糖尿病患者急性心肌梗死12例误诊分析

目的总结糖尿病患者急性心肌梗死（AMI）误诊的经验教训，减少误漏诊，提高抢救成功率。方法分析12例被误漏诊的糖尿病AMI患者的病历资料，查找和总结误漏诊的原因。结果12例被误漏诊的糖尿病AMI患者占同期该类住院患者的41％（12／29），AMI被延误诊断的时间为6～12h，误诊的原因和疾病有：无胸痛者3例被漏诊，疼痛不典型误诊为急腹症2例，以呼吸困难、神志障碍、心力衰竭、休克等为突出表现而误诊为其他疾病者共7例，其中被误诊为支气管哮喘1例，急性脑血管疾病2例，糖尿病高渗性昏迷1例，急性左心衰竭2例，感染性休克1例。结论糖尿病患者发生AMI时容易被误诊，应提高警惕。     

误诊为急性心肌梗死而误溶栓5例分析

急性心肌梗死(AMI)一旦确诊，早期给予溶栓治疗可使闭塞的冠状动脉再通，心肌得到再灌注，从而可挽救濒死心肌或缩小坏死范围，改善预后。这一疗法目前在临床已广泛应用，但此方法要求医生在溶栓前短时间内必须诊断正确，若误诊误溶，则导致不良后果。2000～2003年，我院对96例AMI患者行溶栓治疗，其中误诊误溶5例。现分析如下。     

87例急性心肌梗死患者的心电图改变与预后

目的：探讨急性心肌梗死（AMI）心电图改变与预后的关系。方法：回顾分析87例未溶栓的AMI病人的临床资料。结果：（1）总病死率18．39％；（2）心律失常：单纯窦速及室上性早搏无1例死亡，频发室早死亡率37．5％，Ⅲ度房室传导阻滞（A-VB)死亡率50％，并发束传导阻滞死亡率43．75％，除左前分支阻滞死亡率为16．7％外，其他束支阻滞死亡率均在50％以上；（3）梗死部位：（1）下壁AMI，胸导ST段下移≥2mm，死亡率60％；（2）前壁AMI，ⅡⅢaVF导联ST段下移≥2mm死亡率33．33％；（4）梗死范围；（1）病理性Q波导联数＞5个的，死亡率31．2％；（2）心电图异常项目数；并发1项心电异常死亡率10．53％，5项异常死亡率75％。结论：AMI并有心电图异常项目，病理性Q波导联数愈多，死亡率愈高；伴有梗死灶对应导联ST段下移幅度大，双支及三支阻滞，三度A－VB，频发室性早搏，及Ron T现象死亡率高。这些可以作为近期预后不良的判断指标。     

天普洛欣静脉溶栓治疗急性心梗45例

近期我们应用天普洛欣（国产尿激酶）治疗45例急性心肌梗塞患者，收到满意效果，现总结报告如下：1资料与方法1．1临床资料45例AMI患者中男27例，女18例，年龄45～71岁，平均59岁；心肌梗塞部位：前壁（包括广泛前壁）23例，下壁1．5例，下壁＋正后壁7例。所有溶栓病例均符合1979年WHO制定的AMI诊断标准，且发病时间在6小时内、无抗凝治疗禁忌。1．2给药方法将天普洛欣100～150万u加入生理盐水100Inl内静脉点滴，于30～60分钟内滴完；然后续接极化液十肝素75～100mg静脉点滴，连用7天，并同时口服肠溶阿斯匹林100mg，每日一次。在静脉溶…     

老年人非典型急性心肌梗死的早期诊断

目的探讨老年非典型急性心肌梗死（AMI）的早期诊断。方法全部病例为我院近5年问所收治392例AMI患者的病历资料，其中非老年（〈60岁）98例，老年（≥60岁）294例，老年临床表现典型者219例，非典型者75例，并着重对非典型患者的资料进行系统回顾性分析。结果75例老年非典型AMI患者临床表现复杂多样，可归纳为8个亚型，分别是：（1）无痛型26例（34．6％），（2）异位痛型22例（29．3％），（3）心衰型6例（8．0％），（4）心律失常型5例（6．6％），（5）中枢型5例（6．6％），（6）周围型4例（5．3％），（7）肺型4例（5．3％），（8）腹型3例（4．0％）；本组病例误（漏）诊情况：非老年病例门（急）诊正确诊断率100％，老年典型病例，误（漏）诊9例（4．1％），老年非典型病例，误（漏）诊13例（17．3％）；预后：非老年组全部临床治愈出院，老年典型组死亡16例（7．3％），老年非典型组死亡12例（16．0％）。结论充分认识老年AMI患者中的不典型表现，只有将临床表现、ECG演变、心肌酶学改变进行综合性分析．才能有助于提高早期诊断率。     

