急性心肌梗死的择期介入治疗

急性心肌梗死（AMI）治疗的首要目标是早期、完全、持续的开通梗死相关动脉（IRA），恢复心肌的组织灌注。急性期的溶栓治疗和介入治疗都可以达到上述目的，并且已经被几十项大规模临床试验所证实。对于已经过了急性期时间窗的AMI患者来说，行择期经皮冠状动脉成形术（PCI）虽然在大多数情况下可以开通已经闭塞的冠脉，但是否可使患者真正受益一直存在着争议。本文结合近年来的文献对择期PCI的疗效和时机选择问题作一综述。     

急性 ST 段抬高型心肌梗死患者早期再灌注现状分析

早期再灌注治疗是急性ST段抬高型心肌梗死（STEMI）最重要的治疗措施。再灌注治疗的获益与其启动时间密切相关。2010年中国《急性ST段抬高型心肌梗死诊断和治疗指南》［1］推荐就诊到球囊扩张时间（door_to_baloon time ,D2B time ）应小于90分钟,静脉溶栓时间应小于30分钟。我国STEMI早期再灌注治疗率、治疗有效率均较低［2］。近年来,随着经皮冠状动脉介入治疗（PCI ）技术的普及和静脉溶栓的进一步推广,STEMI早期再灌注的疗效有了一定进步。本文回顾分析647例STEMI患者临床资料,对我中心早期再灌注治疗质量作出评价。     

急性心肌梗死合并脑卒中现状

急性心肌梗死(acute myocardial infarction,AMI)是危及中老年人健康的危重疾病,脑卒中是AMI后罕见但严重的并发症,可进一步增加患者的致残率及死亡率。随着询证医学及再灌注治疗的发展,AMI的预后已经得到了很大的改善,但目前心肌梗死合并脑卒中的发病机制尚未明确,也无规范的预防策略,在临床上仍是一大难题。本文针对AMI合并脑卒中的发病率、危险因素、发病机制、治疗及预后作一综述。     

急诊介入治疗老年急性心肌梗死的疗效及安全性

早期血运重建作为急性心肌梗死(AMI)的标准治疗方法已经被广泛接受,经皮冠状动脉介入治疗(PCI)具有快速开通血管、恢复有效冠状动脉血流的特点,可以明显提高AMI患者的生存率。但是由于老年人冠状动脉复杂病变比例高,冠状动脉钙化和扭曲严重,并且多合并其他疾病,对于有适应证的老年AMI患者的治疗往往过于保守。我院对有适应证的老年AMI患者实施急诊介入治疗,同样取得良好的效果。     

80岁急性心肌梗死患者溶栓成功并行支架安置术1例

再灌注治疗是急件sT段抬高型心肌梗死(STEMI)救治最早最有力的措施[1],我们成功溶栓治疗了一位80岁急性STEMI患者,再通后病程第3日再次ST段抬高,及时实施了冠状动脉支架植入术(PCI).     

急性心肌梗死后并发脑卒中研究的现状

急性心肌梗死(AMI)是当今发达国家和发展中国家的主要死亡原因之一。近年来,药物治疗和血运重建技术的进步极大地提高了AMI患者的存活率,然而,在AMI期间出现了多种并发症,而AMI后的脑卒中死亡率仍然很高。本文讨论了AMI后卒中的发生率、危险因素、可能的机制和处理办法。     

静脉溶栓后选择性PCI对急性心肌梗死患者远期预后的影响

目的探讨静脉溶栓后选择性经皮冠状动脉介入治疗(PCI)对急性心肌梗死(AMI)患者远期预后的影响.方法AMI患者114例,60例仅接受静脉溶栓者为药物组,54例静脉溶栓后平均(9.1±2.4)d行PCI者为手术组,分别于溶栓后及PCI后3、6、12个月随访主要心脏不良事件(MACE)发生情况.随访复查超声心动图,计算左室的整体室壁运动指数和左室射血分数.结果两组住院期间无死亡及心绞痛复发,手术组血管造影和操作成功率均为100%,无操作相关心肌梗死、急诊冠脉搭桥术(CABG).随访期间死亡率、因不稳定型心绞痛或心绞痛复发再次入院者手术组均显著少于药物组(P＜0.05),手术组总的临床终点事件发生率明显低于药物组(P＜0.01).结论 AMI患者静脉溶栓后选择性PCI能改善其远期预后.     

