急性心肌梗死患者经皮冠状动脉介入治疗术后早期再发心肌梗死的预测及分析

目的分析老年急性心肌梗死患者PCI术后早期再发心肌梗死的预测危险因素。方法连续选取行PCI术的老年急性心肌梗死患者共2 252例,将未发生心肌再梗死的患者2 176例作为无再梗死组,发生早期再发心肌梗死患者76例作为再梗死组,对再发心肌梗死的危险因素进行分析。结果 PCI术后早期再发心肌梗死发生率为3.4%,且以男性为主。与无再梗死组比较,再梗死组糖尿病患病率和入院时血糖水平较高,心功能较差、血管狭窄程度较重,PCI术前、术后TIMI血流分级较差,术后血栓形成和夹层发生率较高,差异有统计学意义(P<0.05,P<0.01)。多因素回归分析显示,老年、血糖增高、糖尿病、心功能(Killip分级)、多支血管病变和PCI术后血栓及夹层形成与早期再发心肌梗死密切相关。结论高龄、血糖增高、糖尿病、心功能、多支血管病变和PCI术后血栓及夹层形成是早期再梗死的高危因素。针对合并这些因素的高危患者应进行积极有效防治。     

急性ST段抬高心肌梗死直接经皮冠状动脉介入术冠状动脉无复流现象对预后的影响

目的研究急诊经皮冠状动脉介入(PCI)治疗冠状动脉(冠脉)中无复流现象的临床意义.方法自2000年1月至2004年1月,回顾性分析我院336例急性ST段抬高心肌梗死(STEMI)直接PCI患者的临床和影像资料.急诊PCI支架置入即刻,在无影响血流的血栓、栓塞、夹层、痉挛情况下,冠脉造影前向血流≤TIMI2级为无复流,TIMI 3级为正常血流.冠脉无复流患者42例,利用Excel随机函数表,由其余294例急诊PCI冠脉前向血流恢复正常的患者中随机抽取45例,为正常血流组.随访6个月,观察有无心脏性猝死和非致命性心脏事件.结果无复流组发生充血性心衰、恶性心律失常、再发心绞痛、心脏性猝死高于冠脉血流正常组,无复流组6个月后左室射血分数显著低于冠脉血流正常组.结论无复流患者的心肌损害严重,梗死或濒临坏死的心肌范围广泛,强烈提示AMI预后不良.     

急性心肌梗死患者直接经皮冠状动脉介入治疗成功后住院期间心力衰竭的预测因素

目的：本研究旨在明确ST段抬高心肌梗死（STEMI）患者成功行直接经皮冠状动脉介入治疗（PCI）后住院期间发生心力衰竭（HF）的预测因素。方法回顾性分析接受直接PCI成功治疗的初发STEMI患者的临床和冠状动脉造影资料,根据住院期间是否发生HF将患者分为HF组和无HF组。确定住院期间HF的发生率、预测因素及其对预后的影响。结果共入选患者834例,男662例（79.4%）,年龄（62.9±12.9）岁。其中,HF组94例（11.3%）,无HF组740例（88.7%）。HF组的30 d全因死亡率显著高于无HF组（24.5%比1.5%,P＜0.001）。Cox回归分析显示,犯罪血管为前降支（HR 2.173,95% CI 1.12～4.212,P=0.022）、ln 24 h N末端B型利钠肽原（NT-proBNP）（HR 1.904,95% CI 1.479～2.452,P＜0.001）、24 h超敏C反应蛋白（hsCRP）≥11.0 mg/L（中位数）（HR 2.901,95% CI 1.309～6.430,P=0.009）和基线血糖（HR 1.022,95% CI 1.000～1.044,P=0.046）是住院期间发生HF的独立预测因素。受试者工作曲线显示,以24 h NT-proBNP≥1171 pg/ml为阈值诊断住院期间HF的敏感性和特异性分别为92.5%和76.8%（c=0.883, P＜0.001）,以24 h hsCRP≥13.5 mg/L为阈值诊断住院期间HF的敏感性和特异性分别为86.0%和77.0%（c=0.829,P＜0.001）。在犯罪血管为前降支的患者中,24 h NT-proBNP＜1171 pg/ml且24 h hsCRP＜13.5 mg/L的患者住院期间HF的发生率为0.4%,而24 h NT-proBNP≥1171 pg/ml且24 h hsCRP≥13.5 mg/L的患者住院期间HF的发生率为60.9%,两者差异有统计学意义（P＜0.001）。结论 STEMI患者即使接受直接PCI成功治疗,其住院期间HF的发生率仍然较高,发生HF者预后差。犯罪血管为前降支、hsCRP、NT-proBNP和基线血糖是住院期间发生HF的独立预测因素。检测并联合应用不同的血清生物标记物是预测STEMI患者直接PCI术后住院期间发生HF的有效方法。     

