aVR导联ST段抬高在预测非ST段抬高型急性心肌梗死患者预后中的价值

目的探讨aVR导联ST段抬高在预测首次非ST段抬高型急性心肌梗死患者短期预后中的价值。方法分析426例非ST段抬高型急性心肌梗死患者入院心电图。结果aVR导联无ST段抬高(n=281)、抬高0.05~0.1mV(n=68)和抬高≥0.1mV(n=77)患者的住院死亡率分别是1.8%、7.4%和15.6%。调整基线预测因子和入院时ST段压低的影响,aVR导联ST段抬高0.05~0.1mV和抬高≥0.1mV患者死亡的优势比分别是4.2(95%可信区间为1.4~13.5;P<0.001)和6.1(95%可信区间为2.4~17.3;P<0.001)。住院期间复发心肌缺血事件和心力衰竭发生率随aVR导联ST段抬高程度增加而增加,而不同程度aVR导联ST段抬高患者血清肌酸激酶和肌酸激酶同工酶相似。aVR导联无ST段抬高、抬高0.05~0.1mV和抬高≥0.1mV患者左主干或3支血管病变发生率分别为16.9%、37.1%和56.2%(P<0.001)。结论首次非ST段抬高型急性心肌梗死伴aVR导联ST段抬高患者预后较差,而这种差的预后与严重的冠状动脉病变有关,对这些患者进行早期介入治疗也许有重要的益处。     

Papillary Muscle Rupture Following Non‐ST‐Elevation Myocardial Infarction: A Case Report

Papillary muscle rupture is a serious mechanical complication of acute myocardial infarction typically seen within 5–7 days following transmural ST‐elevation myocardial infarction. The incidence of papillary muscle rupture has markedly decreased in the modern era due to improved diagnosis and early coronary revascularization of ST‐elevation myocardial infarction. As a result, papillary muscle rupture is increasingly seen following non‐ST‐elevation myocardial infarction where both diagnosis and revascularization can be delayed. In this report, we describe two cases of papillary muscle rupture following delayed presentation of non‐ST‐elevation myocardial infarction and delayed recognition of papillary muscle rupture.     

Essential Thrombocythemia: A Case of Acute ST‐Segment Elevation Myocardial Infarction in a Young Female

Essential thrombocythemia (ET) is a clonal disorder of the myeloid stem cell that causes abnormal proliferation of the megakaryocytes. The main feature of the disease is arterial and venous thrombosis caused by platelet dysfunction. Coronary artery involvement leading to acute coronary syndromes is a rare complication of the ET. We report a coronary angioplasty and stenting in a 30‐year‐old female patient with acute ST‐segment elevation myocardial infarction (MI) as the first clinical sign of essential thrombocythemia. Facilitated percutaneous coronary intervention with GPIIb/IIIa and/or thrombolytic therapy may be considered as the first treatment modality for this patient group. Copyright © 2009 Wiley Periodicals, Inc.     

急性ST段抬高心肌梗死患者再灌注心电图变化及其可能的影响因素

目的 探讨急性ST段抬高心肌梗死(STEMI)患者缺血再灌注损伤心电图改变及其发生机理.方法 分析60例STEMI患者再灌注治疗(溶栓或冠状动脉介入治疗)后缺血再灌注损伤性心电图改变特点及影响因素;根据再灌注治疗后是否发生再灌注损伤性心电图改变而将患者分为再灌注损伤性心电图改变组和再灌注无损伤性心电图改变组;抽静脉血测定活性氧(ROS)、丙二醛(MDA)、还原型谷胱甘肽(GSH)、总抗氧化力(T-AOC)及γ-谷氨酰半胱氨酸合成酶(γ-GCS)活性.结果 再灌注心电图心律失常发生率高(65.00%),且以加速性室性自主心律最多见,其次非持续性室速、窦缓和房室传导阻滞;并易出现再灌注损伤性ST段抬高(46.67%).单因素分析发现冠状动脉血管病变数目、发病至CK达高峰时间、再灌注时间与STEMI患者易发再灌注损伤性心电图改变有关(P<0.05).溶栓治疗再灌注损伤性心电图改变发生率高于冠状动脉介入治疗(P<0.05).再灌注心电图改变组血清ROS、MDA显著增高而GSH、T-AOC显著降低;γ-GCS活性高于对照组和缺血组(P<0.05).结论 STE-MI患者缺血再灌注后再灌注损伤性心律失常与ST段抬高较常见;再灌注复氧后产生氧自由基增多,自由基生成系统/清除系统失衡,可能是发生再灌注损伤性心电图改变重要机制.     

