冠状动脉侧支循环在急性心肌梗死远期预后中的价值探讨

目的：探讨冠状动脉侧支循环在急性心肌梗死远期预后的价值。方法：对70例急性心肌梗死患者行冠状动脉造影及三件随访资料分析研究。结果：36例侧支积分＞1（CC组＝有侧支循环）,34例侧支积分＝0（NCC组＝无侧支循环）,两组比较,CC组的多支（双支以上）病变率较高（D＜0．01）,NCC组的单支病变率较高（P＜0．01）。两组冠脉狭窄、迂曲、钙化程度相似（P＞0．05）。随访发现,CC组前两年内心功能优于NCC组,心绞痛及再梗率低于NCC组（P＜0．01）,无病死者。但两组心梗后第三年预后相似(P＞0．05）结论：侧支循环对心肌梗死急性期及心梗后两年内有重要保护作用,而对第三年预后无保护作用。     

急诊经皮冠状动脉介入治疗AMI的临床疗效观察

目的探讨急诊经皮冠状动脉介入治疗术(PCI)治疗急性心肌梗死(AMI)的临床疗效。方法回顾性分析我院2004年7月～2007年10月40例AMI患者发病24h内急诊PCI的临床资料。结果40例急诊PCI成功,成功率85%,病死率0.13%,急诊手术因开通时间短,手术快,术后恢复好,术中并发症虽比较凶险,但只要处理得当容易及时纠正,急诊PCI仍然安全有效。结论急诊PCI虽有风险,但手术难度不大,手术时间短,病人受益大于风险,可见急诊PCI治疗急性心肌梗死是可行的。     

合并冠状动脉侧支循环的AMI患者临床及冠状动脉特征分析

目的：探讨已建立冠状动脉侧支循环的初发急性心肌梗死患者临床及冠状动脉特征。方法：82例确诊为初发急性心肌梗死患者,按有无侧支循环分为有侧支循环组32例和无侧支循环组50例,对两组患者的心血管危险因素及冠状动脉病变特点进行比较分析。结果：和无侧支循环组相比,有侧支循环组患者吸烟比例（21．88．％13548．00％,P〈0．05）、饮酒比例（12．50％粥34．00％,P〈0．05）、糖尿病比例（9．38％傩32．00％。P〈0．05）及心源性休克比例（6．25％傩24．00％,P〈0．05）均较低。梗死前心绞痛比例（65．63％傩38．00％,P〈0．05）及左室射血分数值[（61．05±7．85）％绑（55．84±13．95）％,P〈0．01]有侧支循环组显著高于无侧支循环组。冠状动脉造影显示,有侧支循环组多支病变比例（66．67％傩52．00％,P〈0．05）及梗死相关动脉为右冠状动脉比例（59．38％傩30．00％,P〈0．01）显著高于无侧支循环组。结论：吸烟、饮酒及糖尿病不利于侧支循环的形成,侧支循环的形成有利于保存心肌梗死患者的心功能,降低心源性休克的发生率。     

冠状动脉侧支循环形成与功能及其影响因素

目的：探讨冠状动脉严重狭窄冠心病患者冠状动脉侧支循环（CCC）形成与功能及其影响因素。方法：采用选择性冠状动脉造影（CAG）的方法,按冠状动脉狭窄程度分为3组：A组：狭窄90%~94%;B组：狭窄95%~99%;C组：狭窄100%。采用Rentrop标准评价CCC形成,将266例患者分为CCC形成组与无CCC形成组;对CCC形成组者,按Werner冠状动脉侧支连接（CC）标准评价CCC功能,分为CC 0级、CC 1级、CC 2级3组,比较分析266例冠状动脉严重狭窄CAD患者、401支冠状动脉CCC形成和功能与冠状动脉狭窄程度及临床特征的关系。结果：C组CCC形成比例高于A与B组（P<0.05 ）, B组CCC形成比例高于A组（P<0.05）; CCC形成组与无CCC形成组患者年龄、性别、高血压、糖尿病、吸烟比例、MI、血清HDL-C及LDL-C水平差异无统计学意义（P>0.05）;在CCC形成患者中,CC 2级组血清HDL-C最高、LDL-C最低,CC 0级组血清HDL-C水平最低、LDL-C最高（P<0.05）。结论：在严重狭窄冠状动脉中,冠状动脉狭窄程度是CCC形成与功能的主要影响因素,CCC形成比例随着狭窄程度加重而升高;在冠状动脉严重狭窄的CAD患者,血清HDL-C及LDL-C水平与CCC的形成无关;但与CCC功能有关,HDL-C水平高者CCC功能好,而LDL-C水平高者则CCC功能差。     

