急性心肌梗死急诊不同再灌注方案的临床分析

目的探讨长沙地区急性心肌梗死不同院前心肌再灌注方案的实际执行状况和效果。方法本研究为非随机、前瞻性试验。入选的急性心肌梗死病例被分为尿激酶(UK)组、重组组织型纤溶酶原激活剂(r-tPA)组、经皮冠状动脉介入治疗(PCI)组和非再灌注组,非再灌注组的病例予以低分子肝素、阿司匹林治疗,观察不同方案的实际实施状况及近期疗效、并发症和费用-效果比。结果①106例AMI病人,87例施行了再灌注治疗(82%),急诊PCI组24例(23%),r-tPA组27例(25%),UK组36例(34%);非再灌注19例(18%)。②再通率为UK组61.3%,r-tPA组81.5%,PCI组95.8%;入院至开始再灌注时间为UK组(38.52±16.21)min,r-tPA组(46.23±17.13)min,PCI组(98.47±20.42)min;入院至再通时间为UK组(73.21±11.34)min,r-tPA组(122.12±23.46)min,PCI组(132.73±13.67)min。③住院期心绞痛发生率,再发心肌梗死率,心衰发生率,病死率在PCI组优于r-tPA组,r-tPA组优于UK组,三组均显著低于非再灌注组。④费用-再通率比为PCI组33893.16元,r-tPA组16717.53元,UK组3037.52元。结论在AMI的实际临床治疗中,大部分病人接受了急诊再灌注治疗。UK方案仍是采用最多的方案,可以在较短时间内实现IRA再通,且费用-效果比低,但再通率偏低,近期效果不满意。急诊PCI的再通率和近期临床效果最佳,但容易受多因素影响而耽误开始再灌注治疗的时间,且费用-效果比高。r-tPA的再通率、近期临床效果均明显高于UK,恢复IRA再通的时间与PCI接近,费用-效果比显著低于急诊PCI,是个比较理想可行的AMI急诊再灌注方案。     

急性心肌梗死急诊静脉溶栓临床分析

目的对比研究急性心肌梗死（AMI）急诊溶栓及院内静脉溶栓效果。方法将35例AMI患者按发生来源分为急诊组和院内组，均以尿激酶静脉溶栓治疗，并对其疗效和安全性进行总结分析。结果两组患者从发病到就诊时间比较无统计学意义（2．6±1．9hVS．2．9±2．1h，P〉0．05）。而急诊组患者就诊到溶栓时间为0．9±0．6h，院内组为2．0±1．4h，P〉0．05。急诊组患者发病到溶栓时间为3．34-1．3h，院内组为5．1±2．1h，P〈0．05。急诊组ck、ck—MB、冠脉再通率、左室射血分数（EF）、住院天数及死亡率各项指标与院内组比较，有统计学意义（P〈0．05）。结论AMI早期溶栓可提高再通率，缩小梗死面积，保护心功能，降低死亡率。     

急诊经皮冠状动脉介入治疗急性心肌梗死的临床疗效评估

目的探讨地市级中心城市医院急诊经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗急性心肌梗死（acute myocardial infarction,AMI）的临床疗效及安全性。方法 45例发病12h以内AMI患者行直接PCI共置入支架49枚,观察梗死相关动脉（infarct related artery,IRA）再通率,住院病死率及主要不良心脏事件（major adverse cardiac event,MACE）发生率。结果支架置入成功率100%;达TIMIⅢ级血流IRA再通率88.9%;住院病死率2.2%;MACE发生率4.4%。结论地市级中心城市医院开展急诊PCI血管再通率高、病死率低、安全有效,能为更多基层AMI患者实行早期PCI治疗。     

