急性ST段抬高型心肌梗死（STEMI）患者院内心血管事件发生率的影响。 方法收集2016年1月至2017年12月就诊的STEMI患者212例,根据发病时间将患者分为上午组（84例）、下午组（64例）及夜间组（64例）,比较三组患者住院期间的主要心血管不良事件（MACE）和次要心血管不良事件发生情况,并采用Logistic回归模型对STEMI患者住院期间MACE的影响因素进行分析。 结果夜间组MACE[20.0%（13/64）、6.0%（5/84）、7.8%（5/64）]及恶性心律失常[18.8%（12/64）、2.4%（2/84）、4.7%（3/64）]发生率均显著高于上午组及下午组（P均<0.017）,而上午组及下午组之间比较,差异均无统计学意义（P均>0.017）。而三组患者间心功能不全、心律失常和出血发生率比较,差异均无统计学意义（χ²=0.696、1.601、2.555,P=0.706、0.449、0.279）。多因素Logistic结果显示夜间发病是STEMI患者住院期间发生MACE的危险因素[OR=3.736,95%CI（1.172,11.902）,P=0.028]。 结论夜间发病会增加STEMI患者院内发生MACE的风险。     

高龄患者急性心肌梗死发作的时间节律与梗塞部位的分析

目的探讨急性心肌梗死(AM I)发作的时间节律的规律性。方法对997例(其中包括412例前壁和423例下壁的AM I患者)的梗塞发生时间、梗塞部位进行分析。结果高龄患者急性心肌梗死的发生率在06∶00到12∶00最高(n=257,占30.78%),而00∶00到06∶00,发生下壁心肌梗死的危险性明显高于其它时间点(n=138/423,32.62%,P<0.01),从06∶00到12∶00,发生前壁心肌梗死的危险性却明显高于其它时间点,(n=156/412,37.86%,P<0.01)。结论急性心肌梗死的发病具有明显的时间节律性,护士应掌握急性心肌梗死发作的时间节律,有针对性的进行监护,提高抢救成功率。     

心肌缺血预适应对急性心肌梗死面积及近期预后的影响

目的 :观察急性心肌梗死前心绞痛发作与梗死范围及近期预后的关系。方法 :选择 178例急性心肌梗死患者 ,根据梗死前 72h以上有无心绞痛 ,分为A组 (有心绞痛 ) 76例 ,B组 (无心绞痛 ) 10 2例。对两组的梗死面积、并发症和病死率进行统计分析。结果 :A组梗死面积小 (两组间有显著差异 ,P <0 0 5 ) ,住院期间严重心律失常、心力衰竭、心原性休克发生率及病死率均低于B组 (两组间有显著差异 ,P <0 0 5 )。结论 :急性心肌梗死前有心绞痛发作对心肌有明显的保护作用     

Association of daylight saving time transitions with incidence and in-hospital mortality of myocardial infarction in Finland

Introduction Circadian rhythm disturbance increases cardiovascular risk but the effects of daylight saving time (DST) transitions on the risk of myocardial infarction (MI) are unclear.

Methods We studied association of DST transitions in 2001–2009 with incidence and in-hospital mortality of MI admissions nationwide in Finland. Incidence rations (IR) of observed incidences on seven days following DST transition were compared to expected incidences.

Results Incidence of MI increased on Wednesday (IR 1.16; CI 1.01–1.34) after spring transition (6298 patients’ cohort). After autumn transition (8161 patients’ cohort), MI incidence decreased on Monday (IR 0.85; CI 0.74–0.97) but increased on Thursday (IR 1.15; CI 1.02–1.30). The overall incidence of MI during the week after each DST transition did not differ from control weeks. Patient age or gender, type of MI or in-hospital mortality were not associated with transitions. Renal insufficiency was more common among MI patients after spring transition (OR 1.81; CI 1.06–3.09; p?p?=?0.007), but more common after autumn transition (OR 1.21; 1.00–1.46; p?Conclusions DST transitions are followed by changes in the temporal pattern but not the overall rate of MI incidence. Comorbidities may modulate the effects DST transitions.

• KEY MESSAGES

• Both spring and autumn daylight saving time transitions changed the temporal occurrence pattern but not the overall incidence of myocardial infarction occurrence on the week following the clock shift.

• The age or gender distribution of patients, ratio of different types of myocardial infarctions or in-hospital mortality were not affected by clock shifts.

