Effect of intracoronary thrombectomy on 30-day mortality in patients with acute myocardial infarction

Insertion of intracoronary thrombectomy (ICT) devices, as a precedent to percutaneous coronary intervention (PCI), theoretically could have a beneficial effect on the outcome in patients with acute myocardial infarction. To examine whether ICT was associated with a lower 30-day mortality rate in patients with acute myocardial infarction, we studied 3,913 patients who underwent PCI within 24 hours after onset. A total of 990 patients (25.3%) were treated with ICT before PCI. The 30-day mortality rate was lower in the patients receiving ICT than in those without (3.7% vs 6.2%, p = 0.004), but this beneficial effect disappeared after adjustment for baseline characteristics (hazard ratio [HR] 0.658, p = 0.166). We also divided the patients into tertiles according to the Thrombolysis In Myocardial Infarction (TIMI) risk score. After adjustment for baseline characteristics, ICT was associated with a lower 30-day mortality rate in patients from the highest TIMI risk score tertile (HR 0.407, p = 0.029), but not in patients from the lower 2 tertiles. ICT was also an independent predictor of a lower 30-day mortality risk in patients aged > or =70 years (HR 0.239, p = 0.007), patients with diabetes mellitus (HR 0.275, p = 0.039), and those with stent implantation (HR 0.437, p = 0.034). In conclusion, in selected patients with high TIMI risk scores, an age > or =70 years, diabetes mellitus, or stenting, ICT is associated with a lower 30-day mortality rate.     

急性冠脉综合征患者并发心房颤动相关因素研究

目的 探讨急性冠脉综合征患者并发心房颤动的相关因素.方法 连续入选我院2012年1月至2012年10月因急性冠脉综合征住院患者368例.按住院期间是否并发心房颤动分为房颤组和非房颤组.结果 368例急性冠脉综合征患者并发心房颤动41例,发生率为11.14％.Logistic多因素分析结果显示,左房内径增大、冠脉多支病变是急性冠脉综合征并发心房颤动的相关危险因素.结论 急性冠脉综合征患者有较高比例并发心房颤动.左房内径增大、冠脉多支病变是急性冠脉综合征患者并发心房颤动的相关危险因素.     

Situation of antithrombotic therapy in elderly patients with atrial fibrillation and acute coronary syndrome

Background Atrial fibrillation is the most common cardiac arrhythmia in clinical practice. The study examines the situation of antithrombotic therapy in elderly patients(more than 60 years old) with non-valvular atrial fibrillation(NVAF) and acute coronary syndrome(ACS) / percutaneous coronary intervention(PCI).Methods This study enrolled 381 elderly patients [mean age(69.95 ± 8.41) years; 289 males, 92 females]with NVAF and ACS / PCI between January 2006 and September 2013. According to clinical data, these patients were categorized into 4 groups: triple therapy(TT) group, dual antiplatelet therapy(DAT) group,vitamin K antagonist(VKA) plus single antiplatelet therapy(SAT) group and VKA group. According to score of CHA2DS2-VASc and HAS-BLED, all the patients were divided into 4 combinations. Statistical methods were used to analyze the situation of antithrombotic therapy and potential associations between the different combinations. Results 38 patients(9.97%) received TT and 300 patients(78.74%) received DAT. TT was received in 20 patients with CHA2DS2-VASc ≥2 and HAS-BLED ≥3, and 16 patients with CHA2DS2-VASc≥2 and HAS-BLED 3. Conclusions Elderly patients who suffered NVAF and ACS / PCI were with high risk of stroke and low risk of bleeding. Majority of these patients received DAT instead of TT.     

Association of interleukin-10 level with increased 30-day mortality in patients with ST-segment elevation acute myocardial infarction undergoing primary coronary intervention.