冠状动脉侧支循环形成与临床意义及其影响因素的研究

目的探讨冠状动脉严重狭窄的冠心病患者(CAD)冠状动脉侧支循环(CCC)形成与临床意义及其影响因素。方法采用选择性冠状动脉造影(CAG)的方法,按冠状动脉狭窄程度分为3组:A组狭窄90%~94%,B组狭窄95%~99%,C组狭窄100%。采用Rentrop标准评价冠状动脉侧支循环形成并对照分析侧支循环形成的良好率,将106例患者分为CCC形成组与无CCC形成组;CCC按Werner冠状动脉侧支连接(CC)标准评价CCC功能,分为CC 0级、CC 1级、CC 2级3组,比较分析106例冠状动脉严重狭窄CAD患者、160支冠状动脉CCC形成和功能与冠状动脉狭窄程度及临床特征的关系。结果C组侧支循环良好率高于A与B组(P<0.05),B组侧支循环良好率高于A组(P<0.05);CCC形成组与无CCC形成组患者年龄、性别、高血压、糖尿病、吸烟比例、心肌梗死(MI)、血清高密度脂蛋白-胆固醇(HDL-C)及低密度脂蛋白-胆固醇(LDL-C)水平等方面差异无统计学意义(P>0.05);在CCC形成患者中,CC 2级组血清HDL-C最高、LDL-C最低,CC 0级组血清HDL-C水平最低、LDL-C最高(P<0.05)。结论在严重狭窄冠状动脉中,冠状动脉狭窄程度是CCC形成与功能的主要影响因素,良好CCC形成比例随着狭窄程度加重而升高;在冠状动脉严重狭窄的CAD患者,血清HDL-C及LDL-C水平与CCC的形成无关;但与CCC功能有关,HDL-C水平高者CCC功能好,而LDL-C水平高者则CCC功能差。     

心肌梗死时冠状动脉侧支循环的临床意义及促发因素

目的 探讨急性心肌梗死(acute myocardial infarction,AMI)患者冠状动脉侧支循环(coronary collateral circulation,CCC)形成的潜在促发因素和临床意义。方法 从2712例AMI患者中入选的1662例符合研究条件的患者分为CCC组和非CCC组。分析两组的基本临床特征和冠状动脉造影数据,利用Logistic回归分析探讨影响CCC形成的潜在因素,以及比较住院期间心脏功能、估计梗死面积大小和主要心血管事件(main cardiovascular event,MACE)。结果 两组之间基线资料总体均衡,CCC组冠心病病史(既往诊断)和陈旧性心肌梗死病史高于非CCC组。冠脉状动造影结果提示,CCC组冠状动脉狭窄程度较大,各支血管存在狭窄的比例较高。Logistic分析显示,CCC的促发因素包括:年龄、冠心病病史、陈旧性心肌梗死病史、冠状动脉狭窄程度。临床结局方面,CCC组住院日较长,心功能较差,但心肌梗死面积并不比非CCC组大,两组之间MACE事件无显著差异。结论 伴随有CCC的AMI患者,存在冠心病病史和陈旧性心肌梗死病史的比例较高,其冠状动脉狭窄程度较高;年龄、冠心病病史、陈旧性心肌梗死病史、冠状动脉狭窄程度等是CCC形成的促发因素;CCC不能有效改善住院期间的心功能和减少住院日,但伴随有CCC的AMI患者,其心肌梗死面积和MACE事件不高于无CCC的AMI患者,提示CCC有不全面的保护作用。     

