急性心肌梗死合并心源性休克治疗的研究进展

心源性休克是急性心肌梗死病人死亡率增高的主要原因。尽管接受了急诊血运重建、机械循环辅助支持及多种血管活性药物治疗,急性心肌梗死相关心源性休克的发病率及死亡率较高,且病人预后差,疾病负担重,是心血管领域的急危重症,因而对此类危重病人的有效管理至关重要。结合国内外相关研究,综述急性心肌梗死相关心源性休克诊治的研究进展。     

急性心肌梗死心源性休克诊疗进展

急性心肌梗死并发心源性休克指心肌梗死患者的心力衰竭导致终末器官低灌注状态,主要依靠血流动力学指标诊断。数十年来心源性休克发病率没有改变,但住院期间心源性休克发病率降低,病死率降低至50%左右。临床上早期正确诊断心源性休克是前提,尽快冠脉血管重建术包括经皮冠脉介入术和冠脉搭桥术是提高生存率的关键,积极有效的药物支持治疗是基础,主动脉内球囊反搏是最广泛应用的有效机械辅助支持手段,以及其他机械辅助支持。     

急性心肌梗死心源性休克诊疗进展

急性心肌梗死并发心源性休克指心肌梗死患者的心力衰竭导致终末器官低灌注状态,主要依靠血流动力学指标诊断。数十年来心源性休克发病率没有改变,但住院期间心源性休克发病率降低,病死率降低至50％左右。临床上早期正确诊断心源性休克是前提,尽快冠脉血管重建术包括经皮冠脉介入术和冠脉搭桥术是提高生存率的关键,积极有效的药物支持治疗是基础,主动脉内球囊反搏是最广泛应用的有效机械辅助支持手段,以及其他机械辅助支持。     

急性心肌梗死合并心源性休克的研究进展

心源性休克是急性心肌梗死的严重并发症 ,是引起急性心肌梗死患者死亡的主要原因。本文综述了急性心肌梗死合并心源性休克在定义、发生机制和治疗等方面的研究进展。     

心肌梗死相关性心源性休克血运重建的研究进展

心肌梗死后并发心源性休克通常与高死亡率相关,冠状动脉血运重建可提高生存率,但最佳血运重建策略仍存在争议.现探讨心肌梗死相关性心源性休克血运重建的相关研究进展.     

急性心肌梗死伴心源性休克的治疗

目的：本文观察早期冠状动脉再通及其他辅助治疗对急性心肌梗死（ＡＭＩ）合并心源性休克患者转归的影响。方法：对ＡＭＩ伴心源性休克的１７例患者进行回顾性研究，除外１例合并心室间隔穿孔。其余１６例患者分为药物组５例，仅应用药物治疗；介入组１１例接受溶栓，行经皮冠状动脉腔内成形术、行支架术、主动脉内球囊反搏、呼吸机辅助呼吸等治疗。介入组患者经冠状动脉造影后根据心肌梗死溶栓试验（ＴＩＭＩ）分级进一步分为再通组与未再通组。对药物组和介入组，再通组和未再通组住院期间病死率进行了比较。结果：药物组患者住院期间全部死亡，病死率１００％。介入组患者４例死亡，病死率３６％，较药物组明显降低（Ｐ＜０．０１）。介入组患者经冠状动脉造影未再通组（ＴＩＭＩ０～Ⅰ级）４例，３例死亡，病死率７５％，再通组（ＴＩＭＩⅡ～Ⅲ级）７例，死亡１例，病死率１４％，与未再通组比较病死率显著降低（Ｐ＜０．０１）。结论：早期冠状动脉再通，同时应用主动脉内球囊反搏，辅助呼吸等治疗将有效地降低ＡＭＩ伴心源性休克患者的病死率     

急性心肌梗死并心源性休克的诊断与治疗

心源性休克是急性心肌梗死(ＡＭＩ心梗)伴泵衰竭的最严重临床表现,与左心室心肌的广泛损害有关。85%的心源性休克是由于左心功能衰竭(心衰)所引起[1],当40%或以上的左心室心肌受损害时常出现心源性休克,其余病人可能有机械性障碍,如室间隔缺损,乳头肌功能不全等,或有严重的右心室心肌梗塞。ＡＭＩ并心源性休克的发生率在70年代以前为15%,现降至5%～7%。心源性休克的临床特征为左心室充盈压增高,心输出量下降,低血压和重要器官灌注低下。ＡＭＩ并心源性休克多为老年人、女性病人、有心梗史或心衰史、或有前壁心梗的病人,约50%的心源性休克患…     