不典型急性心肌梗塞102例误漏诊原因分析

目的：分析不典型胸痛急性心肌梗塞(AMI)误漏诊原因，以便降低AMI误诊率。方法：回顾性分析我院1980年1月至2005年2月收治的因不典型AMI而误、漏诊的102例AMI患者的临床资料。结果：本组(1)误诊为：①脑血管疾病24例(23．5％)；②肺心病．心衰等23例(22．5％)；③非心源性休克23例(22．5％)；①消化道疾病14例(13．7％)；⑤咽喉炎．牙病，颈椎病6例(5．9％)；(2)漏诊原因：①合并糖尿病8例(7．8％)；②大量失血4例(3．9％)。结论：熟悉各种不典型急性心肌梗塞临床表现，注意检查心电图，联合检测心肌钙蛋白T及CK—MB，有助于减少急性心肌梗塞误、漏诊率。     

溶栓治疗对急性心肌梗死患者凝血与纤溶系统的影响

目的：探讨急性心肌梗死（AMI）患者凝血及纤溶系统变化及其临床意义。方法：对51例AMI患者（37例溶栓治疗，14例未溶栓治疗）在治疗前，治疗后4h、12h、24h、48h、1周测定凝血酶原时间（PT）、活化的部分凝血活酶时间（APTT）、纤溶酶原（PCG）活性、α2抗纤溶酶（α2AP）活性、纤维蛋白原（Fg）含量、D二聚体（D-Dimer）含量。结果：AMI溶栓治疗后4h，PCG、α2AP活性及Fg含量大幅度降低，D－Dimer含量明显增高，PT、APTT明显延长；溶栓后48h各项指标已分别恢复至溶栓前水平。结论：溶栓治疗可使AMI患者凝血活性明显减弱，纤溶活性明显增强，但溶栓剂的作用时限短暂，监测PT、APTT、Fg等指标对预防出血有一定意义。     

左束支阻滞合并心肌梗死的心电图诊断探讨

目的分析完全性左未支阻滞（CLBBB）并发急性心肌梗死（AMI）的心电图特征方法分析430例AMI中出现CLBBB的QRS形态改变以及ST—T变化。结果430例中9例伴CLBBB，其中5例出现AMI的QRS形态特征性的变化。结论AMI伴CLBBB时，Rv5上升支可出现切迹、顿挫；前侧壁梗死时，Rv5可出现rS或RS型，S波切迹；Rv6，7急转为R波，此外V1-V4导联可出现振幅递减现象。     

活血化瘀,益气通脉改善Ⅱ型糖尿病急性心肌梗死患者PAI-1/D-dimer纤溶指标的研究

目的：探讨合并Ⅱ型糖尿病（NIDDM）急性心肌梗死（AMI）患者中医介入溶栓治疗对改善纤溶受抑及临床预后的作用。方法：分正常对照组20例，治疗组分非糖尿病AMI组23例，非中医介入NIDDM＋AMI组22例，中医介入NIDDM＋AMI组24例。中医介入患者按证属与溶栓同步给与生脉或参附注射液，与抗凝治疗同步给于葛根素注射液。检测各组患者组织型纤溶酶原激活剂（t-PA），纤溶酶原激活物抑制剂-1（PAI-1），及D-二聚体（D—dimer）的血浆水平并计算PAI-1／D—dimer百分比。观察中医介入溶栓治疗后纤溶的指标和临床预后。结果：Ⅱ型糖尿病AMI患者PAI-1显著高于对照组及非糖尿病AMI组P〈0．05，D—dimer上升幅值则显著低于非糖尿病AMI组P〈0．05，PAI-1／D-dimer比值百分数也分别显著高于对照组及非糖尿病AMI组P〈0．01。中医介入NIDDM＋AMI组，中医介入溶栓后，PAI-1，D—dimer及PAI-1／D—dimer的纤溶及临床指标与非糖尿病AMI组比较无显箸差异，P〉0．05，非中医介入NIDDM＋AMI组的纤溶及临床指标与非糖尿病组比较有显著差异，P〈0．05。结论：中医介入治疗可改善Ⅱ型糖尿病患者纤溶受抑状态及临床预后。D—dimer及PAI-1／D-dimer百分比能反映Ⅱ型糖尿病AMI患者纤溶受抑状态及对治疗及预后的影响。     

