女性ST段抬高型心肌梗死患者院内病死率的研究

目的:研究ST段抬高型心肌梗死(STEMI)患者的院内病死率的性别差异及其原因。方法:入选急性心肌梗死(AMI)患者共1 189例,其中男性869例,女性320例。先比较女性与男性之间年龄,合并症等基线资料和典型症状,院内病死率等临床资料的差异,再分析STEMI患者院内病死率的性别差异。结果:与男性比较,女性STEMI患者年龄大(68.51岁vs.60.76岁,P0.001),2型糖尿病、高血压患病率高(24.4%vs.14.6%,P0.001;61.3%vs.42.2%,P0.001),脑力劳动者少(3.4%vs.23.7%,P0.001),吸烟和饮酒者少(27.2%vs.68.1%,P0.001;2.2%vs.27.0%,P0.001);女性患者中有明显诱因和出现典型胸痛者少(27.5%vs.35.9%,P=0.008;50.9%vs.68.2%,P0.001),出现并发症者多(41.9%vs.32.2%,P=0.002),接受急诊再灌注治疗比例低(67.2%vs.77.7%,P0.001),院内病死率高(17.5%vs.7.9%,P0.001)。女性对STEMI患者院内病死率的影响很明显(OR 2.459,95%CI 1.684~3.593,P0.001);校正年龄,2型糖尿病,高血压等因素的影响后,STEMI患者院内病死率的性别差异消失(P=0.109),而年龄,高血压和低急诊再灌注治疗率为STEMI患者院内病死率增高的独立危险因素(P0.001,P=0.022,P0.001)。结论:女性STEMI患者的院内病死率高于男性。这是由于女性STEMI患者年龄大,合并高血压者多,接受急诊再灌注治疗的比率低所致。女性不是造成STEM2患者院内病死率增高的独立危险因素。     

ST-segment elevation myocardial infarction

Opinion statement ST-segment elevation myocardial infarction (MI) is an emergency medical condition. Expediting the steps leading to coronary reperfusion is of critical importance in improving survival after acute MI. After the diagnosis of acute MI is made, patients should be treated with oxygen, aspirin, nitroglycerin, beta-blockers, heparin, and analgesics, barring any contraindications. If an experienced cardiac catheterization laboratory is available within 60 to 90 minutes, then catheter-based reperfusion therapy is recommended; otherwise, thrombolysis should be considered as an alternate therapy. Therapy with a reduced-dose thrombolytic agent and a glycoprotein IIb/IIIa receptor inhibitor appears to be of an added benefit in establishing TIMI (Thrombolysis in Myocardial Infarction) 3 flow, but this approach awaits final approval prior to widespread use. The adjunctive use of glycoprotein IIb/IIIa receptor inhibitors with percutaneous transluminal coronary angioplasty, with or without stenting, appears to be beneficial and is being used more frequently in the acute setting. Coronary angiography should be performed in patients who fail to respond to thrombolytic therapy or who have evidence of recurrent ischemia. This procedure should not be routinely performed in patients who have responded to thrombolytic therapy. Four to 6 days after an acute MI event, assessment of left ventricular function is recommended. Submaximal exercise test (with or without nuclear or echocardiographic imaging) should be considered in patients prior to discharge from the hospital—an exception can be made in patients with one-vessel disease treated successfully with percutaneous transluminal coronary angioplasty. After discharge, a regular exercise test should be obtained 4 to 6 weeks after an uncomplicated acute MI event. Secondary prevention measures such as weight loss, cessation of smoking, aspirin, beta-blockers, lipid-lowering agents, and angiotensin-converting enzyme inhibitors should be considered in all patients, barring contraindications.     

