Effect of primary coronary intervention on heart rate variability and left ventricular function in patients with acute myocardial infarction

AIM: Several studies showed that primary percutaneous coronary interventions (PCI) have a favourable impact on left ventricular remodeling and heart rate variability (HRV) both at short- and long-term follow-up in patients suffering an acute myocardial infarction (AMI). However, no previous study investigated the relationship between left ventricular remodeling and changes in HRV during follow-up in AMI patients treated by primary PCI. METHODS: We studied 28 patients with AMI (57+/-8 years, 27 men), treated by PCI within 12 hours of symptom onset. Patients underwent a 24-hour ECG Holter recording and left ventricular ejection fraction (LVEF) echocardiographic assessment before discharge, and at 1-month and 6-month follow-up. HRV was measured in the time- and frequency-domain. RESULTS: A significant improvement of both time- and frequency-domain HRV variables was observed at 1-month and at 6-month follow-up with the most significant changes being found for standard deviation of normal-normal beat intervals (SDNN) in the time-domain (95.5+/-26.1 ms vs 125.5+/-29.8 ms vs 142.8+/-28.8 ms, respectively; P<0.001) and for very low frequency (VLF) amplitude in the frequency-domain (36.7+/-9.8 ms vs 44.1+/-11.1 vs 48.9+/-12.2 ms, respectively; P<0.001). In contrast, compared to basal values, LVEF was substantially unchanged at 1-month and 6-month follow-up (48.8+/-8.5% vs 50.8+/-10% vs 49.6+/-9%, respectively; P=0.25). At 6-month follow-up 11 patients showed an improvement of >or= 5% of LVEF, whereas 17 patients did not show any improvement of LVEF. HRV variables significantly improved in a similar way in these two subgroups both at 1-month and at 6-month follow-up. CONCLUSION: Our data demonstrate that, in AMI patients treated by primary PCI, HRV improves over time, independent of changes in LVEF. The clinical implications of these findings deserve to be addressed in future studies.     

Suppressive effect of nicorandil in ventricular arrhythmias after reperfusion therapy in patients with acute myocardial infarction

BACKGROUND: Nicorandil is reported to inhibit reperfusion arrhythmias in patients with acute myocardial infarction (AMI), but few studies have counted ventricular arrhythmias with Holter electrocardiograms in patients treated with nicorandil following AMI reperfusion. OBJECTIVES: In the present study, we examined the effects of nicorandil by investigating the occurrence of ventricular arrhythmia with Holter electrocardiogram monitoring after percutaneous coronary intervention with acute myocardial infarction. METHODS: Forty patients with AMI who underwent successful percutaneous coronary intervention (PCI) were enrolled and randomly assigned to nicorandil or placebo groups. Following PCI, nicorandil was infused intravenously at 6 mg/hr for 24 hr, with Holter electrocardiogram monitoring. Patients with 100 or more premature ventricular contractions (PVCs) over the 24-hour period were studied. The total number of PVCs, frequency of occurrence of ventricular tachycardia, and clinical characteristics were compared between the two groups. RESULTS: Fourteen patients in the nicorandil group and 12 patients in the placebo group exhibited 100 or more PVCs over the 24-hour period. Lesion characteristics and procedural factors did not differ between the two groups. Fewer PVCs were counted in the nicorandil group than in the placebo group(144.6 +/- 106.5 vs 286.8 +/- 159.1 beats/day, p = 0.012). The frequency of coupled PVCs was lower in the nicorandil group (6.9 +/- 6.9 vs 16.3 +/- 12.8 beats/day, p = 0.025). Although the frequency of ventricular tachycardia did not differ between the two groups, ventricular tachycardia duration was significantly shorter in the nicorandil group (3.73 +/- 2.30 vs 8.34 +/- 7.45 sec, p = 0.03). CONCLUSIONS: Our study indicates nicorandil inhibits ventricular arrhythmias following PCI for patients with AMI. Nicorandil treatment following PCI for AMI is convenient and may reduce the rate of cardiac events by inhibiting ventricular arrhythmias, thereby potentially improving the prognosis.     