急诊室早期rt-PA溶栓抢救AMI的护理

我们从1996年4月～1997年4月在急诊科门诊用重组织型纤溶酶原激活剂（rt－PA），成功地抢救了9例急性心肌梗塞患者，其中1例心跳骤停的患者，也完全康复出院，现将应用rt－PA疗法的护理体会报告如下：1对象与方法1．l对象AMI患者9例中男8例，女1例，年龄44～77（平均626）岁，其中70岁以上2例。梗塞部位：下壁4例，前间壁3例，广泛前壁2例。全部患者均符合WHO关于AMI的诊断标准。其中1例太急诊科40分钟后突然意识丧失，全身抽搐呈角弓反张状，血压、脉搏测不到，心电图示室颤。1．2溶栓条件①符合WHO诊断标准的AMI患者；②发病在6小…     

Long-term trends in the use of coronary reperfusion strategies in acute myocardial infarction: a community-wide perspective

Background The objectives of our study were to examine long-term (1986–2003) trends in the use of percutaneous coronary interventions (PCI) and thrombolytic therapy in the management of patients hospitalized with acute myocardial infarction (AMI) while our secondary study goal was to examine factors associated with use of these coronary reperfusion strategies. While there have been considerable changes in the management of patients hospitalized with AMI over time, limited contemporary data are available about changing trends in the use of different coronary reperfusion strategies, particularly from the more generalizable perspective of a population-based investigation. Methods The study sample consisted of 9,422 greater Worcester (MA) residents hospitalized with confirmed AMI at all metropolitan Worcester medical centers in 10 annual periods between 1986 and 2003. Results Divergent trends in the use of PCI and thrombolytic therapy during hospitalization for AMI were noted. Use of thrombolytic therapy increased after its introduction to clinical practice in the mid-1980’s through the early 1990’s with a progressive decline in use thereafter. In 2003, 3.5% of patients hospitalized with AMI were treated with clot lysing therapy. On the other hand, marked increases in the use of PCI during hospitalization for AMI were noted over time. In 2003, 42.1% of patients with AMI received a PCI. Several demographic and clinical factors were associated with the use of these different treatment strategies. Conclusions The results of our study in a large Northeast community suggest evolving changes in the hospital management of patients with AMI. Current management practices emphasize the utilization of PCI to restore coronary reperfusion to the infarct related artery. Condensed Abstract We examined long-term trends in the use of percutaneous coronary interventions (PCI) and thrombolytic therapy in the management of patients hospitalized with acute myocardial infarction (AMI). The study sample consisted of 9,422 greater Worcester (MA) residents hospitalized with AMI at all area medical centers between 1986 and 2003. Use of thrombolytic therapy increased from the mid-1980’s through the early 1990’s with a progressive decline in use thereafter. In 2003, 3.5% of patients hospitalized with AMI were treated with clot lysing therapy. Marked increases in the use of PCI during hospitalization for AMI were noted. In 2003, 42.1% of patients hospitalized with AMI received a PCI.     