Mid‐Ventricular Obstructive Hypertrophic Cardiomyopathy and Apical Aneurysm Mimicking Acute ST‐Elevation Myocardial Infarction

Nonischemic ST‐segment elevation may be confused as acute ST‐elevation myocardial infarction (STEMI), especially in patients with atypical presenting symptoms. Among the possible differential diagnosis, hypertrophic cardiomyopathy (HCM) should be considered. Mid‐ventricular obstructive hypertrophic cardiomyopathy (MVOHCM) is a rare type of cardiomyopathy, accounting for approximately 5% of all HCM cases. ST‐segment elevation on electrocardiogram (ECG) in patients with MVOHCM is a rare clinical presentation. We present a case of MVOHCM and apical aneurysm mimicking acute STEMI     

急性ST段抬高型心肌梗死的急诊介入治疗与择期介入治疗预后对比

目的 观察急诊介入治疗与择期介入治疗对急性ST段抬高型心肌梗死患者的治疗效果及预后.方法 回顾性分析524例急性ST段抬高型心肌梗死患者的临床资料.其中471例来诊时在急诊冠状动脉介入治疗时间窗内,行急诊冠状动脉介入治疗(急诊介入治疗组);53例来诊时已超出急诊介入治疗时间窗,常规保守治疗7～10天后择期行冠状动脉介入...     

Prognostic Value of TIMI Score versus GRACE Score in ST-segment Elevation Myocardial Infarction

Background

The TIMI Score for ST-segment elevation myocardial infarction (STEMI) was created and validated specifically for this clinical scenario, while the GRACE score is generic to any type of acute coronary syndrome.

Objective

Between TIMI and GRACE scores, identify the one of better prognostic performance in patients with STEMI.

Methods

We included 152 individuals consecutively admitted for STEMI. The TIMI and GRACE scores were tested for their discriminatory ability (C-statistics) and calibration (Hosmer-Lemeshow) in relation to hospital death.

Results

The TIMI score showed equal distribution of patients in the ranges of low, intermediate and high risk (39 %, 27 % and 34 %, respectively), as opposed to the GRACE Score that showed predominant distribution at low risk (80 %, 13 % and 7%, respectively). Case-fatality was 11%. The C-statistics of the TIMI score was 0.87 (95%CI = 0.76 to 0.98), similar to GRACE (0.87, 95%CI = 0.75 to 0.99) - p = 0.71. The TIMI score showed satisfactory calibration represented by χ2 = 1.4 (p = 0.92), well above the calibration of the GRACE score, which showed χ2 = 14 (p = 0.08). This calibration is reflected in the expected incidence ranges for low, intermediate and high risk, according to the TIMI score (0 %, 4.9 % and 25 %, respectively), differently to GRACE (2.4%, 25% and 73%), which featured middle range incidence inappropriately.

Conclusion

Although the scores show similar discriminatory capacity for hospital death, the TIMI score had better calibration than GRACE. These findings need to be validated populations of different risk profiles.     

Direct Stenting Versus Pre‐Dilation in ST‐Elevation Myocardial Infarction: A Systematic Review and Meta‐Analysis

Objectives

This study aimed at comparing direct stenting (DS) versus stenting with pre‐dilation (SP) in patients with ST‐elevation myocardial infarction (STEMI), using a systematic review and meta‐analysis of published evidence.

Background

There is conflicting evidence whether stenting strategy impacts clinical outcomes in patients with STEMI.

Methods

We searched EMBASE, MEDLINE, and CENTRAL, from inception to December 2014. The primary endpoint was mortality. Secondary endpoints included major adverse cardiac events (MACEs), ST‐segment resolution, and angiographic outcomes.