急性心肌梗死的择期介入治疗

急性心肌梗死(AMI)治疗的首要目标是早期、完全、持续的开通梗死相关动脉(IRA),恢复心肌的组织灌注.急性期的溶栓治疗和介入治疗都可以达到上述目的,并且已经被几十项大规模临床试验所证实.对于已经过了急性期时间窗的AMI患者来说,行择期经皮冠状动脉成形术(PCI)虽然在大多数情况下可以开通已经闭塞的冠脉,但是否可使患者真正受益一直存在着争议.本文结合近年来的文献对择期PCI的疗效和时机选择问题作一综述.     

急性ST段抬高型心肌梗死的治疗策略

急性ST段抬高型心肌梗死(STEMI)是由于冠状动脉粥样硬化斑块破裂、激活血小板和凝血过程而使冠状动脉血栓性完全阻塞引发的心肌细胞缺血性坏死。早期、持续、有效的心肌再灌注治疗是STEMI的首选治疗方式,明显缩小心肌梗死(MI)面积,挽救心功能,显著改善临床预后。近年,随着对急性心肌梗死(AMI)再灌注治疗策略认识的提高和辅助治疗手段的不断发展,STEMI 12 h内再灌注治疗成功率提高40%,院内和30 d病死率降低50%。以直接经皮冠状动脉介入治疗(PCI)为主的心肌梗死“绿色通道”已在大多数医院得到建立。同时,药物洗脱支架的临床应用使STEMI 1年无事件生存率明显改善,再次血运重建率显著降低。     

溶栓后转运PCI:降低中国农村急性心肌梗死的病死率

中国农村急性心肌梗死(AMI)的病死率逐年增加,已超越城市。县级医院溶栓和溶栓后转运经皮冠状动脉介入治疗(PCI)是救治ST段抬高型心肌梗死患者的利器。建立区域性基层医院溶栓后转运PCI紧急救治体系,有望降低中国AMI病死率。     

Management of patients after thrombolytic therapy for acute myocardial infarction

The coronary artery thrombus that causes acute myocardial infarction can be lysed, and reperfusion can be achieved, in the first few hours after infarction. However, the infarct vessel will reocclude in 15-30% of patients, and this event is frequently associated with pain, reinfarction, arrhythmias, or death. The risk of reocclusion is greatest in patients with high-grade residual stenosis after thrombolysis. Percutaneous coronary angioplasty may be performed safely after thrombolytic therapy. Angioplasty effectively decreases the degree of residual stenosis, and may thereby reduce the risk of reocclusion and consequent ischemic events. However, a substantial proportion of patients with acute infarction are not suitable candidates for angioplasty. Coronary artery bypass surgery has also been safely performed within several days after thrombolytic therapy. Further studies are needed to determine which patients will benefit most from this aggressive approach to acute myocardial infarction.     

Effect of coronary artery revascularization on in-hospital outcomes and long-term prognoses in acute myocardial infarction patients with prior is-chemic stroke

Objective To investigate whether coronary artery revascularization therapies (CART), including percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), can improve the in-hospital and long-term outcomes for acute myocardial infarction (AMI) patients with prior ischemic stroke (IS). Methods A total of 387 AMI patients with prior IS were enrolled consecutively from January 15, 2005 to December 24, 2011 in this cohort study. All patients were categorized into the CART group (n = 204) or the conservative medications (CM) group (n = 183). In-hospital cardiocerebral events and long-term mortality of the two groups after an average follow-up of 36 months were recorded by Kaplan-Meier survival curves and compared by Logistic regression and the Cox regression model. Results The CART patients were younger (66.5 ± 9.7 years vs. 71.7 ± 9.7 years, P < 0.01), had less non-ST segment elevation myocardial infarction (11.8% vs. 20.8%, P = 0.016) and more multiple-vascular coronary lesions (50% vs. 69.4%, P = 0.031). The hospitalization incidence of cardiocerebral events in the CART group was 9.3% while 26.2% in the CM group (P < 0.01). CART significantly reduced the risk of in-hospital cardiocerebral events by 65% [adjusted odds ratio (OR) = 0.35, 95% CI: 0.13–0.92]. By the end of follow-up, 57 cases (41.6%) died in CM group (n = 137) and 24 cases (12.2%) died in CART group (n = 197). Cox regression indicated that CART decreased the long-term mortality by 72% [adjusted hazard ratio (HR) = 0.28, 95% CI: 0.06–0.46], while categorical analysis indicated no significant difference between PCI and CABG. Conclusions CART has a significant effect on improving the in-hospital and long-term prognoses for AMI patients with prior IS.     