Underuse of Thrombolytic Therapy in Acute Myocardial Infarction and Left Bundle Branch Block

Thrombolytic therapy reduces mortality in patients with acute myocardial infarction (AMI) and left bundle branch block (LBBB). The difficulty in accurately diagnosing AMI in patients with LBBB, however, might result in their undertreatment. Among 3,890 patients hospitalized with chest pain, 241 (6.2%) had LBBB at presentation. The only variable independently associated with AMI among patients with LBBB was in‐hospital left ventricular failure (odds ratio [OR]: 4.32, 95% confidence interval [CI]: 1.95–9.57, p < 0.0005). Only 16 (29%) of the LBBB patients with AMI received thrombolytic therapy compared with 583 (78%) of the 747 patients with ST‐elevation AMI (p < 0.0005). A further 19 (10%) LBBB patients without AMI also received thrombolysis. Difficulty in making an accurate early diagnosis in patients with LBBB ensures that the majority of those with AMI fail to receive thrombolytic therapy while others without AMI are treated inappropriately. Improved diagnostic and therapeutic strategies are needed for patients with acute coronary syndromes and LBBB. Copyright © 2010 Wiley Periodicals, Inc.     

Thrombolytic therapy in older patients

OBJECTIVES: We compared outcomes following thrombolytic therapy and primary angioplasty with no reperfusion therapy in a population-based cohort of older patients presenting with acute myocardial infarction (AMI) and indications for acute reperfusion. BACKGROUND: Evidence supporting the efficacy of acute reperfusion (thrombolytic therapy or primary angioplasty) in the elderly with suspected AMI is not as strong as it is in younger groups. METHODS: From a national cohort of Medicare beneficiaries with AMI, we identified 37,983 patients age 65 or older who presented within 12 h of symptom onset with ST elevation or left bundle branch block. A total of 14,341 (37.8%) received thrombolytic therapy and 1,599 (4.2%) underwent primary angioplasty within 6 h of hospital arrival. RESULTS: After adjustment for demographic, clinical, hospital and physician factors, and co-interventions, thrombolytic therapy was not associated with a better 30-day survival (odds ratio [OR] 1.01; 95% confidence interval [CI]: 0.94 to 1.09) compared with no therapy, whereas primary angioplasty was (OR 0.79; 95% CI: 0.66 to 0.94). At one year, both thrombolytic therapy (OR 0.84; 95% CI: 0.79 to 0.89) and primary angioplasty (OR 0.71; 95% CI: 0.61 to 0.83) were associated with a survival benefit. CONCLUSIONS: In this national sample of older patients, those who received thrombolytic therapy or primary angioplasty had lower mortality at one year compared with those who did not receive a reperfusion strategy. However, only primary angioplasty was associated with better survival at 30 days. Our findings should heighten interest in further investigating the best approach to the treatment of older patients with suspected AMI and ST segment elevation or left bundle branch block.     

The effect of thrombolytic therapy on left ventricular aneurysm formation in acute myocardial infarction: relationship to successful reperfusion and vessel patency

BACKGROUND: Although there is increasing evidence for the beneficial effect of thrombolytic therapy on global left ventricular (LV) function in acute myocardial infarction (AMI), the data concerning the early effect of thrombolytic therapy on the incidence of left ventricular aneurysm (LVA) formation and its relationship to clinical and angiographic determinants are limited. HYPOTHESIS: The study aimed to determine the independent factors involved in the development of LVA and to evaluate whether thrombolytic therapy has any preventive effect on the development of LVA in AMI. METHODS: In all, 350 consecutive patients suffering from a first attack of AMI were included. Of these, 205 who arrived within 12 h of onset of symptoms received thrombolytic therapy (thrombolytic group) and the remaining 145 patients served as control group. All patients received aspirin and maximal-dose anticoagulation with intravenous heparin therapy. Early successful reperfusion was assessed by enzymatic and electrocardiographic evidence, and late vessel patency was evaluated according to Thrombolysis in Myocardial Infarction (TIMI) classification. Patients with TIMI grade 2 or 3 flow were considered to have vessel patency. RESULTS: The overall incidence of LVA was 11.7% (41/350), and no statistical difference was found between the incidence of LVA between the two groups (11.7 vs. 11.7%, p>0.05). However, the patients receiving thrombolytic therapy and exhibiting a patent infarct-related artery (PIRA) (n = 125, 61%), had a significantly reduced incidence of LVA compared with those who did not (7.2 vs. 18.8%, p= 0.015). In univariate analysis, vessel patency, proximal left anterior descending artery (LAD) stenosis, total LAD occlusion, multivessel disease, and hypertension were found to be important factors in LVA formation after AMI. After adjustment for other clinical and angiographic variables, total LAD occlusion (odds ratio [OR] 3.62,95% confidence interval [CI] 2.45-8.42, p = 0.0014), absence of PIRA (OR 2.92, 95% CI 1.41-09, p = 0.0037) and proximal LAD stenosis (OR 2.11, 95% CI 1.05-4.71, p = 0.045) remained the independent determinants of LVA formation after AMI. CONCLUSION: Our data indicate that not all patients who received thrombolytic therapy, but only those with PIRA had evidently reduced the incidence of LVA. Patients with total LAD occlusion, with proximal LAD stenosis, and without PIRA were found to have increased risk for formation of LVA after AMI. These findings indicate that the presence of vessel patency has a preventive effect on LVA formation in AMI.     

