重组链激酶溶栓治疗后急性心肌梗死患者纤溶活性及血管活性物质的改变

目的：探讨重组链激酶溶栓治疗后急性心肌梗死患者血浆纤溶活性及血管活性物质的改变及其相互关系。方法：以发光底物显色及放射免疫法测定３７例急性心肌梗死患者血浆组织型纤溶酶原激活物（ｔ－ＰＡ）及其抑制物（ＰＡＩ）、降钙素基因相关肽（ＣＧＲＰ）、内皮素、血管紧张素Ⅱ及醛固酮含量。结果：溶栓组和对照组相比ｔ－ＰＡ上升，ＰＡＩ下降，ｔ－ＰＡ／ＰＡＩ及ＣＧＲＰ上升，溶栓后２小时达高峰，６小时维持较高水平，２４小时回降。两组急性心肌梗死患者血浆内皮素、血管紧张素Ⅱ、醛固酮持续升高达正常值的３～４倍。结论：溶栓后血浆ｔ－ＰＡ／ＰＡＩ及ＣＧＲＰ迅速升高表现出同步消长关系。所有急性心肌梗死患者内皮素、血管紧张素Ⅱ、醛固酮持续升高，三者表现出正反馈调节。     

Influence of tissue affinity of angiotensin-converting enzyme inhibitors on left ventricular remodeling after myocardial infarction

Background: The demonstration of local renin-angiotension systems has raised the question of whether angiotensinconverting enzyme (ACE) inhibitors with different tissue affinities differ with regard to their effects on postinfarction remodeling. Hypothesis: The study was undertaken to investigate the influence of ACE inhibitors with different tissue affinity on morphology and function of the infarcted left ventricle. Methods: In all, 52 patients (17 women, 35 men, 38-73 years) with large acute myocardial infarction were randomized to receive either 25-75 mg/day captopril or 10-20 mg/day fosinopril beginning on the Day 7 after infarction. Of these, 28 had anterior and 24 had posterior wall infarctions. Infarct size was determined by the creatine kinase integral method. Fifty patients were examined by cinemagnetic resonance imaging (CMRI) 1 and 26 weeks after infarction. The following parameters were determined: left ventricular enddiastolic and end-systolic volume index (LVEDVI, LVESVI), ejection fraction (LVEF), infarct weight, and muscle mass (LVMM). The volume-to-mass ratio (VMR) was calculated and the clinical status according to the guidelines of the New York Heart Association (NYHA) was documented at each examination time. The results were compared with those of a historical sample without ACE-inhibitor therapy examined in an identical manner (n = 31, 10 women, 21 men, 36-75 years). Results: LVEDVI and LVESVI increased in the first 6 months after infarction by 24.9 and 36.6%, respectively, in the historical sample; by 11.0 and 7.8%, respectively, under captopril; and by 13.1 and 10.7%, respectively, under fosinopril. LVEF decreased by 14.9% in the untreated sample, by 3.7% under captopril and by 5.0% under fosinopril. Infarct weight and LVMM increased by 12.7 and 15.3%, respectively, without ACE inhibition, by 5.7 and 10.1%, respectively, in patients treated with captopril, and by 6.1 and 9.3%, respectively, in patients treated with fosinopril. The VMR increased by 7.4% in the historical sample, by 3.5% in the captopril group, and by 1.8% in the fosinopril group. The NYHA clinical status improved by 18.2% without ACE inhibition, by 42.9% in the captopril group, and by 26.3% in the fosinopril group. The differences between the two ACE-inhibitor groups and the reference group were all significant, while the differences between the captopril group and the fosinopril group were significant only for VMR (p<0.01) and NYHA class (p < 0.05). Conclusions: Both captopril and fosinopril have a comparable positive influence on postinfarction remodeling and on clinical status. Lipophilicity and tissue affinity do not seem to play a clinically important role in ACE-inhibitor therapy after infarction.     

Transcatheter closure of recurrent postmyocardial infarction ventricular septal defects utilizing the Amplatzer postinfarction VSD device: a case series.

The initial therapy for postmyocardial infarction ventricular septal defects is surgical repair of the defect. Unfortunately, a significant number of patients develop recurrent ventricular septal defects (VSDs) following operative repair. Transcatheter closure offers an alternative to reoperation in these critically ill patients. We present a series of four patients in whom recurrent ventricular septal defects were closed using an Amplatzer VSD device.     

