Primary versus rescue percutaneous coronary intervention in patients with acute myocardial infarction

OBJECTIVE: To compare angiographic and clinical outcomes of patients with acute myocardial infarction (AMI) who underwent primary percutaneous coronary intervention (PCI) versus rescue PCI following failed thrombolysis. BACKGROUND: Patients presenting with AMI are treated either with primary PCI or with thrombolysis. When thrombolysis fails, rescue PCI is performed. METHODS AND RESULTS: We compared the outcome of 105 consecutive patients with AMI who underwent either primary PCI (60 patients) or rescue PCI (45 patients) between January 1997 and January 1999. The patients were followed for up to 6 months. Time delay to reperfusion was significantly longer in the rescue PCI group (354 vs. 189 min; p < 0.001). The majority of patients received a stent (93%). Glycoprotein (GP) IIb/IIIa inhibitors were used in 53% of patients in the primary PCI group and in 22% in the rescue group. TIMI grade 3 flow was achieved in 93.3% of patients in the primary PCI group and in 88.8% in the rescue group (p = 0.08). Post-procedure ejection fraction was 53% in the primary PCI group and 47% in the rescue group (p = 0.014). A composite endpoint of death, recurrent MI, repeat PCI, coronary artery bypass grafting (CABG) and recurrent angina at 6 months occurred in 35% of the patients in the primary PCI group and 26.7% in the rescue group (p = 0.36). CONCLUSION: Despite a significant delay to reperfusion and a lower immediate post-procedure ejection fraction, the clinical outcome of patients treated with rescue PCI following failed thrombolysis appears to be similar to that of patients treated with primary PCI at 6 months.     

延迟冠状动脉介入治疗对急性心肌梗死患者预后的影响

目的探讨延迟经皮冠状动脉介入治疗（PC I）对急性心肌梗死（AM I）患者预后的影响。方法对38例ST段抬高的AM I患者经静脉溶栓后常规行延迟PC I（延迟组）,然后与经静脉溶栓后药物保守治疗（对照组）的34例患者进行对比分析,观察住院期间和随访6个月时的临床不良事件和超声心动图的变化。结果与保守治疗比较,常规施行延迟PC I可以降低住院期间的病死率（0%vs15%,P<0.05）,缩短平均住院时间（15 dvs28 d,P<0.05）,减少住院期间心绞痛发作（5%vs35%,P<0.05）及再次心肌梗死（0%vs9%,P<0.05）;还可以明显降低6个月病死率（3%vs12%,P<0.05）和再住院率（8%vs26%,P<0.05）,防止左心室进一步重构,改善患者心脏功能。结论常规施行延迟PC I可以提高AM I患者住院期间和6个月的治疗效果,改善临床预后。     

延迟冠状动脉介入治疗与静脉溶栓后药物保守治疗的对比研究

目的　评价静脉溶栓治疗后常规行延迟冠状动脉介入 (PCI)的价值。方法　对 98例ST段抬高性心肌梗死 (STEMI)患者常规行延迟PCI,然后与既往行静脉溶栓后药物保守治疗的 82例患者对照观察住院期间和随访 6个月时的临床不良事件和超声心动图的变化。所有患者分为对照组 (静脉溶栓后保守治疗 )、试验 1组 (静脉溶栓成功后行延迟PCI)和试验 2组 (静脉溶栓失败后行延迟PCI)。结果　与静脉溶栓保守治疗比较 ,静脉溶栓后常规施行延迟PCI可以降低住院期间的死亡率(4 9%vs 0 % ,0 % )、缩短平均住院时间 (2 5 3dvs13 5d ,15 1d)、减少对靶病变血管重建治疗的需要(7 3%vs 0 % ,0 % )和降低血栓形成或心肌梗死的发生率 (7 3%vs 0 % ,0 % ) ,还可以明显降低 6个月死亡率 (13 4 %vs 1 4 % ,0 % )、减少再次心肌梗死 (12 2 %vs 4 2 % ,4 5 % )和卒中 (2 4 %vs 0 % ,0 % )的发生、减少因缺血做靶血管重建治疗 (2 8%vs 4 2 % ,4 5 % )和防止左室进一步发生重塑。结论　常规施行延迟PCI可以防止再发性缺血、再次梗死和梗死相关动脉再闭塞和改善左室功能 ,因而提高住院期间和 6个月的治疗效果。     

Clinical benefits of intracoronary high-dose tirofiban therapy in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