• The effect of daylight saving time transitions on MI incidence may be modified by the presence of diabetes.

     

《简明心肌梗死图解》对急性心肌梗死患者再灌注决定时间的影响

目的探讨《简明心肌梗死图解》对急性ST段抬高心肌梗死(STEMI)患者再灌注治疗决定时间的影响。方法将2013年6月至2014年6月期间就诊于首都医科大学大兴医院适合急诊经皮冠状动脉介入治疗(PCI)的急性STEMI患者随机分为常规组和图解组;常规组采用目前临床常用的方法向患者和患者家属交代病情;图解组在常规方法的基础上借助《简明心肌梗死图解》向患者及其亲属进行简明扼要的STEMI医学知识紧急培训,帮助其迅速了解STEMI的发病机制和再灌注治疗的重要性;两组患者均在做出再灌注治疗决定并签署急诊PCI知情同意书后,尽快施行急诊PCI,并收住冠心病监护病房进一步治疗。结果图解组(n=49)患者的再灌注决定时间、进门-首次球囊扩张时间均明显短于常规组(n=50)[(15.1±11.5)min比(25.9±12.9)min,(105.7±28.4)min比(117.1±29.2)min,P均0.05]。结论简明心肌梗死图解可以缩短STEMI患者再灌注治疗决定时间、缩短进门-首次球囊扩张时间。     

心肌梗塞后患者进行非心脏手术的一些问题

本文分析了14例心肌梗塞(MI)后患者进行17次非心脏手术的临床情况.4次在MI后6个月内进行,有1例死亡.13次在MI6个月以后进行,无近期死亡.我们体会到:在MI后6个月内遇有危及生命的外科情况,如胃肠穿孔、肠梗阻等,即使冒一定风险,也应急症手术.有些疾病如胆石症急性发作、上消化道出血等,力争内科治疗缓解病情,于MI半年后择期手术.在MI急性期发现可切除的恶性肿瘤,若情况允许,以尽早施行手术为宜.高龄及心功能不全也为手术危险因素.心肌梗塞后患者必须进行较大的非心脏手术而又有冠脉供血不足时,可考虑先行冠脉旁路手术,再作非心脏手术.     

冠脉内多普勒超声评价倍他乐克对猪急性心肌梗死相关冠脉血流的影响

目的 应用冠脉内多普勒超声评价倍他乐克对猪急性心肌梗死相关冠脉血流的影响。方法 小型家猪8头，先用血管内多普勒超声测定正常状态的左冠回旋支的血流频谱，记录平均峰值流速（APV）、舒张收缩流速比值（DSVR）、冠脉血流储备（CFR），先静脉应用倍他乐克5mg，重复测定上述指标;再通过闭胸法将其近端闭塞，制作急性心肌梗死模型;120min后将冠脉开通，静脉内再次应用倍他乐克5mg，再次测定相关指标，对比其变化。结果 ①应用倍他乐克后，APV逐渐降低，于20min时达最低，30min时恢复，各时间阶段比较有显著性差异（P〈0.01）;DSVR和CFR增加（P〈0.01）;②应用倍他乐克使平均动脉压和心率降低（P〈0.01）。结论 倍他乐克可使冠脉血流减少，同时减轻心脏负荷，增加冠脉血流储备和舒张期供血。     

介入治疗对ST段抬高的急性心肌梗死患者1～5年病死率的影响

目的 探讨介入治疗是否降低首次ST段抬高的急性心肌梗死患者1～5年全因死亡率。方法 对年龄〈75岁首次息性ST段抬高的心肌梗死患者510例进行1～5年临床随访。结果 介入治疗275例（其中急诊介入220例，择期介入55例），非介入治疗235例。介入治疗组全因死亡率3．6％。非介入治疗组全因死亡率19．1％。Kaplan-Meier生存分析显示：介入治疗组1～5年生存率高于非介入治疗组，差异有显著性；Cox回归多因素分析显示：介入治疗与全因死亡独立相关。结论 对75岁以下的ST段抬高的急性心肌梗死患者介入治疗能显著降低1～5年的病死率。     

