冠状动脉介入术后亚急性血栓致急性心肌梗死二例

[例1] 男,70岁.主因阵发性胸闷、胸痛3年,加重3 d人院.既往有高血压病及帕金森病史.查体:血压180/80 mmHg,心率为80/min,律齐,各瓣膜听诊区未闻及病理性杂音,心界不大.心电图示:窦性心律,T波倒置或双向(Ⅲ,Ⅴ<,1～4>).     

冠状动脉介入术后亚急性血栓致急性心肌梗死二例

[例1] 男,70岁.主因阵发性胸闷、胸痛3年,加重3 d人院.既往有高血压病及帕金森病史.查体:血压180/80 mmHg,心率为80/min,律齐,各瓣膜听诊区未闻及病理性杂音,心界不大.心电图示:窦性心律,T波倒置或双向(Ⅲ,Ⅴ<,1～4>).     

无负荷量替罗非班在老年急性冠状动脉综合征患者介入术中的应用

目的研究老年急性冠状动脉综合征（ACS）患者经皮冠状动脉介入（PCI）术中应用无负荷量替罗非班的有效性及安全性。方法将180例老年ACS患者按入院顺序随机分为替罗非班非负荷量组、负荷量组和对照组,各60例。非负荷量组PCI术中（导丝通过病变后即刻）替罗非班以0．15μg／（kg·min）的剂量维持静脉滴注24h,负荷量组PCI术中替罗非班以10μg/kg于3min内推注完毕,后0．15μg/（kg·min）的剂量维持静脉滴注24h。对照组不使用替罗非班。比较3组术中、术后血小板聚集率的水平,PCI术后即刻罪犯血管（CV）的心肌梗死溶栓试验（TIMI）血流分级,术前与术后心肌酶[肌酸激酶（CK）,肌酸激酶同T酶（CK—MB）,乳酸脱氢酶（LDH）,心肌肌钙蛋白I（cTnI）]变化,以及术后30d内的主要不良心血管事件（MACE）、术后出血的发生率。结果与对照组相比,替罗非班非负荷量组和负荷量组血小板聚集率明显下降,术后心肌酶水平明显降低,30d内的MACE事件发生率也降低[血小板聚集率：用药后12h对照组（58．5±1．5）％、非负荷量组（28．6±1．4）％、负荷量组（32．6±3．2）％,用药后24h对照组（57．9±2．3）％、非负荷量组（44．2±1．7）％、负荷量组（46．1±1．9）％;心肌酶CK—MB：对照组（16．6±3．5）U／L、非负荷量组（13．3±2．2）U／L、负荷量组（12．5±4．0）U／L;LDH：对照组（298±61）U／L、非负荷量组（245±52）U／L、负荷量组（257±48）U／L;cTnI：对照组（0．78±0．17）μg/L、非负荷量组（0．37±O．18）μg/L、负荷量组（0．28±0．23）μg/L;30d内的MACE事件发生率：3．3％（2／60）、1．7％（1／60）比13．3％（8／60）,均P〈0．05]。非负荷量组和负荷量组血小板聚集率、心肌酶水平、CV的TIMI血流分级、30d内的MACE事件、出血并发症发生率比较,差异均无统计学意义（均P〉0．05）。结论老年ACS患者介入术中使用无负荷量替岁非班,能明显降低血小板聚集率,改善CV的TIMI血流,减少不良心脏事件。     

生物可降解支架在经皮冠状动脉介入治疗中的应用

生物可降解支架是近年来用于经皮冠状动脉介入治疗的新型支架。该类支架具有晚期血栓形成发生率低、对边支影响小、对血管内皮功能影响小等优点。本文对生物可降解支架所使用的材料、目前使用的生物可降解支架种类、临床试验结果、各种冠脉病变时生物可降解支架的使用等作一简述。     

护理干预在经皮冠状动脉介入治疗中的效果观察

经皮冠状动脉介入治疗(PCI)技术已成为冠心病的一种最常用、最成熟的方法之一。目前,PCI已发展为球囊扩张、成形术、支架术、斑块旋磨术等为主体的一系列综合技术。操作途经采用桡动脉、股动脉两种,具有创伤小、病人痛苦少、操     

