304例急性心肌梗死之死亡病例分析

目的：了解急性心肌梗死(AMI)死亡病例特点，以提高防治效果。方法：对我院1992年至2001年收治住院的304例患者，进行死亡病例与存活病例比较分析，比较各年龄段病死率、男女病死率，比较两组患者危险因素、梗塞部位，分析死亡原因、死亡时间。结果：随年龄增高，AMI病死率增加；女性病死率高于男性；死亡病例组危险因素中陈旧性心肌梗死(OMI)及糖尿病、高脂血症病史明显高于存活病例组；前下壁、前侧壁心肌梗死病死率最高；住院一周内病死率最高。结论：高龄，前下壁或前侧壁梗死，OMI或糖尿病、高脂血症病史是AMI死亡病例的高危因素。     

Diabetes increases mortality after myocardial infarction by oxidizing CaMKII

Diabetes increases oxidant stress and doubles the risk of dying after myocardial infarction, but the mechanisms underlying increased mortality are unknown. Mice with streptozotocin-induced diabetes developed profound heart rate slowing and doubled mortality compared with controls after myocardial infarction. Oxidized Ca²⁺/calmodulin-dependent protein kinase II (ox-CaMKII) was significantly increased in pacemaker tissues from diabetic patients compared with that in nondiabetic patients after myocardial infarction. Streptozotocin-treated mice had increased pacemaker cell ox-CaMKII and apoptosis, which were further enhanced by myocardial infarction. We developed a knockin mouse model of oxidation-resistant CaMKIIδ (MM-VV), the isoform associated with cardiovascular disease. Streptozotocin-treated MM-VV mice and WT mice infused with MitoTEMPO, a mitochondrial targeted antioxidant, expressed significantly less ox-CaMKII, exhibited increased pacemaker cell survival, maintained normal heart rates, and were resistant to diabetes-attributable mortality after myocardial infarction. Our findings suggest that activation of a mitochondrial/ox-CaMKII pathway contributes to increased sudden death in diabetic patients after myocardial infarction.     

再发性心肌梗死的预后分析及护理探讨

对再发性心梗(RMI)38例进行回顾性分析，并与同期住院的初发心梗病人(AMI)123例就临床特征、并发症和死亡原因进行比较。结果 RMI组发生率和死亡部高于AMI组，提示护理对初发心梗后康复期的病人有重要价值，应密切观察细微病情变化，早期发现、预防并发症，控制心力衰竭发生，积极预防再发性心梗。     

Mortality due to pulmonary embolism,myocardial infarction,and stroke among incident dialysis patients

See also Zoccali C, Mallamaci F. Pulmonary embolism in chronic kidney disease: a lethal, overlooked and research orphan disease. This issue, pp 2481–3. Summary. Background: It is has been suggested that dialysis patients have lower mortality rates for pulmonary embolism than the general population, because of platelet dysfunction and bleeding tendency. However, there is limited information whether dialysis is indeed associated with a decreased mortality risk from pulmonary embolism. Objective: The aim of our study was to evaluate whether mortality rate ratios for pulmonary embolism were lower than for myocardial infarction and stroke in dialysis patients compared with the general population. Methods: Cardiovascular causes of death for 130 439 incident dialysis patients registered in the ERA‐EDTA Registry were compared with the cardiovascular causes of death for the European general population. Results: The age‐ and sex‐standardized mortality rate (SMR) from pulmonary embolism was 12.2 (95% CI 10.2–14.6) times higher in dialysis patients than in the general population. The SMRs in dialysis patients compared with the general population were 11.0 (95% CI 10.6–11.4) for myocardial infarction, 8.4 (95% CI 8.0–8.8) for stroke, and 8.3 (95% CI 8.0–8.5) for other cardiovascular diseases. In dialysis patients, primary kidney disease due to diabetes was associated with an increased mortality risk due to pulmonary embolism (HR 1.9; 95% CI 1.0–3.8), myocardial infarction (HR 4.1; 95% CI 3.4–4.9), stroke (HR 3.5; 95% CI 2.8–4.4), and other cardiovascular causes of death (HR 3.4; 95% CI 2.9–3.9) compared with patients with polycystic kidney disease. Conclusions: Dialysis patients were found to have an unexpected highly increased mortality rate for pulmonary embolism and increased mortality rates for myocardial infarction and stroke.     