不同年龄段ST段抬高型心肌梗死男女患者院内病死率的性别差异

目的研究不同年龄段ST段抬高型心肌梗死(STEMI)患者不同性别院内病死率的差异。方法入选1994年1月1日至2006年12月31日首都医科大学宣武医院心脏科收治住院的STEMI患者1189例,其中男性869例,女性320例,年龄23~91岁。根据年龄分为3组:A组(65岁)571例;B组(65~74岁)419例;C组(≥75岁)199例。收集患者年龄、性别、2型糖尿病、血脂、血压等方面的临床资料。结果 A组中,与男性STEMI患者比较,女性(3.1%vs.8.3%)院内病死率升高,差异具有统计学意义(P0.05)。在B组中,与男性STEMI患者比较,女性院内病死率升高(11.9%vs.20.1%)。C组中,男性与女性STEMI患者病死率差异无统计学意义(P0.05)。三组中,随着年龄增长,女性对男性院内病死率的优势比(OR)亦呈逐步下降趋势(2.861 vs.1.875 vs.1.143)。通过多因素分析,校正混杂因素后,在A组,年龄(OR=1.154,95%CI:1.052~1.264),高血压(OR=7.685,95%CI:2.276~25.946)为STEMI患者院内病死的独立危险因素,急诊再灌注治疗(OR=7.685,95%CI:0.007~0.098)为STEMI患者院内病死的保护因素。在B组,女性(OR=1.875,95%CI:1.088~3.232)是STEMI患者院内病死的独立危险因素。结论女性STEMI患者院内病死率较男性高,年龄越大其差异越小。在65岁人群中,年龄,高血压为STEMI患者院内病死的危险因素,急诊再灌注治疗为保护因素;在65~74岁人群中,女性为STEMI患者院内病死的危险因素。     

影响急性ST段抬高心肌梗死住院病死率性别间差异的因素分析

目的:调查急性ST段抬高心肌梗死(STEMI)住院病死率性别间有无显著差异及其影响因素。方法:分析1993年～2006年我院心内科首次发作且发病24 h内入院的1 278例急性STEMI患者的临床资料。结果:女性患者年龄、并发高血压病、糖尿病、入院空腹血糖、总胆固醇、低密度脂蛋白胆固醇显著高于男性,女性患者无发病诱因、症状不典型者多,发病至就诊时间延长,且住院期间接受血管紧张素转换酶抑制剂(ACEI)、β-受体阻滞剂、他汀类药物以及冠脉介入治疗(PCI)的比例低于男性;Logistic回归分析显示,女性患者住院病死率显著高于男性的影响因素是年龄较大、并发高血压病、入院空腹血糖较高且较少接受ACEI、β-受体阻滞剂以及PCI治疗。结论:急性STEMI患者女性住院病死率较男性高,与其并发较多危险因素且未接受更积极的治疗有关。     

Comparison of mortality rates in women versus men presenting with ST-segment elevation myocardial infarction

Women who present with coronary artery disease have different characteristics, undergo different treatment, and have a different prognosis than men. The increasing use of coronary stenting has improved the outcome of percutaneous coronary intervention (PCI). However, little is known about the outcomes for men versus women after PCI, especially for those presenting with a diagnosis of acute coronary syndrome. Thus, we compared the baseline features, management, and long-term outlook of men versus women undergoing PCI. All consecutive patients who had undergone PCI with stents at our center from July 1, 2002 to June 30, 2004 were identified retrospectively. The primary end point was the long-term rate of major adverse cardiac events (i.e., death, infarction, and repeat revascularization). The secondary end points were the individual components of the major adverse cardiac events and stent thrombosis. A total of 833 patients were included, 210 women (25.2%) and 623 men (75.8%). The women were significantly older (70.9 vs 63 years, p <0.001) and more often had diabetes mellitus (36.2% vs 21.0%, p <0.001) and hypertension (82.3% vs 73.7%, p = 0.006). The number of drug-eluting stents and the length were significantly lower in the female patients. The incidence of major adverse cardiac events after a median follow-up of 60 months was similar for both women and men (38.8% vs 46.4%, p = 0.075), with a trend toward greater mortality rate for women (21.2% vs 15.4%, p = 0.090). All other end points occurred with similar frequencies. Only in the subgroup of ST-segment elevation myocardial infarction were the rates of death significantly greater for the women than for the men (20.0% vs 8.1%; p = 0.029). In conclusion, very long-term follow-up of women undergoing PCI with coronary artery stenting resulted in similar rates of cardiac event compared to those of men, but greater care should be given to women presenting with ST-segment elevation myocardial infarction. Also, despite their greater baseline risk profile, women were significantly less likely to have received effective treatment, the use of including drug-eluting stents.     

Triglyceride glucose index predicts in-hospital mortality in patients with ST-segment elevation myocardial infarction who underwent primary angiography

OBJECTIVES To assess the correlation between triglyceride glucose(TyG) index and in-hospital mortality in patients with STsegment elevation myocardial infarction(STEMI).METHODS A total of 2190 patients with STEMI who underwent primary angiography within 12 h from symptom onset were selected from the prospective, nationwide, multicenter CAMI registry. TyG index was calculated with the formula: Ln [fasting triglycerides(mmol/L) × fasting glucose(mmol/L)/2]. Patients were divided into three groups ...     