静脉溶栓后选择性PCI对急性心肌梗死患者远期预后的影响

目的探讨静脉溶栓后选择性经皮冠状动脉介入治疗(PCI)对急性心肌梗死(AMI)患者远期预后的影响.方法AMI患者114例,60例仅接受静脉溶栓者为药物组,54例静脉溶栓后平均(9.1±2.4)d行PCI者为手术组,分别于溶栓后及PCI后3、6、12个月随访主要心脏不良事件(MACE)发生情况.随访复查超声心动图,计算左室的整体室壁运动指数和左室射血分数.结果两组住院期间无死亡及心绞痛复发,手术组血管造影和操作成功率均为100%,无操作相关心肌梗死、急诊冠脉搭桥术(CABG).随访期间死亡率、因不稳定型心绞痛或心绞痛复发再次入院者手术组均显著少于药物组(P＜0.05),手术组总的临床终点事件发生率明显低于药物组(P＜0.01).结论 AMI患者静脉溶栓后选择性PCI能改善其远期预后.     

急性心肌梗塞静脉溶栓远期疗效的对比研究

采用超声心动图、24小时动态心电图、心电图运动试验及心室晚电位等检查。对94例急性心肌梗塞用静脉溶栓治疗的患者，于溶栓后6个月～3年对其进行随访。结果表明：经溶栓治疗后梗塞相关冠状动脉再通可防止梗塞后心室重构，有效改善左室功能，增加心电稳定性，提高运动耐量，从而改善患者晚期预后，降低病死率。     

Magnesium use in the treatment of acute myocardial infarction in the United States (observations from the Second National Registry of Myocardial Infarction)

The use of magnesium in patients with acute myocardial infarction (AMI) is debated, largely as a result of conflicting data from randomized controlled trials. This study evaluated the use and impact on mortality of intravenous magnesium in the treatment of patients with AMI in the United States based on data from the Second National Registry of Myocardial Infarction. Only 5.1% of 173,728 patients from 1,326 hospitals received intravenous magnesium within the first 24 hours after an AMI, and this was more common in the 59,798 patients who received thrombolytic therapy or who underwent primary percutaneous transluminal coronary angioplasty (PTCA) or coronary bypass grafting (CABG) than in the 113,930 patients who did not receive any reperfusion therapy (8.5% vs 3.4%, p <0.01). Magnesium use was associated with younger age, Q-wave AMI, congestive heart failure on admission, thrombolytic therapy, primary PTCA or CABG, ventricular tachycardia or ventricular fibrillation, and beta blocker or lidocaine use in the first 24 hours (all odds ratio > 1.2, p <0.001). Magnesium use was associated with increased mortality (odds ratio 1.25, 95% confidence interval 1.12 to 1.34) and with a higher mortality in patients without initial reperfusion therapy (20.2% vs 13.2%, p <0.0001) or who underwent primary PTCA or CABG (10.2% vs 7.3%, p = 0.002), but not in patients who received thrombolytic therapy (6.2% vs 5.9%, p = NS). Thus, magnesium is used infrequently in the treatment of AMI and may be associated with worse outcome.     

Feasibility of thrombolytic therapy--a one year prospective study.

