急性心肌梗死患者初期支架植入和rt-PA静脉溶栓加补救支架植入对比研究

目的比较急性心肌梗死(AMI)患者冠状动脉内初期支架植入和静脉rt-PA溶栓加补救支架植入治疗的临床疗效.方法 98例首次AMI患者随机给以冠状动脉内初期支架植入(初期支架组48例)和静脉rt-PA溶栓加补救支架植入(溶栓加支架组50例).所有患者行急诊冠状动脉造影以TIMI血流分级法判断梗死相关冠状动脉(IRA)开通情况.记录住院期心脏事件;出院前用二维超声心动图测定两组患者左心室舒张末期和收缩末期容量并推算左心室射血分数(LVEF).结果急诊冠状动脉造影显示支架组47例(97.91%)溶栓加支架组50例(100%)IRA血流TIMI 2-3级,但前者IRA前向血流TIMI 3级者明显增多(分别为93.8%和60.0%,P=0.0001).两组患者住院期死亡率和心脏事件相似,但出院前超声心动图显示支架组LVEF(62.01%±14.03%)高于溶栓加支架组(50.01%±132%),P=0.0001.结论与静脉rt-PA溶栓加补支架治疗相比,AMI初期支架植入可更好改善急性期心肌再灌注,并减少患者住院期心功能减退.     

梗死前心绞痛对女性急性前壁心肌梗死的保护作用研究

目的　观察梗死前心绞痛对女性急性前壁心肌梗死有无保护作用。方法　选择女性急性前壁心肌梗死 98例 ,有梗死前心绞痛者为A组 ( 4 8例 )、无梗死前心绞痛为B组 ( 5 0例 ) ,行心电图、心肌酶、超声心动图、核素心血池等检查。对心电图QRS积分值、心肌酶峰峰值、左室射血分数、心源性休克、室壁瘤形成及短期病死率进行比较。结果　B组心肌梗死患者QRS积分值、心肌酶峰值、心源性休克、室壁瘤形成及 1个月病死率明显高于A组 ,P <0 .0 5 ,左室射血分数明显低于A组 ,P <0 .0 5。结论　梗死前 2 4小时内心绞痛可减低女性急性心肌梗死患者QRS积分值、保护心功能、降低短期病死率     

血清Angptl2/Angptl1比值与稳定型心绞痛患者急性心肌梗死发生风险的相关性分析

目的探究血清血管生成素样蛋白2/血管生成素样蛋白1(Angptl2/Angptl1)比值在稳定型心绞痛患者急性心肌梗死的表达情况及与疾病发生风险的关系。方法选取2018年2月至2019年3月于西安高新医院接受治疗的205例稳定型心绞痛患者,根据住院期间是否发生急性心肌梗死分为对照组(126例)与急性心肌梗死组(79例),收集患者临床资料,采用酶联免疫吸附法检测血清中Angptl2、Angptl1水平,计算Angptl2/Angptl1比值;Pearson相关性分析Angptl2/Angptl1与冠状动脉病变评分的关系;采用Logistic分析影响稳定型心绞痛患者发生急性心肌梗死的危险因素,受试者工作特征曲线(ROC)评估Angptl2、Angptl2/Angptl1在稳定型心绞痛患者发生急性心肌梗死中的诊断价值。结果急性心肌梗死组高血压患病例数、饮酒例数、血清Angptl2、Angptl2/Angptl1水平均显著高于对照组,高密度脂蛋白(HDL)水平、Gensini积分显著低于对照组(P均<0.05),两组Angptl1水平无明显变化(P>0.05)。血清Angptl2、Angptl2/Angptl1与Gensini积分呈负相关,(r=-0.457,r=-0.384,P均<0.05)。高血压、Gensini积分、Angptl2、Angptl2/Angptl1是影响稳定型心绞痛患者发生急性心肌梗死的危险因素。Angptl2预测的稳定型心绞痛患者急性心肌梗死的AUC值为0.836(95%CI:0.778~0.884),敏感性71.38%,特异性82.74%;Angptl2/Angptl1对稳定型心绞痛患者急性心肌梗死预测的AUC值为0.877(95%CI:0.821~0.916),敏感性79.51%,特异性88.74%。结论稳定型心绞痛患者发生急性心肌梗死后血清Angptl2水平、Angptl2/Angptl1比值升高,Angptl1水平无明显变化,Angptl2、Angptl2/Angptl1在稳定型心绞痛患者发生急性心肌梗死中均具有一定的预测价值,Angptl2/Angptl1预测价值更优。     