Thrombolytic therapy for acute myocardial infarction in patients with prior coronary bypass surgery: Results from the thrombolysis in myocardial infarction (TIMI) 4 trial

Little data exist on the value of intravenous thrombolysis for acute myocardial infarction in patients with previous coronary bypass surgery. The Thrombolysis In Myocardial Infarction (TIMI) 4 trial was a randomized study comparing tissue plasminogen activator, anistreplase, or a combination in patients with evolving myocardial infarction; patients with previous coronary bypass surgery were not excluded. Coronary angiography was performed 90 minutes and 18–36 hours after randomization, a myocardial perfusion scan was performed at 18–36 hours and predischarge, and a radionuclide ventriculogram was obtained predischarge. Angiographic and clinical outcome variables were determined in patients with and without a history of coronary bypass surgery. A total of 416 patients were randomized and 13 of them had previous bypass surgery; of these, 6 had an occluded vein graft as the infarct-related vessel. The incidence of TIMI grade 3 flow at 90 minutes was lower in patients with previous coronary surgery as compared with controls (42% vs. 49%), and overall patency was significantly lower (50% vs. 77%, p = 0.04). This trend persisted at 18–36 hours after randomization. Furthermore, patients with previous coronary surgery had more thrombus in their infarct-related arteries, especially with occlusion of a vein graft (83% vs. 32%, p=0.04) and higher rates of recurrent ischemia (15% vs. 8%) and recurrent infarction (23% vs. 5%, p=0.03) than controls. Thus, in patients with previous coronary bypass surgery intravenous thrombolysis yields results that are inferior to those achieved in patients without such a history and alternative methods of reperfusion should be considered.     

Risk assessment in patients with acute myocardial infarction treated with thrombolytic therapy

OBJECTIVE: Several noninvasive methods have prognostic information regarding mortality and new coronary events after an acute myocardial infarction (AMI). The practical for clinical decision-making in the immediate postmyocardial infarction (MI) period is, however, less evident. We investigated consecutive patients with AMI treated with thrombolysis to further clarify this issue. DESIGN: A total of 100 patients (27% women) aged 64 +/- 9 years (mean +/- SD) were studied. Risk assessment based on a clinical score system, myocardial perfusion scintigraphy single photon emission computed tomography (SPECT) at rest and during adenosine stress, echocardiography, radionuclide angiography, symptom-limited exercise stress test, and 24-h Holter ECG recording with ST-analysis and analysis of heart rate variability (HRV) were performed 5-8 days after hospital admission. Mortality, nonfatal reinfarction, and the need for revascularization were followed during 12 months. SETTING: A university hospital. RESULTS: A total of 6 patients died, seven had a nonfatal reinfarction, and 23 were revascularized. Inability to perform an exercise test (P = 0.004) and an ejection fraction (EF) < 40% (P = 0.002) were the only parameters separating those who died from the survivors. No method could predict a nonfatal reinfarction. Patients suffering either death or nonfatal reinfarction had a clinical risk assessment score 2 points higher (8.8 vs. 6.7, P = 0.05) than the group without such events. A positive symptom-limited exercise stress test (P = 0.027), ST-depressions on Holter ECG (P = 0.04), and reversibility on myocardial perfusion scintigraphy (P = 0.029) predicted the need for revascularization. CONCLUSION: Risk assessment based on clinical information, exercise stress testing, and an estimate of left ventricular function (e.g. via echocardiography) contribute with prognostic information in thrombolysed MI-patients. Additional noninvasive investigations such as adenosine-SPECT, analysis of HRV, and Holter-monitoring do not add to these commonly available tools in risk stratification of subjects at low to medium risk.     

基层医院急性心肌梗死治疗疗效观察

目的 观察基层医院急性心肌梗死(AMI)早期不同时间溶栓治疗的疗效.方法 124例AMI患者按发病到溶栓时间的不同分为5组:A组不超过2 h,B组2～4 h,C组4～6 h,D组6～12 h,静脉溶栓后观察各组患者冠状动脉再通率、并发症及死亡率.E组:静脉溶栓后冠状动脉不能再通但尚在发病后6 h以内者送外院进行补救性经皮冠状动脉介入治疗(PCI).结果 本组患者冠状动脉再通率总体为67.0%.A、B、C、D组分别是82.1%、75.0%、72.4%、42.9%;总体出血发生率为8.9%,A、B、C、D组分别是0、6.7%、10.3%、17.1%;总体30 d内死亡率为8.9%,A、B、C、D组分别是0、3.1%、6.9%、22.9%,冠状动脉再通率、出血发生率、总体30 d内死亡率比较,A、B、C组差异无统计学意义(P>0.05).但A、B、C组与D组比较差异有统计学意义(P<0.05).E组患者5例中4例冠状动脉再通,成功率80%.结论 AMI静脉溶栓冠状动脉再通率与时间呈负相关,溶栓时间越早冠状动脉再通率越高,出血并发症越少,死亡率越低,进行补救性PCI可使冠状动脉再通率进一步提高.     