Long-term prospective assessment of left ventricular thrombus in anterior wall acute myocardial infarction and implications for a rational approach to embolic risk

To prospectively assess the predictive value of left ventricular (LV) thrombus anatomy for defining the embolic risk after acute myocardial infarction (AMI), 2 comparable groups of patients with a first anterior AMI (group A, 97 thrombolysed patients; group B, 125 patients untreated with antithrombotic drugs [total 222]) underwent prospective serial echocardiography (follow-up 39 +/- 13 months) at different time periods. LV thrombi were detected in 26 patients in group A (27%) and in 71 in group B (57%; p <0.005). Embolism occurred in 12 patients (5.4%; 1 in group A [1%] vs 11% in group B [9%], p < 0.04). At multivariate analysis, thrombus morphologic changes were the most powerful predictor of embolism (p <0.001), followed by protruding shape (p <0.01) and mobility (p <0.02). In patients untreated with thrombolysis, a higher occurrence of thrombus morphologic changes (48% vs 8%, p <0.002) and protruding shape (69% vs 31%, p <0.002) were observed, whereas thrombus mobility was similar in the 2 groups (18% vs 8%, p = NS). Thrombus resolution occurred more frequently in thrombolysed patients (85% vs 56%, p <0.002). Thus, after anterior AMI, changes in LV thrombus anatomy frequently occur and appear the most powerful predictor of embolization. A minor prevalence of thrombus, a more favorable thrombus anatomy, and a higher resolution rate may contribute to reduce embolic risk after thrombolysis.     

Patients Operated for Tetralogy of Fallot and with Non-Sustained Ventricular Tachycardia Have Reduced Heart Rate Variability

BACKGROUND: To study heart rate variability (HRV) in patients operated for tetralogy of Fallot (ToF) and to identify any correlation between HRV and ventricular tachycardia (VT). PATIENTS AND METHODS: We studied HRV in 23 consecutive patients operated for ToF (mean age 14 +/- 6.6 years; mean follow-up 10.6 +/- 5.2 years). Seven patients had non-sustained VT on Holter monitoring. Two control groups were included: 18 healthy subjects and 15 patients operated for other congenital heart disease. There were no differences in age, age at surgery (in the operated groups), follow-up, and mean heart rate between the three groups. Four time and four frequency domain indices were calculated: mean duration of RR intervals, standard deviation of all RR intervals (SD), square root of the mean squared differences of successive RR intervals (r-MSSD), percent of differences between adjacent RR intervals (pNN50), total power (TP), low frequency (LF), high frequency (HF), and LF/HF ratio. RESULTS: HRV indices were identical in the two control groups but were significantly reduced in patients with ToF. Within the patients who had been operated on for ToF, HRV indices were significantly lower in the seven with non-sustained VT than in those without arrhythmias: SD (95 +/- 15 vs. 135 +/- 54 ms; p = 0.01), r-MSSD (26 +/- 9 vs. 45 +/- 20 ms; p = 0.03), pNN50 (4.4 +/- 3.4 vs. 16.5 +/- 12.5%; p = 0.001) and HF (111 +/- 97 vs. 352 +/- 291 ms(2); p = 0.009). Using stepwise multivariate regression analysis, pNN50, age at surgery, degree of pulmonary regurgitation and higher right/left ventricular ratio were independent predictive variables for VT (p < 0.0001; r(2) = 0.85). CONCLUSIONS: ToF patients, particularly those with ventricular arrhythmias, have significant impairment of sympatho-vagal balance, characterized by a reduction of vagal drive.     

Significance of R-on-T phenomenon in early ventricular tachyarrhythmia susceptibility after acute myocardial infarction in the thrombolytic era

We investigated the clinical significance and mechanism of the R-on-T phenomenon in the current thrombolytic era as potential precipitant of R-on-T-induced early ventricular tachyarrhythmias in patients with a thrombolysed acute myocardial infarction. We also examined the role of QT dispersion on ventricular vulnerability and its association with R-on-T-initiated ventricular tachyarrhythmias. A total of 93 patients underwent 24-hour Holter monitoring starting at hospital admission before thrombolysis. Patients were classified into 2 groups: those with (n = 76) and those without (n = 17) reperfusion according to electrocardiographic criteria. All R-on-T ventricular premature complexes (VPCs) and R-on-T-initiated arrhythmic events (ventricular tachycardia [VT], ventricular fibrillation) were counted to estimate arrhythmia density and severity in 2 time periods during and after completion of thrombolysis. Measurements of QT and QTc intervals and dispersion parameters were obtained on the 12-lead electrocardiogram before thrombolysis and at 24 hours in patients with and without R-on-T VTs. Overall, R-on-T VPCs were rarely observed (1.8% of total VPCs over 24 hours), occurring more frequently during than after thrombolysis (at a rate of 8 vs 0.6 VPCs/hour, p = NS) and at a higher rate during thrombolysis in nonreperfused than in perfused patients (15 vs 8/hour, p = NS). Three VF episodes were observed in 1 reperfused patient, and all were R-on-T initiated. Episodes of nonsustained R-on-T VTs (3.3% of total VTs over 24 hours) appeared more frequent during than after thrombolysis (at a rate of 0.8 vs 0.05 VPCs/ hour, p = NS), and compared with non-R-on-T VTs they were significantly faster (374 +/- 56 ms vs 411 +/- 69 ms; p < 0.05), with a trend toward longer duration. Our findings indicate that R-on-T VPCs and R-on-T VTs are early rare features in acute myocardial infarction, and do not serve as triggers of severe ventricular tachyarrhythmia. The study of ventricular repolarization did not elicit an identifiable risk factor of R-on-T VT susceptibility.     