Prognostic significance of angina pectoris recurring soon after myocardial infarction

The prognostic significance of an early occurrence, or recurrence,of angina pectoris after myocardial infarction was studied in254 patients (221 male, 33 female; mean age 58±11 years).During the in-hospital rehabilitation program, 41 patients (16%)had anginal pain. The mean follow-up was 21 months (range 12–33months). Among the 254 patients, 21 died, five had recurrentmyocardial infarction, 13 had unstable angina, and 22 underwentaortocoronary bypass surgery. An early recurrence of anginapectoris was predictive of combined (medical+surgical) events(21 patients, P<0.05), medical events (11 patients, P<0.05)and surgical events (10 patients, P<0.001), but failed topredict individual death (six patients), recurrent myocardialinfarction (two patients) or unstable angina (three patients).Of the events that occurred in the 254 patients, 34% were predictedby the early recurrence of angina pectoris. Early post-infarctionangina was observed more frequently in older patients and patientswith previous history of angina pectoris. This represents animportant prognostic factor after myocardial infarction, whichdefines a high-risk group of patients requiring further investigationand appropriate therapeutic approaches.     

老年人急性心肌梗死急诊冠状动脉内支架治疗

目的　评价急诊冠状动脉 (冠脉 )内支架治疗老年人急性心肌梗死 (AMI)的临床疗效。方法　对比分析 84例老年与 88例非老年人AMI急诊冠脉内支架术结果。结果　老年组 84支梗死相关血管 ,置入支架 86枚 ,围手术期死亡 2例 ,手术成功率为 97 6 % ;非老年组 88支梗死相关血管 ,置入支架 88枚 ,围手术期死亡 1例 ,手术成功率 98 9%。老年组与非老年组支架特点及出院时左室射血分数差异无显著性。两组均无严重的出血并发症。结论　老年人AMI急诊冠脉内支架治疗安全有效。     

Decreased no-reflow in patients with anterior myocardial infarction and pre-infarction angina.

AIMS: Pre-infarction angina is associated with better outcome after myocardial infarction. The aim of this study was to assess whether pre-infarction angina is associated with decreased no-reflow after coronary recanalization. METHODS AND RESULTS: Twenty-three patients underwent intracoronary myocardial contrast echocardiography during the acute phase of anterior myocardial infarction after successful recanalization, and before hospital discharge. Myocardial perfusion was graded semi-quantitatively in the area at risk (dyssynergic segments). Global left ventricular function was assessed by radionuclide angiography on days 8 and 42 and regional wall motion was assessed by 2D echocardiography on days 0 and 42. Fourteen patients had pre-infarction angina (angina less than 7 days before myocardial infarction) and nine did not. Baseline characteristics were similar in the two groups. The myocardial contrast echocardiography perfusion score in the area at risk after recanalization was higher in the patients with pre-infarction angina than in those without (0.72 +/- 0.19 vs 0.53 +/- 0.22, P=0.04), and the incidence of no-reflow (myocardial contrast echocardiography perfusion score < or =0.5) was lower (14% vs 56%, P=0.04). This difference persisted 8 +/- 2 days after myocardial infarction (0. 87 +/- 0.11 vs 0.69 +/- 0.26, P=0.04), and was associated with greater mid-term (day 42) improvement in left ventricular function in patients with pre-infarction angina than in those without, as assessed by changes in radionuclide left ventricular ejection fraction (+5.8 +/- 8.1% vs -3.3 +/- 4.6%, respectively;P=0.01) and by changes in regional wall motion score on 2D echocardiography (-0. 61 +/- 0.39 vs -0.24 +/- 0.17, respectively;P=0.04). CONCLUSION: Pre-infarction angina is associated with preservation of the microvasculature, reflected by reduced no-reflow. This may be a mechanism underlying greater recovery of left ventricular function in patients with pre-infarction angina.     