心肌梗死部位对缺血性二尖瓣反流影响的研究

目的探讨心肌梗死部位和缺血性二尖瓣反流的关系。方法应用超声心动图检测正常人前壁及下壁心肌梗死患者二尖瓣反流程度及左室、二尖瓣装置重构情况。结果下壁心肌梗死患者反流发生率高,程度重;左室和二尖瓣装置重构方面,下壁心肌梗死患者收缩功能更低,收缩末期容积指数更大;二尖瓣瓣叶闭合面积、瓣环面积、后乳头肌与二尖瓣前瓣环的距离的增加更为明显。多元逐步回归分析结果表明前壁和下壁心肌梗死患者的反流主要决定因素也不同。结论下壁心肌梗死较前壁心肌梗死反流更严重,其原因主要在于左室、二尖瓣装置重构的不同。     

Depressed heart rate response to vasodilator stress for myocardial SPECT predicts mortality in patients after myocardial infarction

Background As heart rate (HR) response during vasodilator stress myocardial perfusion studies can be a marker of HR variability, we investigated its prognostic value in patients after myocardial infarction (MI).Methods Subjects were 147 survivors of MI who underwent vasodilator stress thallium-201 scintigraphy. HR response was measured as peak to basal (P/B) ratios during vasodilator infusion. End points for survival analysis were all-cause deaths, non-fatal recurrent MI, and soft events. Results: HR response was significantly depressed in the post-MI patients compared to controls (p<0.0005). HR response correlated to LVEF (r=0.37, p<0.0001) and summed stress scores (r=−0.18, p<0.05), but not with antianginal medication. During 58±30 mo of follow-up, there were 15 deaths, 7 recurrent MI, and 11 soft events. Low HR response, old age, low LVEF, and high difference score were significant univariate risk factors for death. Multivariate analysis identified low HR response (p=0.03), high stress score (p=0.02), and low LVEF (p=0.05) as independent predictors of mortality. The predictive value of HR response was incremental to that offered by other variables (p=0.02). Conclusions HR response, readily attained during vasodilator stress myocardial perfusion studies, may provide useful additional prognostic information in post-MI patients.     

不同年龄急性心肌梗死患者静脉溶栓治疗疗效的比较研究

目的探讨不同年龄组急性心肌梗死(AMI)患者静脉溶栓的疗效。方法比较不同年龄组AMI患者分别经静脉溶栓、一般内科治疗以及经皮冠状动脉介入治疗(PCI)3组心绞痛持续时间、病死率、心力衰竭发生率、梗死血管再通率、净有效率的差异。结果～60、～65、～70、～75岁年龄组间AMI病例静脉溶栓治疗的心绞痛持续时间、再通率、净有效率差异无统计学意义(P>0.05);心绞痛持续时间较一般内科治疗同年龄组短(P<0.01);再通率平均63.24%,较PCI组低(P<0.05)。结论75岁以下AMI病例对静脉溶栓疗效的影响,其差异无统计学意义。故以年龄判定是否施行静脉溶栓治疗不尽合理。     

急性心肌梗死患者急诊与延迟冠状动脉介入治疗后左心功能变化的超声心动图观察

目的应用超声心动图评价冠状动脉介入治疗（PCI）的临床疗效,比较急诊PCI与延迟PCI在改善急性心肌梗死（AMI）患者心功能中的价值。方法选择冠状动脉左前降支（LAD）为“罪犯血管”的AMI患者22例,急诊PCI组13例,延迟PCI组9例。应用双平面Simpson法测量患者术后不同时间段左室收缩功能及心腔内径的改变。结果术后1个月和3个月时两组患者心功能均较术后7d明显改善（P〈0.05）,而左室内径较术后7d缩小（P〈0.05）。术后各阶段两组患者心功能比较差异无统计学意义。结论静脉溶栓后延迟PCI与急诊PCI术后1个月和3个月时均有心功能明显改善。     

