两个年龄段急性心肌梗死患者临床特征的比较

目的：比较〈60岁及≥60岁急性心肌梗死（AMI）患者的临床特征。方法：回顾分析2012年8月-2013年8月因AMI在我院心脏科住院患者200例,将其分为〈60岁和〉160岁两个年龄组,比较两组患者的冠心病危险因素、临床化验指标、左室收缩功能、冠脉病变的严重程度（改良Gensini评分等）。结果：〈60岁组患者中男性比例、吸烟者比例、高脂血症患者以及阳性家族史比例更高（P〈0．05或P〈0．01）,而高血压病患者、脑梗死患者比例低于≥60岁组（P〈0．01）。临床检验发现〈60岁组患者肾小球滤过率（eGFR）、三酰甘油（TG）、总胆固醇（TC）、载脂蛋白B（ApoB）均显著高于≥60岁组患者（P〈0．01）。〈60岁和≥60岁AMI患者冠脉造影结果比较发现前者单支病变比例更高（P〈0．05）,而后者三支病变比例更高（P〈0．01）。前者改良的Gensini评分显著低于后者（P〈0．05）。结论：〈60岁和≥60岁AMI患者的传统冠心病危险因素、临床检查指标以及冠脉病变特点均有显著不同。     

Cocaine-induced angina pectoris and acute myocardial infarction in patients younger than 40 years

Cocaine has profound effects on the cardiovascular system. Although small doses may slow the heart rate by central vagal stimulation, larger doses result in an increased heart rate from stimulation of the central and peripheral sympathetic nervous system. Cocaine can also result in a significant increase in blood pressure through sympathetically mediated tachycardia and vasoconstriction. An extremely high dose can produce a direct toxic action on the heart muscle, resulting in cardiac failure and immediate death.^1,2 This report describes 3 patients in their 30s who were referred for coronary angiography after having angina pectoris or acute myocardial infarction (AMI), or both, coincident with an increase in frequency of cocaine use.     

小于50岁急性心肌梗死患者的临床特点

目的:探讨年龄50岁急性心肌梗死(AMI)患者的临床特点。方法:以246例临床确诊的初发AMI患者为研究对象,按年龄分为50岁组与50岁组,比较两组的临床资料。结果:年龄50岁AMI患者的男性比例、吸烟率、饮酒率、血清胆固醇水平、左室射血分数、广泛前壁心梗发生率、单支病变率、介入治疗率均显著高于50岁组患者;而左室舒张末期内径、急性左心衰发生率、室壁瘤发生率及住院期间病死率显著低于50岁组患者(P0.05)。结论:年龄50岁的AMI患者的临床特点与50岁患者有诸多不同。     

Mortality and morbidity rates of patients older and younger than 75 years with acute myocardial infarction treated with intravenous streptokinase

The influence of patient age on mortality risk and on the incidence of serious hemorrhagic complications after treatment of acute myocardial infarction (AMI) with intravenous streptokinase (SK) and heparin was examined in 120 consecutive patients. No upper age limit was set for patient inclusion. The mortality rate increased abruptly in patients aged 75 years or older such that the 24 patients in that age group had a 10-fold higher in-hospital mortality rate (33% vs 3%) and 1-year mortality rate (42% vs 4%) than the 96 patients younger than 75 years. This increased mortality rate in the elderly patients was related to a 2-fold higher incidence of major hemorrhagic complications (24% vs 11%) and an increased incidence of anterior AMI, healed prior AMI, multiple-vessel coronary artery disease and extensive myocardial necrosis estimated by peak creatine kinase-MB. Hemorrhagic complications were more frequent in women than in men and in patients with diabetes mellitus or systemic hypertension; all of these conditions were more prevalent in patients aged 75 years and older than in those younger than 75 years. In contrast, the incidence of hemorrhagic complications in nondiabetic elderly men (1 of 12) was similar to the incidence of bleeding in the patients younger than 75 years. Based on our data and those from other studies reporting no reduction in mortality in elderly patients with AMI who are treated with intravenous SK, it is recommended that patients aged 75 years or older should not be routinely treated with intravenous SK.(ABSTRACT TRUNCATED AT 250 WORDS)     

Emergency percutaneous transluminal coronary angioplasty for acute myocardial infarction in patients 70 years of age and older

