肝素缓释支架置入急性心肌梗死患者后的血管再生及心肌功能改善

背景：采用裸金属支架置入治疗心肌梗死可在一定程度上改善心肌功能,但容易出现血栓等情况。目的：分析肝素缓释支架对急性心肌梗死后患者血管再生及心肌功能改善的影响。方法：纳入急性心肌梗死患者87例,其中男47例,女40例,年龄55-81岁,分两组治疗,观察组(n=45)经皮冠状动脉置入肝素缓释支架,对照组(n=42)经皮冠状动脉置入裸金属支架。随访12个月,观察两组血管再生、心肌功能改善及心脏不良事件发生情况。结果与结论：观察组新生血管密度A值、心肌存活面积A值、左心室射血分数均高于对照组(P < 0.05);随访3个月时,观察组有1例出现再次血运重建,1例出现急性复发心肌梗死;对照组有1例患者出现再次血运重建,1例出现急性复发心肌梗死,1例出现心脏性死亡,两组心脏不良反应情况比较差异无显著性意义。表明经皮冠状动脉置入肝素缓释支架治疗急性心肌梗死可有效促进血管再生,改善心肌功能,并具有良好的生物相容性。中国组织工程研究杂志出版内容重点：生物材料;骨生物材料; 口腔生物材料; 纳米材料; 缓释材料; 材料相容性;组织工程     

国产雷帕霉素药物涂层支架置入ST抬高型心肌梗死患者的近期预后

背景：冠状动脉药物涂层支架置入治疗是急性ST段抬高型心肌梗死的最佳治疗方法,但由于老年患者合并危险因素较多,死亡率随着年龄的增加而增高。 目的：观察不同年龄ST段抬高型心肌梗死患者置入国产雷帕霉素药物涂层支架的临床特征及住院期间预后特点。 方法：回顾性分析307例因初发ST段抬高型心肌梗死接受急诊冠状动脉国产雷帕霉素药物涂层支架置入治疗患者的临床资料,根据年龄分为3组,非老年组(< 65岁,n=175)、普通老年组(65-74岁,n=83)、高龄组(≥75岁,n=49),比较3组住院期间的临床特征、病死率及联合心血管事件发生情况。 结果与结论：与非老年组相比,普通老年组、高龄组女性比例较高(P < 0.05),吸烟者较少(P < 0.05),既往高血压病史比例增加(P < 0.05),血红蛋白、总胆固醇、三酰甘油、低密度脂蛋白胆固醇水平降低(P < 0.05)。随着年龄的增长,血清肌酐水平逐渐升高,恶性心律失常发生率与住院期间心源性死亡发生率逐渐增加。与非老年组、普通老年组比较,高龄组心功能Killip分级≥Ⅱ级比例、3支或左主干病变比例较高(P < 0.05),成功再灌注率下降(P < 0.05),急性充血性心力衰竭、联合心血管事件的发生率较高(P < 0.05)。多因素Logistic回归分析显示,年龄是患者住院期间病死率的独立危险因素(P < 0.01)。中国组织工程研究杂志出版内容重点：生物材料;骨生物材料; 口腔生物材料; 纳米材料; 缓释材料; 材料相容性;组织工程全文链接：     

心血管病患者药物涂层支架载入药物的筛选与应用

BACKGROUND: Drug-eluting stents have achieved better treatment outcomes, but late stent thrombosis shakes its status. With the development of drug-eluting stents, loaded drugs are the key to reduce stent thrombosis. OBJECTIVE: To analyze the screening and application of drug-eluting stents. METHODS: A computer-based search was performed for literatures published from 2010 to 2016 in databases of PubMed and WanFang using the keywords of “drug eluting stents; rapamycin (sirolimus); paclitaxel; heparin; zotarolimus; everolimus” in English and Chinese, respectively. According to inclusion and exclusion criteria, 30 eligible literatures were included for analysis. RESULTS AND CONCLUISON: An ideal drug-eluting stent can selectively inhibit vascular smooth muscle and is expected to be anti-coagulated, but makes no effects on vascular endothelial cells or promoting the cell proliferation. Most of the loaded drugs are antithrombotic and anti-proliferative drugs, among which, rapamycin-eluting and paclitaxel-eluting stents are extensively used. Regardless of delaying the proliferation of vascular endothelial cells and increasing the thrombosis risk, most of drug-eluting stents are still loaded with these two drugs, and only few stents loaded with rapamycin derivatives, such as everolimus, zotarolimus, tacrolimus and pimecrolimus. Current research focuses on developing a stent with rapid drug releasing and anti-proliferative capacity. Meanwhile, the combination of drugs and biphasic releasing are another novel idea.      