Arrhythmia and its risk factors post myocardial infarction:A prospective study

Objectives:To determine the occurrence of arrhythmia and its associated risk factors in the first week after acute myocardial infarction(MI).Methods:A total of 100 patients with acute MI were recruited,who were followed up for one week to determine the occurrence of arrhythmia and its association with electrolyte disturbances,left ventricular ejection fraction(LVEF),and demographic factors.Univariate and multivariate logistic regression was used to identify significant risk factors of arrhythmia.Results:Among 100 cases,arrhythmia was seen in 27 patients.Sinus tachycardia was the commonest,followed by ventricular premature beats and sinus bradycardia.Ejection fraction,serum calcium and magnesium were significantly different between non-arrhythmia and arrhythmia patients(P<0.05).Multivariate logistic regression analysis showed that ejection fraction was an independent significant risk factor of arrhythmia.Patients with ejection fraction>40%had a significantly lower risk of arrhythmia with an adjusted odds ratio of 0.22(95%CI:0.08 to 0.64).Conclusions:Arrhythmia is common in the first week after myocardial infarction.The type of arrhythmia and the type of block may depend on the heart muscles involved during myocardial infarction.Ejection fraction is a risk factor that may affect the occurrence of arrhythmia.     

Epidemiological trends in mortality,event rates and case fatality of acute myocardial infarction from 2004 to 2015: results from the KORA MI registry

AimThis study examines epidemiological trends of acute myocardial infarction (AMI) in Germany from 2004–2015 across different age groups, using data of the population-based KORA myocardial infarction registry.MethodsAnnual age-standardised, age-group- and sex-specific mortality and event rates (incident and recurrent) per 100,000 population as well as 28-day case fatality were calculated from all registered cases of AMI and coronary heart disease deaths in 25–74-year-olds from 2004–2015 and 75–84-year-olds from 2009–2015. Average annual percentage changes (AAPC) were calculated by joinpoint regression. ResultsMortality rates declined considerably among the elderly (75–84 years), in men by –6.0% annually, due to declines of case fatality by –3.0% and incidence rate by 3.4% and in women by –10.0%, driven by declines in incidence (–9.1%) and recurrence rate (–4.9%). Significant mortality declines also occurred in males, 65–74 years of age (AAPC –3.8%). Among the age groups 25–54 years and 55–64 years, there was no substantial decline in mortality, event rates or case fatality except for a decline of incidence rate in 55–64-year-old men (AAPC –1.8%).ConclusionInhomogeneous AMI trends across age-groups indicate progress in prevention and treatment for the population >64 years, while among <55-year-olds, we found no significant trend in AMI morbidity and mortality.

KEY MESSAGES

• Age standardised AMI mortality continued to decline from 2009 to 2015 in the study region.
• Declines in AMI mortality were driven by declines in event rates (both incidence and recurrence rates) and case fatality.
• AMI trends were inconsistent across different age groups with the strongest declines in mortality and event rates among the elderly population (75–84 years of age).

     

The role of exercise testing soon after acute myocardial infarction

Summary

Exercise testing is a readily available form of evaluation following acute myocardial infarction, especially in the early stages of recovery. Care is necessary to exclude bad-risk patients, but 70% of patients can be included. Either a treadmill or bicycle ergometer can be used. The important prognostic variables are left ventricular function indexes, and ventricular arrhythmias.

Résumé

Chez les sujets récemment atteints d'un infarctus du myocarde, l'épreuve ergométrique rípétée permet une bonne estimation du degré de récupération fonctionnelle. Chez certains patients à haut risque, ce type d'investigation est contre-indiqué, mais 70% des sujets peu vent ětre inclus. On utilise de préférence une bicyclette ergomítrique (évent. un tapis roulant). Les paramètres importants, quant au prognostic au long cours, sont les indices fonctionnels du ventricule gauche et l'arythmie ventriculaire.

Zusammenfassung

Die Kontrolle der Übungs- oder Arbeitsbelastung ist eine leicht zugängliche Art der Evaluation des Patienten nach akutem Myokardinfarkt, besonders in den Frtihstadien nach dem Ereignis. Sorgfalt ist nötig zum Ausschluss von Risikopatienten, jedoch können 70% der Patienten auf diese Weise untersucht werden. Als Übungsgerät können sowohl Tretmiihle wie Fahrrad-Ergometer benutzt werden. Die prognostisch wichtigen Variabeln sind die Indizes der Funktion des linken Ventrikels und ventrikuläre Arrhythmien.

Resumen

Las pruebas del ejercicio son un tipo de evaluación fácilmente asequible tras un infarto agudo de miocardio, especialmente en los primeros estadios de la recuperación. Tiene que tenerse cuidado de excluir aquellos pacientes que corren mucho peligro, pero pueden incluirse el 70% de los demas. Puede emplearse un tapiz rodante o una bicicleta ergométrica. Las variables pronosticadoras importantes son los índices de la función ventricular izquierda y las arritmias ventriculares.     