梗塞前心绞痛对急性心肌梗塞患者的有益作用

43例首次穿壁性急性心肌梗塞(AMI)患者于静脉内溶栓后90min行冠状动脉造影.其中24例AMI前6h内有心绞痛(甲组),另19例梗塞前无心绞痛(乙组).尽管两组多支冠状动脉病变及侧支循环发生率相似.但甲组异常Q波导联数、QRS积分、CPK峰值及CPK峰值距发病时间显著低于乙组.而梗塞相关冠状动脉再通率显著高于乙组.22例IRA开通患者中,有心绞痛者其基础左心室功能较无心绞痛者好.出院前超声心动图检查显示,甲组左心室局部和整体收缩功能、舒张充盈明显改善,而乙组收缩功能降低、舒张充盈无明显变化.住院期心脏事件发生率甲组显著低于乙组.本文提示,梗塞前心绞痛可能由于早期心肌再灌注和缺血预适应对梗塞大小、左心室功能及预后具有益作用.     

Plasminogen activator inhibitor-1 4G4G genotype is associated with myocardial infarction but not with stable coronary artery disease

Background  A case control study was conducted to test the hypothesis that plasminogen activator inhibitor type-1 (PAI-1) 4G/5G gene polymorphism confers an increased risk for myocardial infarction (MI) in patients with known coronary atherosclerosis. Methods  One hundred fifty-six consecutive patients who presented with acute MI and 111 stable coronary artery disease (SCAD) patients with documented critical coronary artery stenoses were prospectively enrolled. PAI-1 4G/5G gene polymorphism and conventional atherosclerotic risk factors were studied in all patients. PAI-1 4G/5G gene polymorphism was studied in another 281 healthy blood bank donors. Results  The frequency 4G4G genotype was significantly higher in the MI group as compared to SCAD group (32.7% vs. 15.3%, P = 0.001) while it was not statistically significant between MI and healthy control groups (32.7% vs. 26.0%, P = 0.136). Comparing with healthy controls SCAD group had significantly lower frequency of 4G4G genotype (P = 0.024). In comparison with SCAD group PAI-1 4G/4G genotype, male sex and smoking habits favored to MI in univariate analysis with a P value of less than 0.2. These variables were included in multivariate regression model to estimate the associated risk for MI. PAI-1 4G/4G genotype was the only independent variable (OR 2.67, 95%CI 1.43–4.96, P = 0.002) associated with MI in this regression model. Comparing with healthy control group 4G4G genotype was not associated with MI (OR 1.38, 95%CI 0.90–2.12). However, presence of 4G4G genotype had a protective effect against development of SCAD (OR 0.52, 96%CI 0.29–0.92). Conclusion  Compared to patients with critical coronary stenoses, PAI-1 4G/4G genotype was found to be an independent predictor for development of MI in this population. PAİ-1 4G4G genotype have a protective effect against development of high grade stable coronary stenoses.     

梗死前心绞痛对初发ST段抬高的急性心肌梗死的影响

目的：观察梗死前心绞痛（PAP）对初发 ST段抬高急性心肌梗死（AMI）进展的影响。方法：280例初发ST段抬高 AMI患者,发病后24h内进行冠脉造影,心电图检查并作 QRS记分。根据有无PAP,患者被分为 PAP （102例）和非PAP组（178例）。根据发病至造影时间患者被分为：早期组（＜2h,60例）、中期组（2-6h,150例）和晚期组（6-24h,70例）。结果：伴有PAP患者较无PAP患者 QRS记分显著降低[（2.4±2.4）分比（3.2±3.0）分],PAP组高 QRS记分比例亦显著低于非 PAP组（8.0％比18.4％）,P 均＜0.05。早期组,PAP与非PAP患者之间 QRS记分无显著差异[（2.0±1.8）分比（2.6±2.8）分,P＝0.35];中期组,PAP患者QRS记分显著低于非PAP组[（2.0±2.1）分比（3.0±3.0）分,P＝0.03];晚期组,PAP和非 PAP患者 QRS记分较中期组显著上升,但两组间比较无显著差异[（4.1±3.3）分比（5.5±2.9）分,P＝0.13];非PAP组患者 QRS记分随着发病时间延长逐渐增加。结论：梗死前心绞痛可延迟急性心肌梗死疾病进展,扩大再灌注治疗时间窗。     