BACKGROUND: The prognostic value of interleukin (IL)-10 in patients with ST-segment elevation acute myocardial infarction (ST-se AMI) is currently unclear. The purpose of this study was to test whether the serum IL-10 level can predict 30-day mortality in patients with ST-se AMI undergoing primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: The study design was a prospective cohort study of 250 consecutive patients with ST-se AMI of onset <12 h who were undergoing primary PCI. Blood samples for serum IL-10 levels were collected in the catheterization laboratory following vascular puncture. The serum IL-10 level was also evaluated in 20 healthy and 30 at-risk control subjects. The mean serum level of IL-10 was significantly higher in the AMI patients than in either group of controls (all values of p<0.0001). Patients with a high serum IL-10 level (> or = 30 pg/ml) had a significantly lower left ventricular ejection fraction (LVEF) (defined as <50%), significantly higher incidence of cardiogenic shock, higher white blood cell (WBC) count, more advanced congestive heart failure (defined as New York Heart Association function classification of > or = 3), and increased 30-day mortality than those patients with a low serum IL-10 level (<30 pg/ml) (all values of p<0.0001). Multiple stepwise logistic regression analysis demonstrated that a high serum IL-10 level, together with low LVEF, high WBC count and unsuccessful reperfusion, was independently predictive of increased 30-day mortality (all values of p<0.005). CONCLUSION: In patients with ST-se AMI, the serum IL-10 level is a major independent predictor of 30-day mortality and should be used for early risk stratification following acute myocardial infarction.     

Troponin I in atrial fibrillation with no coronary atherosclerosis

A number of reports have raised the possibility that myocardial strain could be associated to increased plasma levels of troponin I. A 69-year-old, male, Caucasian, patient was admitted with prolonged chest pain and dyspnoea. The electrocardiogram showed atrial fibrillation with a ventricular rate of about 120 to 150/minute. After treatment with digoxin and amiodarone, the patient returned to sinus rhythm. An elevation in the plasma levels of troponin I was noted, with a maximum value of 0.66 ng/ml. Coronary angiography showed absence of coronary artery atherosclerotic lesions. Atrial fibrillation of recent onset and with a relatively high heart rate may be yet another situation in which acute myocardial strain could be the cause of the abnormal release of cardiac troponin I.     

阿托伐他汀对血脂正常的病窦综合征患者心房颤动复发的影响

目的探讨阿托伐他汀对血脂正常的病窦综合征(SSS)患者心房颤动(AF)复发的防治作用。方法选择62例SSS合并阵发性AF(PAF)未行心脏永久起搏器植入术且血脂正常的患者,随机分为对照组(常规治疗组)和治疗组(常规治疗基础上加阿托伐他汀20 mg/d),随访观察12个月,观察AF发作次数、AF持续时间及血浆C反应蛋白(CRP)水平、血脂水平的变化。结果治疗后治疗组AF的发作次数、AF持续时间虽没有明显降低但显著低于对照组(13.4±2.8次/年vs 16.2±3.6次/年,62.4±7.2小时/年vs 66.3±4.7小时/年),血CRP水平显著降低(7.95±0.87 mg/L vs 9.52±1.31 mg/L)且显著低于对照组(7.95±0.87 mg/L vs 10.02±1.37mg/L)。治疗组的血脂在治疗12个月时较治疗前明显改善(P<0.05),而对照组的上述指标则无明显改善。结论阿托伐他汀对血脂正常、未行心脏永久起搏器植入术的SSS患者AF的复发具有明显的防治作用。其机制可能与他汀类药物抑制炎症反应及调脂有关。     

Admission C-reactive protein levels and 30-day mortality in patients with acute myocardial infarction