脉搏指数连续心输出量监测在急性心肌梗死合并心源性休克患者中的应用

目的探讨脉搏指数连续心输出量监测(PICCO)在急性心肌梗死(AMI)合并心源性休克(CS)患者中的应用价值。方法入选2012年1月至2013年1月因AMI合并心源性休克(CS)入住南京鼓楼医院集团宿迁市人民医院心血管内科重症监护病房(CCU)患者56例。其中男性35例,女性21例,年龄28~75岁,平均(56.5±2.3)岁。随机分成PICCO组(27例)及对照组(29例)。对照组入CCU后立即监测血压,心率,呼吸次数,血氧饱和度及心电图,记录体温变化,深静脉穿刺监测中心静脉压(CVP)。PICCO组在此基础上,进行深静脉置管+股动脉置管+PICCO模块连接。监测心脏指数(CI),血管外肺水指数(EVLWI)及血清N-末端脑钠肽前体(NT-pro BNP)变化情况。结果与PICCO治疗24 h比较,治疗48 h EVLWI[(8.85±0.73)ml/kg vs.(7.41±1.36)ml/kg]下降,CI[(2.21±0.45)L/min·m2 vs.(2.60±0.17)L/min·m2]增加,NT-pro BNP[(4069.48±65.32)pg/ml vs.(3721±20.32)pg/ml]下降,差异具有统计学意义(P0.05)。随着时间延长,EVLWI下降,CI增加,NT-pro BNP呈降低的趋势。同时,EVLWI与NT-pro BNP呈直线正相关(r=0.78,P0.05)。PICCO组患者血管活性药物使用时间,入住CCU时间,机械通气时间,病死率以及出院时血清NT-pro BNP水平明显低于对照组,差异有统计学意义(P均0.05)。结论 PICCO对于AMI合并CS患者的治疗具有重要价值。     

急性心肌梗死合并心源性休克介入治疗15例

据文献报道 ,急性心肌梗死 (AMI)合并心源性休克时 ,内科药物治疗的病死率达 80 %以上 ,经皮冠状动脉腔内成形术(PTCA )可降低病死率至 5 0 %以下。 1994～ 2 0 0 0年 ,我院对15例 AMI合并心源性休克患者行 PTCA治疗 ,效果良好。现报告如下。临床资料 :15例均为我院收治的 AMI患者 ,男 12例 ,女3例 ;年龄 30～ 72岁 ,平均 (5 8± 10 .6 )岁。前侧壁心梗 6例 ,下后壁心梗 9例。休克发病至行 PTCA时间均在 6 h之内。 15例均符合心源性休克诊断标准 :1收缩压 (SBP) <80 m m Hg;2左室舒张末期压 >2 0 mm Hg;3有明显末梢灌注不足表现…     

急性心肌梗死心原性休克的诊断和治疗进展

心原性休克主要是指由于大面积心肌缺血或坏死后,心脏泵血功能严重受损,心输出量锐减所产生的以低血压、周围循环和组织低灌注并伴左心室充盈压增高为主要特征的临床综合征。长期以来,急性心肌梗死(AMI)并发心原性休克的发生率和病死率均无明显改善,仅到了90年代以后,随着介入治疗技术的开展、不断完善和主动脉内球囊反搏的广泛应用,其病死率才有所下降,但仍然是急性心肌梗死最主要的院内死亡原因[1]。现将近年来急性心肌梗死合并心原性休克的诊断和治疗进展综述如下。1发生率和病死率急性心肌梗死并发心原性休克的发生率约2.5%～20%[14],…     

Revascularization,stenting, and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock

