老年再发性心肌梗死的临床与病理分析

总结老年急性心肌梗死（ＡＭＩ）住院期间再发心肌梗死（ＲＭＩ）１０例。诱因有情绪激动、饮餐、便秘、肺部感染、失眠等。心电图表现可不典型。死亡５例,４例尸检结果表明,老年ＡＭＩ后ＲＭＩ,冠脉狭窄程度均〉７５％,冠脉内均能发现朝霞生血栓;梗死面积较可见原梗塞部位位延展,又可见二处以上的梗塞灶,积极的防治,如改善心脏功能及冠脉循环,缓解心绞痛,避免诱发因素,可以减地梗率和病死率。     

50例老年急性心肌梗死QT离散度改变的临床分析

急性心肌梗死（ＡＭＩ）是老年人的常见病，其早期死亡原因多为心室颤动（简称室颤）。新近的研究表明，室颤的发生与患者体表心电图ＱＴ离散度（ＱＴｃｄ）的增加有关。本文测定了５０例老年ＡＭＩ患者心电图ＱＴｃ、ＱＴｃｄ的变化，旨在探讨老年人ＡＭＩ后ＱＴｃｄ改变...     

心肌梗塞伴有糖尿病患者的自主神经损害与室性心律失常的关系

心肌梗塞(ＭＩ)患者伴糖代谢紊乱增加了心原性猝死的危险。我们对62例ＭＩ伴有糖尿病患者进行了心脏自主神经功能检查和心率变异性(ＨＲＶ)检测,旨在探讨其对ＭＩ患者猝死危险性的预测价值。一、对象与方法62例ＭＩ患者,年龄43～71(635±65)岁,男59例,女3例。梗塞部位:前壁12例,间壁16例,下壁17例,复合壁17例。符合ＷＨＯ糖尿病诊断标准。在ＭＩ3周后进行自主神经功能测定和ＨＲＶ检查。检查时间:ＭＩ后3周至1个月35例,1至3个月19例,5个月8例。室性心律失常(ＶＡ)、持续性室性心动过速(ＳＶＴ)和心室颤动(室颤)根据Ｈｏｌｔｅｒ和心电监护记…     

急性下壁心肌梗死从发生至猝死的动态心电图二例

急性下壁心肌梗死从发生至猝死的动态心电图二例毛振华，蒋美娟通常认为急性心肌梗死（ＡＭＩ）早期心脏性猝死的原因大多是原发性室颤。我们在观察２例下壁ＡＭＩ猝死患者的动态心电图（ＤＣＧ），却发现以心室率变慢，以至突然停搏而无原发性室颤的猝死，现报道如下：例...     

心肌梗塞及心绞痛患者心电图高频成分的变化

本文研究了６１例心肌梗塞（ＭＩ）、８例经冠脉造影证实的心绞痛（ＡＰ）患者和３４例正常人的高频心电图，并观察了ＭＩ不同时间，不同梗塞范围时的高频切迹（ＨＦＮ）变化。结果表明，ＭＩ组和ＡＰ组ＨＦＮ数均较正常人显著增多，ＨＦＮ数随梗塞时间延长而增多，并与梗塞范围呈正相关。ＡＰ组ＨＦＮ数较Ｍ１２周内多，但与Ｍ１２周后相比无统计学差异。     

冠状动脉内支架治疗急性心肌梗塞46例临床报告

目的　为探讨冠状动脉内支架治疗急性心肌梗塞的可行性和安全性。方法　对４６ 例经球囊扩张后效果不理想的急性心肌梗塞（ＡＭＩ）患者行冠脉内支架置入。其中男３８ 例,女８ 例,平均年龄为５６．２ 岁。全部采用球囊扩张法置入支架。结果　４６ 例患者术前梗塞相关血管均为ＴＩＭＩ３ 级血流,经置入冠脉内支架后梗塞血管均恢复ＴＩＭＩⅢ级血流,血管开通率１００％ 。８ 例球囊扩张后见冠脉内有残余血栓,置入支架后消失,造影未发现血栓进入远端血管;１ 例患者因Ⅲ°ＡＶＢ 给以临时起搏治疗,术后 ６小时因临时起搏电极刺破右室所致心包填塞死亡。其余 ４５ 例患者在４～３８ 个月的随访中均未发生死亡,无梗塞后心绞痛及再次心肌梗塞,６ 例患者于术后４ 周行冠脉造影复查,原支架置入处血流通畅,无管腔再狭窄。结论　冠脉内支架置入是急性心肌梗塞患者一个安全而有效的治疗方法     