BACKGROUND: Elevated C-reactive protein levels are associated with an increased risk of subsequent cardiovascular events in patients with unstable angina. However, limited information is available concerning the value of C-reactive protein levels in patients with acute myocardial infarction. METHODS: We prospectively studied 448 consecutive patients (mean [+/- SD] age, 60 +/- 12 years) with acute myocardial infarction. Serum C-reactive protein levels were measured within 12 to 24 hours of symptom onset, and divided into tertiles. Infarct size was determined by echocardiographic examination that was performed on day 2 or 3. Patients were followed for 30 days for mortality and subsequent cardiac events. RESULTS: At 30 days, 4 deaths (3%) occurred in patients in the lowest C-reactive protein tertile, 15 (10%) in patients in the middle tertile (P = 0.02 vs. the lowest tertile), and 33 (22%) in patients in the highest tertile (P <0.001 vs. the lowest tertile). In a multivariate analysis, C-reactive protein in the upper tertile was associated with 30-day mortality (relative risk = 3.0; 95% confidence interval [CI]: 1.3 to 7.2; P = 0.01) and the development of heart failure (odds ratio = 2.6; 95% CI: 1.5 to 4.6; P = 0.0006). C-reactive protein levels were not associated with the development of postinfarction angina, recurrent myocardial infarction, or the need for revascularization. CONCLUSION: Plasma C-reactive protein level obtained within 12 to 24 hours of symptom onset is an independent marker of 30-day mortality and the development of heart failure in patients with acute myocardial infarction. These findings suggest that C-reactive protein levels may be related to inflammatory processes associated with infarct expansion and postinfarction ventricular remodeling.     

雷米普利与胺碘酮联合应用对急性冠脉综合征合并心房颤动患者的影响

目的观察血管紧张素转换酶抑制剂雷米普利联合胺碘酮治疗急性冠脉综合征(acute coronary syndrome,ACS)合并心房纤颤(atrial fibrillation,AF)患者的临床疗效。方法选择2006年1月至2008年1月住院的ACS合并AF患者163例,其中包括88例不稳定型心绞痛(unstable angina,UA)和75例急性心肌梗死(acute myocardial infarction,AMI)。UA组与AMI组分别分为治疗组和对照组,具体分组为UA治疗组(A组,n=44)、UA观察组(B组,n=44)、AMI治疗组(C组,n=37)和AMI观察组(D组,n=38)。4组均给予胺碘酮治疗,治疗组加用雷米普利(5mg/d)。观察治疗24h、3d和7d时AF的转复情况。治疗并随访2年,比较4组治疗前后左心房内径及窦性心律维持率。结果 4组24h和3d AF的转复率比较,差异无统计学意义(P0.05);A组、C组7d时的转复率均大于B组、D组,差异有统计学意义(P0.05);治疗组和观察组的左心房内径、窦性心律维持率在治疗后6个月比较,差异无统计学意义(P0.05);但在治疗后12、18、24个月,治疗组左心房内径显著低于观察组,差异有统计学意义(P0.05);窦性心律维持率高于观察组,差异有统计学意义(P0.05)。结论雷米普利与胺碘酮联合应用于ACS合并AF患者能提高AF的转复率,缩短转复时间,长期使用可减小左心房内径,并且有效维持窦性心律。     

睡眠呼吸暂停低通气综合征并发心房颤动的实验模型

目的构建睡眠呼吸暂停低通气综合征(SAHS)并发心房颤动(简称房颤)的实验模型并研究其特点。方法健康成年杂种犬10只,麻醉后开胸,将多极电生理导管分别缝于左右心房、肺静脉及上腔静脉表面。调整呼吸机模拟SAHS和持续气道内正压通气(CPAP)各1h,间断测量血压、心率、各部位有效不应期(ERP)和心房易颤窗口(WOV),进行血气和心率变异性(HRV)分析。结果随着SAHS时间的延长,PH值、动脉血氧分压和血氧饱和度逐渐降低,动脉二氧化碳分压逐渐增加。SAHS开始的前30 min,血压和心率逐渐增加,反映交感活性(LF)和迷走活性(HF)的指标均逐渐上升,LF/HF不变,ERP和WOV无明显变化。后30 min血压和心率开始下降至基础水平以下,反映迷走神经活性的指标逐渐占主导(LF/HF值降低),ERP显著缩短,WOV显著增加。ERP和WOV的变化在上腔静脉表现最为明显。持续气道正压呼吸后,以上各项指标均恢复至基础水平左右。结论本实验成功构建了一种新的SAHS动物模型。该模型显示了与临床SAHS患者相似的病理生理和电生理特点。恢复气道通气后,该模型所造成的病理生理变化和电生理变化均能逆转。     