To investigate the benefits of intracoronary high-dose tirofiban during primary percutaneous coronary intervention (PCI) for patients with acute ST-segment elevation myocardial infarction (STEMI) .Methods Fifty-eight patients with STEMI presented within 12 h of symptoms were randomly allocated to study group (n = 28,intracor-onary high-dose tirofiban) and control group (n = 30,intravenous high-dose tirofiban) .The culprit vessels were targe-ted with primary PCI in all patients.Clinical characteristics,angiographic findings,brain natriuretic peptide (BNP) at 7-day and in-hospital outcomes were compared between groups,as well as left ventricular ejection fraction (LVEF) and major adverse cardiac events (MACE,including death,reinfarction,worsening heart failure and target vessel revascu-larization) at 30-day clinical follow-up.Results Compared with the control group,the study group showed better thrombolysis in myocardial infarction (TIMI) flow grades immediately after PCI (96.4% vs 76.7% ,P = 0.02) .The 30-day composite major adverse cardiac events rate was lower in the study group (3.6% vs 23.3% ,P = 0.02) ,and the LVEF and BNP in the study group at 7 days was better than that in the control group (P = 0.01 and 0.02,respec-tively) .No significant difference in hemorrhagic complications in hospital between groups was noted (P = 0.61) .Conclusions The study indicates that intracoronary high-dose bolus administration of tirofiban for patients with STEMI who underwent primary PCI can significantly improve the reperfusion level in the infarct area and clinical outcomes at 30 days follow-up.It is better and safer to apply intravenous bolus injection for improving coronary flow,LVEF and short-term clinical outcomes.     

Is transport with platelet GP IIb/IIIa inhibition for primary percutaneous coronary intervention more efficient than on-site thrombolysis in patients with STEMI admitted to community hospitals? Randomised study. Early results

INTRODUCTION: The advantage of primary percutaneous coronary intervention (pPCI) in the management of ST-elevation myocardial infarction (STEMI) over thrombolytic therapy has been demonstrated. However, an optimal medical treatment of STEMI patients admitted to regional hospitals without catheterisation facilities has not yet been established. Delay in initiation of pPCI resulting from transportation to the catheterisation laboratory may diminish the benefits of such therapy in comparison with thrombolysis administered in a regional hospital. Early initiation of therapy with platelet glycoprotein IIb/IIIa receptor inhibitor, which provides protection for the transportation, may be a reasonable solution to maintain the advantage of pPCI over thrombolysis alone in STEMI patients. METHODS: The studied group comprised patients with STEMI (infarct duration time <12 hours, typical clinical and electrocardiographic criteria of MI) who were randomly assigned in 13 regional hospitals located 20 to 150 km from invasive centre to one of two subgroups, either to thrombolysis in the community hospital or to transport after thrombolysis initiation with platelet GP IIb/IIIa receptor inhibitor (tirofiban; 10 mg/kg in intravenous bolus in the emergency room of the community hospital followed by continuous intravenous infusion of 0.1 mg/kg/min during transport as well as coronary procedure) in order to receive pPCI. All patients with cardiogenic shock on admission were routinely treated with PCI and were excluded from the study. RESULTS: 341 patients were included in the study (169 were randomised to receive thrombolytic therapy and 172--transport with intention to perform PCI). Mean time between onset of MI and randomisation was similar in the transport and thrombolysis groups, (139+/-133 min. vs 143+/-117 min., respectively, p=0.94). Mean infusion time of tirofiban to the beginning of PCI in the transport group was 121+/-36 min. Anterior MI was present in 42.6% of patients in the PCI group and in 41.5% in the thrombolytic group (p=0.085). Mean time from randomisation to pPCI was 158+/-60 min., and to thrombolysis initiation in 44+/-43 min. (p <0.0001). None of the patients died during transfer. In a 30-day follow-up we noted (pPCI vs thrombolytic group, respectively): mortality 3.49% vs 8.88% (p=0.04); reinfarction 1.16% vs 5.92% (p=0.02), stroke 0.58% vs 1.18% (p=0.55). In-hospital stay was significantly shorter in the transport group (9+/-3 days vs 14+/-7 days, p <0.0001). During hospitalisation, 17 (10.05%) patients initially assigned to thrombolysis alone had to be transferred to the catheterisation laboratory to undergo PCI (rescue PCI or PCI for postinfarction angina). Combined end-point (death/reinfarction/stroke) was reached more frequently in the thrombolytic group (15.98% vs 5.23%, p=0.001). CONCLUSIONS: A strategy of invasive therapy involving transport with GP IIb/IIIa receptor inhibitor and pPCI in STEMI patients admitted to hospital without catheterisation facilities was found to be more effective than thrombolytic therapy alone employed in the regional hospitals.     