Safety and Efficacy of Overlapping Homogenous Drug-Eluting Stents in Patients with Acute Myocardial Infarction: Results from Korea Acute Myocardial Infarction Registry

The aim of this study was to compare safety and efficacy of 4 homogenous overlapping drug-eluting stents (DES) in acute myocardial infarction (AMI) patients. We selected 1,349 consecutive patients (62.1 ± 14.9 yr, 69.4% male) who received homogenous overlapping DESs in diffuse de novo coronary lesions from Korea Acute Myocardial Infarction Registry from April 2006 through September 2010. They were divided into 4 groups based on type of DES implanted - Paclitaxel (PES), Sirolimus (SES), Zotarolimus (ZES) and Everolimus (EES)-eluting stents. Primary endpoint was 12-month MACE. We also studied EES versus other DESs (PES + SES + ZES). Mean stent length was 26.2 ± 7.5 mm and mean stent diameter was 3.1 ± 0.4 mm. Average number of stents used per vessel was 2.2 ± 0.5. Incidence of major adverse cardiac events (MACE) in PES, SES, ZES, and EES groups were 9.5%, 9.2%, 7.5%, and 3.8%, respectively (P = 0.013). In EES group, overall MACE and repeat revascularization were lowest, and no incidence of stent thrombosis was observed. Non-fatal MI was highest in PES, almost similar in SES and EES with no incidence in ZES group (P = 0.044). Cox proportional hazard analysis revealed no differences in the incidence of primary endpoint (P = 0.409). This study shows no significant differences in 12-month MACE among 4 groups.     

Two-year clinical outcomes of patients with long segments drug-eluting stents: comparison of sirolimus-eluting stent with paclitaxel-eluting stent

Limited data are available on the long-term clinical efficacy of drug-eluting stent (DES) in diffuse long lesions. From May 2006 to May 2007, a total of 335 consecutive patients (374 lesions) were underwent percutaneous coronary intervention with implantation of long DES (≥ 30 mm) in real world practice. Eight-month angiographic outcomes and 2-yr clinical outcomes were compared between SES (n = 218) and PES (n = 117). Study endpoints were major adverse cardiac events including cardiac death, myocardial infarction, target-lesion revascularization, target-vessel revascularization and stent thrombosis. Baseline characteristics were similar in the two groups as were mean stent length (44.9 ± 15.2 mm in SES and 47.4 ± 15.9 in PES, P = 0.121). Late loss at 8 months follow-up was significantly lower in SES than in PES group (0.4 ± 0.6 mm in SES vs 0.7 ± 0.8 mm in PES, P = 0.007). Mean follow-up duration was 849 ± 256 days, and 2-yr cumulative major adverse cardiac events were significantly lower in the SES than in the PES group (5.5% in SES vs 15.4% in PES, P = 0.003). In conclusion, long-term DES use in diffuse long coronary lesions is associated with favorable results, with SES being more effective and safer than PES in this real-world clinical experience.     

The impact of initial treatment delay using primary angioplasty on mortality among patients with acute myocardial infarction: from the Korea acute myocardial infarction registry

The impact of treatment delays to reperfusion on patient mortality after primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) is controversial. We analyzed 5,069 patients included in the Korea Acute Myocardial Infarction Registry (KAMIR) between November 2005 and January 2007. We selected 1,416 patients who presented within 12 hr of symptom onset and who were treated with primary PCI. The overall mortality at one month was 4.4%. The medians of door-to-balloon time, symptom onset-to-balloon time, and symptom onset-to-door time were 90 (interquartile range, 65-136), 274 (185-442), and 163 min (90-285), respectively. One-month mortality was not increased significantly with any increasing delay in door-to-balloon time (4.3% for < or =90 min, 4.4% for >90 min; p=0.94), symptom onset-to-balloon time (3.9% for < or =240 min, 4.8% for >240 min; p=0.41), and symptom onset-to-door time (3.3% for < or =120 min, 5.0% for >120 min; p=0.13). These time variables had no impact on one-month mortality in any subgroup. Thus, this first nationwide registry data in Korea showed a good result of primary PCI, and the patient prognosis may not depend on the initial treatment delay using the current protocols.     