白细胞计数对急性ST段抬高型心肌梗死患者长期预后的影响

目的探讨白细胞计数对急性ST段抬高型心肌梗死(STEMI)长期预后的影响。方法选择STEMI患者545例,依据白细胞水平将患者分为A组274例(白细胞≤10.0×10~9/L)和B组271例(白细胞10.0×10~9/L),比较2组患者住院期间主要不良心脑血管事件(MACCE)、病死率及长期MACCE发生率。结果 A组平均年龄明显高于B组[(63.8±11.4岁)vs(60.4±11.4岁),P=0.001];A组住院期间MACCE发生率明显低于B组(5.1%vs 10.3%,P=0.013)。随访28个月,A组MACCE发生率明显低于B组(12.9%vs 16.9%,P=0.018),全因病死率明显低于B组(2.6%vs 5.7%,P=0.045)。白细胞计数是STEMI患者长期MACCE的独立预测因素(HR=1.166,95%CI:1.104~1.231,P=0.036)。结论白细胞计数升高预示STEMI患者近、远期预后不良。     

Early management of ST-segment elevation myocardial infarction

Improvements in the management of ST-segment elevation myocardial infarction(STEMI) have led to a reduction in the acute and long-term mortality rates. The first important decision in the care of patients who have STEMI is the method of reperfusion.Whether percutaneous intervention (PCI) or fibrinolytic therapy is chosen depends on a number of factors. This article reviews the data on PCI and fibrinolytics in the context of consensus guidelines, outlines adjunctive medical therapies important in the first 24 hours, and discusses a strategy for making the decisions and a hypothetical construct for evaluating new drugs and procedures in the future.     

Prognostic value of TIMI and GRACE risk scores for in-hospital mortality in Chinese patients with ST-segment elevation myocardial infarction

正Objective To evaluate the prognostic value of the Thrombolysis In Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) risk scores for in-hospital mortality in Chinese ST-segment elevation myocardial infarction (STEMI) patients.Meth-o dsPresent data are obtained from the prospective, mul-     

心电图异常J波对急性ST段抬高型心肌梗死短期预后的预测价值

目的:探讨急性ST段抬高型心肌梗死(STEMI)患者心电图异常J波与短期临床预后的关系。方法:回顾性分析2007年1月至2012年12月在我院行急诊冠状动脉介入治疗(PCI)的204例急性STEMI患者心电图及相关临床资料,应用单因素、多因素Logistic回归分析预测患者住院期间死亡的危险因素。结果:204例患者中,心电图检获异常J波的患者约占40%,多分布于心电图下壁导联。心电图异常J波阳性患者住院期间持续性室性心动过速或心室颤动的发生率显著高于异常J波阴性患者(10%对2%,P=0.008)。在12例(6%)心因性死亡患者中,6例存在异常J波。Logistic回归分析显示,心电图存在异常J波并不能预测急性STEMI患者住院期间死亡(HR=0.99,95%CI:0.34~2.90,P=0.987),而年龄则可作为此类患者短期预后的独立预测因子(HR=1.08,95%CI:1.01~1.15,P=0.02)。结论:在急性STEMI患者中,异常J波阳性患者住院期间持续性室性心动过速或心室颤动的发生率显著高于J波阴性的患者,但心电图异常J波并不能预测此类患者的短期预后。     

Electrocardiogram mimics of acute ST-segment elevation myocardial infarction: insights from cardiac magnetic resonance imaging in patients with tako-tsubo (stress) cardiomyopathy