急性心肌梗死经桡动脉急诊冠状动脉介入治疗的临床分析

目的评价急性心肌梗死（AMI）经桡动脉途径急诊冠状动脉介入（PCI）的临床应用价值。方法对31例AMI患者经桡动脉途径急诊PCI治疗,观察疗效及并发症。结果从桡动脉穿刺到支架植入平均时间39.24分,31例PCI全部成功,PCI成功率为100%;经桡动脉PCI成功率96.77%,最终TIMI血流3级达到96.77%。术后并发症：桡动脉痉挛4例（12.90%）,暂时桡动脉闭塞2例（6.45%）,桡动脉穿刺部位血肿1例（3.22%）。平均卧床时间（94±12.3）小时,平均住院天数（9.4±3.1）天。结论AMI经桡动脉途径急诊PCI治疗安全有效,并发症少,患者痛苦少,可以作为AMI急诊PCI途径之一。     

急性心肌梗死静脉溶栓再灌注治疗后冠状动脉造影分析

目的对70例急性ST段抬高型心肌梗死(STEMI)静脉溶栓再灌注治疗后患者行冠状动脉造影,旨在分析STEMI静脉溶栓治疗效果,评价梗死相关动脉(IRA)再通情况。方法将70例STEMI静脉溶栓再灌注(尿激酶)治疗后患者根据临床溶栓再通指标判定标准,分为静脉溶栓再通组43例及非再通组27例两组。除住院期间死亡4例外,其余患者均于发病30d内进行冠状动脉造影/择期经皮冠状动脉介入治疗(PCI),评价冠脉再灌注情况,分析比较STEMI静脉溶栓再灌注治疗效果。结果经冠状动脉造影显示静脉溶栓再灌注治疗总再通率、再通组及非再通组冠脉再通率分别为61.4%、83.7%、7.4%。不良事件发生率为17.1%,病死率5.71%。结论静脉溶栓再灌注治疗冠脉再通率低,且再通者多为TIMI2级的部分灌注,不良事件发生率高。     

急性心肌梗塞急诊冠脉介入治疗的临床分析

目的探讨急性心肌梗塞（AMI）急诊经皮冠状动脉介入治疗（PCI）的治疗价值。方法对2004年5月～2006年9月AMI患者470例行急诊PCI治疗，在发病后平均（7.36±4、57）h内行急诊PCI。结果AMI急诊PCI成功率为98．87％，住院死亡率为4.68％。结论对于发病在12h内的AMI患者行急诊PCI，可开通梗塞相关动脉（IRA），改善心肌再灌注和近期预后。     

SPECT心肌灌注显像对急性心肌梗死患者PCI术后疗效评估

目的：探讨单光子发射型计算机断层（SPECT）心肌灌注显像评价心肌梗死（AMI）急诊经皮冠脉介入治疗（PCI）后的心肌灌注状况的价值。方法：采用99mTc-tetrofosmin（P53）SPECT心显像对54例行PCI治疗的AMI患者评估心肌灌注情况,并记录6个月心脏事件发生率。结果：SPECT显示无复流（NR）组22例,有复流组32例,两组心肌梗死患者的近期预后的差异有显著性意义（P〈0.05）。NR组不良事件发生率较非NR组有增加趋势;另外,急诊PCI组的预后明显好于择期PCI组,差异有显著性意义（P〈0.05）。结论：SPECT心肌灌注显像可对AMI患者梗死相关血管（IRA）再通治疗疗效可靠的无创性评价,NR者预示心肌微循环灌注不良,心功能差,近中期预后差;急诊介入治疗可以明显改善AMI患者的预后。     