Prognostic value of left atrium remodeling after primary percutaneous coronary intervention in patients with ST elevation acute myocardial infarction

The purpose of this study is to assess the relationship between left atrial (LA) size and outcome after acute myocardial infarction (AMI) in patients undergoing primary percutaneous coronary intervention (PCI) and to evaluate dynamic changes in LA size during long-term follow-up. Echocardiographic analyses were performed on 253 AMI patients (174 male and 79 female, 65.4 ± 13.7 yr) undergoing PCI. These subjects were studied at baseline and at 12 months. Clinical follow-up were done at 30.8 ± 7.5 months. We assessed LA volume index (LAVI) at AMI-onset and at 12-month. Change of LAVI was an independent predictor of new onset of atrial fibrillation or hospitalization for heart failure (P = 0.002). Subjects who survived the 12-month period displayed an increased LAVI mean of 1.86 ± 4.01 mL/m(2) (from 26.1 ± 8.6 to 28.0 ± 10.1 mL/m(2), P < 0.001). The subject group that displayed an increased LAVI correlated with a low left ventricular ejection fraction, large left ventricle systolic and diastolic dimensions and an enlarged LA size. In conclusion, change of LAVI is useful parameter to predict subsequent adverse cardiac event in AMI patients. Post-AMI echocardiographic evaluation of LAVI provides important prognostic information that is significantly greater than that obtained from clinical and laboratory parameters alone.     

可降解涂层雷帕霉素洗脱支架在冠状动脉狭窄病变处理中的安全性

背景：临床可以采用冠状动脉支架置入治疗各种冠状动脉狭窄病变,术中可以选择药物洗脱性支架和裸金属支架等不同的支架类型,但不同厂家生产的支架在治疗效果和安全性等方面可能存在一定的差异。目的：探讨不同厂家可降解涂层雷帕霉素洗脱支架在冠状动脉狭窄病变处理中的安全性。方法：纳入冠状动脉狭窄病变患者196例,其中男116例,女80例,年龄37-81岁,均分为两组治疗,分别置入微创公司生产的Firebird可降解涂层雷帕霉素洗脱支架与乐普公司生产的Partner可降解涂层雷帕霉素洗脱支架。治疗后随访12个月,对比两组的再狭窄率、急性心肌梗死发生率、冠状动脉旁路移植或再次经皮冠状动脉介入治疗率及死亡率。结果与结论：随访12个月,两组再狭窄率、急性心肌梗死发生率、冠状动脉旁路移植或再次经皮冠状动脉介入治疗率及死亡率比较差异均无显著性意义(P > 0.05)。经随访,两组均未发生与支架材料相关的不良反应。表明在治疗冠状动脉狭窄病变的过程中,置入不同品牌的可降解涂层雷帕霉素洗脱支架均可获得良好的效果,无不良反应发生,具有一定的安全性。中国组织工程研究杂志出版内容重点：组织构建;骨细胞;软骨细胞;细胞培养;成纤维细胞;血管内皮细胞;骨质疏松;组织工程     

Very late stent thrombosis after drug-eluting stent implantation in a patient without aspirin and clopidogrel resistance

Very late stent thrombosis (VLST) after implantation of drug-eluting stent is rare, but very fatal complication after percutaneous coronary intervention. We report a case of VLST of a sirolimus-eluting Cypher stent (Cordis, Johnson and Johnson) presenting as acute ST elevation myocardial infarction at 26 months after deployment with continued combined dual antiplatelet medication of aspirin and clopidogrel. The patient did not show anti-platelet resistance.     

Impact of the metabolic syndrome on the clinical outcome of patients with acute ST-elevation myocardial infarction

We sought to determine the prevalence of metabolic syndrome (MS) in patients with acute myocardial infarction and its effect on clinical outcomes. Employing data from the Korea Acute Myocardial Infarction Registry, a total of 1,990 patients suffered from acute ST-elevation myocardial infarction (STEMI) between November 2005 and December 2006 were categorized according to the National Cholesterol Education Program-Adult Treatment Panel III criteria of MS. Primary study outcomes included major adverse cardiac events (MACE) during one-year follow-up. Patients were grouped based on existence of MS: group I: MS (n=1,182, 777 men, 62.8±12.3 yr); group II: Non-MS (n=808, 675 men, 64.2±13.1 yr). Group I showed lower left ventricular ejection fraction (LVEF) (P=0.005). There were no differences between two groups in the coronary angiographic findings except for multivessel involvement (P=0.01). The incidence of in-hospital death was higher in group I than in group II (P=0.047), but the rates of composite MACE during one-year clinical follow-up showed no significant differences. Multivariate analysis showed that low LVEF, old age, MS, low high density lipoprotein cholesterol and multivessel involvement were associated with high in-hospital death rate. In conclusion, MS is an important predictor for in-hospital death in patients with STEMI.     