急诊冠状动脉介入治疗对急性心肌梗死患者左心室功能的影响研究

目的应用超声心动图(ECHO)分析评价急诊经皮冠状动脉介入术(PCI)及静脉溶栓治疗对急性心肌梗死(AMI)患者左心室功能的影响。方法 60例AMI患者,随机分为PCI组(30例)与溶栓组(30例),两组的内科治疗相同。应用彩色多普勒超声测定两组患者治疗后第2、4周的左室舒张末期内径(LVD)、左室舒张末期容积(LVEDV)、左室收缩末期容积(LVESV)、射血分数(EF)及左室短轴缩短率(FS)的变化情况,以评价左心室功能。结果 PCI组患者治疗后第4周与第2周LVD、LVEDV、LVESV比较差异均无统计学意义(P>0.05),EF及FS比较差异均有统计学意义(P<0.05)。溶栓组患者治疗后第4周与第2周LVD、LVEDV、LVESV比较差异均有统计学意义(P<0.05);EF及FS比较差异均无统计学意义(P>0.05,);溶栓组治疗第2、4周的LVD、LVEDV、LVESV、EF及FS与PCI组比较差异均有统计学意义(P<0.05)。结论直接PCI开通梗死相关动脉,改善左室重构,提高左心室功能较静脉药物溶栓疗效显著。     

雷帕霉素药物洗脱支架在冠状动脉介入治疗中的疗效

目前，冠心病介入治疗已经进入了药物洗脱支架时代，其为解决经皮冠状动脉介入治疗（Percutaneous coronary intervention，PCI）后再狭窄这一难题带来了新的希望。雷帕霉素通过影响细胞周期调节蛋白，抑制G1期至S1期的细胞分裂，抑制血管平滑肌细胞（VSMC）过渡增殖及迁移，减轻炎症反应而减少再狭窄。本文旨在总结我院应用雷帕霉素洗脱支架（SES，Cypher）的初步经验，进一步了解雷帕霉素洗脱支架在PCI临床应用的安全性和有效性。     

冠状动脉介入治疗后不典型急性心包填塞二例

[例1]男,61岁.急性下壁心肌梗死20天冠状动脉介入治疗(PCI)术后半小时,病人排尿1 500 ml后,突然出现持续性胸闷、气短,血压由130/80 mmHg下降至40/?mmHg,呼吸40/min,尚可平卧,口唇无发绀,颈静脉无怒张,肺无罗音,心率38/min,肝脾不大,未见心音遥远、奇脉等体征,心电示波交界区性心律,初步诊断为大量排尿引起迷走反射,立即给予阿托品、扩容升压等处理,很快恢复窦性心律,90～110/min,血压波动在90～100/50～60 mmHg,经过近1小时观察,症状无明显缓解,血压一直需用大量升压药物维持.     

急性ST段抬高型心肌梗死溶栓治疗后经皮冠状动脉介入治疗的必要性和时机

溶栓治疗和经皮冠状动脉介入治疗(PCI)是急性ST段抬高型心肌梗死后恢复冠状动脉血液供应的两种有效方法。溶栓治疗后PCI的必要性一直存在争论。本文对球囊时代和支架时代单纯溶栓治疗和溶栓治疗后PCI的疗效作比较,论证急性ST段抬高型心肌梗死溶栓治疗后PCI的策略和时机。     

经皮冠状动脉介入术治疗冠状动脉左主干病变疗效观察

目的 观察经皮冠状动脉介入术(PCI)治疗无保护冠状动脉左主干(ULMCA)病变的疗效.方法 对40例ULMCA病变患者采用PCI治疗,随访6～20个月,观察心血管不良事件(MACE)的发生情况.结果 所有患者经PCI治疗即时成功率100.0％,术中无严重并发症.住院期间未发生严重心血管不良事件.术后随访6～20(7±2)个月,术后4周发生急性心肌梗死l例,CAG证实回旋支开口亚急性支架内血栓形成,再次PCI治愈;术后动员28例患者在6～12个月进行CAG复查,其中回旋支开口支架内再狭窄3例,左主干远端-前降支开口再狭窄1例,2例再狭窄患者有心绞痛症状,3例再次行PCI,无需要CABG患者.随访期间无死亡病例.心血管不良事件总的发生率12.5％ (5/40),再狭窄率10.0％(4/40).结论 对经过选择的ULMCA病变进行PCI是安全可行的,有良好的近远期预后.     