Direct percutaneous transluminal coronary angioplasty (PTCA) was performed as the primary means of establishing reperfusion during acute myocardial infarction in 105 elderly patients (mean age +/- standard deviation 75 +/- 4 years) at a mean of 5.5 +/- 4.0 hours from symptom onset. Fifty-two patients (50%) had anterior infarctions, 70 (67%) had significant narrowing in greater than 1 vessel, and 12 (11%) were in cardiogenic shock. Primary success was achieved in 91% of the infarct-related arteries. Four patients with failed PTCA underwent emergency bypass surgery; 10 had early symptomatic reocclusion of the dilated vessel. There was 1 death acutely in the catheterization laboratory. The overall in-hospital mortality was 18%. Three-vessel coronary artery disease and cardiogenic shock on presentation were the strongest predictors of in-hospital death. Global ejection fraction improved from 54 +/- 13 to 61 +/- 15% (p less than 0.001). The 1- and 5-year survival rates, including in-hospital deaths, were 73 and 67%, respectively. It is concluded that direct PTCA is an effective means of salvaging ischemic myocardium during acute myocardial infarction in the elderly patient. It is associated with a high success rate and low complication rate. The short- and long-term survival in this high-risk group of patients are improved compared with survival rates in historical controls.     

Comparison of outcome of paramedic-witnessed cardiac arrest in patients younger and older than 70 years

To obtain further information concerning differences in the mechanism of out-of-hospital cardiac arrest between elderly and younger patients, 381 consecutive patients who experienced out-of-hospital cardiac arrest, and whose arrest was witnessed by paramedics, were studied. In 91% of cases the arrest occurred at the time the patient's cardiac rhythm was monitored. Patients were divided into 2 age groups: elderly patients were greater than 70 years (187) and younger patients were less than 70 years (194). Elderly patients more commonly had a past history of heart failure (25 vs 10%, p less than 0.003) and were more commonly taking digoxin (40 vs 20%, p less than 0.005) and diuretics (35 vs 25%, p less than 0.004). Before the cardiac arrest, elderly patients were more likely to be complaining of dyspnea (53 vs 40%, p less than 0.009), whereas younger patients were more likely to complain of chest pain (27 vs 13%, p less than 0.001). Forty-two percent of younger patients demonstrated ventricular fibrillation as the initial out-of-hospital rhythm associated with the arrest, compared to only 22% of elderly patients (p less than 0.001). Besides patient age, initial cardiac rhythm varied according to the patient's complaint preceding the arrest. Sixty-eight percent of patients with chest pain demonstrated ventricular fibrillation, whereas only 21% of patients with dyspnea demonstrated ventricular fibrillation. Elderly patients could be as successfully resuscitated as younger patients; however, 24% of younger patients survived, compared to only 10% of elderly patients (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Acute myocardial infarction: contemporary risk and management in older versus younger patients

The in-hospital management and risk of death of 101 patients 70 years of age or older with acute myocardial infarction in 1987 (group 1) were compared with management and risk for 106 temporally matched patients less than 70 years old (group 2). In group 1, 49% had histories of previous myocardial infarction, compared to 25% in group 2 (P less than 0.001), and 23% of group 1 presented without cardiac pain, versus 7% of group 2 (P less than 0.001). Among the younger patients, other conventional risk factors were, in contrast, more common (Q wave infarction 84% in group 2 versus 70% in group 1; P less than 0.05) or higher (peak creatine kinase values 2222 iu/L in group 2 versus 1366 iu/L in group 1; P less than 0.001). Prior to infarction, all cardiac drugs were used more frequently in the older group 1 patients, whereas post infarction thrombolysis, beta-blockers and acetylsalicylic acid use were all more common (P less than 0.01 to P less than 0.001) in the younger group 2 patients. Post infarction exercise testing, left ventricular ejection fraction calculations and coronary angiography were all performed less frequently in group 1 (P less than 0.001). The in-hospital mortality was 35% for group 1 versus 7% for group 2 (P less than 0.001). Among all 207 study subjects, multiple logistic regression revealed thrombolysis, absence of cardiac pain, and age 70 years or older to be associated with the greatest relative mortality risk. Increased relative risk to a lesser degree was associated with previous infarction, male sex and post infarction use of antiarrhythmic medication.(ABSTRACT TRUNCATED AT 250 WORDS)     

Emergency percutaneous transluminal coronary angioplasty during acute myocardial infarction for patients more than 70 years of age

