急性冠脉综合征患者血清Sirtuin 1与冠脉病变相关

目的:探讨急性冠脉综合征患者血清Sirtuin 1 (SIRT1)水平与冠脉病变的相关性和影响冠脉病变的因素。方法:分析81例中日友好医院心脏科急性冠脉综合征住院患者的临床数据,酶联免疫吸附测定法检测外周静脉血血清SIRT1水平,血运重建前进行SYNTAX评分评估冠脉病变程度。根据SYNTAX评分中位数将患者分为高SY...     

急性冠状动脉综合征治疗研究进展

不稳定性心绞痛和非Q波心肌梗死是临床上常见急症 ,称之为急性冠状动脉综合征 ,该综合征具有较高发生率和死亡率 ,早期正确处理非常必要。本文作者复习近年来有关文献 ,就急性冠状动脉综合征治疗研究进展作一介绍。     

Non-ST segment elevation acute coronary syndromes: treatment guidelines for the nurse practitioner

PURPOSE: To increase awareness among nurse practitioners (NPs) of the American College of Cardiology (ACC)/American Heart Association (AHA) 2002 guideline update for the diagnosis and treatment of acute coronary syndrome, and for secondary prevention in patients with unstable angina (UA) and non-ST segment elevation myocardial infarction (NSTEMI). DATA SOURCES: ACC/AHA 2002 guideline update for the management of patients with UA and NSTEMI, ACC/AHA guidelines for patients with coronary and other atherosclerotic vascular disease, 2006 update, selected research and clinical articles. CONCLUSIONS: Recent research has shown that patients with UA/NSTEMI benefit from the routine, long-term use of dual antiplatelet therapy with aspirin and clopidogrel. In suitable patients, outcome is also improved by adoption of an early invasive strategy combined with aggressive medical therapy. IMPLICATIONS FOR PRACTICE: Familiarity with the patient as well as current management recommendations can improve clinical outcomes for patients with UA/NSTEMI. Thus, NPs can play a pivotal role in the management of coronary disease, both during and following an acute ischemic event.     

Emergency department treatment of acute coronary syndromes

Acute coronary syndrome (ACS) is a broad term encompassing a spectrum of acute myocardial ischemia and injury ranging from unstable angina and non-ST-segment elevation myocardial infarction to ST-segment elevation myocardial infarction. ACS accounts for approximately 1.2 million hospital admissions in the United States annually. The aging of the United States population, along with the national obesity epidemic and the associated increase in metabolic syndrome, means that the number of individuals at risk for ACS will continue to increase for the foreseeable future. This article reviews the current evidence and guidelines for the treatment of patients along the continuum of ACS.     

Acute Coronary Syndrome in Octogenarians: Expect the Unexpected

Background

Ischemic heart disease is the leading cause of death in the United States and the world. Advanced age is the strongest risk factor for ischemic heart disease and the best independent predictor for poor outcomes after acute coronary syndrome (ACS). Elderly patients are at high risk for ACS, and numerous studies have shown that octogenarians in particular experience increased morbidity and mortality compared to younger patients.

不同性别非ST段抬高急性冠状动脉综合征患者的临床特征

目的 探讨不同性别非ST段抬高急性冠状动脉综合征（ACS）患者的临床特征.方法回顾性分析首次发作不稳定型心绞痛（UA）或非ST段抬高心肌梗死（NSTEMI）患者临床资料,记录患者临床特点、治疗方法以及住院事件的发生率等情况.分析不同性别患者的临床与病变特征和住院临床结果.结果 869例患者,女性223例（25.7%）,与男性相比,女性患者有原发性高血压史较多（P＜0.001）,心肌梗死史较少（P=0.001）,吸烟史较少（P＜0.001）,糖尿病、卒中等病史差异无显著性;女性患者的年龄较大（P＜0.001）,入院时收缩压较高（P＜0.001）,空腹血糖较高（P＝0.001）,血清胆固醇较高（P＜0.001）,血肌酐较低（P＜0.001）,白细胞计数较低（P＝0.02）,左心室射血分数较高（P＜0.001）;男性和女性患者的多支血管病变比例差异无显著性;两组患者血运重建率相似,院内主要不良心脏事件的发生率差异无显著性.结论冠状动脉造影阳性非ST段抬高的ACS患者中,女性多见,心肌梗死和吸烟史较少,血糖、血脂较高,左心室收缩功能较好,不同性别患者的院内事件发生率差异无显著性.     