Chronic lymphocytic leukemia involving the coronary arteries with accompanying acute myocardial infarction

An 83-year-old man with chronic lymphocytic leukemia (CLL) for 10 years presented with dyspnea and hypotension. Blood investigations and electrocardiogram were consistent with acute myocardial infarction. The patient deteriorated quickly and died shortly thereafter. At autopsy, there was severe atherosclerosis of the coronary arteries and an inferolateral left ventricular wall myocardial infarct. Microscopy showed that CLL involved the nodes, liver, spleen, bowel, and kidneys. The coronary artery walls were infiltrated with leukemia cells invading the tunica media and the atheromatous plaque. Infiltration of the coronary arteries by CLL is not common and the possible role in coronary syndromes is discussed.     

Primary percutaneous coronary intervention for acute myocardial infarction with idiopathic thrombocytopenic purpura: a case report

Acute myocardial infarction (AMI) is rare in patients with idiopathic thrombocytopenic purpura (ITP). We describe a case of an AMI during thrombocytopenia in a patient with chronic ITP. A 47-yr-old woman presented with anterior chest pain and a low platelet count (21,000/microliter) at admission. Urgent coronary angiography revealed total occlusion of proximal right coronary artery and primary percutaneous coronary intervention (PCI) was performed successfully. This case suggests that primary PCI may be a therapeutic option for an AMI in patients with ITP, even though the patient had severe thrombocytopenia.     

Assessment of the left atrial volume index and plasma NT-proANP level in patients with acute ST-elevation myocardial infarction

OBJECTIVES:

Acute ST-elevation myocardial infarction is associated with ventricular dysfunction due to ischemia-induced progressive myocardial damage. The decrease in ventricular compliance causes left atrial dilatation and stretching of the atrial myocardium, which are the main stimuli for the secretion of atrial natriuretic peptide. The aim of this study was to evaluate left atrial dimensions and atrial natriuretic peptide levels in patients early after their first acute ST-elevation myocardial infarction and assess the probable interaction between coronary lesions and these measurements.

METHODS:

A total of 110 patients with acute myocardial infarction and 50 controls were studied. Plasma atrial natriuretic peptide was measured at admission. Left ventricular function, diameter, and volume index were evaluated using transthoracic echocardiography. Gensini and vessel scores of the patients who underwent coronary angiography were calculated.

RESULTS:

Plasma atrial natriuretic peptide in the patients with myocardial infarction was increased compared with that in controls (3.90±3.75 vs. 1.35±0.72 nmol/L, p<0.001). Although the left atrial diameter was comparable in patients and controls, the left atrial volume index was increased in patients with acute myocardial infarction (26.5±7.1 vs. 21.3±4.9 mL/m², p<0.01). Multivariate regression analysis showed a strong independent correlation between the left atrial volume index and the plasma atrial natriuretic peptide level (β = 0.23, p = 0.03).

CONCLUSIONS:

The left atrial volume index and plasma atrial natriuretic peptide level were correlated in patients with acute myocardial infarction.     