Thirty-five patients greater than 70 years of age with acute myocardial infarction (AMI) were treated with emergency percutaneous transluminal coronary angioplasty (PTCA). Seventeen (49%) patients received previous thrombolytic therapy: streptokinase (10 patients), tissue plasminogen activator (6) and combined tissue plasminogen activator and urokinase (1). Infarct-related artery patency was achieved in 26 patients (74%) after PTCA. Total in-hospital mortality was 34%. Univariate analysis showed a higher in-hospital mortality in patients with an occluded vessel after PTCA (78%) than in those patients with a patient infarct-related artery (19%) (p = 0.003). Symptomatic coronary reocclusion occurred in 3 patients (15%) during the hospital stay. Compared with emergency PTCA in 200 consecutively treated patients less than 70 years of age, the in-hospital mortality was increased (34 vs 6%, p less than 0.001), and the primary success rate was reduced (66 vs 90%, p less than 0.001). At a mean follow-up of 28 months, there has been a 13% out-of-hospital mortality rate in the elderly patients (3 patients died). Of the 20 surviving patients, 14 are asymptomatic and 6 have class II angina. In conclusion, emergency PTCA for AMI in elderly patients is associated with a decreased success rate and a higher mortality rate. However, the in-hospital mortality rate is not dissimilar to that in elderly AMI patients treated with conventional therapy or thrombolytic therapy alone, and the postdischarge mortality rates are low.     

Early exercise training in patients older than age 65 years compared with that in younger patients after acute myocardial infarction or coronary artery bypass grafting

To evaluate potential benefits that elderly cardiac patients might gain from early exercise programs, 361 such patients were studied: group I--60 patients aged 44 years or younger; group II--114 patients aged 45 to 54 years; group III--111 patients aged 55 to 64 years; and group IV--76 elderly patients aged 65 years or older. All patients participated in a 12-week exercise program within 6 weeks of acute myocardial infarction or coronary artery bypass grafting. All patients performed symptom-limited exercise tests before and after completion of the exercise program. Between tests, elderly patients manifested significant differences in body weight (76.9 to 75.2 kg), percent body fat (22.3 to 20.8 kg), heart rate at rest (77 to 68 beats/min), maximal heart rate (126 to 138 beats/min), maximal METs (5.3 to 8.1), submaximal average double product (17,305 to 14,071), and submaximal average rating of perceived exertion (12 to 10 [p less than 0.05]). Magnitudes of change were similar among groups, although the elderly patient group had a significantly lower absolute physical work capacity at testing after training than the other 3 groups (p less than 0.05). In the 25 elderly patients who received beta-blocking drugs, METs increased from 5.1 to 7.8 (p less than 0.05). In the remaining 51 elderly patients not receiving beta-blocking drugs, METs increased from 5.4 to 8.2 (p less than 0.05). The magnitude of increase in patients who received beta-blocking drugs was not significantly different from that in patients not receiving beta-blocking drugs.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of clinical presentation of acute myocardial infarction in patients older than 65 years of age to younger patients: the Multicenter Chest Pain Study experience

To assess whether the manifestations of acute ischemic heart disease in the elderly are less typical than in younger patients, the presenting clinical features and their associated relative risks for acute myocardial infarction (AMI) were compared in 2,625 patients greater than or equal to 65 years of age and 5,109 patients less than 65 years of age. These patients were evaluated for acute chest pain in the emergency departments of 7 hospitals. The same features were associated with increased relative risks for AMI in younger and elderly patients. The relative risks among older patients, however, were consistently closer to 1.0 for classic features, including male gender, pressure-like quality of pain, substernal location, typical pattern of pain radiation and electrocardiographic evidence of ischemia or AMI. Analyses for the endpoint "acute ischemic heart disease" (i.e., AMI or unstable angina) yielded similar findings. Elderly patients were more likely to be admitted to the hospital (56 vs 35%; p less than 0.0001) and to the coronary care unit (37 vs 23%; p less than 0.0001) in the absence of either AMI or unstable angina. These data support the hypothesis that diagnosis of acute chest pain is especially difficult in elderly patients.     

First time myocardial revascularization in patients younger than 70 years. Single versus double internal mammary artery.