The prognostic value of atrial fibrillation on 30-day clinical outcome in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

This study evaluated the association between atrial fibrillation (AF) and 30-day clinical outcome in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Between January 2005 and October 2009, 783 consecutive patients with acute STEMI undergoing primary PCI were enrolled. Of these patients, 85 (10.9%) with AF during admission were categorized into group 1, while the remaining 698 (89.1%) with sinus rhythm during admission served as group 2. The results demonstrated that the incidence of advanced Killip score (defined as ≥ score 3) and advanced congestive heart failure (defined as ≥ NYHA class 3) were significantly higher, whereas the left ventricular ejection fraction (LVEF) was notably lower in group 1 than in group 2 (all P < 0.003). Additionally, the normal blood flow in the infarct-related artery was notably lower in group 1 than in group 2 (P = 0.003). Moreover, the incidences of new-onset stroke and 30-day mortality were remarkably higher in group 1 than in group 2 (all P < 0.003). Furthermore, Kaplan-Meier analysis demonstrated that the 30-day survival rate was markedly lower in AF patients than in those with sinus rhythm. However, multivariate stepwise Cox regression analysis demonstrated that the advanced Killip score and low LVEF were significantly and independently predictive of 30-day mortality (all P < 0.004). In conclusion, AF was significantly associated with 30-day mortality.     

Hypokalemia and hypothermia are associated with 30-day mortality in patients with acute paraquat poisoning

BACKGROUND: Clinical predictors associated with acute paraquat (PQ) poisoning have not been systematically studied. OBJECTIVE: To identify independent predictors of death in patients with acute PQ poisoning. METHODS: This is a retrospective study executed in the emergency department of a university hospital. One hundred three consecutive patients poisoned with PQ between January 1999 and December 2004 were enrolled. Urine PQ concentration, electrolyte and renal function, detailed history, and Acute Physiology and Chronic Health Evaluation II were extracted from medical records. The outcome measure was 30-day mortality. Multivariate analysis was done by Cox-proportional hazard regression model. Receiver operating characteristics area under the curve was calculated for selected predictors. RESULTS: The crude 30-day mortality was 67.9% (70 of 103). Independent predictors of death were acute renal failure (hazard ratio, 3.53; 95% confidence interval, 1.97-6.32), hypokalemia (2.07, 1.21-3.51), hypothermia (2.91, 1.67-5.07), suicide (2.11, 1.04-4.29), and self-reported ingested dose (2.06, 1.38-3.06). The receiver operating characteristics area under the curve of serum potassium concentrations, maximal urine PQ concentrations, and Acute Physiology and Chronic Health Evaluation II scores were 0.75 (95% confidence interval, 0.60-0.81), 0.71 (0.66-0.84), and 0.80 (0.71-0.88), respectively. Under the cutoff value of 3.6 mEq/L, hypokalemia had a sensitivity of 75% and specificity of 54% in predicting mortality. CONCLUSION: The identified risk factors may allow better identification of those at greater mortality risk. Future development of a tailored clinical scoring system incorporating the identified risk factors for acute PQ poisoning may be of great help.     

他汀类药物对急性冠状动脉综合征合并心房颤动患者介入术后的心肌保护作用

目的观察急性冠状动脉综合征合并心房颤动患者行PCI术后,他汀类药物对围手术期心肌损伤的保护作用。方法选择具备PCI指征的急性冠状动脉综合征患者247例,分为合并心房颤动组(心房颤动组)132例和未合并心房颤动组(未心房颤动组)115例,在PCI术前开始服用他汀类药物,分别测量PCI术前及术后6h及1周时肌钙蛋白I(cTnI)、肌酸激酶同工酶(CK-MB)及高敏C反应蛋白(hs-CRP)水平。结果 2组患者PCI术前CK-MB水平比较差异无统计学意义(P>0.05),心房颤动组患者cTnI、hs-CRP高于未心房颤动组(P<0.05);PCI术后6h,2组患者cTnl、CK-MB和hs-CRP均明显升高,心房颤动组升高更明显(P<0.05);PCI术1周后,2组患者上述指标均有所下降,心房颤动组下降较未心房颤动组明显,但未回复到术前水平。结论对急性冠状动脉综合征合并心房颤动的患者行PCI治疗,他汀类药物抗炎、保护心肌作用更强,其机制可能与他汀类药物的多效性相关。     