环氧合酶-1和前列腺素E2在多潘立酮对大鼠胃黏膜保护中的作用

目的　研究多潘立酮对大鼠胃黏膜损伤是否具有保护作用 ,并探讨胃黏膜细胞中环氧合酶 1(COX 1)及前列腺素 (PG)E2是否参与其中。方法　研究分为对照组和实验组。后者分别用多潘立酮 0 .5mg/kg、1mg/kg和 2mg/kg灌胃 ,3次 /d ,连续 3d。各组大鼠灌入无水乙醇后 ,肉眼观察胃黏膜损伤指数 (LI) ,光镜下观察黏膜缺损深度 ,并计算黏膜缺损深度与胃壁全层厚度百分比。放射免疫法测定各组胃黏膜PGE2的水平。免疫组织化学方法检测COX 1和COX 2蛋白表达水平并以平均吸光度值表示其强度。RT PCR检测胃黏膜COX 1和COX 2mRNA表达变化。结果　多潘立酮 1mg/kg组的LI及黏膜缺损深度与胃壁全层厚度百分比显著低于对照组 (P <0 .0 5 ) ,0 .5mg/kg组和 2mg/kg的组LI亦显著低于对照组 (P <0 .0 5 )。多潘立酮 1mg/kg组大鼠胃黏膜COX 1蛋白表达水平及PGE2水平显著高于空白对照组 (P <0 .0 1)。各实验组和对照组在胃黏膜细胞内均无COX 2蛋白表达。三个实验组COX 1mRNA表达量与对照组比较差异均有显著性 (P <0 .0 1)。各组均未检测到COX 2mRNA表达。结论　多潘立酮对胃黏膜损伤具有保护作用 ,其机制之一可能与其增加胃黏膜COX 1mRNA和COX 1蛋白表达及促进胃黏膜PGE2分泌有关。     

急性冠状动脉综合征心电图改变的临床意义

目的 探讨急性冠状动脉综合征心电图改变的临床意义。方法 对104例接受经皮穿刺腔内冠状动脉成形术加支架植入术的急性冠状动脉综合征患者（Ⅰ组Q波心肌梗死54例、Ⅱ组非Q波心肌梗死12例和Ⅲ组不稳定心绞痛38例）的冠状动脉病变和心电图改变进行分析。结果 冠状动脉完全闭塞Ⅰ组占75．55％，Ⅱ组占33．33％，差异有显著性意义（P＜0．05）。Ⅲ组无冠状动脉完全闭塞。3例冠状动脉多支病变差异无显著性意义（P＞0．05）。Ⅰ组：前壁心肌梗死多于下壁（32／54：22／54），发生持续性窦性心动过速、三度房室传导阻滞、室性心律失常、死亡率高。Ⅱ组：广泛持续性ST－T改变或以T波深倒置演变特征或Q波迅速消失，ST－T动态改变。Ⅲ组：胸痛发作时ST－T改变或伪性改善，不发作时ST－T正常或仍有改变。结论 急性冠状动脉综合征心电图表现有多种形式。无Q波心肌梗死并不少见。心电图的易变性是急性冠状动脉综合征的特征之一。     

Evaluation of the response to pharmacological stress in chronic aortic regurgitation

We evaluated the hemodynamic response of patients with chronic aortic regurgitation and decreased ejection fraction (EF), mean value +/- SD (37 +/- 9), to dobutamine stress echocardiography (DSE). Eleven patients were studied with DSE. Nine patients were in New York Heart Association (NYHA) Class II and two in NYHA Class III. Ten patients received medical treatment in the only other periodic evaluation. With DSE in nine patients, a significant decrease in left ventricular end-diastolic and end-systolic diameters (LVEDD and LVESD) as well as LV end-diastolic and end-systolic volumes (LVEDV and LVESV) was documented in comparison to resting values. EF and fractional shortening (FS) improved significantly with DSE. Systolic wall stress (SWS) and pulmonary arterial systolic pressure (PASP) did not change. Average follow-up was 6.7 months. Three patients underwent valve replacement with mechanical prostheses. Two of them are in NYHA Class I and the other died of LV failure 3 days after surgery. One patient deteriorated beyond surgical treatment and was in NYHA Class II. The other seven patients remain in NYHA Class II and await valve replacement. In patients with chronic aortic regurgitation and depressed EF, the variables relevant to myocardial reserve appear to be EF, FS, LVEDD, LVESD, LVEDV, and LVESV.     