急性心肌梗塞患者的死亡方式和死亡原因──80例临床病理研究

本文报告８０年代经尸检证实的急性心肌梗塞（ＡＭＩ）８０例，旨在研究ＡＭＩ的死亡方式和死亡原因。死亡方式分为４组：Ⅰ组心源性猝死１１例；Ⅱ组合并恶性肿瘤１６例；Ⅲ组多脏器功能衰竭２２例；Ⅳ组ＡＭＩ及其并发症２３例。死亡原因：泵衰竭５２例，心脏破裂１０例，心律失常９例，非心脏性死因９例。讨论了死亡方式和死亡原因的关系，以及死亡原因升降的有关因素，指出泵衰竭目前仍然是ＡＭＩ的主要并发症和防治的重点。     

不稳定性心绞痛的冠脉造影

不稳定性心绞痛（ＵＡ）是介于稳定性心绞痛与心肌梗死（ＭＩ）之间的一组急性心肌缺血综合征。由于ＵＡ有向ＭＩ转化的倾向,故曾有多个术语描述此综合征,如：梗塞前心绞痛、急性冠脉不全、中间冠脉综合征和即将发生的冠脉阻塞等。近期发作的ＵＡ病人中,自诊断后１月内...     

老年危重症患者并发急性心肌梗死漏诊原因探讨

目的探索老年人急性心肌梗死（ＡＭＩ）易漏诊的原因，以提高对老年人心肌梗死的正确诊断率。方法总结２０年中尸检有ＡＭＩ老年患者的临床与病理资料。结果４６例ＡＭＩ中１１例（２３．９％）发生在危重疾病的终末期，其中９例漏诊，占４６例的１９．６％，占１１例的８１．８％。１１例临床上均患冠心病及其它疾病，尸检均有冠状动脉粥样硬化病变１～３支，管腔狭窄Ⅲ～Ⅳ级。心肌梗死部位：左室前壁或前侧壁６例，心内膜下２例，左室乳头肌、室间隔、心尖部和右室各１例。４例心脏破裂。结论ＡＭＩ的症状易被肿瘤晚期症状和脑血管病的意识障碍等所掩盖，临床上应尽可能多次检查心电图及心肌酶谱，以降低ＡＭＩ漏诊率。     

老年心肌缺血者QTc和QTcd变化及临床意义

测定了６４例老年心肌缺血（ＭＩＳ）患者和２１例心肌梗塞（ＭＩ）患者心电图的ＱＴｃ间期和ＱＴｃ离散度（ＱＴｃｄ），并与心血管神经官能症（ＣＶＮ）及正常老年人进行比较；探讨ＱＴｃ、ＱＴｃｄ与致命性室性心律失常（ＦＶＡ）、心原性猝死（ＣＳＤ）的关系；分析ＭＩ不同部位的ＱＴｃｄ变化以及稳定性心绞痛（ＳＡＰ）和不稳定性心绞痛（ＵＳＡＰ）的ＱＴｃｄ差异。结果：老年女性患者ＱＴｃ较男性长（Ｐ＜０．０５），而ＱＴｃｄ两者无差异；老年ＭＩＳ患者ＱＴｃ和ＱＴｃｄ较正常组明显延长（Ｐ＜０．０１）；ＭＩ前壁、下壁和后壁３组ＱＴｃｄ无明显差异（Ｐ＞０．０５）；ＵＳＡＰ患者ＱＴｃｄ较ＳＡＰ长（Ｐ＜０．０５）。     

Clinical and pathological analysis of sudden coronary death in hospitalized elderly patients]

Forty-five hospitalized elderly patients with coronary heart disease who died suddenly within 6 hours after the onset of symptoms were analyzed clinically and pathologically and summarized as following. (1) All the cases showed abnormal ST segments or T waves on ECG. (2) Various degrees of cardiac dysfunction were found clinically in all the patients. (3) Pathological examination of 31 cases revealed serious coronary atherosclerosis. New myocardial necrosis and/or multiple myocardial scars existed in about two-thirds of the patients. Based on these findings and characteristics, it is speculated that sudden coronary death in the elderly patients is caused by imbalance between oxygen supply and demand in the myocardium or deterioration of the cardiac function, which may result in fatal ventricular arrhythmia. Therefore, the prevention of sudden coronary death in the elderly patients should be focusing on reduction of myocardial ischemia, improvement of myocardial metabolism and protection of cardiac function.     