急性心肌梗塞冠脉内溶栓与支架术疗效的比较

目的：观察急性心肌梗塞患者冠脉内溶栓及急诊置人支架术的效果。方法：根据冠状动脉造影资料，50例病人中，33例成功支架植入为支架组；17例不适合或支架失败者为冠脉内溶栓组，经导管注入50万单位尿激酶至梗塞相关血管，术中监测TIMI血流，再灌注性心律失常，心电图及心肌酶和心功能。结果：血管开通率，支架组达到97％，冠脉内溶栓组只达到59％，两组差异有显著性（P〈0．05）。结论：植入支架是急性心肌梗塞患者恢复心肌血流灌注的最好方法。对于不适合植入支架者，冠脉内溶栓也是一种值得应用的方法。     

Coronary artery stenting in unstable angina pectoris: a comparison with stable angina pectoris

OBJECTIVE: To compare early complication rates in unselected cases of coronary artery stenting in patients with stable v unstable angina. SETTING: Tertiary referral centre. PATIENTS: 390 patients with stable angina pectoris (SAP) and 306 with unstable angina (UAP). Patients treated for acute myocardial infarction (primary angioplasty) or cardiogenic shock were excluded. INTERVENTIONS: 268 coronary stents were attempted in 211 patients (30.3%). Stents used included AVE (63%), Freedom (14%), NIR (7%), Palmaz-Schatz (5%), JO (5%), and Multilink (4%). Intravascular ultrasound was not used in any of the cases. All stented patients were treated with ticlopidine and aspirin together with periprocedural unfractionated heparin. RESULTS: 123 stents were successfully deployed in 99 SAP patients v 132 stents in 103 UAP patients. Failed deployment occurred with nine stents in SAP patients, v four in UAP patients (NS). Stent thrombosis occurred in four SAP patients and 11 UAP patients. Multivariate analysis showed no relation between stent thrombosis and clinical presentation (SAP v UAP), age, sex, target vessel, stent length, or make of stent. Stent thrombosis was associated with small vessel size (p < 0.001) and bailout stenting (p = 0.01) compared with elective stenting and stenting for suboptimal PTCA, with strong trends toward smaller stent diameter (p = 0.052) and number of stents deployed (p = 0.06). Most stent thromboses occurred in vessels < 3 mm diameter. CONCLUSIONS: Coronary artery stenting in unstable angina is safe in vessels >/= 3 mm diameter, with comparable initial success and stent thrombosis rates to stenting in stable angina.     

直接冠状动脉内支架置入术对急性心肌梗死无复流的影响

目的评价直接冠状动脉(冠脉)内支架置入术对ST段抬高型急性心肌梗死无复流的影响。方法对157例ST段抬高型急性心肌梗死患者分别行直接冠脉内支架置入(直接支架组,85例)和球囊预扩张后支架置入(常规支架组,72例)。比较两组介入治疗时平均X线曝光时间、造影剂用量、术后TIMI血流分级和心电图ST段变化。结果直接支架组和常规支架组比较,前者节省球囊,平均X线曝光时间和造影剂用量均显著降低[(24.6±16.9)minvs(34.4±17.5)min,(115±37)mLvs(166±61)mL;P均<0.05];二者术后TIMI3级差异无统计学意义(91.8%vs83.3%,P=0.107);前者TIMI0~1级未见显著降低,但有明显的下降趋势(3.5%vs11.1%,P=0.064);前者心电图ST段无回落发生率显著降低(22.4%vs41.7%,P=0.009)。结论对于ST段抬高型急性心肌梗死中适当的冠脉病变,直接冠脉内支架置入术不仅可以节省球囊,减少X线曝光时间和造影剂用量,而且可能减少无复流发生。     