Randomized clinical trials have demonstrated a reduction in mortality with early revascularization of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock, and recent single-center studies have particularly suggested further benefit for coronary stenting. The purpose of this study was to examine the use of revascularization and coronary stenting for patients with shock from a multicenter, international perspective. Patients with AMI complicated by cardiogenic shock (n = 583) who enrolled between April 1999 and June 2001 were prospectively identified from the large, multinational, observational Global Registry of Acute Coronary Events. We examined the use of coronary reperfusion strategies, adjunctive therapy, and hospital mortality in this group of patients. Cardiac catheterization (52%) and revascularization (43%) were performed in approximately half of the cardiogenic shock patients. Elderly patients (age >/=75 years) comprised 40% of the shock cohort. Regional differences were seen in the use of revascularization, adjunctive medical therapy, and type of revascularization used (coronary stenting). Total hospital mortality was 59%, but case fatality rates ranged from 35% for patients who underwent coronary stenting to 74% for patients who did not undergo any cardiac catheterization. Percutaneous coronary intervention with coronary stenting was the most powerful predictor of hospital survival (odds ratio 3.99, 95% confidence interval 2.41 to 6.62). Thus, cardiogenic shock continues to be a devastating complication of AMI, and relative underuse of a revascularization strategy may be related to the large proportion of elderly patients in this population. In this multinational registry study, coronary stenting was the most powerful independent predictor of hospital survival.     

Revascularization strategies in cardiogenic shock complicating acute myocardial infarction: A systematic review and meta-analysis

BackgroundThe optimal revascularization strategy in patients with multi-vessel disease (MVD) presenting with acute myocardial infarction (AMI) and cardiogenic shock (CS) remains unclear.ObjectiveTo investigate the comparative differences between culprit-only revascularization (COR) versus instant multi-vessel revascularization (IMVR) in AMI and CS.Methods13 studies were selected using MEDLINE, EMBASE and the CENTRAL (Inception - 31 November2017). Outcomes were assessed at short-term (in-hospital or ≤30 days duration) and long-term duration (≥6 months). Estimates were reported as random effects relative risk (RR) with 95% confidence interval (CI).ResultsIn analysis of 7311 patients, COR significantly reduced the relative risk of short-term all-cause mortality (RR: 0.87; 95% CI, 0.77–0.97; p = 0.01, I² = 50%) and renal failure (RR: 0.75; 95% CI, 0.61–0.94; p = 0.01, I² = 7%) compared with IMVR. There were no significant differences between both the strategies in terms of reinfarction (RR: 1.25; 95% CI, 0.59–2.63; p = 0.56, I² = 0%), major bleeding (RR: 0.88; 95% CI, 0.75–1.04; p = 0.14, I² = 0%) and stroke (RR: 0.77; 95% CI, 0.50–1.17; p = 0.22, I² = 0%) at short term duration. Similarly, no significant differences were observed between both groups regarding all-cause mortality (RR; 1.01; 95% CI, 0.85–1.20; p = 0.93, I² = 61%) and reinfarction (RR: 0.71; 95% CI, 0.34–1.47; p = 0.35, I² = 26%) at long term duration.ConclusionIn MVD patients presenting with AMI and CS, IMVR was comparable to COR in terms of all-cause mortality at long term follow up duration. These results are predominantly derived from observational data and more randomized controlled trials are required to validate this impression.     

急诊经皮冠状动脉介入治疗老年急性心肌梗死合并心源性休克的临床观察

目的探讨急诊PCI对老年急性心肌梗死(AMI)合并心源性休克(CS)的近期和中期疗效,并分析患者院内存活率的影响因素。方法选择行PCI的老年AMI合并CS患者共86例,按治疗结果分为院内病死组(病死组,32例)和院内存活组(存活组,54例),采用logistic回归分析死亡的预测因素,统计患者的临床特点、影像学特点、介入治疗成功率、院内病死率及存活时间。结果病死组既往有心肌梗死患者高于存活组(43.8%vs24.1%,P=0.049),存活组发病至PCI时间明显低于病死组[(9.8±3.2)hvs(12.7±5.9)h,P=0.004];病死组梗死发生部位为前降支,发生率明显高于存活组(59.4%vs35.2%,P=0.025);Kaplan-Meier生存分析显示1年生存率为51.2%。logistic多元回归分析显示,发病至PCI时间及梗死相关动脉与院内病死率显著相关(P<0.05)。结论急诊PCI对老年AMI合并CS患者有较好的近期和中期疗效。     