An important subset of patients (10%) with chest pain and ST-segment elevation on initial electrocardiogram (ECG) do not have acute coronary occlusion. In our experience, 5% of women presenting with chest pain and ST-segment elevation are proven to have the newly recognized syndrome of tako-tsubo (stress) cardiomyopathy (TC). Patients with TC present with clinical and electrocardiographic features mimicking ST-segment elevation anterior myocardial infarction due to left anterior descending (LAD) occlusion. The initial and subsequent ECG findings in TC are therefore of clinical importance. Thirty-three consecutive patients with TC were identified from within a single institution community-based cardiology practice. All were female aged 32 to 90 years (mean, 68 years) with acute chest pain associated with an emotional or physical stressful event, and akinesia of the mid-distal left ventricle but without significant atherosclerotic coronary artery obstruction. All patients with TC presented with anterior ST-segment elevation most marked in leads V₁ to V₅, maximal in leads V₂ and V₃. Distribution of ST-segment elevation was similar to 44 female control patients with acute (LAD) occlusion. ST-segment elevation magnitude was less in patients with TC (1.4 ± 1.5 mm) than in patients with LAD occlusion (2.4 ± 2.2 mm) (P < .001) but with considerable overlap. Left ventricular ejection fraction (LVEF) was significantly lower in TC patients (29% ± 9%) than in patients with LAD occlusion (42% ± 13%) (P < .05). Peak troponin T was significantly lower in patients with TC (0.64 ± 0.86 ng/mL) than in patients with LAD occlusion (3.88 ± 4.9 ng/mL) (P < .0001). Cardiovascular magnetic resonance imaging detected myocardial necrosis in 1 patient with TC. At follow-up, LVEF returned to normal (> 50%) in all patients with TC. In patients with TC, ECG evolution was characterized by resolution of ST-segment elevation, appearance of T-wave inversion (most marked in precordial leads V₃-V₆ and limb leads aVL, I, and −aVR), QTc interval prolongation (378 ± 60 milliseconds [initial] vs 470 ± 72 milliseconds [follow-up], P < .05), and reappearance of precordial R waves. In conclusion, patients with TC frequently present with anterior ST-segment elevation, which cannot be reliably distinguished from that of acute LAD occlusion. In TC, the combination of minimal troponin release, absent delayed hyperenhancement on cardiac magnetic resonance imaging (in most of patients), and return to normal LVEF is consistent with the presence of significant myocardial stunning. The ECG evolution of progressive T-wave inversion, QTc interval lengthening, and R-wave reappearance could be the electrophysiologic manifestation of an underlying stunned myocardium in this condition.     

Contemporary management of ST-segment elevation myocardial infarction

ST-elevation myocardial infarction (STEMI), which constitutes nearly 25–40 % of current acute myocardial infarction (AMI) cases, is a medical emergency that requires prompt recognition and treatment. Since the 2013 STEMI practice guidelines, a wealth of additional data that may further advance optimal STEMI practices has emerged. These data highlight the importance of improving patient treatment and transport algorithms for STEMI from non-primary percutaneous coronary intervention (PCI) centers. In addition, a focus on the reduction of total pain-to-balloon (P2B) times rather than simply door-to-balloon (D2B) times may further improve outcomes after primary PCI for STEMI. The early administration of newer oral P2Y12 inhibitors, including crushed forms of these agents for faster absorption, represents another treatment advancement. Recent data also suggest avoiding concurrent morphine use due to interactions with P2Y12 inhibitors. Furthermore, new technological advancements and investigational therapies, including Bioresorbable Vascular Scaffolds and the use of pre-intervention intravenous microbubbles with transthoracic ultrasound, hold promise to play a useful role in future STEMI care. Despite these advancements, the prompt recognition of STEMI, at both the patient and health care system level, remains the cornerstone of optimal treatment.     

Primary percutaneous coronary intervention for patients presenting with ST-segment elevation myocardial infarction: process improvement in a rural ST-segment elevation myocardial infarction receiving center

Background

Rural ST-segment elevation myocardial infarction (STEMI) care networks may be particularly disadvantaged in achieving a door-to-balloon time (D2B) of less than or equal to 90 minutes recommended in current guidelines.

ST-Elevation Myocardial Infarction Process Upgrade Project

A multidisciplinary STEMI process upgrade group at a rural percutaneous coronary intervention center implemented evidence-based strategies to reduce time to electrocardiogram (ECG) and D2B, including catheterization laboratory activation triggered by either a prehospital ECG demonstrating STEMI or an emergency department physician diagnosing STEMI, single-call catheterization laboratory activation, catheterization laboratory response time less than or equal to 30 minutes, and prompt data feedback.

Evaluating success

An ongoing regional STEMI registry was used to collect process time intervals, including time to ECG and D2B, in a consecutive series of STEMI patients presenting before (group 1) and after (group 2) strategy implementation. Significant reductions in time to first ECG in the emergency department and D2B were seen in group 2 compared with group 1.

Conclusions

Important improvement in the process of acute STEMI patient care was accomplished in the rural percutaneous coronary intervention center setting by implementing evidence-based strategies.