尿激酶院前溶栓治疗对急性心肌梗死患者心血管事件再发风险的影响研究

目的：探讨尿激酶院前溶栓治疗对急性心肌梗死患者心血管事件再发风险的影响。方法：选取本院心内科急性心肌梗死患者89例,观察组45例,采用院前溶栓治疗,对照组44例,采用院后溶栓治疗,采用酶联免疫吸附试验（ELISA）方法测定氨基末端脑钠肽前体（NT-proBNP）、超敏C反应蛋白（hs-CRP）水平,比较两组冠脉再通率、NT-proBNP和hs-CRP水平的差异。结果：观察组冠脉再通率明显高于对照组（P<0.05）,治疗前,两组NT-proBNP、hs-CRP水平比较差异无统计学意义（P>0.05）,治疗后,两组上述指标均呈下降倾向,其中观察组NT-proBNP、hs-CRP水平明显低于对照组,两组比较差异具有统计学意义（P<0.05）,且心绞痛再发、AMI再发和心力衰竭等心血管事件发生率明显降低,两组比较差异具有统计学意义（P<0.05）。结论：尿激酶院前溶栓治疗有助于改善急性心肌梗死患者冠脉再通,降低心血管事件再发风险,其可能与院前溶栓显著抑制NT-proBNP、hs-CRP水平有关。     

A Noncontrast CMR Risk Score for Long-Term Risk Stratification in Reperfused ST-Segment Elevation Myocardial Infarction

ObjectivesThis study compared the prognostic value of a noncontrast CMR risk score for the composite of all-cause death, nonfatal myocardial infarction, and new congestive heart failure.BackgroundA cardiovascular magnetic resonance (CMR) risk score including left ventricular ejection fraction (LVEF), myocardial infarct (MI) size, and microvascular obstruction (MVO) was recently proposed to risk-stratify patients with ST-segment elevation myocardial infarction (STEMI).MethodsThe Eitel CMR risk score and GRACE (Global Registry of Acute Coronary Events) score were used as a reference (Score 1: acute MI size ≥19% LV, LVEF ≤47%, MVO >1.4% LV and GRACE score). MVO was replaced by intramyocardial hemorrhage (IMH) in Score 2 (acute MI size ≥19% LV, LVEF ≤47%, IMH, and GRACE score). Score 3 included only LVEF ≤45%, IMH, and GRACE score.ResultsThere were 370 patients in the derivation cohort and 234 patients in the validation cohort. In the derivation cohort, the 3 scores performed similarly and better than GRACE score to predict the 1-year composite endpoint with C-statistics of 0.83, 0.83, 0.82, and 0.74, respectively. In the validation cohort, there was good discrimination and calibration of score 3, with a C-statistic of 0.87 and P = 0.71 in a Hosmer-Lemeshow test for goodness of fit, on the 1-year composite outcome. Kaplan-Meier curves for 5-year composite outcome showed that those with LVEF ≤45% (high-risk) and LVEF >45% and IMH (intermediate-risk) had significantly higher cumulative events than those with LVEF >45% and no IMH (low-risk), log-rank tests: P = 0.02 and P = 0.03, respectively. The HR for the high-risk group was 2.3 (95% CI: 1.1-4.7) and for the intermediate-risk group was 2.0 (95% CI: 1.0-3.8), and these remained significant after adjusting for the GRACE score.ConclusionsThis noncontrast CMR risk score has performance comparable to an established risk score, and patients with STEMI could be stratified into low risk (LVEF >45% and no IMH), intermediate risk (LVEF >45% and IMH), and high risk (LVEF ≤45%). (A Trial of Low-dose Adjunctive alTeplase During prIMary PCI [T-TIME]; NCT02257294) (Detection and Significance of Heart Injury in ST Elevation Myocardial Infarction [BHF MR-MI]; NCT02072850)     

Hyperacute Management of Ischemic Strokes: JACC Focus Seminar

Acute ischemic stroke is the leading cause of disability and among the leading causes of mortality worldwide. Intravenous tissue plasminogen activator has been a cornerstone for treatment of acute ischemic stroke for more than 20 years; however, its use is limited due to a narrow therapeutic window, several contraindications, and low efficacy to recanalize the artery in large vessel occlusion. Recently, the addition of endovascular mechanical thrombectomy of large artery occlusion has revolutionized the stroke treatment for most disabling strokes. The paper reviews updates to the thrombolytic treatment as well as catheter-based treatment, and results from recent trials in the selection of patients in an extended time window using perfusion imaging.     