急诊经皮冠状动脉介入治疗的伦理问题探讨

急性心肌梗死是心血管疾病急危重症,急诊经皮冠状动脉介入术（percutaneous coronary intervention,PCI）是急性心肌梗死治疗的首选方法.在临床实践中存在适应证模糊、不能有效沟通、治疗欠公平等伦理学问题,影响了急诊PCI的合理应用和发展,甚至导致医患纠纷的发生.通过对患者生命权、知情权、公平权等权利的重视,在医学伦理学的基本原则下指导介入技术的实施,使其可以更好地为患者服务.     

冠心病患者侧支循环与冠状动脉病变的关系

对９０例临床诊断为冠心病患者进行冠状动脉赞赏影,６２例有冠状动脉狭窄,其中２０例存在侧支循环,占３２．３％。经分析发现侧支循环与冠状动脉狭窄程度及冠状动脉病变支数有关,病变越严重,侧支循环发生率越高,多支病变单支病变更易形成侧支循环。     

冠状动脉侧支循环形成病人冠脉病变特点分析

目的 :分析冠状动脉 (冠脉 )侧支循环形成的冠心病病人的冠脉病变特点 ,探讨冠状动脉侧支循环形成相关因素。方法 :分析 12 2例选择性冠状动脉造影 (冠造 )证实冠脉侧支循环形成的冠心病病人 (侧支循环形成组 ,A组 )及 131例冠脉病变程度相似而无冠脉侧支循环形成病人 (无侧支循环形成组 ,B组 )的冠脉造影资料及临床资料。结果 :98 4 %的A组患者有 1支冠脉完全闭塞或次全闭塞 ;与B组相比 ,A组患者中多支冠脉闭塞率明显增高(30 0 0 %比 11 4 5 % ,P <0 0 1) ;完全闭塞率明显增高 (75 77%比 6 0 2 7% ,P <0 0 5 )。此外 ,完全闭塞冠脉的侧支循环形成率较次全闭塞冠脉明显增高 (5 8 0 9%比 4 0 2 0 % ,P <0 0 5 )。结论 :冠脉侧支循环形成患者 98 4 %存在完全或次全冠脉闭塞性病变 ,其严重程度是侧支循环能否形成最主要的决定因素     

冠心病人冠状动脉侧支循环形成的相关因素分析

目的 对影响冠心病冠状动脉侧支循环形成的相关因素进行评估。方法 回顾性分析１４２例经冠状动脉造影证实管腔狭窄≥７５％的冠心病人的侧支循环开放情况，以及与高血压、冠状动脉病变部位及左这一壁厚度的关系。结果 在高血压组侧支循环为Ⅱ￣Ⅲ级形式占７０．３％，而在 高血压 占４４．３５５，差异有显著性；右冠状动脉病变的Ⅱ￣Ⅲ级形式占６１．９１％，而在左冠脉病以占４０．５１５，差异有显著性；侧支循环开放程度与     

急性心肌梗死冠脉侧支血流分数与Rentrop分级的相关性

目的 测定急性心肌梗死患者压力源性冠脉侧支血流分数（PDCF）,评价PDCF与传统的Rentrop分级间的相关性。方法 29例急性心肌梗死患者行介入术,术中应用冠脉内压力导丝根据Pw/Pa计算PDCF,以0．24为PDCF截值将29例分为2组：A组（19例）PDCF〉0．24,B组（10例）PDCF≤0．24。术后根据冠脉造影行Rentrop分级。使用统计学方法对数据进行线性回归分析,讨论PDCF与Rentrop分级间的相关性。结果 Rentrop分级同PDCF呈正相关（γ=0．75,P〈0．01）,但Rentrop≤1级的PDCF分布范围较为离散。结论 冠脉内压力源性PDCF测量可对AMI时侧支循环血流作出定量评价。     

