右室心肌梗死对急性下壁心肌梗死临床特征和预后的影响

目的：分析右室心肌梗死(心梗)对急性下壁心梗临床特征和预后的影响。方法：比较急性单纯性下壁心梗(第一组)和急性下壁心梗合并右室心梗(第二组)两组患的临床特征和院内病死率。结果：共176例患符合入选条件，第一组115例，第二组61例。第一组低血压、快速心律失常(包括阵发性室上性心动过速，阵发性心房颤动，领发室性早搏，室性心动过速，心室纤颤等)、缓慢心律失常(包括窦性心动过缓，房室传导阻滞)、心功能不全的发生率和院内病死率显低于第二组(P＜0．05)。静脉溶栓、急诊PTCA和未行再灌注治疗的院内病死率在第一组的分别为3．23％，3．33％和29．17％，在第二组分别为9．25％，13．04％和82．35％。结论：当急性下壁心梗合并右室心梗时，患的临床表现更为严重，院内病死率增高。积极行溶栓或急诊PTCA治疗，可显降低其院内病死率.     

单纯急性下壁心肌梗死及其合并右心室心肌梗死对右心长轴功能的影响

目的应用心肌组织多普勒技术结合M型超声心动图,评价单纯急性下壁心肌梗死及其合并右心室心肌梗死对右心室长轴功能的影响。方法选择首次急性下壁心肌梗死患者28例,分为单纯急性下壁心肌梗死18例(Ⅰ组),急性下壁心肌梗死伴右心室心肌梗死10例(Ⅱ组),另选健康体检者20例(Ⅲ组)。在标准心尖四腔心切面二维图像指引下,应用M型超声记录右心房室环右心室游离壁及中心纤维支架处运动曲线,测量收缩期、舒张早期、舒张晚期最大运动幅度(SD,DED,DAD)及收缩期、舒张早期、舒张晚期平均运动速度(SMV,DEMV,DAMV),计算DED/DAD比值。心肌组织多普勒记录该处运动速度曲线,测量上述各期最大运动速度(Sm、Em、Am)及Em/Am比值。结果与Ⅲ组比较,Ⅰ组和Ⅱ组右心房室环右心室游离壁处SD、DED、DED/DAD、SMV、DEMV、Sm及Em均明显下降。DAD、DAMV、Am虽有下降,但差异无统计学意义。结论急性下壁心肌梗死无论是否合并右心室心肌梗死均可影响右心室长轴功能,导致右心室整体功能降低。     

心肌梗死合并室间隔穿孔的临床特征及近期预后分析

目的 初步探讨急性心肌梗死(AMI)并发室间隔穿孔(VSR)的临床特点、高危因素及近期预后情况.方法选择我院2001年1月至2012年6月期间AMI后VSR的患者73例,分析其临床特征、治疗方案及近期(1月内)死亡率.结果 73例AMI后VSR患者,前壁心肌梗死明显多于下壁、后壁,穿孔部位亦以室间隔心尖部常见.在梗死后1个月内有34例(46.6%)患者存活,39例(53.4%)死亡.与近期存活组相比,近期死亡组的女性比例、VSR直径、左室舒张末期内径、左室射血分数、是否置入IABP差异有统计学意义(P＜0.05).Logistic回归分析显示,左室射血分数低及未使用IABP辅助与近期死亡相关.结论 AMI合并VSR近期死亡率高.左室射血分数低、VSR直径大、左室舒张末期内径大、女性、未置入IABP辅助为近期死亡的高危因素,左室射血分数低及未使用IABP辅助为独立危险因素.对于AMI后VSR有近期死亡高危因素的患者,在积极药物治疗及使用循环辅助装置基础上尽早外科手术治疗可能改善近期预后.     

急性右室心肌梗死的心电向量图观察

目的：通过心电图与心电向量图同时依次记录,及时诊断急性右室心肌梗死。方法选自临床诊断明确,心肌酶谱升高,有典型急性右室心肌梗死心电图与心电向量图资料。分析在左室下壁心肌梗死条件下,急性右室心肌梗死的心电向量图改变。结果5例急性右室心肌梗死患者的心电向量图以 ST 向量向右侧增大为主要特点。结论心电向量图对急性右室心肌梗死具有较高的诊断价值。     

Clinical correlates of acute right ventricular infarction in acute inferior myocardial infarction