血栓抽吸导管在年轻急性ST段抬高型心肌梗死介入治疗中的应用研究

目的：探讨年轻急性ST段抬高型心肌梗死（STEMI）患者直接经皮冠状动脉介入治疗（PCI）使用血栓抽吸导管的疗效及安全性。方法：79例年轻急性STEMI患者,根据急诊PCI是否使用血栓抽吸导管分为抽吸组（使用抽吸导管,37例）及常规治疗组（不使用抽吸导管,42例）,观察两组的术后冠脉血流 TIMI分级、心绞痛症状、心功能状况、主要不良心血管事件（MACE）等指标的差异。结果：与常规治疗组比较,抽吸组在术后 TIMI血流分级[（2.33±0.48）级比（3.00±0.00）级]、2h ST段50％回落率（45.24％比70.27％）、1周时的LVEF值[（47.21±9.28）％比（52.16±7.87）％]显著上升;心绞痛症状（50.00％比27.03％）、随访中心功能分级[（1.52±0.71）级比（1.22±0.42）级]显著减少或降低（P＜0.05或 P＜0.01）。MACE事件两组间比较差异无统计学意义（P均＞0.05）。结论：年轻急性ST段抬高型心肌梗死患者 PCI中使用血栓抽吸导管有助于改善冠脉血流,减少心绞痛症状,改善心功能,而且安全。     

Primary coronary angioplasty in patients with ST segment elevation acute myocardial infarction and diabetes

BACKGROUND: Subjects with diabetes constitute 13-25% of patients with ST segment elevation acute myocardial infarction (STEMI). In spite of the introduction of thrombolytic therapy, patients with STEMI and diabetes continue to have worse prognosis than those without diabetes. Primary percutaneous coronary intervention (PCI) has been shown in recent years to be the most effective therapy in patients with STEMI. AIM: To compare the outcome of STEMI patients with or without diabetes who underwent primary PCI. METHODS: The study group consisted of 500 consecutive patients with STEMI. The occurrence of major adverse cardiac events (MACE) which included death, reinfarction or repeated PCI of the target vessel, was analysed peri-operatively and during a six-month follow-up period.Results. Diabetes was diagnosed in 68 (13.6%) patients. The mean time duration from the onset of STEMI symptoms to treatment was similar in patients with or without diabetes (230+/-97 min vs 231+/-139 min, NS). Patients with diabetes were older (61.9+/-8.9 vs 57.9+/-10.8 years, p=0.004), had higher body mass index (29+/-4 vs 27+/-5, p=0.002), more frequent history of coronary artery disease (57.4% vs 37.9%, p=0.002), higher prevalence of arterial hypertension (71.6% vs 56.8%, p=0.02) and more frequently the left anterior descending artery as the infarct-related artery (58.8% vs 42.1%, p=0.01). Immediately after PCI, epicardial and myocardial reperfusion rates were lower in patients with rather than without diabetes (TIMI 3: 84.9% vs 91.3%, p=NS, cTFC: 32+/-26 vs 22+/-16, p<0.0001, and MPG3: 25% vs 41.9% p=0.008). Diabetes increased the risk of MACE during in-hospital period by 2.7 times. The rate of MACE during a six-month follow-up period was almost two times higher in patients with rather than without diabetes (death: 8.8% vs 5.1%, reinfarction: 1.5% vs 1.2%, repeated PCI: 11.8% vs 6.9%). CONCLUSIONS: Primary PCI-achieved epicardial and myocardial reperfusion rate is lower in STEMI patients with rather than without diabetes. The presence of diabetes almost doubles the risk of MACE during a six-month follow-up.     