直接冠脉介入治疗急性心肌梗死临床分析

目的 探讨急性心肌梗死直接经皮冠脉介入治疗(PCI)的疗效,方法及安全性.方法 建立急性心肌梗死"绿色通道",对236例急性心肌梗死患者,采用经股动脉或经桡动脉途径常规方法,行直接PCI,观察梗塞相关动脉的开通率、血流情况、术中并发症,住院期间主要心血管事件,随访观察预后、再狭窄及再次血运重建情况.结果 呼叫到球囊开通时间为(88±36)min,227例患者成功开通梗死相关动脉.TIMI血流3级(96.2%),9例发生无再流,共植入支架235个.无严重手术并发症发生,15例心原性休克患者11例存活(73.3%),5例心肺复苏患者3例生存.住院期间死亡10例,死亡原因为心力衰竭、休克和室颤.随访期间再发心肌梗死7例,死亡4例.87例复查冠脉造影,19例再狭窄,12例再次行PCI术,3例行冠脉搭桥术.结论 直接PCI治疗急性心肌梗死安全有效,在有条件的医院可首选PCI作为急性心肌梗死治疗的方法.     

Correlation between balloon release pressure and no-reflow in patients with acute myocardial infarction undergoing direct percutaneous coronary intervention

Background Balloon release pressure may increase the incidence of no reflow after direct percutaneous coronaryintervention （PCI）. This randomized controlled study was designed to analyze the correlation between balloon releasepressure and no-reflow in patients with acute myocardial infarction （AMI） undergoing direct PCI.Methods There were 156 AMI patients who underwent PCI from January 1, 2010 to December 31, 2012, and weredivided into two groups according to the stent inflation pressure： a conventional pressure group and a high pressure group.After PCI, angiography was conducted to assess the thrombolysis in myocardial infarction （TIMI） grade with related artery.Examinations were undertaken on all patients before and after the operation including cardiac enzymes, total cholesterol,low-density lipoprotein, blood glucose, homocysteine, 13-thromboglobulin （I3-TG）, Hamilton depression scale （HAMD） andself-rating anxiety scale （SAS）. After interventional therapy, the afore-mentioned parameters in both the conventionalpressure group and high pressure group were again analyzed.Results The results showed that CK-MB, HAMD, SAS were significantly different （P 〈0.05） in all patients after PCI,especially the CK-MB in the high pressure group （（25.7_＋7.6） U/L vs. （76.7＋11.8） U/L）. CK-MB, HAMD, SAS, and I3-TGwere comparative before PCI but they were significantly changed （P 〈0.05） after intervention. No-reflow phenomenonoccurred in 13 patients in the high pressure group, which was significantly higher than in the conventional pressure group（17.11% vs. 6.25%, P 〈0.05）.Conclusion In stent implantation, using a pressure less than 1823.4 kPa balloon to release pressure may be the betterchoice to reduce the occurrence of no-reflow followinq direct PCI.     

Clinical relevance of angiographic coronary collaterals during primary coronary intervention for acute ST-elevation myocardial infarction