The Role of Clopidogrel in Revascularized and Nonrevascularized Patients with Acute Coronary Syndromes

Despite many recent advancements in the treatment of coronary heart disease, it continues to be an important source of patient morbidity and mortality as well as a significant source of healthcare-related expenditures. Clopidogrel has become an integral part of the management of acute coronary syndromes (ACS) and, consequently, has become one of the world's best selling drugs. Numerous trials have demonstrated the clinical efficacy of clopidogrel in revascularized and nonrevascularized ACS including unstable angina as well as non-ST elevation and ST-elevation myocardial infarction. As a result of these trials, the use of clopidogrel has been incorporated into the American College of Cardiology/American Heart Association guidelines. Additionally, numerous analyses have proven clopidogrel to be highly cost effective. However, clopidogrel remains underutilized and guideline adherence remains inadequate despite the robust clinical data and guidelines. Institution of disease-management programs and quality-improvement initiatives appear to be an excellent strategy to promote guideline adherence and appropriate use of clopidogrel.     

Evidence-Based Medical Therapy of Patients with Acute Coronary Syndromes

Acute coronary syndromes (ACS) present a major health challenge in modern medicine. With new clinical trials being conducted, our knowledge of latest therapies for ACS continually evolves. In this article, we review currently available medical therapies and provide evidence-based rationale for current pharmacologic therapies. Among the antiplatelet therapies, aspirin, clopidogrel, and glycoprotein IIb/IIIa inhibitors demonstrate significant efficacy in reducing morbidity and mortality. Among the anticoagulants, unfractionated heparin and low molecular weight heparin, particularly enoxaparin sodium, remain the hallmarks of therapy against which newer anticoagulants are often compared. Bivalirudin has recently showed significant efficacy in decreasing cardiovascular events and mortality, but with potentially less risk of bleeding than heparin. Results of trials evaluating warfarin remain inconsistent regarding potential benefits. Finally, fondaparinux sodium, recently tested, shows promise as a powerful yet safe anticoagulant. Fibrinolysis is an acceptable modality for reperfusion if facilities equipped for primary percutaneous revascularization are not available. Regarding anti-ischemic therapy, beta-adrenoceptor antagonists and nitrates remain critical in the early management of ACS. Inhibitors of the renin-angiotensin-aldosterone system have also shown significant reductions in the morbidity and mortality of patients presenting with ACS, particularly in patients with left ventricular dysfunction and clinical heart failure, with ACE inhibitors being first-line agents and angiotensin receptor antagonists being a reasonable substitute if ACE inhibitors are not tolerated. Among the lipid-lowering therapies, statins (HMG-CoA reductase inhibitors) have been documented as being the most well tolerated and most efficacious therapies for ACS patients and data exist that they should be administered early in ACS management. Studies evaluating combination therapy (antiplatelet drugs, beta-adrenoceptor antagonists, ACE inhibitors, and lipid-lowering agents) show a clear benefit in mortality in patients with known coronary artery disease. Efforts to improve these key evidence-based medical therapies are numerous and include such programs as the American College of Cardiology's Guidelines Applied in Practice, international patient registries such as the Global Registry of Acute Coronary Events, and studies such as CRUSADE. Finally, patients with diabetes mellitus pose a challenge to clinicians both in terms of their glycemic control and in their apparent relative resistance to antiplatelet therapy. Studies involving ACS patients suggest that stringent glycemic control may result in benefits in both morbidity and mortality.     

替罗非班在血栓抽吸前后使用对急性ST段抬高型心肌梗死患者的影响

目的比较在急性ST段抬高心肌梗死(STEMI)患者急诊经皮冠状动脉介入(PCI)术中,血栓抽吸导管前后使用替罗非班对心肌再灌注水平、术后不良事件的影响。方法 153例接受急诊PCI术的急性STEMI患者,造影证实病变处有明显血栓负荷后,将患者随机分为A、B 2组,A组80例患者为血管造影后使用替罗非班,再进行血栓抽吸,最后行PCI治疗,B组73例为血管造影后行血栓抽吸,再使用替罗非班,最后行PCI治疗。比较2组心肌再灌注水平、不良事件发生率。结果 A组和B组患者在心肌呈色分级、出院时射血分数(EF)值方面有显著性差异,A组患者显示有较好的预后。但2组间心肌梗死溶栓(TIMI)血流、校正的心肌梗死溶栓帧数(CT-FC)、ST段回落率、住院期间不良事件发生率差异无统计学意义(P>0.05)。结论在接受急诊PCI术的急性STEMI患者中,血栓抽吸前使用替罗非班较血栓抽吸后使用对改善心肌再灌注及出院时的EF值有利。     