Randomized early versus late abciximab in acute myocardial infarction treated with primary coronary intervention (RELAx-AMI Trial).

OBJECTIVES: This prospective randomized trial evaluates the impact of early abciximab administration on angiographic and left ventricular function parameters. BACKGROUND: Glycoprotein IIb/IIIa inhibitors improve myocardial reperfusion in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI), but optimal timing of administration remains unclear. METHODS: Two-hundred ten consecutive patients with first AMI undergoing primary PCI were randomized to abciximab administration either in the emergency room (early group: 105 patients) or in the catheterization laboratory, after coronary angiography (late group: 105 patients). Primary end points were initial Thrombolysis In Myocardial Infarction (TIMI) flow grade, corrected TIMI frame count (cTFC), and myocardial blush grade (MBG), as well as left ventricular function recovery as assessed by serial echocardiographic evaluations. RESULTS: Angiographic pre-PCI analysis showed a significantly better initial TIMI flow grade 3 (24% vs. 10%; p = 0.01), cTFC (78 +/- 30 frames vs. 92 +/- 21 frames; p = 0.001), and MBG 2 or 3 (15% vs. 6%; p = 0.02) favoring the early group. Consistently, post-PCI tissue perfusion parameters were significantly improved in the early group, as assessed by 60-min ST-segment reduction > or =70% (50% vs. 35%; p = 0.03) and MBG 2 or 3 (79% vs. 58%; p = 0.001). Left ventricular function recovery at 1 month was significantly greater in the early group (mean gain ejection fraction 8 +/- 7% vs. 6 +/- 7%, p = 0.02; mean gain wall motion score index 0.4 +/- 0.3 vs. 0.3 +/- 0.3, p = 0.03). CONCLUSIONS: In patients with AMI treated with primary PCI, early abciximab administration improves pre-PCI angiographic findings, post-PCI tissue perfusion, and 1-month left ventricular function recovery, possibly by starting early recanalization of the infarct-related artery.     

Primary versus rescue percutaneous coronary intervention in patients with acute myocardial infarction

OBJECTIVE: To compare angiographic and clinical outcomes of patients with acute myocardial infarction (AMI) who underwent primary percutaneous coronary intervention (PCI) versus rescue PCI following failed thrombolysis. BACKGROUND: Patients presenting with AMI are treated either with primary PCI or with thrombolysis. When thrombolysis fails, rescue PCI is performed. METHODS AND RESULTS: We compared the outcome of 105 consecutive patients with AMI who underwent either primary PCI (60 patients) or rescue PCI (45 patients) between January 1997 and January 1999. The patients were followed for up to 6 months. Time delay to reperfusion was significantly longer in the rescue PCI group (354 vs. 189 min; p < 0.001). The majority of patients received a stent (93%). Glycoprotein (GP) IIb/IIIa inhibitors were used in 53% of patients in the primary PCI group and in 22% in the rescue group. TIMI grade 3 flow was achieved in 93.3% of patients in the primary PCI group and in 88.8% in the rescue group (p = 0.08). Post-procedure ejection fraction was 53% in the primary PCI group and 47% in the rescue group (p = 0.014). A composite endpoint of death, recurrent MI, repeat PCI, coronary artery bypass grafting (CABG) and recurrent angina at 6 months occurred in 35% of the patients in the primary PCI group and 26.7% in the rescue group (p = 0.36). CONCLUSION: Despite a significant delay to reperfusion and a lower immediate post-procedure ejection fraction, the clinical outcome of patients treated with rescue PCI following failed thrombolysis appears to be similar to that of patients treated with primary PCI at 6 months.     

Thrombolysis significantly reduces transient myocardial ischaemia following first acute myocardial infarction.