A one year prospective study was conducted on all the patients admitted with clinical diagnosis of acute myocardial infarction (AMI) to determine the proportion of patients who can be given thrombolytic therapy. Factors responsible for non-administration were analysed. 213 patients with AMI entered the study. Standard inclusion criteria for thrombolytic therapy were used. 101 (47%) patients failed to meet the inclusion criteria. This included 7 (3.3%) who failed to satisfy the electrocardiographic (ECG) criteria. Nine patients with atypical symptoms were unable to reach within the stipulated 6 hours while the remaining 85 (40%) patients were delayed inspite of typical features due to inability of the patient to attribute the symptoms to the heart, lack of proper transport facility and self medication. 112 patients (53%) met the inclusion criteria but 7 patients were excluded because of age (> 70 years), and another 8 because of contraindications. Of the remaining 97 patients, 47 failed to receive thrombolytic therapy due to lack of awareness of the benefits of thrombolytic therapy by the first treating physician, misinterpretation of ECG, inability to afford and refusal to give consent. Only 50 patients (23%) received thrombolytic therapy. This low figure can be easily improved upon by the correction of a number of remediable factors.     

Consequences of overutilization and underutilization of thrombolytic therapy in clinical practice. TRACE Study Group. TRAndolapril Cardiac Evaluation

OBJECTIVES: The aim of this study was to evaluate the consequences, measured as mortality and in-hospital stroke, of the use of thrombolytic therapy among patients with acute myocardial infarction (AMI), who do not fulfill accepted criteria or who have contraindications to thrombolytic therapy (i.e., overutilization) and among patients who are withheld thrombolytic treatment despite fulfilling indications and having no contraindications (i.e., underutilization). BACKGROUND: The implementation of treatment with thrombolysis in clinical practice is not in accordance with the accepted criteria from randomized studies. The consequence has been over- and underutilization of thrombolytic therapy among patients with AMI in clinical practice. The outcome of overutilization of thrombolytic therapy has not been described previously. METHODS: We examined 6,676 consecutive patients admitted to the hospital with an AMI and recorded characteristics, in-hospital complications and long-term mortality. RESULTS: Overall, 41% of the patients received thrombolytic therapy. Thrombolytic therapy was underutilized in 14.3% and overutilized in 12.9% of the patients. The use of thrombolytic therapy was associated with reduced mortality in every subgroup examined, including patients without an accepted indication, with an accepted indication and in patients with prior stroke. The risk ratio of in-hospital stroke was not increased in connection with thrombolytic therapy, not even in patients with prior stroke (relative risk = 0.237, 95% confidence interval: 0.031 to 1.810, p = 0.17). CONCLUSIONS: With the large benefit known to be associated with thrombolytic therapy and the favorable result of thrombolytic therapy in patients with contraindications observed in this study, we conclude that a formal evaluation of thrombolytic therapy in wider patient categories is warranted.     

院前、院内小剂量重组组织型纤溶酶原激活剂静脉溶栓治疗急性心肌梗死的临床研究

目的 :评价静脉小剂量重组组织型纤溶酶原激活剂 (rt PA)院前救治急性心肌梗死的临床疗效 ,及其安全性和可行性。　　方法 :所有确诊为急性心肌梗死的患者 ,院前给予小剂量rt PA (5 0mg)进行静脉溶栓治疗 (院前组 ,n =60 ) ,与院内应用小剂量rt PA (5 0mg)进行静脉溶栓的患者 (院内组 ,n =5 7)进行比较 ,观察发病—溶栓时间延迟对rt PA静脉溶栓疗效的影响。　　结果 :院前组的冠状动脉总再通率为 91 7% ,明显高于院内组的 80 7% (P <0 0 5 ) ;病死率两组相比无显著性差异 (3 3 %vs 3 5 % ,P >0 0 5 ) ;两组患者均无需要输血的严重出血并发症 ;两组轻度出血的发生率 ,分别占病例总数的3 3 %和 3 5 % ,无显著性差异。　　结论 :院前小剂量rt PA (5 0mg)静脉溶栓治疗急性心肌梗死 ,只要适应证选择适当 ,能争取最大限度地挽救濒危的心肌组织 ,方法快速、简单、安全、有效 ,是可行的 ,并可能提高再通率。