大剂量替罗非班对急性ST段抬高型心肌梗死患者急诊介入治疗短期疗效及安全性研究

目的探讨急性ST段抬高型心肌梗死(STEMI)患者行急诊经皮冠状动脉介入治疗(PCI)时,早期应用大剂量替罗非班对介入治疗疗效的影响。方法入选116例STEMI急诊介入治疗的患者,所有患者均于冠状动脉造影前给予阿司匹林300 mg、氯吡格雷600 mg,按随机数字法分为大剂量替罗非班组(A组25μg/kg,负荷剂量静脉推注)39例,常规剂量组(B组10μg/kg,负荷剂量静脉推注)39例,替罗非班负荷剂量均于3 min内静脉推注,继之0.15μg·kg~(-1)·min~(-1)静脉维持泵入36 h。对照组(C组)38例。PCI术后梗死相关血管的心肌梗死溶栓(TIMI)血流分级、TIMI心肌灌注分级(TMPG)、术后即刻和24 h ST段完全回落率、术后1周左右(5～7 d)的左心室射血分数(LVEF)、术后1个月的主要心血管事件(死亡、再发心肌梗死、靶血管血运重建、反复心绞痛发作)及TIMI出血事件作为评价指标。结果术前3组患者基线资料(年龄、性别构成、危险因素、心功能Killip分级、治疗时间段、住院天数等)差异无统计学意义,具有可比性。术后即刻TIMI 3级血流获得率A组(97.4%)和B组(89.7%)高于C组(76.3%),差异有统计学意义(均为P<0.05),但A、B组相比差异无统计学意义(P>0.05)。PCI术后3组的TMPG 3级率相比差异有统计学意义(A组:82.1%,B组:69.2%,C组:47.4%,P<0.01)。术后24 h ST段完全回落率及1周左右的LVEF,A组显著高于C组(64.1%比42.2%,61%±9%比55%±9%,P<0.05)。术后1个月随访,3组在主要心血管事件的发生率上差异无统计学意义(P>0.05),仅A组术后1个月反复心绞痛的发作率明显低于C组(2.6%比13.2%,P=0.04)。3组在主要出血事件的发生率上差异无统计学意义(均为P>0.05)。结论对于急性STEMI患者,早期应用大剂量替罗非班可以获得更好的即刻造影结果,且并未明显增加主要出血事件的发生率,可提高临床预后。     

不同缺血时间对急性ST段抬高型心肌梗死患者介入血栓抽吸获益程度的影响

目的 探讨不同缺血时间对急性ST段抬高型心肌梗死(STEMI)患者介入血栓抽吸(TA)获益程度的影响。方法 纳入STEMI且接受经皮冠状动脉介入治疗（PCI）患者198例,其中109例接受TA治疗患者作为TA组,89例未接受TA治疗患者作为对照组。根据心肌总缺血时间（TTT）将患者分为早期PCI组（TTT≤4h）72例和非早期PCI组（TTT＞4h）126例。采用心肌梗死溶栓试验(TIMI)血流分级评价患者心外膜冠脉血流情况,并分析TA和TTT对STEMI患者PCI预后的影响。结果 PCI术前TA组TIMI血流分级0级患者比例高于对照组（P＜0.05）。早期PCI组接受TA患者比例高于非早期PCI组,而发生主要不良心血管事件(MACE)患者比例低于非早期PCI组（P＜0.05）。STEMI患者接受TA治疗与MACE的发生呈负相关（P＜0.001）,而TTT与PCI术后全因死亡和MACE的发生均呈正相关（P＜0.001）。Logistic回归分析结果显示,对于所有STEMI患者,TTT＞4h明显增加MACE的发生风险,接受TA治疗降低MACE的发生风险（P＜0.05）。对于TA组患者,TTT＞4h增加全因死亡和MACE的发生风险（P＜0.05）。结论 对于接受PCI时行TA治疗的STEMI患者,TTT＞4h增加其全因死亡和MACE的发生风险。     

替罗非班应用时机对急性ST段抬高心肌梗死急诊介入治疗的影响

目的观察早期应用替罗非班对急性ST段抬高心肌梗死(STEMI)急诊PCI效果的影响。方法将发病12 h急诊PCI的STEMI患者240例随机分为早期组(冠状动脉造影前1～3 h应用替罗非班)和即刻组(冠状动脉造影后即刻应用替罗非班),每组120例。观察2组PCI前后TIMI血流分级和梗死区心肌灌注(TMP)分级,PCI后30 d主要不良心血管事件(MACE)情况。结果与即刻组比较,早期组PCI前TIMI 3级血流和TMP 3级比例明显升高(30.8% vs 10.8%,33.3% vs 12.5%,P0.05);早期组PCI后TMP 3级明显升高(77.5% vs 51.7%,P0.05)。早期组发生MACE 3例,即刻组4例(2.5% vs 3.3%,P0.05)。结论对STEMI急诊PCI的患者,早期应用替罗非班能改善梗死相关血管的血流及心肌灌注。     