急性冠状动脉综合征患者血清晚期氧化蛋白产物水平的测定意义

目的 探讨血清晚期氧化蛋白产物（AOPP）水平在急性冠状动脉综合征（ACS）中的意义及对预后的影响.方法 选择ACS患者共55例,其中不稳定型心绞痛（UAP）29例,急性心肌梗死（AMI）26例;正常对照组30例;采用分光光度计法检测所有入选者的血清AOPP浓度,并记录4周内所有患者的病情转归情况.结果 2组ACS患者AOPP水平均明显高于正常对照组（均P＜0.01）,AMI组AOPP水平高于UAP组（P＜0.05）;病情转归及预后差者AOPP水平相对高（P＜0.01）.结论 AOPP与ACS的发生有关,并且与病情的严重程度呈正相关,对病情转归有一定预测价值.     

急性心肌梗死“墓碑样”ST段改变的临床意义

目的：探讨急性心肌梗死（AMI）时,"墓碑样"ST段改变的临床意义和预后。方法：48例AMI患者,根据ST段形态分为墓碑样组（n=11）和对照组（n=37）。比较两组间ST段上抬高度、ST段抬高导联数、CK峰值、QT离散度、心脏严重并发症例数和死亡率以及广泛心肌梗死（ST段抬高导联数＞5个）的发生例数。结果：除广泛心肌梗死的例数二组之间比较无差异（P＞0.05）外,墓碑样组均大于对照组,差异显著（P＜0.05）。墓碑样组室性心律失常的发生率和由此引起的死亡数亦大于对照组（P＜0．05）。结论：有"墓碑样"ST段改变者预后较差,与心肌梗死范围相比,心肌缺血损伤程度较重可能是其预后不良的更重要原因。     

非ST段抬高急性冠状动脉综合征女性患者二年随访

目的研究非ST段抬高急性冠状动脉综合征（NSTE-ACS）女性患者的临床特点、治疗现状及2年自然病程。方法本研究为国际性急性冠状动脉综合征登记试验（OASIS）的一部分。按统一方案登记因NSTE-ACS入院的患者,对入选患者的治疗不作任何干预,记录其临床特征、主要药物及干预治疗、重大事件,进行前瞻性、多中心的追踪记录2年,分析女性患者的特点并与男性患者对比进行单因素分析。结果中国大陆地区共注册2 294例NSTE-ACS患者,女性占37.7%（864例）,平均年龄65.1±6.7岁,就诊时有不稳定心绞痛及心电图异常者分别占90.7%、92.6%。女性患者既往有高血压、糖尿病史者分别占64.1%、23.4%,显著高于男性（P≤0.001）。女性患者既往有冠心病、陈旧心肌梗死、吸烟、接受经皮冠状动脉介入（PCI）者分别占39.4%、16.8%、11.7%、2.3%,均明显低于男性（P≤0.001）。既往接受冠状动脉旁路移植术（CABG）者占0.5%,低于男性（P≤0.05）。住院期间女性患者抗血小板制剂、β-受体阻滞剂治疗率分别为92.8%、64.8%,低于男性（P≤0.05）;硝酸酯类药、转换酶抑制剂、钙拮抗剂和调血脂治疗率分别为96.9%、60.0%、59.1%、47.1%,与男性相比差异无统计学意义。出院后女性患者药物治疗率下降幅度比男性更为明显。随访2年时女性患者抗血小板制剂、β-受体阻滞剂、转换酶抑制剂、调血脂药的服用率分别为68.4%、39.5%、27.4%和19.4%,均显著低于男性（P≤0.05）。住院期间女性患者PCI、CABG治疗率分别为10.5%和2.7%;2年随访期间分别为13.4%和4.8%。女性血运重建治疗无论是在住院期间或2年随访期间均显著低于男性（P≤0.001）。2年随访期间女性患者死亡、再发心肌梗死、卒中、心力衰竭、因顽固心肌缺血住院率分别为7.4%、4.7%、6.8%、15.4%和31.3%,与男性相比差异均无统计学意义（P值均〉0.05）。结论 NSTE-ACS女性患者接受治疗和/或重视治疗的程度明显低于男性。在目前治疗不及男性的情况下女性的重大事件发生率与男性组相比无统计学差异,女性性别是NSTE-ACS重要事件的保护因素。     