急性心肌梗死急诊经皮冠状动脉介入治疗患者院内死亡因素分析

目的:分析急性心肌梗死(AMI)患者行急诊经皮冠状动脉介入治疗(PCI)手术住院期间死亡的危险因素及死亡原因。方法:438例接受急诊PCI的AMI患者,根据住院期间存活与否,分为死亡组(21例)和存活组(417例),比较两组患者的临床特征和冠状动脉造影及介入治疗结果,分析发生院内死亡的原因及死亡预测因素。结果:死亡组患者中年龄65岁、心功能Killp分级≥Ⅱ级、心源性休克、广泛前壁梗死、多支闭塞(≥2支)、近段闭塞、梗死相关动脉(IRA)开通后即刻TIMI血流≤Ⅱ级、IRA开通后即刻血压下降与存活组相比较差异有统计学意义(均P0.05)。多因素logistic回归分析表明年龄65岁、心功能Killp分级≥Ⅱ级、心源性休克、广泛前壁梗死、IRA开通后即刻TIMI血流≤Ⅱ级是急诊PCI患者围术期死亡的独立预测因素。死亡原因中,心源性休克8例(38.1%)、恶性心律失常6例(28.6%)分居第1和第2位。结论:年龄65岁、心功能Killp分级≥Ⅱ级、心源性休克、广泛前壁梗死、IRA开通后即刻TIMI血流≤Ⅱ级是急诊PCI患者围术期死亡的危险因素。心源性休克、恶性心律失常是急诊PCI手术住院期间主要死亡原因。     

老年急性心肌梗死患者直接冠状动脉介入治疗术后随访分析

目的分析老年急性心肌梗死患者直接PCI术后的危险因素。方法将619例直接行PCI的急性心肌梗死患者,按年龄分为老年组(≥65岁)236例和对照组(<65岁)383例,全部入选患者行PCI术后记录主要不良心脏事件,进行回顾性分析,采用Log-Rank检验进行两组的生存分析,Cox回归分析用于预后多因素分析。结果老年组患者女性比例、左心功能不全、肾功能不全比例高于对照组,差异有统计学意义(P<0.01)。高血压、糖尿病、血肌酐水平、LVEF值、无复流、支架的数目是老年组预后的独立危险因素。结论老年AMI患者直接PCI是有效可行的治疗手段。     

血清CD62P在急性心肌梗塞患者经皮冠状动脉介入术后的表达

目的:研究血清CD62P在急性心肌梗塞(AMI)患者行经皮冠状动脉介入术(PCI)前、后的表达变化。方法:60例AMI患者行PCI干预治疗,分别检测患者术前,术后即刻和术后7d的血清CD62P分子的表达,并对其结果进行比较分析。结果:PCI术后即刻AMI患者血清CD62P分子表达较术前显著降低[(42.68±2.35)ng/ml:(45.82±3.66)ng/ml,P0.05],术后7d血清CD62P分子表达[(38.82±3.14)ng/ml]较术后即刻又有显著降低(P0.05)。结论:急性心肌梗塞患者行经皮冠状动脉介入术后血清CD62P表达较术前明显下降,说明及时开通闭塞冠脉和有效的抗血小板治疗能减轻急性冠脉综合征的炎症反应。     

急性ST段抬高型心肌梗死患者直接经皮冠状动脉介入术后住院期间死亡率的性别差异

目的探讨性别差异是否影响接受直接经皮冠状动脉介入治疗(PCI)的急性ST段抬高型心肌梗死(STEMI)患者的预后。方法选择2008年1月至2013年12月因急性STEMI住院并接受急诊直接PCI治疗的患者578例。比较男性和女性在基线特征、冠状动脉造影结果及住院期间死亡率方面的差异。结果 578例患者中男性455例(78.7%),女性123例(21.3%)。女性的平均年龄较男性大[(68±10)岁比(61±12)岁,t=-6.817,P<0.01],高血压(75.6%比52.3%,χ2=21.484,P<0.01)和糖尿病(43.1%比27.7%,χ2=10.737,P<0.01)的患病率均高于男性;而男性的吸烟比例高于女性(63.5%比13.0%,χ2=99.108,P<0.01)。两组患者的冠状动脉造影结果差异无统计学意义。女性的住院期间死亡率高于男性(8.9%比4.4%,χ2=3.945,P=0.047),校正年龄、高血压、糖尿病、吸烟史和血小板糖蛋白Ⅱb/Ⅲa受体拮抗剂的使用后这种性别差异无统计学意义(OR:1.036,95%CI:0.339³.169,P=0.95)。结论对接受急诊直接PCI治疗的STEMI患者而言,女性的住院期间死亡率高于男性,但这种差异可能是由于本研究样本人群女性年龄偏大、并存疾病更多所致。     