Performance of stent thrombosis and bleeding risk scores in out-of-hospital cardiac arrest due to acute coronary syndromes

BackgroundPatients with out-of-hospital cardiac arrest (OHCA) due to acute coronary syndromes (ACS) who undergo percutaneous coronary intervention (PCI) are at high risk of bleeding and thrombosis. While predictive bleeding and stent thrombosis risk scores have been established, their performance in patients with OHCA has not been evaluated.MethodsAll consecutive patients admitted for OHCA due to ACS who underwent PCI between January 2007 and December 2019 were included. The ACTION and CRUSADE bleeding risk scores and the Dangas score for early stent thrombosis risk were calculated for each patient. A C-statistic analysis was performed to assess the performance of these scores.ResultsAmong 386 included patients, 82 patients (21.2%) experienced severe bleeding and 30 patients (7.8%) experienced stent thrombosis. The predictive performance of the ACTION and CRUSADE bleeding risk scores for major bleeding was poor, with areas under the curve (AUCs) of 0.596 and 0.548, respectively. Likewise, the predictive performance of the Dangas stent thrombosis risk score was poor (AUC 0.513). Using multivariable analysis, prolonged low-flow (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00–1.05; P = 0.025), reduced haematocrit or fibrinogen at admission (OR 0.93, 95% CI 0.88–0.98; P = 0.010 and OR 0.61; 95% CI 0.41–0.89; P = 0.012, respectively) and the use of glycoprotein IIb/IIIa inhibitors (OR 2.10, 95% CI 1.18–3.73; P = 0.011) were independent risk factors for major bleeding.ConclusionThe classic bleeding and stent thrombosis risk scores have poor performance in a population of patients with ACS complicated by OHCA. Other predictive factors might be more pertinent to determine major bleeding and stent thrombosis risks in this specific population.     

Dynamic Myocardial Perfusion CT for the Detection of Hemodynamically Significant Coronary Artery Disease

ObjectivesIn this international, multicenter study, using third-generation dual-source computed tomography (CT), we investigated the diagnostic performance of dynamic stress CT myocardial perfusion imaging (CT-MPI) in addition to coronary CT angiography (CTA) compared to invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR).BackgroundCT-MPI combined with coronary CTA integrates coronary artery anatomy with inducible myocardial ischemia, showing promising results for the diagnosis of hemodynamically significant coronary artery disease in single-center studies.MethodsAt 9 centers in Europe, Japan, and the United States, 132 patients scheduled for ICA were enrolled; 114 patients successfully completed coronary CTA, adenosine-stress dynamic CT-MPI, and ICA. Invasive FFR was performed in vessels with 25% to 90% stenosis. Data were analyzed by independent core laboratories. For the primary analysis, for each coronary artery the presence of hemodynamically significant obstruction was interpreted by coronary CTA with CT-MPI compared to coronary CTA alone, using an FFR of ≤0.80 and angiographic severity as reference. Territorial absolute myocardial blood flow (MBF) and relative MBF were compared using C-statistics.ResultsICA and FFR identified hemodynamically significant stenoses in 74 of 289 coronary vessels (26%). Coronary CTA with ≥50% stenosis demonstrated a per-vessel sensitivity, specificity, and accuracy for the detection of hemodynamically significant stenosis of 96% (95% CI: 91%-100%), 72% (95% CI: 66%-78%), and 78% (95% CI: 73%-83%), respectively. Coronary CTA with CT-MPI showed a lower sensitivity (84%; 95% CI: 75%-92%) but higher specificity (89%; 95% CI: 85%-93%) and accuracy (88%; 95% CI: 84%-92%). The areas under the receiver-operating characteristic curve of absolute MBF and relative MBF were 0.79 (95% CI: 0.71-0.86) and 0.82 (95% CI: 0.74-0.88), respectively. The median dose-length product of CT-MPI and coronary CTA were 313 mGy·cm and 138 mGy·cm, respectively.ConclusionsDynamic CT-MPI offers incremental diagnostic value over coronary CTA alone for the identification of hemodynamically significant coronary artery disease. Generalized results from this multicenter study encourage broader consideration of dynamic CT-MPI in clinical practice. (Dynamic Stress Perfusion CT for Detection of Inducible Myocardial Ischemia [SPECIFIC]; NCT02810795)     

老年急性心肌梗死住院期康复

目的:探讨老年急性心肌梗死(AMI)患者住院期康复治疗的疗效、安全性。方法:比较20例接受四周程序康复治疗的老年AMI患者和19例对照患者的临床疗效、安全性。结果:20例老年AMI患者康复治疗未发生并发症;出院3个月后能生活自理的有18例(90％),左室射血分数(LVEF)>50％的患者13例(65％),未发生心绞痛和再梗。对照组发生心绞痛3例,再梗死1例,心衰2例,心源性猝死1例;出院3个月后能生活自理的仅12例(63％),LVEF>50％的患者仅6例(32％)。康复组的临床疗效及心功能(LVEF)均显著好于对照组(P<0.05)。结论:老年急性心肌梗死康复治疗是安全、有效、可行的。