Right ventricular infarction was diagnosed on the basis of ST-segment elevation greater than or equal to 1 mm in at least one right precordial lead (V3R-V6R) in 20 of 50 patients with first acute inferior myocardial infarction. Seventy five percent of these had ST elevation in 2 or more right precordial leads. Giddiness and hiccups were more common amongst such patients (P less than 0.05). Signs of right ventricular dysfunction-raised jugular venous pressure (65%), Kussmaull's sign (45%), hypotension (without cardiogenic shock, 40%) and right-sided third sound (25%) in the absence of clinical left ventricular failure, were noted in 65% of such patients. Eleven patients had 2 or more of the above signs. ST elevation in 2 or more right precordial leads was found in 10 of these 11 patients. A more complicated course in the hospital characterised by bradyarrhythmias, hypotension and cardiogenic shock, combined with a greater mortality was seen in such patients. We conclude that the bedside diagnosis of haemodynamically significant right ventricular infarction can be made on the basis of a combination of clinical signs and ST elevation in 2 or more right precordial leads, even in units not equipped for bedside haemodynamic monitoring, echocardiography and radionuclide studies. This should lead to a better identification and management of such patients.     

急性下壁心肌梗死伴右室梗死的临床表现和预后分析

目的探讨急性下壁心肌梗死(心梗)不伴或伴右室心梗患者的临床特征、治疗和预后。方法回顾既往6年住我院的103例急性下壁心梗患者,比较下壁心梗不伴右室心梗(65例)和伴右室心梗(38例)两组患者的临床特征和院内死亡率。结果发生低血压、心源性休克、快速心律失常(阵发性心房颤动,非持续性室性心动过速)、缓慢心律失常(包括窦性心动过缓,Ⅲ度房室传导阻滞)在下壁伴右室心梗组高于下壁心梗组,两组比较有显著性差异(P<0.05)。两组左心室射血分数(LVEF)及经皮冠脉介入(PCI)治疗患者的院内病死率比较无显著差异(P>0.05)。结论血流动力学障碍和心律失常是右室心梗住院并发症高的主要因素,右室心梗是独立于左室功能损害的危险因素,早期介入治疗能改善住院死亡率。     

急性下壁梗死伴或不伴右心室心肌梗死患者临床特征的比较

目的：比较急性下壁心肌梗死（IWMI）伴或不伴右心室心肌梗死（RVMI）患者的临床特征差异。方法纳入2006年10月~2012年12月总参保健处发病12 h内入院的急性下壁心肌梗死（IWMI）患者256例,根据冠状动脉造影（CAG）结果将患者分为IWMI不合并RVMI组（n=167）和IWMI合并RVMI组（n=89）,比较两组患者冠心病发病主要危险因素（包括吸烟、高血压、糖尿病、高脂血症、冠心病家族史）、临床表现、并发症和治疗用药的差异。结果两组患者冠心病主要危险因素无差异（P＞0.05）。IWMI合并RVMI患者出现低血压（80.0% vs.19.8%,P＜0.05）、颈静脉怒张（50.6%vs.1.8%）和Kussmaul征（51.7%vs.1.2%）的比例明显增加（P均＜0.01）,需要更多地应用正性肌力药物（60.7%vs.16.2%）来维持血压,且病死率较高（77.9%vs.0.6%,P＜0.05）。结论在IWMI基础上伴RVMI多合并右心功能障碍,可导致预后不良。     

Scintigraphically detected predominant right ventricular dysfunction in acute myocardial infarction: clinical and hemodynamic correlates and implications for therapy and prognosis

To determine the clinical and hemodynamic correlates as well as therapeutic and prognostic implications of predominant right ventricular dysfunction complicating acute myocardial infarction, 43 consecutive patients with scintigraphic evidence of right ventricular dyssynergy and a depressed right ventricular ejection fraction (less than 0.39) in association with normal or near normal left ventricular ejection fraction (greater than or equal to 0.45) were prospectively evaluated. All 43 patients had acute inferior infarction, forming 40% of patients with acute inferior infarction, and only eight (24%) had elevated jugular venous pressure on admission. On hemodynamic monitoring, 74% of patients had a depressed cardiac index (less than or equal to 2.5 liters/min per m2), averaging 2.0 +/- 0.05 for the group. Of these, 30% did not demonstrate previously described hemodynamic criteria of predominant right ventricular infarction (right atrial pressure greater than or equal to 10 mm Hg or right atrial to pulmonary capillary wedge pressure ratio greater than or equal to 0.8, or both). The left ventricular end-diastolic volume was reduced to 49 +/- 11 ml/m2 (n = 22) and correlated significantly with the stroke volume index (r = 0.82; p less than 0.0001) and cardiac index (r = 0.57; p = 0.005). The follow-up right ventricular ejection fraction, determined in 33 patients, showed an increase of 10% or greater in 26 (79%), increasing from a mean value of 0.30 +/- 0.06 to 0.40 +/- 0.09 (p less than 0.0001) without a significant overall change in the mean left ventricular ejection fraction (0.56 +/- 0.10 to 0.56 +/- 0.11, p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnosis and prognosis of right ventricular infarction.