In order to investigate whether thrombolysis affects residual myocardial ischaemia, we prospectively performed a predischarge maximal exercise test and early out-of-hospital ambulatory ST segment monitoring in 123 consecutive men surviving a first acute myocardial infarction (AMI). Seventy-four patients fulfilled our criteria for thrombolysis, but only the last 35 patients included received thrombolytic therapy. As thrombolysis was not available in our Department at the start of the study, the first 39 patients included were conservatively treated (controls). No significant differences in baseline clinical characteristics were found between the two groups. In-hospital atrial fibrillation and digoxin therapy was more prevalent in controls (P less than 0.05). During exercise, thrombolysed patients reached a higher maximal work capacity compared with controls: 160 +/- 41 vs 139 +/- 34 W (P less than 0.02). Thrombolysis resulted in a non-significant reduction in exercise-induced ST segment depression: prevalence 43% vs 62% in controls. However, during ambulatory monitoring the duration of transient myocardial ischaemia was significantly reduced in thrombolysed patients: 322 min vs 1144 min in controls (P less than 0.05). Thrombolysed patients reached a higher heart rate during transient ischaemic episodes: 114 +/- 17 vs 93 +/- 11 b.min-1 in controls (P less than 0.001). In conclusion, thrombolytic therapy administered for a first AMI significantly reduces the burden of transient myocardial ischaemia. This may explain the improvement in myocardial function during physical activities, which was also observed in this study.     

Effect of thrombolytic therapy on the prevalence of ventricular late potentials in patients after myocardial infraction

Sudden cardiac death is one of the most important problems of modern cardiology. More than 50% of these deaths are caused by ventricular arrhythmias. It has been known for twenty years that ventricular late potentials (LP) might be the substrate for serious ventricular arrhythmias and prevalence of LP correlates closely, among the others, with myocardium necrosis. The purpose of the study was to assess the influence of applied therapy in acute phase of myocardial infarction on LP presence, evaluation of relationship between the degree of left ventricular LV (V) myocardium damage and LP occurrence and assessment if LP can be non-invasive reperfusion markers. 120 consecutive patients (20 women, 100 men, mean age 53.3) with first acute myocardial infarction (AMI) treated either with thrombolytic or non-thrombolytic therapy were enrolled into the study. The patients were divided into three groups. Group IA--patients treated with thrombolysis with non-invasive features of reperfusion (n = 30), group IB--patients treated with thrombolysis, without reperfusion features (n = 31) and group II--patients treated with non-thrombolytic therapy. Within 24 hours of admission signal-averaged ECG was recorded (before and after treatment) and 24-hour ECG monitoring and echocardiography were performed. The examinations were repeated before discharge (approximately 21 days after AMI). All patients were followed up for one year. The prevalence of LP was 16.7% in the group IA, 48.4% in the group IB and 57.6% in the group II (p < 0.001). LVEF was 48.9% in the group IA, 42% in the group IB and 43.9% in the group II (I vs IB vs II p < 0.001). Significant changes of LP parameters before and after thrombolysis were observed only in the group 1A (in 40% of patients) (tQRS--122.4 +/- 6.1 msec vs 104.1 +/- 7.1 msec p < 0.001, LAS--49.8 +/- 4.8 msec vs 30.7 +/- 4.7 msec p < 0.001, RMS--13.6 +/- 4.4 uV vs 29.1 +/- 8.3 uV p < 0.001). There was no statistical significance in ventricular arrhythmia assessment but there was marked correlation with LP occurrence in all groups. 1-year mortality rate was 6.7% in group IA, 12.9% in group IB and 8.5% in group II (NS). CONCLUSIONS: Successful thrombolysis significantly reduces LP incidence in the late phase of myocardial infarction. LVEF correlates negatively with LP presence. LP presence in the first day of AMI may predict sudden cardiac death. LP occurrence can be significant non-invasive reperfusion markers.     

Effect of distal protection device on the microvascular integrity in acute myocardial infarction during primary percutaneous coronary intervention.

BACKGROUND: The use of a distal protection device during primary percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) may preserve the microvascular integrity of the myocardium. METHODS AND RESULTS: A total of 58 consecutive patients with AMI, who had undergone primary PCI within 24 h after onset, were enrolled (30 patients with the PercuSurge GuardWire System, 28 without). The coronary flow velocity reserve was not different between the 2 groups. In patients with a distal protection device, the post-PCI Thrombolysis In Myocardial Infarction myocardial perfusion grades (TMP) were more favorable (TMP 0/1: 13.3%, TMP 2: 23.3%, TMP 3: 63.4% vs TMP 0/1: 35.7%, TMP 2: 35.7%, TMP 3: 28.6%, p=0.023). These patients also exhibited lower basal and hyperemic microvascular resistance index levels (4.33+/-2.22 vs 5.55+/-2.36 mmHg . cm(-1) . s, p=0.047; 2.39+/-1.40 vs 3.14+/-1.36 mmHg . cm(-1) . s, p=0.045, respectively), and longer basal diastolic deceleration time (679+/-273 vs 519+/-289 ms, p=0.035) after PCI. CONCLUSION: Distal protection with the PercuSurge GuardWire system may effectively preserve the microvascular integrity of the myocardium during primary PCI in AMI patients.     