Background Collaterals to occluded infarct-related coronary arteries （IRA） have been observed after the onset of acute ST-elevation myocardial infarction （STEMI）.We sought to investigate the impact of early coronary collateralization,as evidenced by angiography,on myocardial reperfusion and outcomes after primary percutaneous coronary intervention （PCI）.Methods Acute procedural results,ST-segment resolution （STR）,enzymatic infarct size,echocardiographic left ventricular function,and major adverse cardiac events （MACE） at 6-month follow-up were assessed in 389 patients with STEMI undergoing primary PCI for occluded IRA （TIMI flow grade 0 or 1） within 12 hours of symptom-onset.Angiographic coronary collateralization to the occluded IRA at first contrast injection was graded according to the Rentrop scoring system.Results Low （Rentrop score of 0 or 1） and high （Rentrop score of 2 or 3） coronary collateralization was detected in 329 and 60 patients,respectively.Patients with high collateralization more commonly had prior stable angina and right coronary artery occlusion,but less often had left anterior descending artery occlusion.At baseline,these patients presented with less extent of ST-segment elevation and lower serum levels of creatine kinase myocardial band （CK-MB） and cardiac troponin Ⅰ （cTnl）.Procedural success rate,STR,corrected TIMI flame count,and area under the curve of CK-MB and cTnl measurements after the procedure were similar between patients with high collateralization and those with low collateralization （for all comparisons P＞0.05）.There were no differences in left ventricular ejection fraction and rates of MACE at 6 months according to baseline angiographic collaterals to occluded IRA.Conclusions In patients with acute STEMI undergoing primary PCI within 12 hours of symptom-onset,coronary collateralization to the occluded IRA was influenced by clinical and angiographic features.Early recruitment of collaterals limits infarct size at baseline,but has no significant impact on myocardial reperfusion after the procedure and subsequent left ventricular function and clinical outcomes.     

Thorombolytic therapy with rescue percutaneous coronary intervention versus primary percutaneous coronary intervention in patients with acute myocardial infarction: a multicenter randomized clinical trial

Background Although thrombolytic therapy with rescue percutaneous coronary intervention （PCI） is a common treatment strategy for ST-segment elevation acute myocardial infarction （STEMI）, scant data are available on its efficacy relative to primary PCI, and comparison was therefore the aim of this study. Methods This multicenter, open-label, randomized, parallel trial was conducted in 12 hospitals on patients （age 〈70 years） with STEMI who presented within 12 hours of symptom onset （mean interval 〉3 hours）. Patients were randomized to three groups： primary PCI group （n=101）; recombinant staphylokinase （r-Sak） group （n=-104）; and recombinant tissue-type plasminogen activator （rt-PA） group （n=-106）. For all patients allocated to the thrombolytic therapy arm, coronary angiography was performed at 90 minutes after drug therapy to confirm infarct-related artery （IRA） patency; rescue PCI was performed in cases with TIMI flow grade 〈2. Bare-metal stent implantation was planned for all patients. Results After randomization it required an average of 113.4 minutes to start thrombolytic therapy （door-to-needle time）and 141.2 minutes to perform first balloon inflation in the IRA （door to balloon time）. Rates of IRA patency （TIMI flow grade 2 or 3） and TIMI flow grade 3 were significantly lower in the thrombolysis group at 90 minutes after drug therapy than in the primary PCI group at the end of the procedure （70.5% vs. 98.0%, P 〈0.0001, and 53.0% vs. 85.9%, P 〈0.0001, respectively）. Rescue PCI with stenting was performed in 117 patients （55.7%） in the thrombolytic therapy arm. Rates of patency and TIMI flow grade 3 were still significantly lower in the rescue PCI than in the primary PCI group （88.9% vs. 97.9%, P=-0.0222, and 68.4% vs. 85.0%, P=0.0190, respectively）. At 30 days post-therapy, mortality rate was significantly higher in the thrombolysis combined with rescue PCI group than in primary PCI group （7.1% vs. 0, P=0.0034）. Rates of death/MI and bleeding complications were significantly higher in the thrombolysis with rescue PCI group than in the primary PCI group （10.0% vs. 1.0%, P=-0.0380, and 28.10% vs. 8.91%, P=-0.O001, respectively）. Conclusions Thrombolytic therapy with rescue PCI was associated with significantly lower rates of coronary patency and TIMI flow grade 3, but with significantly higher rates of mortality, death/MI and hemorrhagic complications at 30 days, as compared with primary PCI in this group of Chinese STEMI patients with late presentation and delayed treatments.     