Results

A total of 9,331 patients enrolled in 12 studies (3 randomized controlled trials, RCTs; 9 non‐randomized studies, NRSs) were included. DS was associated with lower mortality (OR 0.55; 95%CI: 0.33–0.94; P = 0.03) in NRSs, and overall (OR 0.56; 95%CI: 0.37–0.86; P = 0.008). Mortality was non‐significantly reduced in RCTs (OR 0.56; 95%CI: 0.26–1.23; P = 0.15). DS was also associated with lower MACE rate (OR 0.71; 95%CI 0.60–0.84; P < 0.0001) in NRSs, but not in RCTs (OR 0.99; 95%CI: 0.61–1.60; P = 0.96). ST‐segment resolution, no reflow, final thrombolysis in myocardial infarction (TIMI) flow and final TIMI myocardial perfusion or blush grade were significantly better with DS in NRSs, and non‐significantly better in RCTs.

Conclusions

The available evidence suggests that DS in STEMI might be associated with better clinical and procedural outcomes, as compared with SP. However, the fact that RCTs account for the minority of available data and that most of the available studies poorly reflect current clinical practice, as well as the existence of publication bias, preclude drawing definitive conclusions.

     

Successful Management of Neonatal Myocardial Infarction with ECMO and Intracoronary r‐tPA lysis

Acute myocardial infarction (MI) is a life‐threatening condition rarely encountered in neonates. The patients usually present with sudden cardiogenic shock. Clinical management in neonates is extremely challenging. If treatment is delayed, the prognosis is dismal. We report on a 4‐day‐old full‐term male newborn presenting with acute MI and cardiogenic shock secondary to proximal thromboembolic occlusion of the left descending coronary artery. Hemodynamic stabilization could only be achieved after extracorporeal membrane oxygenation (ECMO) support. Coronary artery patency restoration was performed by selective intracoronary lysis with recombinant tissue plasminogen activator (r‐tPA). ECMO support could be discontinued and myocardial function recovered within 6 weeks. We discuss the potential etiologies of acute perinatal MI and the role of ECMO support in the immediate post‐MI period. Prompt recognition, timely referral to a cardiac center with availability of specialized advanced treatment options, and management in an orchestrated interdisciplinary approach are crucial for achieving a good outcome.     

急性非ST段抬高性心肌梗死患者冠状动脉病变特点及其临床意义

目的分析急性非ST段抬高性心肌梗死患者冠状动脉病变特点及其临床意义。方法选择冠状动脉造影资料与临床资料完整的急性非ST段抬高性心肌梗死83例,以及同期急性ST段抬高性心肌梗死109例,分别就冠状动脉病变支数、狭窄程度、侧枝循环形成情况及临床特征进行对比分析。结果急性非ST段抬高性心肌梗死患者单支病变较ST段抬高性心肌梗死患者少(P<0.05),非ST段抬高性心肌梗死患者三支病变较ST段抬高性心肌梗死患者多(P<0.05),非ST段抬高性心肌梗死患者≥90%的狭窄病变较ST段抬高性心肌梗死患者多,但<90%的狭窄病变较ST段抬高性心肌梗死患者少(P<0.05),而两组间血管100%闭塞情况相似(P>0.05);非ST段抬高性心肌梗死患者Ⅱ级以上的侧枝循环较ST段抬高性心肌梗死患者多见(P<0.05);非ST段抬高性心肌梗死患者既往心绞痛与陈旧性心肌梗死病史多见(P<0.05),肌酸激酶同工酶峰值较ST段抬高性心肌梗死组明显要低(P<0.01),急性肺水肿、心源性休克、致死性心律失常等严重急性并发症比ST段抬高性心肌梗死组明显要少(P<0.05),左心室射血分数、住院期间死亡率和随访3年的冠心病死亡率与ST段抬高性心肌梗死组相似(P>0.05),而梗死后心绞痛比ST段抬高性心肌梗死组则明显增多(P<0.05)。结论急性非ST段抬高性心肌梗死冠状动脉病变相对复杂,多支及严重狭窄病变多,发作前多已有缺血预适应,且侧枝循环多见,这是心肌梗死形成非ST段抬高的主要原因,也决定了非ST段抬高性心肌梗死患者的临床特征。     