急性前壁与非前壁心肌梗死患者直接经皮冠状动脉介入干预后临床远期预后分析

目的 探讨急性前壁与非前壁急性心肌梗死（AMI）患者直接经皮冠状动脉介入干预（PCI）后临床远期预后。方法 连续行直接PCI的287例AMI患者根据心肌梗死的不同部位分成急性前壁心肌梗死组（AW-AMI组,142例）和急性非前壁心肌梗死组（NAW-AMI组,145例）,分析其临床基本特征、冠状动脉病变特点,主要观察终点为住院期病死率与随访期（平均17.3±9.8个月）主要心血管事件（MACE）,包括非致命心肌梗死,非致命心力衰竭,靶血管血运重建及总心脏性死亡的发生率。结果 与NAW-AMI组比较,AW-AMI组的CK与CK-MB峰值显著升高[（3 533±2 888）U/L比（2322±1638）U/L,（158±197）U/L比（95±64）U/L,P均<0.01],左室射血分数降低（0.55±0.13比0.61±0.12,P<0.05）以及住院期病死率增高（4.1％比0,P<0.05）。平均随访17.3±9.8）个月,AW-AMI组的非致命性心力衰竭、总心脏死亡率及复合终点事件发生率高于NAW-AMI组（P均<0.05）。多变量分析显示,前壁心肌梗死和前降支近段病变与AMI患者直接PCI治疗后心脏性死亡发生相关（P均<0.05）。结论 前壁心肌梗死与主要心血管事件发生率增高有关,AW-AMI行直接PCI患者的长期临床预后较NAW-AMI行直接PCI者差。     

急性心肌梗塞直接经皮冠状动脉介入术的临床护理

目的:探讨急性心肌梗塞直接经皮冠状动脉介入治疗(PC I)病人的护理价值。方法:回顾性分析2000年4月至2004年1月在我院直接PC I且成功开通梗塞相关血管(IRA)的AM I患者26例的资料。结果:26例急性心肌梗塞直接PC I均获得成功。26例患者共置入支架43枚,其中4例(15.39%)术中出现再灌注性心律失常,因及时发现,并给予对症处理后恢复,因为正确护理未发生并发症。结论:加强PC I护理有助于急性心肌梗塞直接PC I成功及减少并发症。     

经皮冠状动脉介入术后九例死亡病例分析

目的 分析PCI术后死亡的危险因素及死亡原因.方法 我院235例完成PCI术的患者术后共有9例死亡,对32项临床因素进行单因素分析,并对有统计意义的因素进行logistic回归分析.结果 单因素分析显示有年龄≥75岁、高血压病史、中风病史、急性非ST段抬高心肌梗死(NSTEMI)、肾小球滤过率(eGFR)＜30ml/min/1.72m2、左主干病变(P分别为0.019、0.005、0.005、0.001、0.000、0.047)等6种情况的患者PCI术后死亡率较高,logistic分析显示NSTEMI、eGFR＜30ml/min/1.72m2、左主干病变(P分别为0.005、0.017、0.026)等3项则是PCI术后死亡的独立危险因素,死亡原因以心源性原因为主,其中支架内血栓形成或可能的支架内血栓形成是最主要原因.结论 NSTEMI、eGFR＜30ml/min/1.72m2、左主干病变等是PCI术后死亡的独立危险因素,支架内血栓形成或可能的支架内血栓形成是最主要死亡原因.     