The values of several non-invasive methods for the diagnosis of right ventricular necrosis in inferior myocardial infarction were compared in 51 consecutive patients who underwent serial radionuclide ventriculography, pyrophosphate scintigraphy, and cross sectional echocardiography. In addition a unipolar electrocardiographic lead V4R was recorded on admission, daily, and during episodes of further pain. Profound right ventricular dysfunction was evident in 50% of patients studied by radionuclide methods after inferior myocardial infarction but recognition on clinical groups alone was poor. Functionally important right ventricular infarction was best detected and followed serially by radionuclide ventriculography. Echocardiographic methods for evaluating right ventricular ejection fraction correlated poorly with radionuclide methods. Increased uptake of radioactivity by the right ventricle on pyrophosphate scintigraphy usually indicated poor right ventricular function, but a scan that was negative in the right ventricular territory did not exclude dysfunction. ST segment elevation in V4R was not specific for right ventricular infarction and its routine use may lead to overdiagnosis of this condition. Serial measurements suggest that profound right ventricular dysfunction persists after acute inferior infarction and is associated with considerable morbidity and mortality. Of 25 patients with severe right ventricular dysfunction, six died in the late hospital period. In the remaining 19 patients mean right ventricular ejection fraction over a two month period did not improve; six patients had persistent right ventricular dyskinesia and features of chronic right ventricular failure developed in three survivors.     

急性下壁心肌梗塞中右室心肌梗塞与房室传导阻滞的关系

目的 探讨急性下壁心肌梗塞(MI)并发右室MI与发生房室传导阻滞的关系.方法 共有120例确诊急性下壁MI的住院患者,根据是否发生房室传导阻滞分为房室传导阻滞组(AVB)和非房室传导阻滞(NAVB)组;是否合并右室MI,则分为右室MI(RVI)组和非右室MI(NRVI)组.结果 急性下壁MI并发AVB组住院死亡率明显高于NAVB组(P<0.05);合并RVI患者,其AVB的发生率明显高于NRVI病人(P<0.01).合并RVI及高血压组患者,其AVB的发生率最高,明显高于RVI组(P<0.05).结论 右室心肌MI是急性下壁心肌MI发生AVB的重要原因之一.     

急性心肌梗死合并心源性休克的特点及预后

目的 观察再灌注治疗时代急性心肌梗死(AMI)合并心源性休克(CS)积极干预治疗对预后的影响.方法 连续入选AMI合并cs的患者89例,保守治疗50例,再灌注治疗39例,其中再灌注成功28例,不成功11例.早置组18例,CS发生1 h内放置主动脉内球囊反搏(IABP)晚置组35例,1 h后放置IABP未放置IABP组36例.结果 IABP早置组病死率明显低于晚置组和未置组(33.3%、74.2%、86.1%,P＜0.01).再灌注成功组病死率明显低于再灌注不成功和保守治疗组(42.8%、81.8%、84.0%,P＜0.01).logistic回归分析显示IABP放置时机(OR 0.22,95% CI 0.063～0.764,P=0.017)和成功再灌注(OR 4.232,95% CI 1.407～12.730,P=0.01)是死亡相关的独立危险因素.结论 积极成功再灌注和尽早应用IABP是降低AMI合并心源性休克病死率的重要和有效治疗措施.     

Comparison of left and right ventricular function in acute myocardial infarction

Pulmonary arterial end-diastolic and mean right atrial pressures were compared in 25 patients with acute myocardial infarction and in one patient with unstable angina. No consistent relationship was observed between these pressures. Simultaneous ventricular function curves relating the stroke work of each ventricle to its respective filling pressure were constructed on 34 occasions, dextran infusion or diuresis being used to alter the filling pressure. The curves from each ventricle were described mathematically by a quadratic (parabolic) function as well as by a straight line function and then compared by canonical correlation analysis. Alterations in the left ventricular function curves occurred with and without depression of right ventricular function curves. These hemodynamic measurements demonstrate that acute myocardial infarction can alter the relationship between left and right ventricular function.     