急性心肌梗死再灌注治疗的策略选择

目的 评价急性心肌梗死（AMI）溶栓治疗的近期疗效并探讨再灌注治疗的最佳策略。方法 选择年龄≤65岁，适合静脉溶栓的AMI患者150例，依发病至溶栓开始时间分为4组。溶栓后2周内进行冠状动脉造影（CAG），梗死相关血管（IRA）的血流量按TIMI标准分级，并与临床判定IRA再通率比较分析。结果 Ⅰ～Ⅳ组TIMI血流2级和3级者，分别为90．90％，60．76％，58．82％和32．35％；TIMI血流0级和1级者分别为13．64％，32．55％，41．18％和67．65％。血管再通率随溶栓开始时间推后而下降，Ⅳ组下降最为明显，而血管闭塞率则逐渐上升。血管再通率及闭塞率Ⅳ组与其他各组差异有非常显著性（P〈0．01）。无创伤性再灌注指标判定IRA未开通的53例中有52例经CAG证实梗死区无血流灌注，说明该指标基本上可以真实地反映IRA是否开通。临床判定IRA开通的97例中有7例TIMI血流为0级或1级，提示IRA内可能再次血栓形成。各组均未发生严重合并症，30天总病死率为4．67％。结论 静脉溶栓治疗AMI安全有效。AMI发病2h以内，溶栓疗效与介入疗效相当，发病〉2h，特别是6h以后，溶栓疗效逐渐下降，为使更多患者受益，再灌注治疗的策略宜首选介入治疗。溶栓失败或出现再次心肌缺血症状者应立即常规实施挽救性介入治疗。对于无条件实施介入治疗的所有适合溶栓的AMI患者均应给予溶栓治疗。     

急性心肌梗死急诊冠脉介入治疗临床分析

急性心肌梗死(AMI)急诊经皮冠状动脉介入治疗(PCI),可开通梗塞相关动脉(IRA)恢复前向血流,改善预后,是AMI再灌注治疗的有效措施,其血运重建的效果优于其他方法已逐步得到公认。     

溶栓治疗急性心肌梗死的临床分析

目的：探讨尿激酶（UK）溶栓后冠脉再通率。方法：分析42例AMI患者尿激酶静脉溶栓治疗后再通者心电图演变，再灌注心律失常。结果：溶栓再通率59.5%，再通者再灌注心律失常率72%。结论：溶栓可挽救濒死的心肌，有效保护心功能。     

磁共振心肌灌注成像评价心肌梗死PTCA治疗前后心肌存活

目的 评价磁共振心肌灌注成像(MRMPI) 检测心肌梗死存活心肌的作用. 方法 选择心肌梗死患者51 例.采用1.5 T MR扫描仪,反转恢复快速小角度激励( IR-turbo FLASH) 序列,全部患者均在静脉注射钆喷替酸葡甲胺(Gd-DTPA) 0.1 mmol/kg、MRMPI 首过期及5~30 min 延迟期成像.21 例行静息、负荷99锝单光子发射计算机体层摄影术( single photon emission computed tomography, SPECT) 进行对照研究.首过期行短轴面成像,延迟期行短轴面及长轴面成像.结果 51例心肌梗死患者,42 例(82.3%) 首过期显示灌注减低;50 例(98%) 延迟增强.在21例168个心肌段SPECT诊断无活性心肌段48个,MRMPI 示梗死区均有延迟增强,SPECT诊断存活心肌段120 个,MRMPI 示97段无延迟增强.以静息、负荷99m锝SPECT 作为参考标准,MRMPI 的敏感度、特异度分别为100%、80.8%. 结论 MRMPI 可有效地检测心肌梗死的存活和非存活心肌,以及其程度和范围.     

Acute myocardial infarction due to myocardial bridge

Myocardial bridge (MB) is regarded as a common anatomic variant rather than a congenital condition anomaly,defined as the intramyocardial course of a portion of the coronary artery.It was first mentioned by Rayman in 1737 and first described by Grainicianu in the early 1920s.The current gold standard for diagnosing     

Evaluation of Myocardial Viability after Myocardial Infarction with Intravenous Real-time Myocardial Contrast Echocardiography