A time-insensitive predictive instrument for acute myocardial infarction mortality: a multicenter study.

This study develops a "time-insensitive" predictive instrument for acute myocardial infarction mortality that would be useful both as a real-time clinical decision aid in the emergency medical setting and also for retrospective assessment and comparison of medical care based on risk-adjusted mortality predictions. This was done using prospectively-collected data on 5,773 patients with chief complaints of chest pain or other symptoms suggesting acute cardiac ischemia who came to six New England hospitals over a 2-year period. In phase one, based upon 4,099 patients, multivariate logistic regression was used to develop the predictive instrument. In phase two, its accuracy and diagnostic performance were tested on an independent sample of 1,387 patients presenting with symptoms compatible with acute cardiac ischemia. Discrimination between patients who lived and those who died was reflected by receiver-operating characteristic (ROC) curve areas of 0.85, 0.80, and 0.76, respectively, for all emergency department study subjects regardless of final diagnosis, subjects who proved to be having acute cardiac ischemia, and subjects who proved to be having acute infarction. Good calibration was shown by the fact that the predicted mortality was found to not vary significantly from actual mortality rates across deciles of predicted probabilities from 0% to 100%. In phase three, based on all 945 study subjects with acute myocardial infarction, each of the six hospitals' actual mortality rates were compared to their rates predicted by the predictive instrument. Actual hospital mortality rates ranged from 9.9% to 19.3%, with one hospital having a significantly higher rate (P = 0.005) and two hospitals both). Predicted mortality rates ranged from 13.4% to 19.4%, with one hospital having a significantly higher predicted rate (P = 0.005) and two hospitals having significantly lower predicted rates (P = 0.04 and P = 0.03). Individual hospitals' differences between actual and predicted mortality ranged from -3.4% to +3.1% (all NS). When grouped by hospital type, the actual mortality rates were 14.9%, 17.3%, and 13.0%, respectively, for urban teaching, smaller city teaching, and rural nonteaching hospitals (all NS). The predicted mortality rates were 16.5%, 17.1%, and 13.6%, respectively, with the rate for rural nonteaching hospitals being significantly lower (P = 0.009). No hospital type had significant differences between their actual and predicted mortality rates (NS). The time-insensitive predictive instrument for acute infarction mortality shows potential for risk-adjusted studies of hospitals mortality for multihospital groups, hospital-to-hospital comparisons, and within-hospital assessment.(ABSTRACT TRUNCATED AT 400 WORDS)     

瑞替普酶院前溶栓治疗急性ST段抬高性心肌梗死临床疗效及安全性观察

目的观察瑞替普酶院前溶栓治疗急性ST段抬高性心肌梗死患者的临床疗效及安全性。方法回顾分析2010年9月-2012年12月收治的62例急性ST段抬高性心肌梗死患者,随机分为两组,其中院前组22例于120救护车上和（或）急诊科进行瑞替普酶溶栓,院内组40例于入院后进行溶栓治疗,比较两组溶栓治疗后60、120min再通率,并发各种不良反应发生率及复合终点事件发生率。结果溶栓后60、120min院前组临床判断再通率均明显高于院内组（P〈0．05）,住院4周内并发各种出血、心力衰竭、低血压及死亡发生率两组差异无统计学意义（P〉0．05）。结论瑞替普酶院前溶栓治疗急性ST段抬高性心肌梗死具有更好的临床疗效及安全性,值得基层医院临床推广。     

河北省急性心肌梗死患者使用急诊医疗服务系统现状分析及对治疗和预后影响

目的:调查河北省急性心肌梗死（acute myocardial infarction, AMI）患者使用急诊医疗服务系统（emergency medical service, EMS）现状及其对患者急性期治疗和近、远期预后的影响。方法:收集河北省主要三级及部分具有代表性的二级医院在2016年1至12月期间住院的AMI患...     