Influence of medical direction on the management of prehospital myocardial infarction

Prehospital management of myocardial infarction was evaluated in two differently structured Emergency Medical Service (EMS) systems in Southern Finland: a physician directed EMS with on-site physician involvement (physician EMS) and an EMS without operational physician involvement with paramedics only (non-physician EMS). The management of 641 consecutive acute ST-elevation myocardial infarction (STEMI) patients between 1997 and 1999 (263 patients in the physician EMS group and 378 patients in non-physician EMS group) were studied. Patients treated in the physician EMS received all necessary medical care including thrombolytic therapy at the scene whereas patients in the non-physician EMS were transported to hospital for definitive treatment after initial care. There were no differences in the demographics of the patients. The delays from onset of pain to initiation of thrombolysis were shorter in the physician EMS-group (124+/-101 min (25-723) versus 196+/-150 min (12-835), p<0.001). In 2% of the patients in the physician EMS group the pain to therapy-time was unknown compared to 27% in the non-physician EMS group (p<0.001). Fifty-two patients (20%) in the physician EMS received thrombolytic therapy after cardiopulmonary resuscitation compared to two patients in the non-physician EMS (p<0.001). Of the resuscitated patients in the physician directed EMS group 60% were discharged from the hospital, and 44% of these had a good neurological recovery. We conclude that a physician directed EMS is able to reduce the pain to therapy delays significantly in STEMI patients and may offer thrombolytic therapy to a wider patient group compared to an EMS without operational medical involvement.     

雷米普利对急性心肌梗死患者的长期抗缺血作用

目的　探讨血管紧张素转换酶抑制剂雷米普利减少心肌梗死后患者心肌缺血及缺血事件的作用。方法　对 4 0例雷米普利组 (治疗组 )和 38例一般治疗组 (对照组 )于出院前 ,出院后 0 .5、1.0年行 2 4小时动态心电图心肌缺血总负荷检测 (TIB) ,并观察缺血相关事件。结果　治疗组TIB在出院后 6个月低于对照组 ,但无统计学差异 (P >0 .0 5 )。出院后 1年 ,治疗组TIB显著低于对照组 (P <0 .0 5 ) ,并且治疗组缺血相关事件亦明显少于对照组 (P <0 .0 5 )。结论　雷米普利对心肌梗死后患者具有长期的抗心肌缺血和减少缺血事件的作用。     

超声心动图评价犬急性心肌梗死早期左心室重构的实验研究

目的 采用超声心动图检测犬急性心肌梗死(AMI)后左心室重构发生时间及6 h内左心室重构变化.方法 对14只健康成年犬麻醉后开胸结扎左冠状动脉左前降支制备AMI模型,成功制备8只AMI模型,超声心动图分别于术前,术后1、2、3、4、5及6 h观察梗死心肌室壁厚度(WIT)、室壁运动积分指数(WMSI)、左心室舒张末期容积(LVEDV)、左心室收缩末期容积(LVESV)、左心室射血分数(LVEF).检查结束后处死实验犬,取梗死区心肌组织行病理学检查.结果 与术前比较,术后1 h实验犬WMSI、LVESV(P<0.01)和LVEDV(P<0.05)增大,LVEF和WIT减小(P<0.01);WMSI术后3、4、5、6 h高于术后1 h(P<0.05);术后4、5、6 h和术后2 h比较,LVEDV和LVESV增高,LVEF降低.病理检查显示:梗死区心肌细胞发生肿胀,肌浆呈颗粒状凝集而分布不均,出现核固缩.结论 犬AMI后1 h即可出现左心室重构,超声心动图可评估AMI后早期左心室重构.     

卡托普利防治急性心肌梗死后左室重塑的作用

目的评价血管紧张素转换酶抑制剂(ACEI)卡托普利防治急性心肌梗死(AMI)后左室重塑(LVR)作用。方法对使用ACEI治疗的26例AMI患者(治疗组)与除常规治疗未用ACEI治疗的26例AMI患者(对照组)6个月后NYHA分级Ⅲ级的心衰症状发生率进行比较。结果治疗组1例发生心力衰竭再住院,对照组6例发生心力衰竭再住院,两组存在显著差异(P<0.05)。结论ACEI防治心肌梗死后左室重塑疗效确切。