心电图指导下直接处理梗死相关动脉对门-囊时间的影响

目的 探讨心电图（ECG）指导下首选指引导管行梗死相关动脉造影和介入治疗（PCI）对急性ST段抬高心肌梗死（STEMI）患者门-囊（D2B）时间和导管室门-首次球囊扩张（C2B）时间的影响.方法 回顾性调查我院2009年1～11月连续收治并行直接PCI的STEMI患者的D2B时间及C2B时间,按治疗策略分为2组：ECG指导组为直接用指引导管行梗死相关动脉（IRA）造影并PCI后再完成全部造影;造影指导组先完成全部造影后再完成IRA的PCI,评价指标是D2B时间和C2B时间及院内和30 d的心脏事件（死亡、靶血管再次重建和非致死性心肌梗死）发生率.结果 190例患者进入本研究,其中ECG指导组82例,造影指导组108例.两组操作成功率分别为87.7%和85.2%（P〉0.05）,门-导管室时间ECG指导组为（63±29）min,造影指导组为（70±42）min,P=0.09.穿刺至首次球囊扩张时间ECG指导组明显低于造影指导组[（9±4）min比（18±7）min,P〈0.01）].C2B和D2B时间ECG指导组均明显低于造影指导组[分别为（15±5）min比（25±7）min,P〈0.01;（78±30）min比（95±42）min,P=0.002）].D2B时间达标率ECG指导组明显高于造影指导组（75.6%比52.7%,P=0.01）.院内心脏事件发生率ECG指导组为6.0%,造影指导组为1.9%,p=0.65.30 d心脏事件发生率两组相似（6.0%比6.4%,p=0.90）.结论 和传统的介入方法相比,ECG指导下直接用指引导管行IRA造影并PCI后完成非IRA造影能明显缩短D2B和C2B时间,提高D2B时间达标率.     

Characteristics and outcome of patients with ST‐elevation infarction in relation to whether they received thrombolysis or underwent acute coronary angiography: Are we selecting the right patients for coronary angiography?

BACKGROUND: During the last decade, there has been an on-going debate with regard to whether percutaneous coronary intervention (PCI) or thrombolysis should be preferred in patients with ST-elevation acute myocardial infarction (AMI). Some studies clearly advocate PCI, while others do not. HYPOTHESIS: The study aimed to describe the characteristics and to evaluate outcome of patients with suspected ST-elevation or left bundle-branch block infarction in relation to whether they received thrombolysis or had an acute coronary angiography aiming at angioplasty. METHODS: The study included all patients admitted to Sahlgrenska University Hospital in G?teborg, Sweden, with suspected acute myocardial infarction who, during 1995-1999, had ST-elevation or left bundle-branch block on admission electrocardiogram (ECG) requiring either thrombolysis or acute coronary angiography. A retrospective evaluation with a follow-up of 1 year after the intervention was made. RESULTS: In all, 413 patients had thrombolytic treatment and 400 had acute coronary angiography. The patients who received thrombolysis were older (mean age 70.3 vs. 64.1 years). Mortality during 1 year of follow-up was 20.9% in the thrombolysis group and 16.6% in the angiography group (p = 0.12). Among patients in whom acute coronary angiography was performed, only 85% underwent acute percutaneous coronary intervention (PCI). There was a mortality of 12.1 vs. 41.7% among those who did not undergo acute PCI. Development of reinfarction, stroke, and requirement of rehospitalization was similar regardless of type of initial intervention. The thrombolysis group more frequently required new coronary angiography (36.9 vs. 20.6%; p<0.0001) and new PCI (17.8 vs. 11.9%; p = 0.01). Despite this, after 1 year symptoms of angina pectoris were observed in 27% of patients in the thrombolysis group and in only 14% of those in the angiography group (p = 0.0002). CONCLUSION: In a Swedish university hospital with a high volume of coronary angioplasty procedures, we found no significant difference in mortality between patients who had thrombolysis and those who underwent acute coronary angiography. However, requirement of revascularization and symptoms of angina pectoris 1 year later was considerably less frequent in those who had undergone acute coronary angiography. However, distribution of baseline characteristics was skewed and efforts should be focused on the selection of patients for the different reperfusion strategies.     