Myocardial rupture. Your patient's survival may depend on you

Myocardial rupture is the second leading cause of in-hospital death from acute myocardial infarction. It is most likely to occur in the elderly, women, and patients with transmural infarction and no previous history of angina. A high index of suspicion is critical to the diagnosis. Myocardial rupture should be suspected when recurrent chest pain or hemodynamic instability develops after myocardial infarction. Rapid intervention and appropriate infarct-limiting therapy may reduce the mortality rate of this catastrophic complication.     

Rationale for testing thrombolysis in acute ischaemic stroke. MAST Group

Stroke is an important health problem in developed countries, being a common cause of death and disability. Prognosis is poor for hospitalised stroke patients, with a 30-day mortality rate of 20-30%, and 30% of the survivors remaining severely disabled. Based on results from experimental animal studies it is thought that early intervention will improve the patients' prognosis. Thrombolytic therapy has been shown to reduce mortality in patients with acute myocardial infarction, and several trials aim to assess its efficacy in patients with acute cerebral infarction. Although many clinical trials have been performed to address this problem, none have provided a clear answer, either because the sample size was insufficient, or by modern standards, the methodology used was not adequate. The Multicenter Acute Stroke Trials (MAST) has been designed to assess the safety and efficacy of thrombolytic therapy with streptokinase for this indication.     

Diabetes,heart rate,and mortality

A large body of evidence indicates that a persistently high heart rate is associated with a significant risk for higher mortality and sudden death in individuals with a variety cardiovascular disorders, as well as in the general population. Heart rates elevated beyond a certain threshold have been found to be a risk factor for mortality in patients with hypertension, in survivors of myocardial infarction, and in patients with impaired cardiac function. Conversely, a naturally slow heart rate, or one that is slow by virtue of sympathetic blockade induced by pharmacologic agents, may result in longer survival. This is particularly evident in the case of beta-adrenergic blocking drugs, especially in patients after myocardial infarction and in those with acute as well as chronic cardiac failure, a syndrome in which there is a complex neurohormonal disturbance with elevated heart rate. Persistently elevated heart rate is also a feature of diabetes mellitus associated with autonomic neuropathy. Whether this also constitutes an independent risk factor for sudden and augmented mortality is not well defined. In this review, the data on the role of increased heart rate as a risk factor for mortality are examined in the context of other factors that may have therapeutic implications.     

Australian and New Zealand 1997 thrombolysis audit

Objectives : To describe patterns of revascularization techniques in acute myocardial infarction in Australasia, particularly time to thrombolysis, site of delivery, patient demographics, revascularization rates and outcomes. Methods : Seventy‐four Australasian emergency departments were surveyed. Data from 1997 were obtained on number of acute myocardial infarction patients, age, gender, time to revascularization, intracranial haemorrhage rate, mortality, location and rate of revascularization and angioplasty. Grouped data were analysed. Results : Thirty‐three hospitals responded (44.6%). Many others could not supply data. Of 2930 acute myocardial infarction patients, 29% received thrombolysis and 5% angioplasty. Tertiary hospitals thrombolysed more in coronary care units (24.2% versus 8.8%), while non‐tertiary hospitals used emergency departments more (16.2% versus 5.9%). Average emergency department door‐to‐needle time was 49.4 min (median 38.6) versus 63.9 min (median 66.8) in coronary care units. More patients had streptokinase than tissue‐type plasminogen activator. Inferior myocardial infarction accounted for 58% of cases. Primary angioplasty commenced on average 61.5 min (median 69.2) after arrival. Conclusions : Australasian revascularization procedure rates, times, mortality and intracranial haemorrhage rates are similar to internationally published values. Thrombolysis starts sooner if given in emergency departments. Hospitals thrombolysing patients in coronary care units should consider emergency department thrombolysis if median times are greater than 50 min.     

Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue.