心肌梗死患者梗死部位存活心肌对心绞痛发作的影响

目的 :探讨心肌梗死 (MI)患者梗死部位存活心肌对心绞痛发作的影响。方法 :6 3例Q波MI患者分别行静息、硝酸甘油 (NTG)介入99mTc MIBI心肌灌注显像 ,评价梗死部位的存活心肌。结果 :① 6 3例MI患者的 5 6 7个心肌节段中 ,静息心肌显像共有 2 39个节段 (4 2 .15 % )灌注异常 ,含服NTG 1.0mg后介入心肌显像 2 39个节段中有 97个节段得到改善 ,占总异常的 4 0 .5 8% ;②不稳定型心绞痛者存活心肌检出率为 5 9.80 % ,稳定型心绞痛者为 2 9.2 9% ,两者比较差异有显著性意义 (P <0 .0 1)。结论 :①硝酸酯类药物介入显像可以提高严重灌注缺损区存活心肌的检出率 ;②MI后 ,有心绞痛发作 ,提示有较多的存活心肌     

Levels of cathepsins in acute myocardial infarction

Aims/objectiveOver expression of matrix degrading enzymes have been implicated in plaque destabilisation and rupture. Cathepsins associated with extracellular matrix breakdown make them intriguing suspects. The aim of the study was to analyse peripheral levels of cathepsin B and cathepsin K and their inhibitor cystatin C during acute myocardial infarction (AMI).Materials and methodsStudy population included AMI patients at acute event (AMI group, n=48), stable angina patients (stable angina group n = 17), and healthy individuals (Control group, n=31). Cathepsin B, cathepsin K, cystatin C, and matrix metalloproteinases (MMP)-9 were analysed by enzyme-linked immunosorbent assay (ELISA) method.ResultsCathepsin B (45.9%) and cathepsin K (92.31%) at acute event of myocardial infarction (AMI group) increased (P=0.001) while cystatin C decreased marginally (12.5%) as compared to controls. Stable angina group, demonstrated only marginal reduction in all the parameters studied as compared to controls.ConclusionCathepsin B and cathepsin K can be further evaluated as biomarkers in identifying high-risk individuals for AMI.     

急性心肌梗死后的延迟冠状动脉内支架植入治疗

目的　评估急性心肌梗死后梗死相关冠状动脉内支架植入的临床疗效。方法　 15 4例急性心肌梗死患者 ,平均年龄 (6 1± 12 )岁于发病后平均 13天行冠状动脉内支架术 ,所有患者常规服用肠溶阿司匹林和噻氯匹定。观察住院期和随访期的临床事件。结果　 15 4例患者共植入 173个支架 (平均 1 1个 /例 )。支架植入的指征 :选择性初发病变 (denovo)占 2 4 3 % ,急性或濒危闭塞占13 9% ,有发生闭塞高危因素的病变占 6 1 8%。所用支架主要为Nir支架 (2 6 % )、Multi Link支架(19% )、XT支架 (13% )、Crossflex支架 (10 % ) ,等等。支架植入时最大球囊充盈压力为 (12± 2 )大气压。平均残余狭窄 (7± 8) %。住院期间无一例死亡、心肌梗死和需重复再通治疗 ,但术后“微坏死(micronecrosis)”率为 1 3%。术后 6个月病死率为 3 9% ,Q波型或非Q波型心肌梗死率为 1 9% ,支架内再狭窄而行再次冠状动脉腔内成形术率 6 1%。总的无心脏事件存活率为 89 6 %。结论　心肌梗死后行冠状动脉内支架术是安全的 ,并能改善患者的近期预后 ,但其远期疗效尚需进一步研究。     

Prognostic significance of plasma osteopontin levels in patients with chronic stable angina.