Reperfusion arrhythmias: are they only a marker of epicardial reperfusion or continuing myocardial ischemia after acute myocardial infarction?

Reperfusion arrhythmias are associated with epicardial reperfusion but may also be a sign of vascular reperfusion injury which can be seen as no-reflow phenomenon on coronary angiography and predicts in-hospital complications and recovery of left ventricular (LV) function. No-reflow phenomenon (thrombolysis in myocardial infarction [TIMI] 相似文献   

Implications of abnormal right ventricular thallium uptake in acute myocardial infarction

The correlates of abnormal right ventricular (RV) thallium uptake were examined in 116 patients with documented acute myocardial infarction (AMI) who underwent predischarge thallium-201 scintigraphy at rest, radionuclide angiography and 24-hour ambulatory electrocardiography. The patients were separated into 2 groups: patients group 1 (n = 31) had increased RV thallium uptake and those in group 2 (n = 85) had no such uptake. The 2 groups were comparable in age, type and site of AMI, peak creatine kinase level, systolic blood pressure and heart rate. However, compared with group 2, group 1 had a lower mean left ventricular (LV) ejection fraction (33 +/- 15% vs 39 +/- 14%, p less than 0.05), higher prevalence of increased lung thallium uptake (45% vs 22%, p less than 0.02), more extensive LV perfusion defects (4.4 +/- 2.9 vs 3.0 +/- 3.0 segments, p less than 0.03) and more complex ventricular arrhythmias (55% vs 35%, p less than 0.05). At a mean follow-up of 6 months, 17 patients (8 in group 1 and 9 in group 2) died from cardiac causes. Actuarial life-table analysis showed that the survival rate was better in group 2 than in group 1 (Mantel-Cox statistics = 4.62, p = 0.03). Thus, patients with AMI and abnormal RV thallium uptake have worse LV function, more complex ventricular arrhythmias and worse prognosis.     

Impact of intravenous beta-blockade before primary angioplasty on survival in patients undergoing mechanical reperfusion therapy for acute myocardial infarction

OBJECTIVES: We sought to examine the effect of intravenous beta-blockers administered before primary percutaneous coronary intervention (PCI) on survival and myocardial recovery after acute myocardial infarction (AMI). BACKGROUND: Studies of primary PCI but not thrombolysis have suggested that beta-blocker administration before reperfusion may enhance survival. Whether oral beta-blocker use before admission modulates this effect is unknown. METHODS: The Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial randomized 2082 AMI patients to either stenting or balloon angioplasty, each +/- abciximab. In accordance with the protocol, intravenous beta-blockers were administered before PCI in the absence of contraindications. RESULTS: A total of 1136 patients (54.5%, BB+ group) received beta-blockers before PCI, whereas 946 (45.5%, BB- group) did not. The 30-day mortality was significantly lower in the BB+ group than in the BB- group (1.5% vs. 2.8%, p = 0.03), an effect entirely limited to patients who had not been receiving beta-blockers before admission (1.2% vs. 2.9%, p = 0.007). In contrast, no survival benefit with pre-procedural beta-blockers was observed in patients receiving beta-blockers at home (3.3% vs. 1.9%, respectively, p = 0.47). By multivariate analysis, pre-procedural beta-blocker use was an independent predictor of lower 30-day mortality among patients without previous beta-blocker therapy (relative risk = 0.38 [95% confidence interval 0.17 to 0.87], p = 0.02). The improvement in left ventricular ejection fraction from baseline to seven months was also greater after intravenous beta-blockers (3.8% vs. 1.3%, p = 0.01), an effect limited to patients not receiving oral beta-blockers before admission. CONCLUSIONS: In patients with AMI undergoing primary PCI, myocardial recovery is enhanced and 30-day mortality is reduced with pre-procedural intravenous beta-blockade, effects confined to patients untreated with oral beta-blocker medication before admission.     