Amiodarone and mortality among elderly patients with acute myocardial infarction with atrial fibrillation

Background Amiodarone has been shown to be safe in patients with acute myocardial infarction (AMI) who are at risk for sudden cardiac death. However, there is limited data concerning the safety of amiodarone in patients who experience AMI complicated by atrial fibrillation. Methods To determine the safety of amiodarone therapy, we conducted a retrospective analysis of elderly patients hospitalized with AMI who experienced atrial fibrillation and had survived to hospital discharge (n = 17,597). Amiodarone prescribed at discharge was evaluated for its association with short-term and long-term mortality in crude and adjusted analyses employing propensity score methods. Results Of the 17,597 patients, 550 patients (3.1%) were prescribed amiodarone, 2317 patients (13.2%) were prescribed other antiarrhythmic agents (excluded from analysis), and 14,730 (83.7%) were prescribed no antiarrhythmic medication at discharge. Thirty-day mortality rates were similar for patients prescribed amiodarone and those not prescribed amiodarone (6.8% amiodarone vs 5.4% no amiodarone, P = .21), but mortality at 1 year was higher among patients prescribed amiodarone (35.6% vs 31.6%, P = .001). However, amiodarone was not associated with mortality at 30 days (odds ratio 0.80, 95% CI 0.53-1.20) or at long-term follow-up (mean duration 612 days, hazard ratio 1.04, 95% CI 0.92-1.18) after multivariable modeling. Conclusions Amiodarone was not independently associated with short-term or long-term mortality in elderly patients discharged after a hospitalization for AMI complicated by atrial fibrillation. Although our data suggest that amiodarone may be safe to use in this population, randomized controlled trial data are needed to confirm this finding. (Am Heart J 2002;144:1095-101.)     

Predictive value of C-reactive protein on 30-day and 1-year mortality in acute coronary syndromes: an analysis from the ACUITY trial

We sought to evaluate the association between C-reactive protein (CRP) sampled on admission and short- and long-term mortality in patients with acute coronary syndromes (ACS) undergoing early invasive treatment. Baseline levels of CRP were determined in 2,974 patients with moderate and high-risk ACS undergoing an early invasive treatment strategy in the large-scale randomized ACUITY trial. The relationship of CRP to 30-day and 1-year clinical outcomes were assessed according to quartiles of CRP values. Patients with CRP levels in the fourth quartile compared to the first quartile had significantly higher 30-day mortality (2.3 vs. 0.3%, P = 0.0004) and 1-year mortality (5.5 vs. 2.8%, P = 0.0003). CRP level as a continuous variable was associated with 30-day mortality (OR [95% CI] for one unit increase in logarithmically transformed CRP level = 1.42 [1.08-1.89], P = 0.01) and 1-year mortality (OR [95% CI] = 1.24, [1.04-1.47], P = 0.02). By multivariable analysis, higher baseline CRP levels independently predicted 30-day and 1-year mortality, a relationship that was particularly strong for patients with the highest quartile of CRP (OR [95% CI] = 5.19 [1.14-23.68], P = 0.009). In troponin-positive patients, increasing quartiles of CRP were associated with a trend for 30-day mortality (P (trend) = 0.08) and a significant increase in 1-year mortality (P (trend) = 0.02); this relationship was not present in troponin-negative patients. Baseline CRP level is a powerful independent predictor of both early and late mortality in patients with ACS being treated with an early invasive strategy, especially in troponin positive patients.