小剂量尿激酶治疗慢性肺栓塞的疗效及安全性分析

目的：探讨小剂量尿激酶溶栓治疗慢性肺栓塞的治疗效果及安全性。方法30例符合诊断标准的慢性肺栓塞患者,用小剂量尿激酶(50万U)缓慢溶栓治疗,观察统计分析临床症状、D-二聚体、肺CT血管成像(CTA)等改善情况。结果30例患者临床症状均明显改善,呼吸困难、胸闷明显缓解,发绀消失,活动耐量较前明显提高。下肢肿胀减轻或消失,皮温正常,皮肤颜色变浅,浅静脉怒张明显缓解。治疗后心率明显下降,维持在75~90次/min,呈窦性心律,三尖瓣区收缩期杂音明显减低,肺动脉瓣区第2心音(P2)>主动脉瓣区第2心音(A2)。复查D-二聚体转阴,肺CTA示原来栓塞部位大部分再通,肺动脉压下降,3例恢复正常。结论小剂量尿激酶溶栓治疗慢性肺栓塞疗效确切、安全。     

Giant right atrial thrombi treated with thrombolysis

The present report describes giant atrial thrombi that were treated with thrombolysis in a community hospital. Two patients with giant atrial thrombi whose treatment involved complications are presented. Both patients developed cardiogenic shock and were treated unsuccessfully with thrombolysis. Because thrombolysis of giant thrombi may be ineffective, patients in this situation may require surgery.     

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.     

The use of thrombolytic therapy in patients presenting to a peripheral metropolitan Emergency Department with acute myocardial infarction

Background: While use of thrombolytic therapy in the management of acute myocardial infarction has become accepted practice in major teaching hospitals, its use in peripheral metropolitan hospitals has not been well accepted.
Aim: To evaluate the use of thrombolytic therapy in the management of acute myocardial infarction in the Emergency Department (ED) of a peripheral metropolitan hospital.
Methods: A mixed prospective and retrospective observational study of 69 patients with acute myocardial infarction, who received thrombolytic therapy during a three year period, was conducted in a community based ED.
Results: Demographic data, door to drug interval, complications occurring during administration of thrombolytics and subsequent interhospital transfer were recorded. The mean door to drug interval in 1992 was 79.7 minutes (95% CI: 50.7 to 109.1) and by 1994 this had fallen to 25.6 minutes (95% CI: 18.9 to 32.3). Hypotension (22%) was the most common complication of therapy observed and cardiac arrest occurred in two cases (3.2%). A single episode of hypotension and vomiting were the only complications that occurred during interhospital transfer. There were no deaths during therapy or transfer.
Conclusion: Thrombolytic therapy can be undertaken in the EDs of peripheral metropolitan hospitals in a safe and timely manner. There is little justification for routine medical escorts in the clinically stable post thrombolysis patient.     

移动卒中单元救治流程的优化及应用效果

目的 探讨优化移动卒中单元（mobile utroke unit,MSU）救治流程对急性缺血性脑卒中患者的效果。 方法 回顾性分析该院2020年1月—6月MSU出车接诊的30例急性缺血性脑卒中静脉溶栓患者,其中MSU救治流程优化后静脉溶栓的18例患者为试验组,MSU运行初期、流程优化前实施静脉溶栓的12例患者为对照组。收集两组的临床资料,比较两组的护理效率及临床结局。结果 试验组的卒中专科护士首次静脉穿刺成功例数、发病至静脉溶栓时间、呼叫120至静脉溶栓时间、MSU到达现场至静脉溶栓时间均优于对照组,差异具有统计学意义（P<0.05）。两组发病至呼叫120时间、呼叫120至MSU到达现场时间、静脉溶栓24 h内症状性颅内出血例数、静脉溶栓后90 d改良Rankin量表评分≤2分的例数比较,差异无统计学意义（P>0.05）。结论 通过优化救治流程可有效缩短患者发病至静脉溶栓时间、呼叫120至静脉溶栓时间及MSU到达现场至静脉溶栓时间,提高护士工作效率,提升患者救治质量。     

Ischemic stroke mimics: A comprehensive review

BackgroundIschemic stroke is the leading cause of disability and one of the leading causes of death. Ischemic stroke mimics (SMs) can account for a noteble number of diagnosed acute strokes and even can be thrombolyzed.MethodsThe aim of our comprehensive review was to summarize the findings of different studies focusing on the prevalence, type, risk factors, presenting symptoms, and outcome of SMs in stroke/thrombolysis situations.ResultsOverall, 61 studies were selected with 62.664 participants. Ischemic stroke mimic rate was 24.8% (15044/60703). Most common types included peripheral vestibular dysfunction in 23.2%, toxic/metabolic in 13.2%, seizure in 13%, functional disorder in 9.7% and migraine in 7.76%. Ischemic stroke mimic have less vascular risk factors, younger age, female predominance, lower (nearly normal) blood pressure, no or less severe symptoms compared to ischemic stroke patients (p < 0.05 in all cases). 61.7% of ischemic stroke patients were thrombolysed vs. 26.3% among SMs (p < 0.001). (p < 0.001). Overall intracranial hemorrhage was reported in 9.4% of stroke vs. 0.7% in SM patients (p < 0.001). Death occurred in 11.3% of stroke vs 1.9% of SM patients (p < 0.001). Excellent outcome was (mRS 0–1) was reported in 41.8% ischemic stroke patients vs. 68.9% SMs (p < 0.001). Apart from HINTS manouvre or Hoover sign there is no specific method in the identification of mimics. MRI DWI or perfusion imaging have a role in the setup of differential diagnosis, but merit further investigation.ConclusionOur article is among the first complex reviews focusing on ischemic stroke mimics. Although it underscores the safety of thrombolysis in this situation, but also draws attention to the need of patient evaluation by physicians experienced in the diagnosis of both ischemic stroke and SMs, especially in vertigo, headache, seizure and conversional disorders.