老年急性右心室心肌梗死误漏诊18例临床分析

目的分析老年急性右心室心肌梗死的误诊、漏诊原因,降低临床误诊率。方法回顾性分析选择总参保健处在2011年1月~2014年2月收治的18例老年急性右室心肌梗死的误诊、漏诊病例资料进行回顾性分析。结果 18例误诊、漏诊患者中误诊为急性前壁心肌梗死2例,心功能不全2例,急性上腹痛2例,脑血管病2例,肺源性心脏病2例,感染性休克1例,急性咽痛1例,急性肠炎1例;仅诊断其他部位心肌梗死而漏诊急性右室心肌梗死者5例。结论老年急性右心室心肌梗死临床表现不典型,易发生误诊、漏诊,临床工作中应提高警惕,仔细辨认尽力减少误漏诊事件的发生。     

Serum magnesium and potassium in acute myocardial infarction. Influence on ventricular arrhythmias

Over a 13-month period, serum potassium and magnesium levels were measured in 590 patients admitted to a coronary care unit. Hypokalemia, often in the absence of diuretic use, occurred in 17% of the 211 patients with acute myocardial infarction. Patients with acute myocardial infarction and a potassium level of less than 4.0 mEq/L (4.0 mmol/L) had an increased risk of ventricular arrhythmias (59% vs 42%). Because hypokalemia is common in acute myocardial infarction and is associated with ventricular arrhythmias, routine measurement of serum potassium levels and prompt correction are recommended. Hypomagnesemia occurred in only 4% of the patients, but it was more common in the group with acute myocardial infarction than in the group without myocardial infarction (6% vs 3%). Ventricular arrhythmias occurred in ten of the 13 patients with both acute myocardial infarction and hypomagnesemia, but eight of these patients also had low serum potassium levels. This low incidence of hypomagnesemia does not justify routine measurement of serum magnesium levels. However, the mean level (2.5 +/- 0.4 mg/dL [1.03 +/- 0.16 mmol/L]) in a reference population of healthy volunteers was unexpectedly high and suggests that the low incidence of hypomagnesemia in our population may not be applicable to other centers and may reflect a higher magnesium content in our geographic area of southeastern Ontario.     

Anteroseptal myocardial infarction clinically mimicking right ventricular infarction.

Acute transmural anteroseptal myocardial infarction with acute left ventricular failure can also raise systemic venous pressure in the absence of right ventricular infarction. Right ventricular infarction, therefore, should not be diagnosed simply by the presence of systemic venous congestion.     

急性心肌梗死并发室间隔破裂的临床特征及冠状动脉造影特点分析

目的分析急性心肌梗死并发室间隔破裂的临床特征及冠状动脉造影特点,为该并发症的防治提供证据。方法对46例急性心肌梗死并发室间隔破裂患者的临床特征、冠状动脉造影特点、保守或外科手术疗效与生存率等数据资料进行回顾性分析,采用SPSS11．0软件统计。结果急性心肌梗死并发室间隔破裂的发病率约为1．88％;好发因素有：高龄（61～70岁）,未行再灌注治疗,无既往心绞痛／心肌梗死史,伴随高血压及高血脂等;易于发生室间隔破裂的最常见梗死部位为同时累及前壁和下壁的大面积梗死;大多数患者中性粒细胞比例、C反应蛋白及红细胞沉降率升高。胸片肺水肿者约30％,约半数患者入院时血流动力学不稳定（心功能Killip分级Ⅲ-Ⅳ级）。累及前壁梗死者其破裂部位多为前间隔远段,下壁＋后壁／右心室梗死者破裂部位多为后间隔基底段。冠状动脉造影提示室间隔破裂者多为前降支单支或三支病变,侧支循环少见。罪犯血管以前降支最为多见,其中又以前降支中段居多。保守治疗的住院死亡率高达65％,外科手术治疗的住院死亡率仅3．85％。结论尽早、成功的再灌注治疗是预防其发生的关键,心脏超声是敏感且简便易行的确诊手段,外科手术治疗明显提高生存率,早期外科手术（梗死后1个月左右）可行。