We asked if the factors that predict overall mortality following two common surgical procedures are different from those that predict adverse occurrences (complications) during the hospitalization or death after an adverse occurrence, which we refer to as "failure to rescue." We examined 5,972 Medicare patients undergoing elective cholecystectomy or transurethral prostatectomy using three outcome measures: 1) the death rate (number of deaths/number of patients); 2) the adverse occurrence rate (number of patients who developed an adverse occurrence/number of patients); and 3) the failure rate (number of deaths in patients who developed an adverse occurrence/number of patients with an adverse occurrence). The death rate was associated with both hospital and patient characteristics. The adverse occurrence rate was associated primarily with patient characteristics. In contrast, failure to rescue was associated more with hospital characteristics, and was less influenced by patient admission severity of illness as measured by the MedisGroups score. We concluded that factors associated with hospital failure to rescue are different from factors associated with adverse occurrences or death. Understanding the reasons behind variation in mortality rates across hospitals should improve our ability to use mortality statistics to help hospitals upgrade the quality of care.     

Registered nurse unions and patient outcomes

Although research shows substantial relationships between several organizational characteristics in hospitals and patient outcomes, the relationship between nurse unions and patient outcomes has not been explored. Because of the workplace chaos of the last half of the 1990s, some nurses are rethinking their relationships with unions; some have the perception that union activity has increased. It is not always clear whether changes in healthcare are associated with patient outcomes, but it is clear that hospitals/health systems with unions often engage in spirited rhetoric about what is best for patients with little objective evidence to support either view. This study examines the relationship between the presence of a bargaining unit for registered nurses and the acute myocardial infarction mortality rate for acute care hospitals in California. The authors also discuss how registered nurse wage, hospital bed size, volume of patients, and other organizational factors may influence and confound this relationship.     

Exercise echocardiography and thallium-201 single-photon emission computed tomography stress test for 5- and 10-year prognosis of mortality and specific cardiac events.

Limited data suggest that stress myocardial perfusion imaging and stress echocardiography have similar prognostic value for composite cardiac events. However, it is not known whether exercise echocardiography and stress thallium are similar in their prediction of specific cardiac events, eg, death, sudden death, myocardial infarction, unstable angina, and congestive heart failure. A total of 206 patients undergoing stress echocardiography and thallium-201 single-photon emission computed tomography imaging during the same exercise test were followed-up for 5 and 10 years. Multivariate Cox regression analyses incorporating clinical, exercise stress test, echocardiographic, and nuclear imaging parameters were used to predict mortality and specific cardiac events. A moderate to large amount of ischemia (> or =4 segments on the basis of a 16-segment model) by exercise stress echocardiography was the strongest predictor of overall mortality (relative risk [RR] 6.2; P <.0001), cardiac death (RR 17.6; P =.01), congestive heart failure (RR 17.4; P =.0005) or sudden death (RR 26.8; P =.003), whereas a moderate to large fixed defect (> or =2 segments on the basis of a 6-segment model) by nuclear imaging was the strongest predictor of myocardial infarction (RR 8.1; P =.0002) or unstable angina (RR 3.0; P =.005) at 5 years. The heterogeneity in the prediction of these specific cardiac events by these 2 modalities was similarly observed at 10 years. The extent of ischemia by stress echocardiography is a better predictor of overall mortality, cardiac death, congestive heart failure, or sudden death, whereas the extent of a fixed defect by nuclear imaging is a better predictor of myocardial infarction or unstable angina.     

His Bundle Electrogram in Patients with Acute Myocardial Infarction

Thirty-seven patients with acute myocardial infarction complicated by atrioventricular or bundle branch block, or a combination of both, has His bundle electrogram studies performed during their stay in the coronary care unit. The acute mortality of the 14 patients with a complicating bundle branch was 50%. Pump failure was the main cause of death. Three patients in this group had a prolonged H-V interval and one patient had a split blundle of His. The presence or absence of a prolonged H-V interval did not affect mortality in this group of patients. The acute mortality of the 16 patients with an inferior wall myocardial infarction was 6%. The H-V interval was normal in all but one of these patients. The atrioventricular block was caused by a proximal block in all cases. The acute mortality of the seven patients with an anterior wall myocardial infarction was 29%. The H-V interval was prolonged in two of seven patients. Pump failure was the acute cause of the deaths. The presence or absence of a prolonged H-V interval did not affect mortality in this group of patients.     