BACKGROUND: We evaluated the early and late outcomes of bilateral internal mammary artery (BIMA) grafting, with or without saphenous vein grafts (SVGs), compared to single internal mammary artery and SVGs in patients < 70 years undergoing first myocardial revascularization. METHODS: From September 1986 to December 1999, 1389 patients underwent first myocardial revascularization using the left internal mammary artery (LIMA) to the left anterior descending artery and SVGs (n = 480) or BIMA (one internal mammary artery on the left anterior descending artery) with or without SVGs (n = 909). Propensity score analysis was used to select 952 (476 of each group) patients with the same preoperative and operative characteristics. Thirty-day outcome and 10-year freedom from all-cause death, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area, redo/percutaneous transluminal coronary angioplasty (PTCA), redo/PTCA in a grafted artery, cardiac events and any events, were evaluated. Follow-up ranged from 3.5 to 16.8 years (mean 8.8+/-4.0 years). RESULTS: Thirty-day mortality was 2.9% in the LIMA group and 1.9% in the BIMA group, p = NS; the BIMA group showed a better 10-year freedom from all-cause death (92.4+/-2.1 vs 87.5+/-3.5%, p = 0.0216), cardiac death (97.4+/-0.9 vs 91.9+/-1.4%, p = 0.0042), AMI (98.7+/-0.5 vs 94.2+/-1.2%, p = 0.0034), AMI in a grafted area (98.9+/-0.5 vs 94.7+/-1.3%, p = 0.0017), cardiac events (95.4+/-1.2 vs 86.8+/-1.8%, p = 0.0026) and any events (88.8+/-2.2 vs 80.7+/-2.1%, p = 0.0124). Cox analysis confirmed that LIMA + SVGs was a risk factor independent of lower freedom from all the above-mentioned events. CONCLUSIONS: Double mammary artery in patients < 70 years who had a first time myocardial revascularization gives a better clinical outcome even 10 years after the operation.     

Complete arterial revascularisation in patients older than 70 years.

BACKGROUND: Coronary artery bypass grafting (CABG) using left internal thoracic artery and vein grafts is standard in patients of advanced age. A number of these patients, however, present without suitable vein grafting material and thus require the use of arterial conduits. In order to investigate the safety and efficacy of complete arterial revascularisation, we have compared the perioperative results of patients older than 70 years with conventional CABG and complete arterial revascularisation. PATIENTS AND METHODS: Group I (n = 172) with conventional CABG in 1999 was compared with 152 patients (group II) with complete arterial CABG between 1996 and July 2000. There were no significant differences regarding age, gender, left ventricular ejection fraction or incidence of three-vessel disease or left main stenosis. The proportion of reoperations was significantly higher in group II (16 %) vs. group I (4 %). RESULTS: A mean of 3.7 +/- 0.7 anastomoses (I) versus 4.0 +/- 0.9 (II) were performed per patient (p = n. s.). Mean operating time (I: 210 +/- 46 min; II: 194 +/- 46 min) and bypass time (I: 87 +/- 25 min; II: 78 +/- 29 min) were significantly lower in group II. Ischemic time (I: 46 +/- 22 min; II: 49 +/- 21 min) was not significantly different. The incidence of sternal dehiscence was 2.9 % (I: n = 5) vs. 1.3 % (II: n = 2). Hospital mortality was 4.6 % in group I vs. 3.9 % (II). CONCLUSION: Complete arterial revascularisation is a safe option in patients aged over 70. It remains to be shown whether it may also have advantage in the long term.     

Prognosis in survivors of acute myocardial infarction occurring at age 70 years or older

To identify prognostic factors in elderly persons who have survived acute myocardial infarction, 113 patients, aged 70 to 91 years (median 76), were followed for an average of 122 months (range 94 to 170). Eighty-four patients died, 61 (73%) from coronary artery disease. Overall mortality rates were 20.4% at 1 year, 30.1% at 2 years, 31.9% at 3 years, 45.1% at 4 years, 51.3% at 5 years and 69% at 10 years. Almost half (44%) of all deaths from coronary causes occurred in the first 2 years. Univariate analysis of 21 historical and clinical variables found several of prognostic significance: age, prior myocardial infarction, previous diastolic hypertension, history of diabetes mellitus, history of heart failure, presence of rales above the scapula, ventricular gallop, Killip class, cardiomegaly on admission chest x-ray and prescribing digitalis or diuretic at discharge. When these prognostic factors were entered into multivariate analysis, only Killip class (p less than 0.001) emerged as an independent predictor of survival.     

35岁以下与45岁以上心肌梗死患者临床特征比较

目的 研究年轻人心肌梗死（ＭＩ）的临床特征及冠脉造影的特点。方法 采集病史、计算吸烟、饮酒、体重指数以及左室射血分数,Ｘ线心胸比,冠状动脉造影,溶栓与非溶栓治疗比较。结果 ３５以岁以下者２７例（组Ⅱ）与４５岁以上者４６例（组Ⅱ）,吸烟指数大于１００者分别为８１．５％、５２．７％（Ｐ〈０．０１）,饮酒指数大于１５０者分别为５５．５％、１３．０％（Ｐ〈０．０１）,有高血压史者分别为１１．１％、５６．６     