Prospective Validation of a Modified Thrombolysis In Myocardial Infarction Risk Score in Emergency Department Patients With Chest Pain and Possible Acute Coronary Syndrome

Objectives: This study attempted to prospectively validate a modified Thrombolysis In Myocardial Infarction (TIMI) risk score that classifies patients with either ST‐segment deviation or cardiac troponin elevation as high risk. The objectives were to determine the ability of the modified score to risk‐stratify emergency department (ED) patients with chest pain and to identify patients safe for early discharge. Methods: This was a prospective cohort study in an urban academic ED over a 9‐month period. Patients over 24 years of age with a primary complaint of chest pain were enrolled. On‐duty physicians completed standardized data collection forms prior to diagnostic testing. Cardiac troponin T‐values of >99th percentile (≥0.01 ng/mL) were considered elevated. The primary outcome was acute myocardial infarction (AMI), revascularization, or death within 30 days. The overall diagnostic accuracy of the risk scores was compared by generating receiver operating characteristic (ROC) curves and comparing the area under the curve. The performance of the risk scores at potential decision thresholds was assessed by calculating the sensitivity and specificity at each potential cut‐point. Results: The study enrolled 1,017 patients with the following characteristics: mean (±SD) age 59.3 (±13.8) years, 60.6% male, 17.9% with a history of diabetes, and 22.4% with a history of myocardial infarction. A total of 117 (11.5%) experienced a cardiac event within 30 days (6.6% AMI, 8.9% revascularization, 0.2% death of cardiac or unknown cause). The modified TIMI risk score outperformed the original with regard to overall diagnostic accuracy (area under the ROC curve = 0.83 vs. 0.79; p = 0.030; absolute difference 0.037; 95% confidence interval [CI] = 0.004 to 0.071). The specificity of the modified score was lower at all cut‐points of >0. Sensitivity and specificity at potential decision thresholds were: >0 = sensitivity 96.6%, specificity 23.7%; >1 = sensitivity 91.5%, specificity 54.2%; and >2 = sensitivity 80.3%, specificity 73.4%. The lowest cut‐point (TIMI/modified TIMI >0) was the only cut‐point to predict cardiac events with sufficient sensitivity to consider early discharge. The sensitivity and specificity of the modified and original TIMI risk scores at this cut‐point were identical. Conclusions: The modified TIMI risk score outperformed the original with regard to overall diagnostic accuracy. However, it had lower specificity at all cut‐points of >0, suggesting suboptimal risk stratification in high‐risk patients. It also lacked sufficient sensitivity and specificity to safely guide patient disposition. Both scores are insufficiently sensitive and specific to recommend as the sole means of determining disposition in ED chest pain patients. ACADEMIC EMERGENCY MEDICINE 2010; 17:368–375 © 2010 by the Society for Academic Emergency Medicine     

急性ST段抬高型心肌梗死自发再灌注患者的临床及造影特点分析

目的探讨罪犯血管发生自发再灌注的急性ST段抬高型心肌梗死(STEMI)的临床及造影特点。方法将2006年1月至2009年12月在安贞医院28病房行直接经皮冠脉介入治疗(PCI)的STEMI患者519例,根据直接PCI术前罪犯血管TIMI血流分级,把患者分为自发再灌注组(TIMI血流Ⅲ级)和无自发再灌注组(TIMI血流0～Ⅱ级)。通过冠脉造影观察直接PCI前罪犯血管自发再灌注的发生率,并对其临床相关因素及造影病变特点进行分析。结果两组患者在年龄、CTnI峰值、≥2支血管病变高血栓负荷以及罪犯病变位于LAD部位方面的差异均有统计学意义(其P值分别为0.000、0.000、0.002、0.000和0.003)。而在性别、高血压、糖尿病、吸烟、高脂血症、既往心绞痛、罪犯血管分布、罪犯病变在LCX和RCA分布以及侧枝循环建立方面,其差异均无统计学意义(P值均>0.05)。结论与未发生自发再灌注的患者相比,自发再灌注的STEMI患者年龄较小,CTnI峰值较低,血栓负荷较重,罪犯病变多位于LAD远段。     