Epidemiology of sudden cardiac death in Spain]

Sudden cardiac death is a remarkable public health problem though its incidence in Spain is lower than in other industrialised countries. Approximately 12% of all natural deaths occur suddenly, and 88% of them are of cardiac origin. This is the form of death in more than 50% of coronary heart disease patients. Moreover, it is the first symptom in 19-26% of cases. This close relationship with coronary heart disease results in cardiovascular risk factors being also risk factors for sudden death. Several factors, such as physical activity or certain drugs may act as sudden death triggers. The more effective strategy addressed to sudden cardiac death prevention includes identification high-risk subgroups of patients (i.e. patients with previous coronary heart disease, heart failure, out-of-hospital sudden death survivors and patients who developed a ventricular fibrillation or tachycardia after a myocardial infarction) and development of efficacious therapeutic interventions. Given that most sudden death are related to coronary heart disease, those primary preventive measures directed to reduce the coronary heart disease incidence rates will also prevent sudden cardiac deaths in population. Finally, community programs directed to reduce the time to reach cardiac emergencies by trained personnel, and to train general population in cardio-respiratory reanimation have shown to be efficacious owing to the fact that most sudden cardiac deaths occur out of hospitals.     

91例猝死患者尸体解剖病理和临床的回顾性分析

目的探讨猝死的病因、病理基础及防治措施。方法回顾性分析我院91例猝死患者的临床病理资料。结果91例猝死患者中,老年人62例,占681%,非老年人29例,占319%。心源性猝死68例,占747%,其中冠心病43例,患者主要有冠状动脉多支严重病变;非心源性猝死23例,其中以急性出血坏死型胰腺炎所占比例最高,有10例。结论猝死以老年男性多见,有广泛严重冠状动脉病变的冠心病患者猝死发生率高。防治冠心病、改善心肌缺血等综合治疗对预防猝死十分必要。胰源性猝死主要为急性出血坏死型胰腺炎所致,误诊率较高。     

64例老年心源性猝死前的临床分析

本文对６４例老年心源性猝死的临床资料，进行回顾性分析，发现老年心源性猝死之前，有以下特点：（１）多患有冠心病等心脏疾患（７５．０％）；（２）有心律失常和（或）心电图异常、心功能不全、心肌梗塞及先兆症状等高危先兆；（３）多数有明确的诱发因素（７１．９％）；（４）猝死的高峰期多在早晨（５９．４％）。     

Pathophysiology of hypertension in the elderly

Combined systolic and diastolic arterial hypertension and isolated systolic hypertension in the elderly are proven risk factors for stroke, sudden death, coronary artery disease, and congestive heart failure. Because hemodynamics, vascular and cardiac adaptations, fluid volume, and endocrine functions are distinctly altered in the elderly hypertensive patient compared with a younger patient, antihypertensive treatment should be individualized, and an unsophisticated regimen, such as a stepped-care approach, is too rigid to be as beneficial for elderly hypertensive patients as for young hypertensive patients.     

The role of the implantable cardioverter-defibrillator for prevention of sudden cardiac death

Sudden cardiac death, which accounts for approximately 350,000 deaths each year, is a major health care problem. Antiarrhythmic drugs have not been reliable in preventing sudden cardiac death. Although beta-blockers, angiotensin-converting enzyme inhibitors, and revascularization play a role in prevention of sudden cardiac death, the development and subsequent refinement of the implantable cardioverter-defibrillator has made the most important contribution to its management. Several randomized, controlled trials have demonstrated improved survival in patients resuscitated from cardiac arrest. Two recent trials also suggest a role for primary prevention in selected patients with coronary artery disease, ventricular dysfunction, and nonsustained ventricular tachycardia in whom sustained ventricular tachycardia is induced. Further technological refinements and development of new, more sensitive risk stratifiers with a higher positive predictive value for sudden cardiac death will expand the indications for this life-saving therapy.     