The latest from the IVD industry: ever-growing importance of laboratory diagnostics in treating cardiovascular disease

As cause of death, cardiovascular disease ranks top in mortality statistics. High blood pressure and other risk factors are common. Every year over 300,000 patients are admitted to hospitals in Germany for the treatment of acute myocardial infarction. Two million patients suffer from cardiac insufficiency, although the unrecorded figure is likely to be far higher. Against this background and in the light of the fact that an early, sound diagnosis of these conditions often saves life, tests have been used for about 50 years in the laboratory to detect substances in the blood which are able to identify the cardiovascular risk as well as the acute condition.     

Comparing risk-adjusted hospital mortality for CABG and AMI patients

The objectives of this study were to compare the risk-adjusted mortality of coronary artery bypass graft (CABG) and acute myocardial infarction (AMI) patients simultaneously in six hospitals in Seoul, Korea, and to investigate the relationship between these performance measures by developing a predictive model of mortality. The medical records of 749 AMI and 564 CABG patients were reviewed. A predictive model was developed using logistic regression, including 170 variables selected as risk factors for risk adjustment. The validity of our predictive model was demonstrated to be within an acceptable range. The results showed that one hospital with a significantly low AMI mortality rate also had a low CABG mortality rate, while another hospital with a significantly high AMI mortality rate also had a high CABG mortality rate. Our results implied that hospitals providing good-quality medical management of coronary artery disease also provided a good-quality surgical service.     

Aspirin for the prevention of vascular death in women.

OBJECTIVE: To review current information relevant to the use of aspirin for preventing vascular death in women, and to provide recommendations based on this information. DATA SOURCES: References from pertinent articles are identified throughout the text. DATA SYNTHESIS: Based on current information, low-dose aspirin is not recommended as primary prevention for cardiovascular death in women; efforts are better focused at promoting risk-factor reduction. Low-dose aspirin is recommended for reducing further cardiovascular morbidity and mortality in women with known cardiovascular disease. Women presenting with unstable angina or myocardial infarction should receive aspirin 325 mg as soon as the diagnosis is confirmed, and this dosage should be continued on a chronic basis. Women who have experienced transient ischemic attacks or ischemic stroke should receive aspirin 1000 mg/d, with a subsequent dosage reduction to 325 mg/d in patients who do not tolerate the higher dose. CONCLUSIONS: Current recommendations are based on the results of studies that involved few women. Further investigation of antiplatelet agents for primary and secondary prevention of vascular death in women is needed.     

老年急性心肌梗死患者住院死亡危险因素分析

目的探讨入院时影响老年急性心肌梗死(AMI)患者住院病死率的危险因素。方法选取因AMI收住的356例老年患者为研究对象。分析病死组(45例)与存活组(311例)患者的临床特征、实验室化验指标、心血管并发症(心源性休克、心力衰竭、室速/室颤),以Logistic多因素逐步回归分析影响老年AMI患者住院病死率的相关因素。结果单因素分析显示:年龄、糖尿病史、陈旧性MI病史、脑卒中病史、肾功能不全、贫血、首发症状呼吸困难、并发心源性休克、心力衰竭、室速/室颤,入院时血清肌酐升高、肾小球滤过率(eGFR)及血红蛋白减低、肌酸激酶及其同工酶峰值水平与老年AMI患者住院病死率相关(均P0.05)。多因素分析显示:年龄、糖尿病史、陈旧性MI病史,并发心源性休克、心力衰竭、室速/室颤,入院时eGFR水平是影响老年AMI患者住院病死率的独立危险因素(均P0.05)。结论年龄、糖尿病及陈旧性MI病史、发生心血管并发症、入院时eGFR水平是影响老年AMI患者住院病死率的独立危险因素。