急性心肌梗死患者急诊PCI术后无复流的危险因素分析

目的探讨急性心肌梗死(AMI)患者急诊PCI术后出现无复流的相关危险因素。方法发病在6h以内,或12 h内仍有持续胸痛的843名AMI患者给予急诊PCI,收集患者的临床、造影和介入治疗资料。PCI术后,根据TIMI血流分级和心肌显色分级两项结果将病人分为两组,正常血流组和无复流组。比较这两组病人基本临床资料、造影结果和手术相关资料的差异,分析AMI患者急诊PCI术后出现无复流的原因。结果急诊PCI术后无复流的发生率约为15.9%。通过单变量分析,既往MI病史、心梗Killip分级、症状至PCI时间、术前IABP应用、术前TIMl分级、病变长度、血栓负荷程度、再灌注方法与急诊PCI术后发生无复流有关(P<0.05)。多变量Logistic回归模型认为,症状至PCI时间(OR:1.60;95%CI:1.02～2.73)、术前TIMI血流分级(OR:1.1;95%CI:1.04～1.16)、病变血管长度(OR:1.40;95%CI:1.19～1.69),血栓负荷程度(OR:2.02;95%CI:1.47～2.76)可作为急诊PCI术后无复流发生的独立危险因素。结论症状至PCI时间、术前TIMI血流分级、病变血管长度和血栓负荷程度可作为AMI患者急诊PCI后发生无复流的独立预测因素。     

非ST段抬高型心肌梗死急诊介入治疗的随访研究

目的：总结非ST段抬高性心肌梗死（NSTEMI）患者行急诊介入治疗（PCI）的临床疗效及随访结果.方法：2000年2月～2005年2月间,共收治142例NSTEMI患者,年龄36～82岁;其中6例行外科搭桥（CABG）治疗,136例行急诊PCI;发病到急诊PCI时间为1.5～11h.结果：136例行PCI者,131例成功,成功率96.3%.共治疗133处病变,置入支架177枚,4例患者仅行球囊扩张术.2例死亡,1例死于心源性休克,1例死于颅内出血.2例术后1周内支架内亚急性血栓形成.住院期间无其他严重心血管事件发生.129例患者门诊随访12个月,无不良心血管事件发生,86例PCI患者术后6～12个月行冠脉造影检查,再狭窄10例,8例金属裸支架者（16%）、2例药物洗脱支架者（5.6%）.结论：非ST段抬高型心肌梗死急诊介入治疗安全有效,能明显改善临床症状.药物洗脱支架可降低再狭窄发生率.     

Feasibility of using 6F angiographic catheters for primary percutaneous coronary intervention in patients with acute myocardial infarction

The transradial access has been used for percutaneous coronary intervention （PCI） for more than 10 years. Many studies have confirmed several advantages of a radial route over the traditional transfemoral approach, some of which include a decreased incidence of access site complications, an earlier ambulation after the procedure which helps make patients more comfortable after the procedure.4-SHowever, the radial artery is easier to spasm as it is smaller than the femoral artery. This kind of phenomenon often happens when shifting from angiographic catheters to guiding catheters.     

老老年急性心肌梗死患者介入治疗的疗效及近期安全性评价

目的评价老老年(≥80岁)急性心肌梗死(AMI)患者行急诊与择期经皮冠状动脉介入治疗术(PCI)的有效性和近期安全性。方法将120例老老年冠心病患者分为急性心肌梗死组(AMI组)和非心肌梗死组(对照组),其中AMI组发病12h内行直接PCI的患者为AMI急诊组,其他AMI患者(AMI择期组)和对照组患者均行择期PCI,两组合称为非急诊组,对各组的临床资料及冠脉介入特点进行回顾性分析。结果 AMI急诊组PCI即刻成功率(72.2%)低于非急诊组(92.2%),差异有统计学意义(P=0.036)。AMI急诊组并发症比非急诊组和AMI择期组高,差异有统计学意义(P<0.001,P=0.039),AMI组并发症及主要不良心脏事件发生率、院内死亡率均比对照组高(P<0.05)。结论在老老年AMI患者中,急诊与择期PCI手术成功率均较高,虽然急诊PCI术发生并发症的风险较高,但两者在院内死亡率和主要不良心脏事件发生率方面差异无统计学意义。