急性ST段抬高性心肌梗死患者直接经皮冠状动脉介入治疗再灌注时间对ST段回落的影响

目的探讨直接经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗中症状发作-球囊扩张时间(symptom-onset-to-balloon,SOTB)对再灌注后心电图ST段的回落、住院期间左心室射血分数、6个月内总的主要心血管事件(包括心绞痛、再发心肌梗死、因心血管事件再入院、心力衰竭和死亡等)发生率的影响。方法回顾性分析2005年1月至2006年7月于北京大学深圳医院行直接PCI治疗的ST段抬高性心肌梗死(ST-elevation myocardial infarction,STEMI)患者225例的基线资料、心电图资料以及随访资料,比较不同时间SOTB(>3 h及≤3 h)术前、术后1 h ST段抬高总和恢复百分比(sumSTR)%、住院期间超声心动图所测的左心室射血分数、随访6个月的主要心血管事件发生率。结果SOTB≤3 h组PCI治疗后1 h ST段完全回落≥70%的患者比例明显高于SOTB>3 h组,差异有统计学意义(57.4%vs.43.2%,P=0.005);住院期间左心室射血分数高于SOTB>3 h组,差异有统计学意义(57.69%±7.64%vs.53.80%±9.03%,P=0.014);6个月主要心血管事件发生率低与SOTB>3 h组,差异有统计学意义(14.9%vs.35.4%,P=0.001)。结论 STEMI患者PCI治疗中SOTB短,ST段回落就迅速而完全,住院期间的左心室射血分数高,6个月主要心血管事件发生率低。     

A comparison of transradial and transfemoral approaches for primary percutaneous coronary intervention in ST-segment elevation myocardial infarction patients in a high volume percutaneous coronary intervention center

Background Large percutaneous coronary intervention （PCI） centers have shown statistically better prognosis with transradial approach （TRA） compared with transfemoral approach （TFA）. So we tried to compare the outcomes between TRA and TFA in one high volume PCI center in ST-segment elevation myocardial infarction （STEMI） patients undergoing primary PCI. Method Six hundred and sixty two STEMI patients who underwent primary PCI with stents implantation were retrospectively included from June 1, 2006 to April 30, 2011 in our hospital and prospectively followed for one year. The primary endpoint was defined as in-hospital net adverse clinical events （NACE） which included death, myocardial infarction （MI）, stroke, target vessel revascularization （TVR） and major bleeding. The secondary endpoint was defined as 1 year major adverse cardiovascular events （MACE） which included death, MI and TVR. Results The occurrence rates of NACE （8.0% vs. 17.0%, P = 0.0018）, access site complications （4.0% vs. 10.7% P = 0.0027） and access site-related major bleeding （2.4% vs. 6.3%, P = 0.0254） were all higher in the TFA group than in the TRA group. The incidence rate of 1 year MACE was similar between TRA and TFA （8.5% vs. 13.2%, P = 0.0932）. The inverse probabilities weighting matched multivariable Cox regression analysis showed TRA was an independent predictor of lower rates of in-hospital NACE （HR： 0.58, 95% CI： 0.34-0.99, P = 0.0477）, in-hospital death （HR： 0.31, 95% CI： 0.10-0.73, P = 0.0499） and access site complications （HR： 0.37, 95% CI： 0.19-0.73, P = 0.0040）. Conclusions TRA showed great efficacy and safety for STEMI patients undergoing primar-y PCI in high volume PCI centers. It should be recommended as routine practice in future, and especially in those patients with high risk of bleeding.     

抽吸导管联合硝普钠在急性心肌梗死介入治疗中的作用

目的:探讨在急性ST段抬高型心肌梗死(STEMI)患者经皮冠状动脉介入（PCI）治疗中应用抽吸导管联合冠脉内注射硝普钠对改善心肌组织灌注及预后的影响。方法:146例于我院行急诊PCI的STEMI患者,分为常规PCI组（常规治疗组）、抽吸导管组（导管抽吸组）、抽吸导管联合硝普钠组（联合措施组）,比较3组术后TIMI血流恢复情况及术后30 d主要不良心血管事件(major adverse cardiac events,MACE)的发生率。结果:单纯使用抽吸导管组及抽吸导管联合硝普钠组与常规PCI组相比均能明显改善STEMI患者术后TIMI血流及预后（P<0.05）,抽吸导管联合硝普钠组与单纯抽吸导管组相比能进一步改善STEMI患者术后TIMI血流（P<0.05）,且能明显减少术后MACE事件的发生率。结论:抽吸导管联合硝普钠可进一步改善心肌梗死患者冠脉血流状态,同时有可降低术后MACE发生率的趋势,尚须大样本证实。     

Does Proximal Location of Culprit Lesion Confer Worse Prognosis in Patients Undergoing Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction?