急性心肌梗死合并心原性休克47例治疗和死亡原因分析

目的 评价急性心肌梗死合并心原性休克47例患者的临床疗效,寻求降低病死率、改善预后的措施.方法 回顾性分析2002年1月至2007年5月共47例心肌梗死合并心原性休克患者,运用心血管活性药物、主动脉内球囊反搏(IABP)、介入手术或冠状动脉旁路移植术的治疗效果.结果 IABP治疗47例(100%),再血管化治疗41例(87.3%),死亡17例(36.2%).经药物和IABP治疗,在接受再血管化前死亡的患者占死亡数的35.3%(6/17),再血管化后死亡的患者占死亡数的64.7%(11/17).死于心功能衰竭者9例,死于肾功能衰竭和呼吸功能衰竭者8例.11例出现急性肾功能衰竭的患者全部死亡.急性肾功能衰竭(r=0.734,P=0.000)、急性呼吸功能衰竭(r=0.606,P=0.000)和糖尿病(r=0.372,P=0.012)与死亡有相关关系.结论 尽管急性心肌梗死合并心原性休克的治疗有了很大的发展,但病死率仍然较高,主要死因是急性心力衰竭、急性肾功能衰竭和急性呼吸功能衰竭.要进一步降低急性心肌梗死合并心原性休克患者住院病死率,可能需要更好的循环辅助装置及加强重要器官的保护.     

Predictors of mortality in patients with acute myocardial infarction and cardiogenic shock.

BACKGROUND: Although cardiogenic shock (CS) is the leading cause of death for acute myocardial infarction (AMI) patients, reliable predictive factors in the acute stage, such as cardiovascular peptides, have not yet been identified. METHODS AND RESULTS: In 42 consecutive AMI patients with CS on admission, successfully treated by primary percutaneous coronary intervention (PCI) within 12 h of onset, related factors including brain natriuretic peptide (BNP), atrial natriuretic peptide (ANP), renin, aldosterone, catecholamines, and adrenomedullin, were investigated 24 h from onset, as well as the 1-year mortality rates. During the 12-month follow-up period, 15 patients died from cardiovascular causes (group D). There were no significant differences in patient characteristics, angiographic findings, and left ventricular systolic function between group D subjects and the survivors (group S: n=27). Multivariate analysis identified high levels of adrenomedullin as an independent predictor of 1-year mortality (risk ratio: 6.42, 95% confidence interval, 1.49-43.31, p<0.05). CONCLUSIONS: The acute-phase plasma concentration of adrenomedullin may be a reliable predictor of mortality in patients with AMI complicated by CS and successfully treated by direct PCI, as may be BNP concentration, peak-creatine kinase value, and ventricular fibrillation.     

Impaired fasting glucose and cardiogenic shock in patients with acute myocardial infarction.

OBJECTIVES: In-hospital outcome after acute myocardial infarction (MI) has not yet been evaluated with regard to the new category of Impaired Fasting Glucose level (IFG) patients defined by the American Diabetes Association (ADA). METHODS: Nine hundred and ninety-nine patients with acute MI from the RICO survey were included in the study. Fasting blood glucose was measured after admission. Patients were grouped according to ADA definitions: Diabetes Mellitus (DM) (FG >/=7mmol/l or personal history of DM); IFG (FG 6.1 to 7mmol/l); NFG (normal FG <6.1mmol/l). RESULTS: Three hundred and eighty-one patients (38%) had DM, 145 (15%) IFG and 473 (47%) NFG. Mortality in the IFG group was twice that of the NFG group (8% vs 4%, P=0.049). A significant increase in cardiogenic shock (12% vs 6%, P=0.011) and ventricular arrhythmia (15% vs 9%, P=0.035) was observed in the IFG vs NFG group. IFG, after adjustment for confounding factors (age, sex, anterior location, and LVEF), was a strong independent predictive factor for cardiogenic shock (P=0.005). CONCLUSION: MI patients with IFG had an overall worse outcome, characterized by a higher risk of developing cardiogenic shock during their hospital stay.