Efficacy and safety of glycoprotein IIb/IIIa receptor antagonists for patients undergoing percutaneous coronary intervention within twelve hours of fibrinolysis

Objective : To compare clinical outcomes between glycoprotein IIb/IIIa receptor antagonist recipients and nonrecipients who underwent percutaneous coronary intervention (PCI) within 12 hr of fibrinolysis. Background : Despite limited evidence, glycoprotein IIb/IIIa receptor antagonists are widely used in ST‐elevation myocardial infarction (STEMI) patients undergoing routine early or rescue PCI after fibrinolysis. Methods: We evaluated 87 and 556 glycoprotein IIb/IIIa receptor antagonist recipients and nonrecipients enrolled in a regional registry of STEMI between October 2002 and December 2005. The primary efficacy endpoint was a composite of death from any cause, reinfarction, and stroke at 1 year of follow‐up. The primary safety endpoint was the rate of in‐hospital major bleeding that was not related to coronary artery bypass grafting. Results : The primary efficacy endpoint occurred in 12% (10 of 81) and 13% (72 of 525) of glycoprotein IIb/IIIa receptor antagonist recipients and nonrecipients, respectively (P = 0.74). The corresponding rates of major bleeding during index hospitalization were 4.8% (4 of 84) and 5.1% (28 of 544) (P = 0.88), respectively. Two glycoprotein IIb/IIIa receptor antagonist recipients and five nonrecipients experienced intracranial hemorrhage. After adjusting for propensity score, the odds of primary efficacy (odds ratio, 0.79; 95% confidence interval, 0.34–1.83) and safety (odds ratio, 0.75; 95% confidence interval, 0.22–2.62) endpoints did not differ according to the use of glycoprotein IIb/IIIa receptor antagonists. Conclusion : In this observational cohort study of unselected patients with STEMI, the administration of glycoprotein IIb/IIIa receptor antagonists provided no additional benefit to PCI performed within 12 hr of fibrinolysis, nor did it compromise patient safety. © 2011 Wiley‐Liss, Inc.     

尿微量白蛋白在评价直接PCI后心肌灌注的意义

目的 探讨急性ST段抬高性心肌梗死(ST-elevation myocardial infarction,STEMI)患者尿微量白蛋白与行直接经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗后心肌灌注的关系.方法 行直接PCI治疗的急性STEMI 158例,以尿白蛋白排泄率(urinary albumin excretion rate,UAER)20 mg/L为界,将患者分为对照组(60例)与异常组(98例).后者义以100 mg/L为界进一步分为低水平组52例和高水平组46例.比较不同组段患者术后2 h ST段回落情况、校正心肌梗死溶栓治疗(thrombolysis in myocardialinfarction,TIMI)帧数、肌酸激酶同工酶-MB(creatine kinase isoenzyme-MB.CK-MB)峰值及峰值时间、主要心血管事件发生情况.结果 对照组术后2 h ST段同落情况、校正TIMI帧数、CK-MB峰值及峰值时间均优于异常组,而低水平组又优于高水平组;异常组行直接PCI治疗后30 d内主要心血管事件发生率高于对照组(16%与5%,X2:4.52,P=0.043).结论 STEMI患者尿微量白蛋白出现及水平高低反映心脏微循环受损,是急性STEMI患者行直接PCI治疗后心肌灌注不良的重要影响因素.     

Time delay in the treatment of acute myocardial infarction (AMI): a comparison of primary percutaneous transluminal coronary angioplasty (PTCA) with thrombolysis

Abstract Background: If primary percutaneous transluminal coronary angioplasty (PTCA) cannot be performed within times comparable to thrombolysis, the possible advantages of that management may be offset by the logistic difficulties associated with its delivery.
Aim: To measure and compare the time delay involved in administration of thrombolysis and primary PTCA over a one year period and examine causes for delay greater than 60 minutes.
Method: Prospective data collection on all patients treated with primary PTCA or thrombolysis. A quality improvement process was applied.
Results: Eighty-five patients were treated with thrombolysis with a delay of 39±8 (SD) minutes, 12 patients being treated more than 60 minutes after presentation. Primary PTCA was used in 79 patients with a delay of 48±12 (SD) minutes, 21 patients being treated after more than 60 minutes. Time delays in the two management groups were significantly different (p=0.03) but that in primary PTCA during routine hours was not significantly different from that in thrombolysis treated patients (p=0.07). Causes for revascularisation delay greater than 60 minutes from presentation are discussed.
Conclusions: With appropriate facilities and organisation, patients with acute myocardial infarction presenting within normal working hours can be treated with primary PTCA without compromising their care due to time delay. Many patients managed with primary revascularisation by thrombolysis or primary PTCA with a delay of more than 60 minutes have identifiable clinically appropriate delays.     