STEMI患者PCI术中注射前列地尔对心肌灌注恢复的影响

目的 探讨在急性ST段抬高型心肌梗死患者经皮冠状动脉介入术中注射前列地尔对患者心功能、心肌灌注、氧化应激和预后的影响.方法 将78例急性S T段抬高型心肌梗死患者按随机数字表法分为两组,各39例.两组均予以经皮冠状动脉介入术和常规支持治疗,观察组在术中冠脉注射前列地尔.比较两组术后梗死相关动脉心肌梗死溶栓试验血流分级和...     

老年急性ST段抬高型心肌梗死患者冠脉介入术后服用麝香保心丸的临床疗效及安全性

目的评价老年急性ST段抬高型心肌梗死患者冠脉介入术后服用麝香保心丸的临床疗效及安全性。方法 66例择期行冠脉介入术的老年急性ST段抬高型心肌梗死患者随机分为对照组与试验组各33例。2组行经皮冠状动脉介入术,对照组术后给予阿司匹林肠溶片、硫酸氢氯吡格雷片;试验组在对照组的基础上给予麝香保心丸。治疗结束后比较2组肌酸激酶(CK)、乳酸脱氢酶(LDH)、脑钠尿肽(BNP)、肌钙蛋白T(Tn T)、左心室射血分数(LVEF)水平以及不良反应发生情况。结果试验组持续ST段抬高0.2 m V患者比例和心绞痛、再次心肌梗死、心源性死亡以及心因性死亡等心血管事件发生率显著低于对照组(P0.05)。治疗后,2组血清肌酸激酶、乳酸脱氢酶、脑钠尿肽以及肌钙蛋白T水平显著低于治疗前,且试验组治疗后上述指标水平均显著低于对照组(P0.05),左心室射血分数水平显著高于治疗前,且试验组治疗后水平显著高于对照组(P0.05)。2组不良反应发生率相比,差异无统计学意义(P0.05)。结论老年急性ST段抬高型心肌梗死患者冠脉介入术后服用麝香保心丸的临床疗效显著,安全性较高。     

Examining Acute Coronary Syndrome Across Ethnicity,Sex, and Age

Acute coronary syndrome (ACS) remains one of the leading causes of death in the United States. With its heightened prevalence, considerable variabilities in the disease process exist across ethnicities, sex, and age. This creates substantial disparities in the recognition and management of ACS, which consequently contributes to poor outcomes. It is of utmost importance that nurse practitioners remain vigilant, cognizant, and maintain a high index of suspicion to accurately identify ACS presentations and thus efficaciously intervene to successfully manage the disease process.     

Acute coronary syndrome

Implementation of the AHA/ACC standards for AMI is crucial for patient management and outcomes. The Centers for Medicare/Medicaid (CMS) has established indicators within the AMI core measure to ensure the evidence-based care is provided during the hospital stay. This core measure includes specific indicators that must be documented in the medical record. Refer to Box 2 for a list of the indicators. A recent announcement by the United States Department of Health and Human Services (HHS) stated the United States is declaring war on heart disease. Current costs for treating heart disease and stroke is estimated to be $1 out of every $6 in health care expenditures. This initiative is called the "Million Hearts Initiative." Ten states will receive $85 million in grants for the purpose of addressing chronic diseases targeting weight reduction, smoking cessation, control of lipids, and prevention of diabetes. Early recognition and early intervention for patients with ACS, followed by management of risk factors with secondary prevention strategies, are key to decreasing ACS-related mortality. Management of the ACS patient does not end with discharge from the hospital, but is continued throughout the patient's lifetime.     