The myocardial viability after myocardial infarction was evaluated by intravenous myocardial contrast echocardiography. Intravenous real-time myocardial contrast echocardiography was performed on 18 patients with myocardial infarction before coronary revascularization. Follow-up echocardiography was performed 3 months after coronary revascularization. Segmental wall motion was assessed using 18-segment LV model and classified as normal, hypokinesis, akinesis and dyskinesis. Viable myocardium was defined by evident improvement of segmental wall motion 3 months after coronary revascularization. Myocardial perfusion was assessed by visual interpretation and divided into 3 conditions： homogeneous opacification; partial or reduced opaciflcation or subendocardial contrast defect; contrast defect. The former two conditions were used as the standard to define the viable myocardium. The results showed that 109 abnormal wall motion segments were detected among 18 patients with myocardial infarction, including 47 segments of hypokinesis, 56 segments of akinesis and 6 segments of dyskinesis. The wall motion of 2 segments with hypokinesis before coronary revascularization which showed homogeneous opacification, 14 of 24 segments with hypokinese and 20 of 24 segments with akinese before coronary revascularization which showed partial or reduced opaciflcation or subendocardial contrast defect was improved 3 months after coronary revascularization. In our study, the sensitivity and specificity of evaluation of myocardial viability after myocardial infarction by intravenous real-time myocardial contrast echocardiography were 94.7% and 78.9%, respectively. It was concluded that intravenous real-time myocardial contrast echocardiography could accurately evaluate myocardial viability after myocardial infarction.     

Acute myocardial infarction: myocardial salvage assessment

Primary coronary revascularization by means of percutaneous coronary intervention(PCI)is a highly effective treatment of acute myocardial infarction re-establishing coronary perfusion and stopping the ongoing necrosis in the dependent myocardium.Single-photon emission computed tomography(SPECT)is the most widely used modality assessing myocardial salvage as the difference between the acute perfusion defect before intervention and the remaining scar size measured in a second scan several days after the event.SPECT allows quantification of area at risk(AAR)and final infarct size(FIS)by tracer injection prior to revascularization and after 1 month,respectively.SPECT provides the most validated measure of myocardial salvage and has been utilized in multiple randomizedclinical trials.However,SPECT is logistically challenging,expensive,and includes radiation exposure.More recently,a large number of studies have suggested that cardiac magnetic resonance(CMR)can determine salvage in a single examination by combining measures of myocardial oedema in the AAR exposed to ischaemia reperfusion with FIS quantification by late gadolinium enhancement.     

心肌声学造影对急性心梗PCI术后心肌灌注的评价

目的:通过心肌声学造影(MCE)对急性心梗经皮冠状动脉支架术(PCI)后心肌灌注的情况进行判断,了解其对左心功能及左室重构的影响.方法:采用病例对照的研究方法,根据PCI术后1周的MCE检查,将急性心梗患者分为灌注正常组、灌注稀疏组和灌注缺失组,并随访检查3个月、6个月的左室射血分数(LVEF)及左室舒张末内径(LVDd)的变化情况,比较组内及组间不同时段LVEF与LVDd的变化.结果:PCI术后3个月灌注稀疏组LVEF恢复到正常;灌注缺损组PCI术后LVEF的平均水平随时间变化而逐渐降低;灌注缺损组患者的LVEF低于灌注稀疏组和灌注正常组(P<0.05);术后6个月灌注缺损组LVDd平均水平高于灌注正常组和灌注稀疏组(P<0.05),灌注缺损组随时间的变化左室内径逐渐增大(P<0.05).结论:急性心梗患者PCI术后心肌微循环较差时,其左室射血分数降低,左室内径增大;MCE有利于对急性心梗患者PCI术后左心功能及左室重构评估.     

水飞蓟素通过抑制心肌细胞凋亡减轻心肌梗死

目的：观察水飞蓟素对心肌梗死小鼠的血流动力学、梗死面积及梗死边缘区凋亡蛋白表达情况。方法：将60只小鼠随机分为心肌梗死组、假手术组、心肌梗死+水飞蓟素组和心肌梗死溶剂组。建模成功4周后检测小鼠血流动力学变化,进行心脏超声检查,评价梗死面积、细胞凋亡指数以及凋亡蛋白Bcl-2、Bax、Cleaved-Caspase3的表达。结果：与心肌梗死组小鼠相比,水飞蓟素可显著减轻心肌梗死,改善心梗小鼠心功能,降低心肌细胞凋亡指数,增强Bcl-2蛋白表达和减弱Bax和Cleaved-Caspase3蛋白表达。结论：水飞蓟素能够减轻心肌梗死,改善心梗小鼠心室收缩功能,保护心肌,减少心肌细胞的凋亡,其机制与升高Bcl-2蛋白、降低Bax和Cleaved-Caspase3蛋白表达水平有关。     