直接PCI治疗高龄急性ST段抬高性心肌梗死

目的评价高龄急性ST段抬高性心肌梗死（ST-segment elevation myocardial infarction,STEMI）患者行直接经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗的安全性和有效性。方法对比分析46例高龄STEMI患者（高龄组）和64例年轻STEMI患者（年轻组）冠状动脉造影特征、直接PCI治疗的情况．即刻手术成功率、住院及随访期间主要心血管事件的发生情况。结果高龄组与年轻组比较,冠状动脉病变多为多支病变（73．9％比28．1％,P〈0．01）;2组手术即刻成功率无明显差异;2组术后达到心肌梗塞溶栓（thrombolysis inmyoxardial infarction,TIMI）3级血流患者比率无明显差异;高龄组手术操作时间较年轻组长[（64．4±25．4）min比（49．7±21．8）min,P〈0．05];高龄组住院期间、随访期间累计总的主要心血管事件发生率明显高于年轻组。随访期间,高龄组1例术后4个月猝死,死亡原因不明,1例术后1年死于脑出血：年轻组无死亡病例。结论对高龄STEMI患者行直接PCI治疗是比较安全而有效的再灌注手段。     

In-hospital mortality among women undergoing contemporary elective percutaneous coronary intervention: a reexamination of the gender gap

BACKGROUND: Previous studies have indicated that, compared with men, women are at increased risk for in-hospital mortality following percutaneous coronary intervention (PCI); however, angioplasty techniques and mortality rates have improved since earlier reports. HYPOTHESIS: We sought to reevaluate and explore further the relationship between gender and angioplasty outcomes in contemporary "real world" practice. METHODS: The influence of gender and other covariates on in-hospital mortality and other adverse events among all patients who underwent elective coronary angioplasty in New York State from 1999 to 2001 (n = 106,262) was examined. RESULTS: In-hospital mortality rates for elective angioplasty were low; however, women demonstrated a two-fold mortality excess compared with men (0.6 vs. 0.3%, p < 0.0001). Women were older and more likely than men to demonstrate certain higher-risk features (heart failure, class III-IV angina, renal failure, vascular disease); however, men were more likely to have depressed ejection fraction, prior myocardial infarction, and prior coronary revascularization. Using multivariate analysis adjusting for clinical risk factors, gender remained an independent predictor of in-hospital mortality at all ages. Women were also more likely to experience nonfatal adverse events following PCI, including more frequent need for emergency bypass surgery. CONCLUSIONS: Despite improvements in angioplasty outcomes with time, women remain at significantly higher risk of in-hospital death than men after elective PCI. This increased mortality is observed in every age group, even after adjusting for other significant comorbidities.     

氯吡格雷在经皮冠状动脉介入治疗中的应用

目的探讨氯吡格雷在经皮冠状动脉介入治疗(PCI)中的应用及疗效。方法选择91例行经皮腔内冠状动脉成形术(PTCA)+支架术的患者,分为两组:A组(26例应用氯吡格雷)和B组(65例应用噻氯匹定),对比观察其抗血小板聚集作用(监测凝血指标),随访有无心血管事件并观察药物不良反应。结果两组比较,氯吡格雷和噻氯匹定的抗血小板聚集疗效和随访的心血管事件无显著差异(P>0.05),A组不良反应总发生率低于B组(P=0.008)。结论氯吡格雷在PCI中的应用是安全有效的。     

直接PCI治疗高龄急性ST段抬高性心肌梗死

目的 评价高龄急性ST段抬高性心肌梗死(ST-segment elevation myocardial infarction,STEMI)患者行直接经皮冠状动脉介入(pereutaneous coronary intervention.PCI)治疗的安全性和有效性.方法 对比分析46例高龄STEMI患者(高龄组)和64例年轻STEMI患者(年轻组)冠状动脉造影特征、直接PCI治疗的情况,即刻手术成功率、住院及随访期间主要心血管事件的发生情况.结果 高龄组与年轻组比较,冠状动脉病变多为多支病变(73.9%比28.1%,P<0.01);2组手术即刻成功率无明显差异;2组术后达到心肌梗塞溶栓(thmmbolysis in myoxardial infarction,TIMI)3级血流患者比率无明显差异;高龄组手术操作时间较年轻组长[(64.4±25.4)min比(49.7±21.8)min,P<0.05];高龄组住院期间、随访期间累计总的主要心血管事件发生率明显高于年轻组.随访期间,高龄组1例术后4个月猝死,死亡原因不明,1例术后1年死于脑出血;年轻组无死亡病例.结论 对高龄STEMI患者行直接PCI治疗是比较安全而有效的再灌注手段.