Optimal medical therapy after MI in the elderly

After an MI, elderly persons should have their modifiable coronary artery risk factors--such as hypertension, dyslipidemia, and diabetes--intensively treated. Aspirin or clopidogrel, beta-blockers, and ACE inhibitors should be given indefinitely, unless contraindications exist. Long-acting nitrates are effective antianginal and anti-ischemic drugs. There are no Class I indications for the use of calcium channel blockers after MI. Postinfarction patients should not receive Class I antiarrhythmic drugs, sotalol, or amiodarone. Those at very high risk for sudden cardiac death should have an implantable cardioverter-defibrillator. Hormonal therapy should not be used in postmenopausal women after MI. The indications for coronary revascularization are prolongation of life and relief of unacceptable symptoms despite optimal medical management.     

Effect of left ventricular aneurysm on risk of sudden and nonsudden cardiac death

Although left ventricular (LV) aneurysm is associated with increased mortality, its independent prognostic significance is controversial. To determine the effect of LV aneurysm on risk, 121 patients with healed myocardial infarction (MI), 55 manifesting akinesia on ventriculography (MI group) and 66 with LV aneurysm characterized by diastolic deformity (eccentricity) and systolic dyskinesia (LV aneurysm group) were studied. At a mean follow-up of 5.7 years, there were 32 cardiac deaths (12 MI vs 20 LV aneurysm), including 9 sudden deaths (1 MI vs 8 LV aneurysm). Multivariate analysis revealed decreasing ejection fraction to be the best predictor of total cardiac death, and revascularization to be protective. Nonsudden cardiac death was predicted by ejection fraction, absence of revascularization and right coronary artery disease, whereas sudden cardiac death was predicted by LV aneurysm and the frequency of ventricular ectopic complexes on Holter monitoring. In the MI group, ejection fraction was the only significant predictor of total cardiac death and nonsudden cardiac death. In the LV aneurysm group, total cardiac death, as well as nonsudden cardiac death, were predicted by ejection fraction, ventricular tachycardia and right coronary artery disease, whereas ventricular tachycardia predicted sudden cardiac death. It is concluded that the risk profile for total cardiac death differs between LV aneurysm and MI patients, and that LV aneurysm constitutes an independent predictor of late sudden cardiac death after MI. Moreover, on a substrate of LV aneurysm, the risk factors for sudden cardiac death and nonsudden cardiac death differ, with ventricular tachycardia being the sole predictor of sudden cardiac death. Furthermore, Holter monitoring is valuable in identifying patients at persistent risk of sudden cardiac death.     

Clinical trial data on the cardioprotective effects of beta-blockade

In most patients with heart failure the underlying cause is coronary artery disease (CAD). They have a poor prognosis and die slowly from deteriorating cardiac function or suddenly from ventricular fibrillation or atheromatous plaque rupture. Two key aims of treatment, therefore, are to slow the progression of underlying CAD and the resulting heart failure and to reduce the risk of sudden death. The impact of drugs on CAD and sudden death can be assessed most effectively in patients who have recovered from a myocardial infarction (post-MI patients). Beta-blockers have been studied in at least 25 trials in post-MI patients and their capacity to reduce mortality and re-infarction has been well documented. About 50% of those who die in post-MI trials die suddenly and beta-blockers particularly propranolol, timolol and metoprolol have been shown to reduce the risk of sudden death significantly. Further evidence that beta-blockers are cardioprotective in post-MI patients can be obtained from trials of other drugs by noting the mortality rates in those patients who were also on a beta-blocker. In three trials of antiarrhythmic drugs and two trials of ACE inhibitors, those on beta-blockers had a better prognosis. There is therefore good evidence that in a patient population known to have serious CAD, beta-blockers can effectively reduce the risk of major coronary events and are particularly effective in reducing the risk of sudden death.     

Implantable cardioverter-defibrillators: indications and unresolved issues

Since the implantable cardioverter-defibrillator was first used clinically in 1980, several large randomized controlled trials have shown that therapy with this device can be beneficial in various patient populations. Evidence suggests that this therapy is useful in the secondary prevention of sudden cardiac death among patients who have survived arrhythmic events. Several trials have also shown the usefulness of implantable cardioverter-defibrillator therapy in the primary prevention of sudden cardiac death in patients with coronary artery disease and nonischemic cardiomyopathy. Other data support the use of this device for various infiltrative and inherited conditions. When used with cardiac resynchronization therapy, implantable cardioverter-defibrillators have improved survival rates and quality of life in patients with severe heart failure. Further research is needed to examine the potential benefits of implantable cardioverter-defibrillators in elderly, female, and hemodialysis-dependent patients, and to determine the optimal waiting period for implantation after myocardial infarction, coronary revascularization, and initial heart-failure diagnosis.