Mid‐ventricular Obstructive Hypertrophic Cardiomyopathy during Pregnancy Complicated by Preeclampsia and Acute Myocardial Infarction: A Case Report

Hypertrophic cardiomyopathy (HCM) with mid‐ventricular obstruction (MVO) is a rare condition occurring in 1% of HCM patients. It is characterized by asymmetric left ventricular hypertrophy with MVO and elevated intraventricular pressure gradients. Myocardial infarction has been associated with mid‐ventricular obstructive HCM. Briefly, this case presents an unusual clinical scenario where a young pregnant woman complicated by preeclampsia presents with myocardial injury and hemodynamic compromise related to undiagnosed HCM with MVO illustrating hemodynamic challenges created by pregnancy and surgery.     

Relationship Between ST‐Segment Morphology and Conduction Disturbances Detected by Signal‐Averaged Electrocardiography in Brugada Syndrome

Background: Although arrhythmogenesis of Brugada syndrome is still unknown, it has been reported to be associated with conduction disturbances. Two ST‐segment morphologies (coved and saddle‐back patterns) have been described in this syndrome. No study has sought to determine which morphology has stronger conduction disturbances, thereby associating with life‐threatening events. Methods: Forty‐six patients who presented the Brugada‐type ECG with either of a characteristic coved (n = 25) or saddle‐back (n = 21) pattern of ST‐segment morphology underwent signal‐averaged ECG (SAECG). SAECG parameters, and the history of life‐threatening events defined as syncope or aborted sudden death, were compared between groups. Results: Although filtered QRS duration did not differ between groups, the incidence of late potentials in the coved group was higher than in the saddle‐back group (22 patients (88%) versus 4 patients (19%); P < 0.01), showing lower RMS₄₀ and longer LAS₄₀. Life‐threatening events occurred in 17 patients (68%) in the coved group and 7 patients (33%) in the saddle‐back group (P = 0.02) . Conclusion: The coved pattern of ST segment was more closely related to conduction disturbances than the saddle‐back pattern in patients with Brugada‐type ECG. Life‐threatening events were more common in patients with the coved ST‐segment elevation. Conduction disturbances in the coved pattern of ST segment may reflect a substrate of arrhythmogenesis in Brugada syndrome.     

一种快捷小鼠心肌梗死模型的建立

目的建立一种快速高效不需要通气辅助呼吸的小鼠心肌梗死模型制作方法,并对制作过程中的技巧细节进行分析。方法 40只C57/B6雄性小鼠,随机分成手术组(25只)和对照组(15只),于麻醉状态下在左侧第3,4肋间隙挤出心脏,手术组结扎冠状动脉左前降支建立小鼠心肌梗死模型;对照组不结扎冠状动脉,其余操作与手术组相同。28天后,心脏超声系统进行心功能测定对比,解剖进行形态对比和病理染色对比心肌梗死和纤维化。结果至术后第28天,手术组心肌梗死小鼠的生存率80%,对照组的小鼠生存率100%。超声检测显示28天后手术组小鼠心功能明显降低,与对照组相比,手术组心室明显扩大,左心室舒张期末内径由3.52±0.10 mm扩大到4.65±0.08 mm(P<0.0001),左心室收缩期末内径由2.60±0.19 mm扩大到4.36±0.13 mm(P<0.0001);左心室射血分数由66.70%±1.41%下降到29.70%±1.64%(P<0.0001),左心室缩短分数由35.90%±1.01%下降到14.20%±0.80%(P<0.0001)。肉眼可见手术组小鼠心脏左心室心腔变大,心室壁明显变薄,梗死面积可达45.10%±1.53%;HE、免疫组织化学、Masson病理染色可见有明显纤维瘢痕形成,有大量炎细胞浸润。结论此种方法制备心肌梗死模型高效快捷,动物死亡率低,结果明显,是一种较好的方法。