动脉内接触性溶栓及机械碎栓治疗急性脑梗死效果观察

目的：观察超选择性动脉内接触性溶栓及机械碎栓治疗急性脑梗死临床效果。方法对2006年1月-2014年1月收治的时间窗内急性脑梗死28例给予超选择性动脉内接触性溶栓及机械碎栓,同时给予扩容、抗血小板等治疗,评价治疗后即刻血管再通率、术后1 h、2周、3个月美国国立卫生研究院脑卒中量表（ NIHSS）、日常活动量表（ ADL）评分情况。结果本组动脉内接触性溶栓后即刻血管完全再通率为75%,部分再通率为25%,4例血管再通后残留狭窄〉80%,给予支架置入术;除1例死于中枢性呼吸衰竭外,其余27例术后1 h、2周、3个月NIHSS、ADL评分较治疗前改善（ P〈0.05）。结论动脉内接触性溶栓结合机械碎栓治疗时间窗内急性脑梗死安全、有效。     

替格瑞洛在中国急性冠脉综合征患者中的早期疗效及安全性观察

目的 探讨替格瑞洛在中国急性冠脉综合征（ACS）患者中的早期疗效及总结治疗经验。方法 2012年9月～2013年7月入我院心内科诊断为ACS的患者199例,其中服用替格瑞洛患者96例,服用氯吡格雷患者103例。替格瑞洛组给予180 mg负荷剂量口服,后90 mg每日2次维持。氯吡格雷组给予300/600 mg口服,后服用氯吡格雷维持剂量75 mg每日1次,所有患者均给予阿司匹林。比较两组的基础临床资料,观察两组服药10天、30天、90天的不良事件,并对两组90天的心血管事件和出血情况进行比较。结果 两组间基础临床资料无统计学差异（P〉0.05）。替格瑞洛组心血管死亡（1%：1.9%）、心肌梗死（0%：1%）、卒中（0%：1.9%）、支架内血栓（0%：1%）、再发心绞痛（2.1%：4.9%）少于氯吡格雷组,呼吸困难（2.1%：0%）、次要出血（3.1%：1.0%）和轻微出血（5.2%：2.9%）多于氯吡格雷组,但均无统计学意义（P〉0.05）。替格瑞洛组主要心血管不良事件总和低于氯吡格雷组（3.1%：10.7%）,差异有统计学意义（P=0.037）。两组均无主要出血。替格瑞洛组次要出血和轻微出血总和高于氯吡格雷组（8.3%：3.9%）,但差异无统计学意义（P=0.188）。结论 替格瑞洛在中国患者中的早期疗效与PLATO（血小板抑制和患者预后研究）研究结果 基本一致,临床疗效确切,具有良好的安全性和耐受性。     

Prior Antiplatelet Use and Cardiovascular Outcomes in Patients Presenting with Acute Coronary Syndromes

Background

Although antiplatelet therapy effectively reduces ischemic events, the cardiovascular (CV) outcome in some cases is still unpredictable.

Objective

The objective of this study was to evaluate the impact of prior single or dual antiplatelet (PAP) use in patients presenting with acute coronary syndromes (ACS).

Methods

Data were collected from the 2nd Gulf Registry of Acute Coronary Events between October 2008 and June 2009. Patients were grouped according to whether they were PAP users or not (NAP). Patients’ characteristics and outcomes were analyzed and compared. Mortality was assessed at 1 and 12 months.

Results

Among 7827 consecutive ACS patients, 41% were PAP users (70% aspirin, 1% clopidogrel, and 29% dual antiplatelet agents). In comparison with NAP use, PAP use was associated with a higher rate of comorbidities, atypical presentation, severe left ventricular dysfunction, three-vessel disease, and a high GRACE risk score. After adjustment for relevant covariates, PAP use was an independent predictor for recurrent ischemia in unstable angina (odds ratio [OR] 1.7; 95% CI 1.17, 2.57) and non-ST-elevation myocardial infarction (NSTEMI) [OR 1.9; 95% CI 1.38, 2.65] and for heart failure in NSTEMI (OR 1.5; 95% CI 1.11, 2.15) and STEMI (OR 1.4; 95% CI 1.08, 1.93). Although PAP use was associated with high mortality in STEMI and NSTEMI, it was not an independent predictor for mortality. Among PAP patients, percutaneous coronary intervention independently reduced the risk of hospital (adjusted OR 0.25; 95% CI 0.20, 0.32), 1-month (OR 0.31; 95% CI 0.26, 0.37), and 12-month mortality (OR 0.28; 95% CI 0.24, 0.33).