ST segment elevation myocardial infarction (STEMI) from proximally located culprit lesion is associated with greater myocardium at jeopardy. In STEMI patients treated with thrombolytics, proximal culprit lesions are known to have worse prognosis. This relation has not been studied in patients undergoing primary percutaneous coronary intervention (PCI). In 3,535 STEMI patients with native coronary artery occlusion pooled from the primary angioplasty in myocardial infarction database, we compared in-hospital and 1-year outcomes between those with proximal (n = 1,606) versus non-proximal (n = 1,929) culprit lesions. Patients with proximal culprits were more likely to die and suffer major adverse cardiovascular events (MACE) during the index hospital stay (3.8% vs 2.2%, P = 0.006; 8.2% vs 5.8%, P = 0.0066, respectively) as well as during 1-year follow-up (6.9% vs 4.5%, P = 0.0013; 22% vs 17%, P = 0.003, respectively) compared to those with non-proximal culprits. After adjustment for baseline differences, proximal culprit was independently predictive of in-hospital death (adjusted odds ratio% 1.58, 95% confidence intervals, CI 1.05-2.40) and MACE (OR 1.41, CI 1.06-1.86), but not 1-year death or MACE. In addition, proximal culprit was independently associated with higher incidence of ventricular arrhythmias and sustained hypotension during the index hospitalization. The univariate impact of proximal culprit lesion on in-hospital death and MACE was comparable to other adverse angiographic characteristics, such as multivessel disease and poor initial thrombolysis in myocardial infarction flow, and greater than that of anterior wall STEMI. In conclusion, proximal location of the culprit lesion is a strong independent predictor of worse in-hospital outcomes in patients with STEMI undergoing primary PCI.     

早期口服尼可地尔在老年急性 ST 段抬高心肌梗死急诊 PCI 中的效果

目的 通过观察早期口服尼可地尔对老年急性ST段抬高心肌梗死（STEMI）患者急诊PCI术后的心肌受损程度、冠脉微循环灌注水平、心脏功能的影响及MACE,探讨尼可地尔对老年急性ST段抬高心肌梗死患者心肌保护作用。方法 2013.7—2015.1入院的115例行急诊PCI的老年STEMI患者（>60岁）,随机分为尼可地尔组57例和对照组58例,尼可地尔组入院确诊后即刻顿服尼可地尔15mg,对照组仅行再灌注治疗,尼可地尔组术后继续口服尼可地尔5mg TID,而对照组口服单硝酸异山梨酯片20mg TID。监测手术前后心肌损伤标志物肌钙蛋白。术中记录所有病人梗死相关动脉情况、PCI后校正TIMI帧数（CTFC）及心肌灌注分级（TMP)。PCI术后一周行超声心动图检查,记录左室射血分数（LVEF）及左室舒张末期内径（LVEDD）。记录PCI术后30d主要不良心脏事件（MACE）。结果 两组患者PCI术后12小时、24小时静脉血cTnI检测结果均较术前明显升高,但均明显低于对照组（P<0.05）。尼可地尔组术后校正的TIMI帧数（CTFC）小于对照组（29.64±3.18 vs 32.70±4.55, P<0.05）;心肌灌注分级TMP2级以上的比例尼可地尔组高于对照组（78.95% vs 62.07%, P<0.05）。尼可地尔组病人的射血分数高于对照组（54.36±5.03vs. 51.09±4.45,P<0.05）。PCI术后30d尼可地尔组MACE发生率低于对照组（7.02% vs 20.69%, P<0.05）。结论：早期口服尼可地尔可减轻老年急性ST段抬高心肌梗死患者急诊PCI术后的心肌受损程度,改善心肌微循环灌注,保护左心室功能,减少了MACE事件发生。     