Thrombolysis increases the risk of free wall rupture in patients with acute myocardial infarction undergoing percutaneous coronary intervention

In spite of the progress made in acute angiographic evaluation and obtaining durable reperfusion of acute myocardial infarction (AMI) in the past two decades, cardiac free wall rupture (FWR) is still one of the causes of mortality following AMI. In this study, we evaluated the role of thrombolysis in the risk of FWR in AMI patients treated with acute percutaneous coronary intervention (PCI). Among 3,786 consecutive AMI patients seen between 1985 and 2003, 3,066 patients were treated by primary PCI or rescue PCI, with or without additional thrombolysis. FWR occurred in 24 of 3,066 patients (0.8%) treated by PCI; female gender (1.4% vs 0.6%, P=0.001), age >75 years, (1.4% vs 0.6%, P=0.001) left main coronary artery (LMCA)-related infarction, (4.5% vs all other arteries, P=0.015), and thrombolytic use (3.1% vs 0.4%, P<0.001) were all associated with higher rates of FWR by univariate analysis. In patients treated with PCI and thrombolysis, FWR occurred in 2.7% with optimal PCI results but in only 4.9% if PCI was unsuccessful (P=NS). The incidence of FWR in patients with optimal PCI without thrombolysis was 0.4% (P<0.001). Multivariable analysis identified thrombolytic use (odds ratio [OR]: 8.49, 95% confidence interval [CI]: 3.66-19.7, P<0.001), LMCA-related infarction (OR: 7.06, 95% CI: 1.89-26.4, P=0.004), and female gender (OR: 3.02, 95% CI: 1.27-7.21, P=0.013) as independent predictors of FWR. Thrombolysis is one of the contributing causes of FWR in AMI patients undergoing PCI, even when PCI is successful.     

粒细胞集落刺激因子动员自体外周血干细胞移植治疗急性心肌梗死的临床研究

目的观察经皮经腔冠状动脉内移植自体外周血干细胞(PBSC)治疗急性心肌梗死(AMI)的疗效。方法自2003年11月至2005年1月共入选AMI患者70例,随机分为干细胞移植组和对照组,两组均为35例。干细胞治疗组在常规AMI治疗(药物与介入治疗)基础上应用粒细胞集落刺激因子(GCSF)皮下注射动员自体骨髄干细胞,连用5天,第6天分离外周血干细胞悬液,将采集后的干细胞悬液经OVERTHEWIRE球囊导管中心腔注入梗死相关动脉(IRA),进行外周血干细胞移植;对照组经AMI常规方法(药物与介入)治疗。在外周血干细胞动员、采集及经冠状动脉回输过程中观察其不良反应。两组患者在移植前及移植后6个月应用超声心动图评价左室形态及心功能变化,室壁节段性运动积分;比较两组患者生存率及心脏事件发生率。结果6个月时干细胞移植组心脏收缩末容积(ESV)明显减小[(63.8±23.9)ML比(52.6±20.3)ML,P=0.01],舒张末容积(EDV)无显著性变化[(134.2±36.7)ML比(119.2±30.3)ML,P=0.07];左室射血分数(LVEF)显著增高[(50.0±8.2)%比(57.1±7.8)%,P<0.001];左室壁节段性运动积分指数(WMSI)明显减低[(1.219±0.190)比(1.101±0.118),P<0.001]。对照组介入术前及术后6个月随访ESV、EDV、LVEF及WMSI均无统计学差异(P=0.490、0.259、0.117、0.395)。两组术后6个月生存率及心脏事件发生率无统计学差异。不良反应:在PBSC动员、分离、采集及回输中总的不良反应共25例次,其中动员时不良反应占37.1%(13/35),分离和采集中的不良反应占14.3%(5/35),经冠状动脉回输过程中出现的不良反应占20.0%(7/35)。结论经皮经腔冠状动脉内移植自体PBSC治疗AMI可以在近期有效地减少心肌梗死缺血面积,减轻左室重构,改善心功能。     

Effects of a distal protection device during primary stenting in patients with acute anterior myocardial infarction.

BACKGROUND: The angiographic no-reflow phenomenon is an adverse prognostic factor in patients with acute myocardial infarction (AMI). The aim of the present study was to evaluate the effects of an occlusive balloon type distal protection device (PercuSurge GuardWire: GW) during primary stenting in patients with anterior AMI. METHODS AND RESULTS: The GW group included 42 patients treated by primary stenting with GW protection and the control group included 30 patients treated by primary stenting after thrombectomy without distal protection. Left ventricular (LV) function was measured and compared by left ventriculography obtained soon after percutaneous coronary intervention (PCI) and 3 weeks after onset. The corrected TIMI frame count values were lower in the GW group than in the control group (27.5+/-2.3 vs 35.1 +/-2.5, p=0.030). The number of patients with myocardial blush grade 3 after PCI was higher in the GW group than in the control group (45.7 vs 20.0%, p=0.029). Peak concentration of creatine kinase myocardial fraction was lower in the GW group than in the control group (326.6+/-41.5 vs 454.9+/-46.2 mg/dl, p=0.043). GW patients showed greater improvement at 3 weeks after PCI in terms of LV ejection fraction (+4.6+/-1.2 vs -1.1+/-1.5, p=0.004), LV end-systolic volume index (+0.5+/-2.4 vs +9.0+/-2.7, p=0.023), and regional wall motion abnormalities (-2.03+/-0.14 vs -2.51+/-0.14, p=0.018). CONCLUSION: Primary stenting with GW protection can restore epicardial coronary flow and myocardial perfusion, and also preserve LV function in anterior AMI.     