Conclusion

PAP use identified a high-risk population across the ACS spectrum. Early coronary revascularization may improve CV outcomes in these patients.     

他汀强化治疗对急性冠脉综合征MMP-9的影响

目的研究早期他汀强化治疗对急性冠脉综合征患者基质金属蛋白酶-9和预后的影响。方法183例急性冠脉综合征患者随机分为他汀治疗组和对照组,入院第2天和治疗4周后分别测定基质金属蛋白酶-9（MMP-9）水平,并比较治疗30d主要终点事件（顽固性缺血状态、新近心肌梗死和死亡）,同时测定血脂水平。另设正常对照组。结果①治疗前他汀治疗组和对照组血清MMP-9水平均较正常组明显增高（P〈0．05）。②治疗组经阿托伐他汀治疗4周血清MMP-9水平较治疗前明显下降（P〈0．01）。对照组4周后MMP-9水平无明显变化,与治疗组相比有高度显著性差别（P〈0．01）。⑧阿托伐他汀治疗4周时血脂水平无明显变化;④治疗组与对照组治疗1个月时,两组终点事件发生率有显著性差别（P〈0．05）。结论早期他汀强化治疗可减少急性冠脉综合征患者终点事件发生,显著改善急性冠脉综合症的预后。     

下肢深静脉血栓形成手术取栓研究

目的探讨手术取栓治疗下肢深静脉血栓形成(DVT)的时机、方法及疗效。方法对218例下肢DVT手术取栓患者的临床资料进行分析。结果203例1次取栓成功,15例再次取栓并行髂静脉人造血管移植术。114例于术后1-3天患肢肿胀消退,28例患者肿胀消退稍慢约需5—7天,仅5例患者需再次取栓及人造血管移植。全组病例随访169例,占77．5％,远期疗效好。结论手术取栓是治疗早期下肢深静脉血栓形成的有效方法,术中要正确判断取栓是否成功,慎重处理髂总静脉闭塞。     

ACE Inhibition Modulates Endothelial Apoptosis and Renewal via Endothelial Progenitor Cells in Patients with Acute Coronary Syndromes

Background

The equilibrium between endothelial apoptosis and endothelial renewal is altered in acute coronary syndromes and may be related to differences in the beneficial effects of angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists (angiotensin receptor blockers).

Methods

We evaluated the effect of treatment on endothelial function in post-myocardial infarction (MI) patients treated with perindopril (group 2, n = 16) or valsartan (group 3, n = 17) at baseline and after 7, 15, and 30 days and in normal controls (group 1, n = 20). Endothelial apoptosis was determined by cultivating serum samples in vitro with human umbilical vein endothelial cells (HUVECs), while endothelial renewal was assessed by mobilization of CD34+ bone marrow cells.

Results

At baseline, post-MI patients had significantly elevated rates of apoptosis (16.6±5.0% and 16.5±8.4% in groups 2 and 3, respectively [both p = 0.01] vs 1.6±0.7% in group 1), which declined in group 2 (10.5±4.4% at 30 days, p = 0.04), but not in group 3. Similar results and trends were found for the Bax/Bcl-2 ratio. CD34+ mobilization was significantly increased in group 2 (3.0±1.0 at baseline to 6.2±1.6 at 15 days, p = 0.03), whereas in group 3 CD34+ mobilization did not change significantly. The findings in group 2 were accompanied by an increase in vascular endothelial growth factor at 15 days, and a reduction in tumor necrosis factor-α and its soluble receptors, versus no change in group 3. Similar findings were observed for angiotensin II and bradykinin.

Conclusion

Our results indicate that perindopril, but not valsartan, reduces the proapoptotic effect of serum on the endothelium and increases endothelial renewal in patients with acute coronary syndromes.