高龄急性ST段抬高型心肌梗死患者临床特征及冠脉造影分析

【摘要】 目的 探讨高龄急性ST段抬高型心肌梗死( STEMI) 患者的临床特征及冠状动脉造影特点。方法 将临床确诊为STEMI年龄≥75 岁的97例患者( 高龄组) 与＜75岁的92例患者( 非高龄组) 进行对照研究,分析其临床特征和冠状动脉造影特点。结果 高龄组的STEMI 危险因素中合并高血压、糖尿病、高血脂、陈旧性心肌梗死、脑卒中史及肺功能减退的比例高于非高龄组,而吸烟史和AMI 阳性家族史低,但差异无统计学意义。高龄患者既往经皮冠状动脉介入治疗（PCI）、肾功能减退（肾小球滤过率降低）较对照组多, 分别是(24.7% VS 10.9%;52.1 4.2 VS 63.7 2.3ml/min.1.73 m2,P<0.05 )。高龄组不典型胸痛更多见,约占34.1%,主要表现为呼吸困难（16.5% VS 6.5%,P<0.05）。其他症状,如消化道症状及晕厥,未达到统计学差异 （13.4% VS 5.4%, P>0.05;5.2% VS 5.4%, P>0.05）。心功能KillipⅠ级在高龄组低于对照组(51.5% VS 71.7%,P<0.01),而KillipⅡ-Ⅲ级则高于对照组(38.2% VS 22.9%,P<0.05),均具有统计学意义。高龄组冠脉多支病变、侧支建立、复杂病变明显高于对照组,分别是（81.4% VS 65.2%,P<0.05;82.5% VS 68.5%,P<0.01;61.1% VS 47.8%,P<0.05）,差别具有统计学意义。结论 高龄STEMI患者既往PCI、肾功能减退、不典型胸痛更多见,冠状动脉多支病变、侧支建立、复杂病变的发生率显著增高。     

70岁以上老年人急性心肌梗死临床特点

目的探讨年龄因素对急性心肌梗死（ＡＭＩ）疾病过程及预后的影响。方法将１９～９６岁４８８例ＡＭＩ住院患者按年龄分组，从发病特点、诱发因素、临床过程及疾病转归等方面进行对比。结果随年龄增长，≥７０岁组女性患者的比率明显增高；≥７０岁组发病与慢性心肌缺血史、高血压、糖尿病明显有关，起病时多无典型胸痛，仅表现为呼吸困难、胃肠道反应、意识障碍等症状，出现心律失常、心力衰竭、心源性休克等并发症及病死率均明显高于１９～５９岁及６０～６９岁两组。结论年龄因素是决定老年ＡＭＩ患者预后的重要指标之一。     

Efficacy of thrombolysis in younger and older adult patients suffering their first acute q-wave myocardial infarction

OBJECTIVES: Advancing age is an independent predictor of increased mortality after acute myocardial infarction (AMI). Several hypotheses have been developed to try to explain this phenomenon, but data available about the efficacy of thrombolytic therapy in older patients are still not conclusive. The goal of this study was to investigate the efficacy of thrombolysis in adult and older patients who suffered their first AMI. DESIGN: Retrospective cohort study. SETTING: A coronary care unit. PARTICIPANTS: The sample included 244 younger (aged <65, n = 166) and older (age 65, n = 78) adult patients suffering their first Q-wave AMI, all receiving thrombolysis with human-recombinant tissue-type plasmin-ogen activator (100 mg total dose within 2.5 hours of the onset of AMI. MEASUREMENTS: Infarct size was estimated by isoenzyme creatine kinase-myoglobin (CK-MB) release, measuring the area under the curve as a function of time. ST elevation, the sum of ST elevation above the baseline, and the sum of R wave height in precordial leads V1-V6 were evaluated using 12-lead electrocardiograms. Myocardial reperfusion was calculated when ST-segment elevation decreased more than 60 with respect to the most abnormal peak detected.RESULTS: CK-MB peak level was significantly smaller in younger patients than in older ones (P< .01) and was significantly correlated with increasing age (P< .0001). Area under the 36-hour CK-MB curve was lower in younger patients than in older ones (P< .0001) and was well correlated with increasing age (P< .01). Reperfusion time was significantly shorter in younger patients (P< .05), and age was significantly correlated with reperfusion time (P< .001). CONCLUSIONS: Infarct size was greater and reperfusion time was longer in older patients than in younger ones with first Q-wave AMI treated with thrombolysis. Infarct size and reperfusion time were linearly correlated with increasing age. These findings may help explain the increase in mortality due to AMI observed with advancing age.