急性心肌梗死家兔心肌MtATPase表达和心肌细胞凋亡的变化

目的： 研究急性心肌梗死后线粒体能量代谢和心肌细胞凋亡的动态变化,探讨二者在缺血心肌细胞演变中的作用和意义。方法: 结扎家兔左冠状动脉主干建立实验性心肌梗死（AMI）模型,采用酶组织化学染色法和脱氧核苷转移酶介导的缺口末端标记技术检测梗死后0.5、1、2、4、8、12 h左室前壁线粒体腺苷三磷酸酶（MtATPase）和细胞凋亡的变化,结合显微图像分析技术定量测定酶活性平均积分吸光度值（IA）和凋亡指数（AI）。结果: (1)AMI 2 h,MtATPase表达开始下降,4 h显著减低,随着缺血时间延长,表达持续下降, 2、4、8、12 h IA分别为168.09±3.75、159.01±2.62、143.12±3.47和127.65±4.64,与对照组比较有明显差异（P<0.05）;(2)AMI 0.5 h仅见少数凋亡心肌细胞,随缺血时间延长,凋亡细胞数目显著增加,4 h达到高峰,然后开始下降,但12 h仍高于对照组, 0.5、1、2、4、8、12 h AI分别为4.74±0.75、10.96±1.06、17.28±1.75、26.83±2.06、20.41±1.52和8.91±0.74,与对照组比差异显著（P<0.01）。结论: 细胞凋亡是AMI心肌细胞一种重要的死亡形式,梗死心肌细胞的演变和线粒体能量代谢密切相关。     

Clinical outcomes of second- versus first-generation drug-eluting stents in patients with acute myocardial infarction: a meta-analysis of randomized controlled trials

Introduction

It remains unclear whether the clinical outcomes of patients with acute myocardial infarction (AMI) receiving second- and first-generation drug-eluting stents (DES) are identical. The study aimed to investigate the differences in clinical utility between the two generations of DES in these specific subjects by a meta-analysis.

Material and methods

We systemically searched PubMed and EMBASE databases and the Cochrane Library up until January 2013. Randomized trials, which compared clinical outcomes of second-generation DES (everolimus- (EES) or zotarolimus-eluting stents (ZES)) with first-generation DES (sirolimus- or paclitaxel-eluting stents) in patients with AMI were included.

Results

Five trials with 1720 AMI subjects were included in the meta-analysis. Pooled analysis demonstrated a trend toward lower incidence of stent thrombosis with the second-generation DES relative to the first-generation one (risk ratio (RR), 0.53; 95% confidence intervals (CI): 0.25–1.13; p = 0.10). However, the second-generation DES did not offer a significant advantage over the first-generation DES in reducing the incidence of target lesion revascularization (TLR) (RR = 1.73; 95% CI: 0.83–3.64; p = 0.15), major adverse cardiac events (MACEs) (RR = 0.97; p = 0.90), or all-cause death (RR = 1.00; p = 1.0). In addition, in elderly patients the second-generation DES seemed to reduce the occurrence of MACEs (RR = 0.65; p = 0.10) and stent thrombosis (RR = 0.40; p = 0.08), and the second-generation EES showed a potential benefit in lowering the MACE rate (RR = 0.55; p = 0.06).

Conclusions

The second-generation DES appeared to lower the risk of stent thrombosis in AMI patients. There might be a lower incidence of MACEs associated with the second-generation EES.     

Predictors of in-hospital mortality in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive treatment

OBJECTIVES:

To identify predictors of in-hospital mortality in patients with acute myocardial infarction undergoing pharmacoinvasive treatment.

METHODS:

This was an observational, prospective study that included 398 patients admitted to a tertiary center for percutaneous coronary intervention within 3 to 24 hours after thrombolysis with tenecteplase. ClinicalTrials.gov: {"type":"clinical-trial","attrs":{"text":"NCT01791764","term_id":"NCT01791764"}}NCT01791764

RESULTS:

The overall in-hospital mortality rate was 5.8%. Compared with patients who survived, patients who died were more likely to be older, have higher rates of diabetes and chronic renal failure, have a lower left ventricular ejection fraction, and demonstrate more evidence of heart failure (Killip class III or IV). Patients who died had significantly lower rates of successful thrombolysis (39% vs. 68%; p = 0.005) and final myocardial blush grade 3 (13.0% vs. 61.9%; p<0.0001). Based on the multivariate analysis, the Global Registry of Acute Coronary Events score (odds ratio 1.05, 95% confidence interval (CI) 1.02-1.09; p = 0.001), left ventricular ejection fraction (odds ratio 0.9, 95% CI 0.89-0.97; p = 0.001), and final myocardial blush grade of 0-2 (odds ratio 8.85, 95% CI 1.34-58.57; p = 0.02) were independent predictors of mortality.

CONCLUSIONS:

In this prospective study that evaluated patients with ST-segment elevation myocardial infarction treated by a pharmacoinvasive strategy, the in-hospital mortality rate was 5.8%. The Global Registry of Acute Coronary Events score, left ventricular ejection fraction, and myocardial blush were independent predictors of mortality in this high-risk group of acute coronary syndrome patients.