急性心肌梗死再灌注心律失常不增加心肌损伤

目的探讨急性心肌梗死（AMI）患者PCI再灌注心律失常的临床意义。方法回顾性分析近年在我院接受直接PCI且成功开通梗死相关血管（IRA）的AMI患者228例。将其中开通IRA后数分钟内发生心肌缺血再灌注损伤（MIRI）的119例患者（MIRI组）分为3个亚组,即严重心动过缓和低血压（缓慢性心律失常组）、需电复律的严重室性心律失常（快速性心律失常组）和IRA前向血流≤TIMI2级且除外急性闭塞（无复流组）。结果（1）临床和造影资料：与无MIRI组相比,MIRI组缺血时间短,梗死前心绞痛所占比例低,多支血管病变、下壁梗死、右冠状动脉IRA、PCI前IRA血流TIM10级和肾功能不全所占比例高,住院病死率较高（13．4％比4．6％,P=0．021）。（2）血清心肌酶水平：缓慢性心律失常组肌酸激酶（OK）峰值中位数显著低于无MIRI组（20LOIU／L比2521IU／L,P=0．039）,肌酸激酶同工酶（CK．MB）峰值中位数有低于无MIRI组的趋势（98IU／L比142IU／L,P=0．091）;快速性心律失常组CK峰值中位数（2317IU／L）和CK-MB峰值中位数（134IU／L）与无MIRI组相比差异无统计学意义（P=0．627,0．500）;无复流组CK峰值中位数（4573IU／L）和CK-MB峰值中位数（338IU／L）均显著高于无MIRI组（P均=0．000）。（3）超声心功能：无复流组左心室射血分数显著低于无MIRI组（38．7％±8．3％比51．2％±8．1％,P=0．000）,左心室舒张末期容积显著大于快速性心律失常组[（135±32）ml比（105±19）ml,P=0．029],左心室收缩末期容积显著大于无MIRI组[（82±33）ml比（54±24）ml,P=0．008]和缓慢性心律失常组[（56±19）ml,P=0．025]。结论再灌注心律失常可能提示梗死区存活心肌多,而且不增加心肌损伤;无复流增加心肌损伤,导致永久的心功能障碍。     

How does delaying treatment affect the long-term prognosis for patients with acute myocardial infarction treated with primary coronary angioplasty?

BACKGROUND: The benefit of thrombolysis in patients with acute myocardial infarction (AMI) strongly depends on the time from the onset of symptoms to the initiation of treatment. For AMI patients treated with percutaneous coronary interventions (PCI) this delay of treatment seems to be important only up to a certain time level. AIM: To assess the effects of time to treatment of AMI with PCI on the short- and long-term prognosis. METHODS: We followed 339 consecutive AMI patients treated with PCI from 1995 to 1999 in our centre. Patients were divided into five groups according to the time to treatment and ischaemic time (time from symptom onset to reperfusion). RESULTS: Time to treatment <90 min was achieved in 35 (10.5%) patients; 91-210 min in 105 (31%); 211-330 min in 72 (21%); 331-690 min in 74 (22%); and >691 min in 53 (15.5%) patients. According to ischaemic time, the patients were divided into groups: <2 h, 2-4 h, 4-6 h, 6-12 h, and >12 h. The ejection fraction of the left ventricle 3-5 days after AMI was 50%, 51%, 45%, 40%, and 46%, and the 30 day mortality - 5.7%, 2.9%, 11.1%, 10.8%, and 11.3%, respectively. Compared with patients treated later, patients with time to treatment <3.5 h had a significantly higher rate of TIMI 3 flow (93.6% vs 83.9%, p=0.007), lower 30-day mortality (3.6% vs 11.1%, p=0.012), lower 3-year mortality (8.6% vs 19.1%, p=0.003), lower frequency of heart failure during hospitalisation (11.4% vs 28.1%, p<0.001) as well as lower maximal level of creatine kinase (32+/-29 vs 44+/-39 micro kat/l, p=0.005). CONCLUSIONS: The success rate of primary PCI to achieve normal flow in an infarct-related artery is high, but it decreases when treatment is started later than 3,5 h from AMI onset. The short-term and long-term mortality as well as the incidence of heart failure during the acute phase of MI are the lowest when PCI is started within 3,5 h from the onset of symptoms.     