超敏C反应蛋白与急性冠脉综合征的相关性研究

[目的]观察急性冠脉综合征（ACS）患者血清超敏C反应蛋白（hsCRP）水平并与非急性冠脉综合征（NACS）患者比较。研究超敏C反应蛋白在急性冠脉综合征发病中的作用和意义。[方法]测定急性冠脉综合征患者各组与非急性冠脉综合征患者各组的血清超敏C反应蛋白，门冬氨酸氨基转移酶（AST），肌酸磷酸激酶同工酶（CK-MB），乳酸脱氢酶（LDH），血清总胆固醇（TC），总甘油三脂（TG），高密度脂蛋白胆固醇（HDL-C），低密度脂蛋白胆固醇（LDL-C），载脂蛋白A1（ApoA1），载脂蛋白B（ApoB）水平并进行统计分析。[结果]ACS患者血清hsCRP水平较正常人群明显升高（P〈0．01），ACS组中急性心梗（AMI）患者血清hsCRP水平显著高于不稳定心绞痛（UAP）患者组（P〈0．05）；冠脉造影（PCI）术后24～48h间血清hsCRP水平明显升高（P〈0．01）；ACS患者血清hsCRP水平与心肌酶谱峰值水平呈明显正相关（P〈0．01）。[结论]血清hsCRP水平可以反映心肌损害程度，是心血管疾病的独立危险因子，可作为ACS临床诊断、预后评价的指标。     

男性急性冠脉综合征患者多支病变预测因素

目的 :研究急性冠脉综合征男性患者多支冠状动脉病变的临床预测因素。方法 :共 10 4例男性患者入选 ,年龄 6 4 .9± 9.6岁。综合患者的人群因素、临床特征和无创伤检查结果 (血液生化和心脏超声等 ) ,结合冠状动脉造影结果进行Logistic回归分析。结果 :冠状动脉造影结果显示单支病变 2 4例 ,多支病变 80例。以多支病变为因变量 ,慢性胸痛、血尿酸水平增高、左心室射血分数降低和左心房扩大是其有统计学意义的自变量 ,其余因素无统计学意义。结论 :慢性胸痛、血尿酸水平增高、左心室射血分数减低和左心房扩大是急性冠脉综合征男性患者多支病变的预测因素。     

慢性心绞痛史及梗死前心绞痛对急性心肌梗死心肌损伤及预后的影响

目的探讨有无慢性心绞痛史及梗死前心绞痛对急性心肌梗死患者心肌损伤及预后的影响。方法选择2003年1月至2007年12月确诊为急性心肌梗死而收住院的93例急性心肌梗死患者,根据其急性心肌梗死发病前心绞痛病史情况分为4组,慢性心绞痛组（Ⅰ组）、梗死前心绞痛组（Ⅱ组）、慢性心绞痛伴梗死前心绞痛组（Ⅲ组）、无心绞痛组（Ⅳ组）,分别观察心肌梗死范围,测定心脏肌酸磷酸激酶（CPK）、同功酶（CK—MB）、血清肌钙蛋白（CTnT）、C-反应蛋白（CRP）和尿微自蛋白分泌率（AER）变化,以及住院期间严重心脏并发症（严重心律失常、KillipⅡ级以上心力衰竭、心源性休克）、心源性病死率、梗死后心绞痛发生率。结果小面积心肌梗死前发生率Ⅰ、Ⅱ、Ⅲ组明显高于Ⅳ组,差异有统计学意义（P〈0．05）;CK、CK—MB、CTnT峰值浓度、CRP、AER变化,Ⅰ、Ⅱ、Ⅲ组明显低于Ⅳ组,差异有统计学意义（P〈0．05）;严重心脏并发症,除心律失常外,Ⅰ、Ⅱ、Ⅲ组明显低于Ⅳ组,差异有统计学意义（P〈0．05）,心律失常Ⅱ、Ⅲ组明显低于Ⅰ、Ⅳ组,差异有统计学意义（P〈0．05）;梗死后心绞痛及住院病死率Ⅰ、Ⅱ、Ⅲ组明显低于Ⅳ组,差异有统计学意义（P〈0．05）。结论梗死前有心绞痛史及梗死前心绞痛可减少其后发生急性心肌梗死时心肌损伤的程度,并影响预后。