“肾阳虚证”下心肌梗死模型与单纯心肌梗死模型大鼠心肌形态学、心肌酶学及血液流变学的比较

目的：建立大鼠“肾阳虚证”下心肌梗死模型,探讨其与单纯心肌梗死模型大鼠在心肌形态学、心肌酶学及血液流变学方面的差异,为评价治疗胸痹心痛中药的药效学提供理论依据。方法：60只Wistar大鼠随机分为空白对照组、肾阳虚模型组、心肌梗死假手术组、单纯心肌梗死模型组及“肾阳虚证”下心肌梗死模型组,每组12只。在大鼠 “肾阳虚”情况下复制急性心肌梗死模型,测定各组大鼠心肌梗死面积 (MIS),血清天门冬氨酸氨基转化酶（AST）、肌酸磷酸激酶（CK）及乳酸脱氢酶（LDH）活性,同时测定血小板黏附率（PAR）、血小板聚集率（PAG）、红细胞沉降率（ESR）、红细胞压积（HCT）、体外血栓长度、血栓干重与湿重以及血栓弹力图等参数。结果： 大鼠“肾阳虚证”下心肌梗死模型与单纯心肌梗死模型在MIS,血清AST、CK及LDH活性,PAR、PAG、ESR及HCT增加程度差异无统计学意义（P>0.05）;肾阳虚模型组、单纯心肌梗死模型组及“肾阳虚证”下心肌梗死模型组大鼠体外血栓干重及长度均明显增加（P<0.05或P<0.01）,“肾阳虚证”下心肌梗死模型组的增加程度大于单纯心肌梗死模型组及肾阳虚模型组,但三者之间差异无统计学意义（P>0.05）;尽管“肾阳虚证”下心肌梗死模型组大鼠血栓弹力图r、k值的缩短程度及ma值的增大程度高于单纯心肌梗死模型组,但2组之间差异无统计学意义（P>0.05）。结论：大鼠“肾阳虚证”下心肌梗死模型与单纯心肌梗死模型心肌梗死面积、血清心肌酶学、红细胞压积、血沉、血小板功能、体外血栓重量及血栓弹力图等指标均无明显差异。     

Relation of myocardial bridge to myocardial infarction: a meta-analysis

Background Small case series have suggested an association of coronary myocardial bridge （MB） with myocardial infarction （MI）.However,the relationship between MB and major adverse cardiac events （MACE） remains largely unknown.The aim of this study was to assess the relationship between MB and MACE involving MI.Methods We performed a systematic search of MEDLINE,PreMEDLINE,and all EMB Reviews as well as a reference list of relevant articles according to the SPICO （Study design,Patient,Intervention,Control-intervention,and Outcome） criteria using the following keywords：myocardial bridging,myocardial bridge,intramural coronary artery,mural coronary artery,tunneled coronary artery,coronary artery overbridging,etc.Bibliographies of the retrieved publications were additionally hand searched.Studies were included for the meta-analysis if they satisfied the following criteria：（1） they evaluate the association of MB with cardiovascular endpoint event; （2） they included individuals with MB and those without MB; 3） they excluded individuals with obstructive coronary artery disease （CAD）.Studies were reviewed by a predetermined protocol including quality assessment.Dates were pooled using a random effect model.Results Seven observational studies that followed 5 486 patients eligible for the enrolled criteria were included from 7 136 initially identified articles.The prevalence of MB was 24.8％ （1 363/5 486）.During 0.5-7.0 years of follow-up of this cohort of population,crude outcome rates were 8.0％ in the MB group and 7.7％ in the non-MB group.The odds ratio of overall MACE and MI were 1.34 （95％ confidence interval （CI）：0.57-3.17,P=0.51,n=7 studies） and 2.75 （95％ CI：1.08-7.02,P ＜0.03,n=5 studies） respectively for subjects of MB compared to non-MB.Conclusion Relationship between MB and MI appears to be a real one,although the study did not reveal a connection of MB to MACE,suggesting whether the necessity of antiplatelet therapy needs to be further studied in a larger cohort of patients with MB prospectively.     