Relationship between peripheral monocytosis and nonrecovery of left ventricular function in patients with left ventricular dysfunction complicated with acute myocardial infarction.

BACKGROUND: Although ischemic heart failure is a major cause of mortality after acute myocardial infarction (AMI), the factors that may influence the nonrecovery of left ventricular function (LVF) after an AMI are still unclear. The aim of this study was to identify predictors of nonrecovery of LVF in patients with left ventricular (LV) dysfunction (defined as an echocardiographic ejection fraction (EF)<40%) complicated with AMI who undergo successful primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: LVF recovery was defined as improvement of LVEF more than 10% compared with baseline LVEF at follow-up. One hundred and eight patients with LV dysfunction after AMI were divided into 2 groups according to the LVF recovery at follow-up: patients with LVF recovery (n=64) vs patients without LVF recovery (n=44). The follow-up LVEF was measured at 8+/-4 months after PCI. Patients without LVF recovery were older (76+/-13 years vs 59+/-14 years, p=0.023) and the baseline peak monocyte count, creatine kinase, and troponin I levels were significantly higher in patients without LVF recovery than in patients with LVF recovery. Delta LVEF (follow-up LVEF-baseline LVEF) correlated with baseline peak monocyte count (r=-0.417, p<0.001), baseline peak creatine kinase (r=-0.269, p=0.005), and baseline peak troponin I levels (r=-0.256, p=0.007). Multivariate analyses showed that baseline peak monocyte count and old age were the independent predictors of nonrecovery of LVF (hazard ratio; 3.38, 95% confidence interval (CI): 1.16-5.43, p=0.012, and hazard ratio; 2.38, 95% CI: 1.09-4.87, p=0.025, respectively). CONCLUSION: Peripheral monocytosis is associated with nonrecovery of LVF in patients with LV dysfunction complicating an AMI who underwent successful primary PCI. These results suggest an important role of monocytes in the expansion of the infarct and the development of chronic ischemic heart failure after reperfusion therapy.     

The potential impact of primary percutaneous coronary intervention on ventricular septal rupture complicating acute myocardial infarction

BACKGROUND: Recent data suggest that the risk of acquired ventricular septal defect (VSD), a complication of acute myocardial infarction (AMI), could be reduced using thrombolytic therapy. There are, however, still no available data regarding the potential impact of primary percutaneous coronary intervention (PCI) on AMI-related VSD in a clinical setting. The purposes of this study were to delineate the incidence and the potential risk factors of AMI-related VSD in the Chinese population, and to determine whether primary PCI could reduce such risk. METHODS AND RESULTS: From May 1993 through March 2003, a total of 1,321 patients with AMI (for < 12 h) underwent primary PCI in our hospital. Of these 1,321 patients, 3 patients (0.23%) developed VSD after undergoing a primary PCI, with a mean (+/- SD) time of occurrence of 25.3 +/- 12.2 h. During the same period, a total of 616 consecutive, unselected patients with early AMI [ie, > 12 h and < or = 7 days] or recent myocardial infarction (MI) [ie, > or = 8 days and < 30 days] who had not received thrombolytic therapy underwent elective PCI. Of these 616 patients, 18 (2.9%) had VSD either on presentation or during hospitalization, with a mean time of occurrence of 71.1 +/- 64.2 h. Clinical variables were utilized to statistically analyze the potential risk factors. Univariate analysis demonstrated that the enrollment variables strongly related to this complication were advanced age, hypertension, nonsmokers, anterior infarction, female gender, and lower body mass index (BMI) [all p < 0.005]. Using multiple stepwise logistic regression analysis, the only variables independently related to VSD were advanced age, female gender, anterior infarction, and low BMI (all p < 0.05). The in-hospital mortality rate was significantly higher in patients with this complication than in patients without this complication (47.6% vs 8.0%; p < 0.0001). The incidence of this complication was significantly lower in patients with AMI who underwent primary PCI than in those with early or recent MI who underwent elective PCI (3.0% vs 0.23%, respectively; p = 0.0001). CONCLUSION: Primary PCI had a striking impact on reducing the incidence of VSD after AMI compared to elective PCI in patients who did not receive thrombolytic therapy. Advanced age, female gender, anterior infarction, and low BMI had potentially increased the risk of this catastrophic complication after AMI in this Chinese population.