替格瑞洛在补救PCI患者中的疗效及安全性

目的 观察替格瑞洛在溶栓失败后补救性经皮冠状动脉介入治疗（PCI）患者中的疗效及安全性。方法 入选2013~2014年因急性ST段抬高型心肌梗死（STEMI）的溶栓失败后12 h内于我院行补救PCI的患者246例。随机将符合条件的患者分为替格瑞洛组（n=121）和氯吡格雷组（n=125）,替格瑞洛组术前给予替格瑞洛180 mg,术后90 mg bid联合阿司匹林100 mg qd;氯吡格雷组术前给予氯吡格雷300 mg,术后75 mg qd联合阿司匹林100 mg qd。采用TIMI血流分级（TFG）、校正的TIMI记帧（CTFC）和TIMI心肌灌注分级（TMPG）评价比较两组术后心肌灌注水平。随访12月比较两组患者的主要不良心脑血管事件（MACCE）的发生率和出血事件及其它不良事件的发生率。结果 两组心肌灌注水平差异无统计学意义。替格瑞洛组与氯吡格雷组相比MACCE复合终点累计发生率降低,差异具有统计学意义（6.6% vs. 15.2% HR=0.395,95%CI:0.166-0.940,P<0.05）。两组总体主要出血、主要致命/危及生命的出血事件发生率差异无统计学意义。结论 替格瑞洛在溶栓失败后补救PCI患者中同样安全有效。     

抽吸导管在急性ST段抬高型心肌梗死直接经皮冠脉介入治疗中的疗效观察

目的评价抽吸导管在急性ST段抬高型心肌梗死（STEMI）直接经皮冠脉介入治疗（PCI）中的疗效。方法随机入选行急诊PCI的急性STEMI患者80例,其中使用抽吸导管后行支架置人术32例（抽吸导管组）,未使用抽吸导管而行球囊扩张及支架置人术48例（直接PCI组）。观察两组术后即刻TIMI血流分级、无复流现象、术后即刻胸痛缓解率、术后1hST段回落≥50％（STR≥50％）发生率和心梗后24h及2周左室舒张末径（LVDD）、左室射血分数（LVEF）。结果抽吸导管组即刻TIMI血流2-3级高于直接PCI组（94％比75％,P〈0．05）,抽吸导管组无复流现象低于直接PCI组;抽吸导管组术后1hSTR≥50％、胸痛缓解率均高于急诊PCI组（94％比71％、88％比71％,均P〈0．05）;抽吸导管组心梗后24hLVDD低于直接PCI组[（54．2±4．1）mm比（56．2±4．2）mm,P〈0．05],心梗后24hLVEF高于直接PCI组[（57．6＋5．24）％比（55．0±4．6）％,P〈0．05],梗后2周LVDD及LVEF两组间差异无统计学意义。结论急诊PCI时联合使用抽吸导管可减少无复流发生,改善心肌再灌注及心肌梗死早期心功能。     

经桡动脉应用单根MAC指引导管行急诊冠状动脉造影和介入治疗

目的探讨经桡动脉应用单根MAC指引导管行急诊冠状动脉造影和介入治疗(PCI)的可行性和安全性。方法前瞻性单中心、随机对照研究,自2011年8月至12月,75例发病12h内的急性ST段抬高心肌梗死(STEMI)、拟行经桡动脉急诊PCI治疗的患者根据随机序号将患者按1:1比例随机分为MAC组和对照组:MAC组(37例)为直接应用MAC指引导管行冠状动脉造影和介入治疗,对照组(38例)为应用造影导管完成冠状动脉造影后再选择指引导管行介入治疗。比较两组患者血管穿刺成功率、导管室准备时间、鞘管置入时间、操作成功率、造影剂用量、操作时间、透视时间和导管室门-球囊(cathlab door to balloon,C2B)时间、穿刺部位并发症以及30天的主要心脏不良事件(死亡、非致死性心肌梗死和靶病变血运重建)发生率。结果 75例患者,其中男性57例,女性18例,年龄(61.5±12.2)岁。两组穿刺置管成功率均为100%,对照组1例患者因右桡尺动脉环而改股动脉路径完成手术。MAC组和对照组相比,两组患者的穿刺置管时间、PCI操作成功率和造影剂用量无明显差异[(1.73±1.08)min比(1.65±0.84)min,t=-0.398,P>0.05;89.2%比89.2%,χ2=0.140,P>0.05;(127±74)ml比(136±33)ml,t=1.159,P>0.05]。操作时间、C2B时间和透视时间MAC组均明显低于对照组[(27.27±6.97)min比(36.33±13.71)min,t=3.582,P<0.001;(15.11±4.77)min比(18.31±3.84)min,t=3.180,P=0.002;(7.61±3.04)min比(11.17±5.99)min,t=3.227,P=0.001]。穿刺部位并发症:局部血肿每组各2例。30天的主要心脏不良事件发生率两组相似(2.7%比2.7%)。结论经桡动脉应用单根MAC指引导管行急诊冠状动脉造影和PCI是安全和可行的,能明显减少操作时间、透视时间和C2B时间。