超声心肌造影技术对心肌梗塞患者心肌微循环的定量评价

目的：探讨超声心肌造影技术在心肌梗塞(简称心梗)患者心肌微循环灌注改变中的应用价值。方法：对30例急性心梗患者进行超声心动图及心肌造影检查,观察患者梗塞区域(AMI组,同时以患者非梗塞区域为自身对照组)心肌微循环灌注并以CPS造影软件进行分析。结果：心肌梗塞患者梗塞区域心肌微循环灌注开始时间(AT)、达峰时间(APT)较同一切面内的非梗塞区域明显延长（P<0.05）,梗塞区域造影剂灌注的峰值强度(PI)及灌注速度(β)均明显低于同一切面内的非梗塞区域（P<0.05）。结论：超声心肌造影技术可以定量评价心梗患者心肌微循环灌注,具有重要的临床应用价值。     

Factors affecting thrombolysis in myocardial infarction myocardial perfusion frame count: insights of myocardial tissue-level reperfusion from a novel index for assessing myocardial perfusion

Background  Myocardial tissue-level perfusion failure is associated with adverse outcomes following ST-elevation myocardial infarction (STEMI) despite successful epicardial recanalization. We have developed a new quantitative index—thrombolysis in myocardial infarction (TIMI) myocardial perfusion frame count (TMPFC)—for assessing myocardial tissue level perfusion. However, factors affecting this novel index of myocardial perfusion are currently unknown.

Methods  A total of 255 consecutive STEMI patients undergoing primary angioplasty were enrolled. Myocardial tissue level perfusion was assessed by TMPFC, which measures the filling and clearance of contrast in the myocardium using cine-angiographic frame counting. We differentiate three groups with two cut off values for TMPFC: a TMPFC of 90 frames was the upper boundary of the 95% confidence interval (CI) for the TMPFC observed in normal arteries, and a TMPFC of 130 was the 75th percentile of TMPFC.

Results  STEMI patients with TMPFC >130 frames (68 patients, 26.7%) had higher clinical and angiographic risk factor profiles as well as a higher 30-day MACE rate compared with those with TMPFC ≤90 frames and those with TMPFC >90 and ≤130 frames. Multivariable analysis identified that the independent predictors of TMPFC >130 frames were age ≥75 years (OR 2.08, 95% CI 1.21 to 3.58, P=0.007), diabetes (OR 1.37, 95% CI 1.01 to 1.86, P=0.042), Killip class ≥2 (OR 1.52, 95% CI 1.05 to 2.21, P=0.027), and prolonged pain-to-balloon time (OR 1.73, 95% CI 1.07 to 2.79, P=0.013). TMPFC >130 frames was identified as the strongest independent predictor of 30-day major adverse cardiac event (MACE) (OR 2.77, 95% CI 1.21 to 6.31, P=0.008), along with age ≥75 years (OR 2.19, 95% CI 1.11 to 4.33, P=0.016), female gender (OR 1.67, 95% CI 1.03 to 2.70, P=0.038), and Killip class ≥2 (OR 1.83, 95% CI 1.07 to 3.14, P=0.021).

Conclusions  STEMI patients with poor myocardial perfusion assessed by TMPFC had higher risk factor profiles. Advanced age, diabetes, higher Killip class, and longer ischemia time were independent predictors of impaired TMPFC after primary percutaneous coronary intervention. These results emphasize that particular attention should be paid on myocardial microvascular reperfusion in STEMI patients with these risk factors.