AIMS: Levels of the secreted glycophosphoprotein osteopontin (OPN) have been associated with the presence and extent of coronary artery disease (CAD). The present study assessed the relationship between plasma OPN concentrations and prognosis in patients with chronic stable angina (CSA). METHODS AND RESULTS: OPN was measured in baseline plasma samples from 799 patients with stable angina pectoris and angiographically documented CAD. Participants were prospectively followed-up for a median of 2.7 years (maximum 4.1 years). The primary study endpoint was the composite of non-fatal myocardial infarction and death from cardiovascular causes. In the univariate Cox proportional hazard analysis, the log-transformed OPN level [hazard ratio (HR) 1.79, 95% CI 1.35-2.36, P < 0.001] was significantly related to adverse outcome. In addition, hypertension, levels of C-reactive protein, and statin use were associated with future adverse events. Levels of OPN (HR, 1.88; P < 0.001) and C-reactive protein (HR, 1.42; P = 0.003), as well as the presence of hypertension (HR, 2.39; P = 0.008) remained statistically significant, independent predictors of adverse cardiovascular outcome in a multivariable Cox proportional hazard analysis. CONCLUSION: Baseline levels of OPN are an independent predictor of future adverse cardiac events in patients with CSA and may be useful for risk stratification.     

老年急性心肌梗死患者冠状动脉内支架置入术的临床疗效

目的：评价老年急性心肌梗死（AMI）患者梗死相关动脉支架置入术的疗效及安全性。方法：对41例年龄≥70岁的老年急性心肌梗死患者在发病12h以内行梗死相关动脉直接经皮冠状动脉腔内成形术（PTCA）加冠状动脉内支架置入术。梗死相关动脉：前降支21例（51．2％）,回旋支7例（17．1％）,右冠状动脉13例（31．7％）。心肌梗死溶栓治疗临床试验（TIMI）血流：0级29例,1级7例,2级5例。结果：41例患者梗死相关动脉共置入支架48个,术中死亡1例,死于心源性休克,手术成功率97．6％（40／41）。术后TIMI血流3级为37例（90．2％）。住院期间死亡1例,死于肾功能衰竭。临床总成功率为95．1％（39／41）。随访36例,1例出现心绞痛,心血管造影证实为再狭窄,行切割球囊成形术;1例出院后因充血性心力衰竭再次入院治疗;其余34例未再发心绞痛。结论：老年AMI患者梗死相关动脉PTCA加支架置入术成功率高、并发症低,近期临床疗效确切。     

冠状动脉内自体骨髓单个核细胞移植治疗急性心肌梗死患者的疗效

目的:探讨急性心肌梗死患者自体骨髓单个核细胞经冠状动脉移植的安全性和对心功能的保护作用。方法:2003年3月以来,84例急性心肌梗死患者急诊静脉溶栓或急诊经皮冠状动脉成形术(PTCA)加支架治疗后2周内行择期冠状动脉造影或PTCA加支架治疗,其中50例抽取骨髓40ml,提取单个核细胞,经冠状动脉注入,另34例不做自体骨髓单个核细胞经冠状动脉移植,作为对照组。81例患者术前和术后6个月、2年均行多巴酚丁胺负荷试验(另3例未完成超声心动图随访观察)。结果:治疗组患者临床随访无明显不良反应,心功能明显改善,运动耐量增加。多巴酚丁胺负荷试验左室射血分数(LVEF)和室壁运动记分指数(WMSI)显著改善,峰值LVEF和WMSI与基础状态LVEF和WMSI的差值在治疗前后相比,与对照组相比均差异有统计学意义。结论:自体骨髓单个核细胞经冠状动脉移植治疗急性心肌梗死患者,经6个月～2年的临床观察无明显不良反应,具备安全性,多巴酚丁胺负荷试验显示出自体骨髓单个核细胞治疗对梗死后心功能有保护作用。     

Acute myocardial infarction associated with acute gouty arthritis

The association of hyperuricemia with increased risk of atherosclerosis has been reported in previous studies but the link of acute gouty arthritis, hyperuricemia and acute myocardial infarction (MI) is not seen frequently. Here we report a 33 year old male who presented with hyperuricemia, acute gouty arthritis and acute myocardial infarction. Hyperuricemia contributed not only to accelerated atherosclerosis but might be blamed for promoting environment for acute myocardial infarction.