Withholding thrombolysis in patients with diabetes mellitus and acute myocardial infarction

The benefits of thrombolytic therapy in a patient with diabetes having a myocardial infarction are now well accepted but this treatment may be withheld inappropriately because of concerns about retinal haemorrhage. We therefore examined whether junior doctors alter their use of thrombolysis for the treatment of acute myocardial infarctions according to the type of diabetic retinopathy present. A questionnaire asking whether thrombolysis would be given to a 50-year-old male smoker with insulin-treated diabetes and an acute anterior MI was shown, with four unlabelled retinal photographs, to all doctors prescribing thrombolytic therapy in a south London teaching hospital and an affiliated district general hospital. In all, 24 medical SHOs, 16 medical registrars/specialist registrars, 3 medical senior registrars, and 23 casualty SHOs were interviewed. Of these 89 % would thrombolyse such a patient with normal fundi, 55 % with background diabetic retinopathy, 54 % if this also involved the macula, and 26 % if they saw proliferative retinopathy. The more senior grades were more aggressive in their approach. As we believe that all patients with an acute anterior myocardial infarction and diabetes should be considered for thrombolysis irrespective of their retinal appearance these results suggest thrombolytic therapy is being withheld inappropriately. Copyright © 1998 John Wiley & Sons, Ltd.     

急性心肌梗死PCI治疗后脑卒中的预防及治疗策略

急性心肌梗死行PCI治疗期间或之后发生缺血性脑卒中是非常少见的事件,但却是灾难性并发症。由于这种事件的发生几率较少,很难拿出标准的治疗方法。文章介绍一些关于PCI围手术期或之后发生缺血性脑卒中的预防及治疗策略,供同道参考。     

Pharmacological management of acute myocardial infarction

The routine medical management of patients with acute myocardial infarction (AMI) has undergone major changes in the last decade. Several large-scale trials have firmly established the effectiveness of thrombolytic therapy, beta blockers, and aspirin in the treatment of AMI. The critical issues include reducing myocardial oxygen demand and restoring adequate blood supply to the ischemic regions of the myocardium. As a result, the ability to intervene in patients with AMI has improved significantly. The purpose of this review is to discuss briefly the results of major trials of primary and secondary pharmacological intervention which had a direct impact on the care of patients with AMI. It concludes with current recommendations for the management of patients with AMI.     

Prognostic importance of previous myocardial infarction in patients receiving thrombolytic therapy for acute infarction

This study evaluated the prognostic significance of reinfarction location by considering the previous site or type of myocardial infarction (MI) among 1601 patients with a history of previous MI who took part in the International (non-Italian) tPA/STK trial and/or the Israeli GUSTO study population. These patients were accordingly divided and hospital mortality was compared by six location groups as follows: acute inferior with previous inferior (8.1% hospital mortality), acute inferior with previous anterior (12.8%), acute anterior with previous inferior (13.3%), acute anterior with previous anterior (11.1%), acute inferior with previous non-Q-wave MI (7.6%), and acute anterior with previous non-Q-wave MI (11.2%) (p = 0.17 for comparison between the six groups). Hospital mortality tended to increase among patients with an anterior reinfarction compared with those with an inferior one (12.1% vs. 9.5%, p = 0.12). Among patients with a reinfarction at a different ECG location from the previous event, mortality tended to be higher compared with patients with two MIs at the same location (13.1% vs. 9.7%, p = 0.07). Recurrent MI following a previous Q-wave MI did not cause a higher mortality compared with a previous non-Q-wave type of MI (11.5% vs. 9.5%, p = 0.24). Among patients sustaining reinfarction, overall mortality did not differ between STK- and tPA-treated patients (11.0% vs. 11.4%, p = NS). In conclusion, the current study identified trends for higher mortality rates in patients with anterior compared with inferior reinfarction, with remote compared with the same ECG location of the two infarctions but not following a previous non-Q-wave compared with Q-wave MI. However, no particular combination of successive MIs location was significantly associated with a higher risk for hospital mortality.     

A pilot study of paramedic-administered,prehospital thrombolysis for acute myocardial infarction

We have implemented a pilot program of supervised paramedic administration of thrombolysis in the field. This program was begun on a small scale by training and equipping one paramedic service of one hospital. Four patients with acute myocardial infarction were rapidly and appropriately treated in the field. We compared these patients with 21 patients who were brought to hospital by ambulance, but treated with thrombolysis conventionally in the emergency department. The patients in the field were treated an average of 86 minutes sooner than the patients treated in the emergency department.