急性心肌梗塞早期心包积液的临床意义

38例急性心肌梗塞 (AMI)早期心包积液病例研究表明 :心肌梗塞急性期心包积液的发生率为 1 4 .5% ,与心肌梗塞是否透壁、心力衰竭有关 (P <0 .0 5)。与心肌梗塞的次数、预后无关 (P >0 .0 5) ,是AMI时常见的良性并发症。     

Pericardial effusion in the course of myocardial infarction: incidence, natural history, and clinical relevance

Incidence and significance of pericardial effusion in patients with acute myocardial infarction (AMI) have not been established. To evaluate these issues, we studied prospectively 138 consecutive patients with AMI. An echocardiogram was obtained in each 1, 3, and 10 days and 3 and 6 months after admission. Fifty four patients with unstable angina and 57 without heart disease were studied as controls. Echocardiographic diagnostic criteria of pericardial effusion were established from 33 additional patients undergoing surgery. Pericardial effusion was found in 28% of patients with AMI. Twenty-five percent of patients with AMI had pericardial effusion on the third day, vs 8% of patients with unstable angina (p less than .02) and 5% of patients without heart disease (p less than .01). At 1, 3, and 10 days and 3 and 6 months prevalence of pericardial effusion was 17%, 25%, 21%, 11%, and 8%, respectively. There was no case of tamponade. Pericardial effusion was more common in anterior AMI (p less than .02) and in patients with heart failure (p less than .05) but it was not significantly associated with early pericarditis, peak creatine kinase-MB, the level of anticoagulation, or mortality. Thus, pericardial effusion is a common event in patients with AMI (incidence of 28%), but does not result in specific complications. The reabsorption rate of pericardial effusion is slow and, in our experience, mild or moderate pericardial effusion does not preclude heparin therapy.     

Frequency of pericardial effusion as determined by M-mode echocardiography in acute myocardial infarction

A pericardial friction rub occurs in 6 to 16% of patients after acute myocardial infarction (AMI), but the incidence of pericardial effusion (PE) is not known. M-mode echocardiography was done 1, 3 and 5 days after AMI in 43 consecutive patients admitted within 24 hours of AMI, and PE was detected in 16 (37%). The PE was small in 7 patients, moderate in 6 and large in 3. A pericardial friction rub developed in 8 (19%), of whom only 4 had PE. Pleuritic chest pain diminished by sitting up and relieved by antiinflammatory agents developed in 12 (28%), of whom only 5 had PE. The peak creatine kinase level was significantly higher in patients with PE (1,769 +/- 1,003 U) than in those without (1,181 +/- 838 units). More patients with PE were in Killip classification II, III or IV (11 of 16 [69%] vs 9 of 27 [33%]). The presence of PE was not associated with age, site of AMI, development of Q waves, use of heparin or previous AMI. In conclusion, PE as detected by M-mode echocardiography is frequently present after AMI, and its presence is not closely associated with the occurrence of a pericardial friction rub or typical pericardial pain.     

Clinical factors associated with persistent pericardial effusion after successful primary coronary angioplasty

STUDY OBJECTIVE: To evaluate the incidence and clinical factors related to the persistence of infarct-associated pericardial effusion (PE) after primary angioplasty. DESIGN: Consecutive case-series analysis. SETTING: Coronary care unit in a university hospital. PATIENTS: Three hundred ninety-one consecutive patients with acute myocardial infarction (AMI) who underwent successful primary percutaneous transluminal coronary angioplasty (PTCA) at hospital admission. INTERVENTIONS: Coronary angiography and primary PTCA on hospital admission and serial echocardiography. MEASUREMENTS AND RESULTS: The status of coronary flow before and after primary PTCA was evaluated by coronary angiography at hospital admission, while PE was studied by echocardiography within 24 h of admission and 1 month after the onset of AMI. PE was present in the acute phase in 76 patients (19%), and patients with PE had a significantly higher incidence of in-hospital death than those without PE (11% vs 2%, p < 0.001). Among 68 patients who had PE in the acute phase and underwent echocardiography 1 month later, PE persisted to 1 month after the onset of AMI (persistent PE) in 26 patients (38%). Patients with persistent PE had a significantly higher incidence of pericardial rub (p = 0.010), Killip class > 1 (p = 0.025), no reflow after PTCA (p = 0.026), lower incidence of collaterals (p = 0.024), and tended to have higher peak creatine kinase (CK) [p = 0.05] levels than those with transient PE. When five variables (peak CK, collaterals, no reflow, pericardial rub, and Killip class > 1) were used in the multivariate analysis, pericardial rub (p = 0.023; odds ratio [OR], 5.45), absence of collaterals (p = 0.011; OR, 0.16), and Killip class > 1 (p = 0.027; OR, 3.80) were the significant variables related to persistent PE. CONCLUSIONS: PE remains a relatively common complication of AMI even in the era of reperfusion therapy and is associated with increased mortality. Furthermore, the presence of a pericardial rub, Killip class > 1, and absence of collateral flow in the early phase of the infarct are associated with persistence of the PE to 1 month after the onset of AMI.     

Regional Pericarditis: A Review of the Pericardial Manifestations of Acute Myocardial Infarction

Regional pericarditis has been described in several settings, but occurs most frequently after transmural myocardial infarction. While the diagnosis remains elusive, it must be considered in all patients with recurrent chest pain following acute myocardial infarction (AMI). Pericarditis classically presents with positional chest pain, a pericardial friction rub, diffuse ST‐segment elevation, and PR depression, but regional ECG changes associated with infarction‐associated pericarditis sometimes exist. Given the magnitude and frequency of AMI, it is imperative to be aware of the myriad of pericardial manifestations of myocardial injury. An illustrative case and a comprehensive review of the literature will be provided. Copyright © 2009 Wiley Periodicals, Inc.     

Pericardial effusion early in acute myocardial infarction

The incidence and significance of pericardial effusions early in acute myocardial infarction remain unclear. Using two-dimensional echocardiography, 172 patients with an acute myocardial infarction were evaluated within 72 h of presentation. Thirty patients (17%) had a pericardial effusion (29 small, 1 moderate) while 142 (83%) did not. No patient developed cardiac tamponade or required pericardiocentesis. Patients with pericardial effusions had higher peak creatine kinase as compared to patients without effusions (2036 +/- 1466 vs. 1483 +/- 1241, p less than 0.05) and a greater number of aneurysms (20% vs. 6%, p less than 0.05). In-hospital mortality was higher in the patients with pericardial effusions (10% vs. 2%, p less than 0.05). In conclusion, pericardial effusions are common in the early AMI period but are generally small and hemodynamically insignificant. They are associated with larger infarcts and greater mortality.     

Factors associated with persistent and transient fascicular blocks in anterior wall acute myocardial infarction

To determine the factors associated with persistent and transient fascicular blocks, 144 patients with Q-wave anterior wall acute myocardial infarction (AMI) were studied. Thirty-three patients had new onset of fascicular block considered to be a consequence of AMI. Multivariate analysis using 16 clinical variables revealed that the number of asynergic segments, serum potassium level and pericardial rub were significant factors related to the occurrence of fascicular block. Among the 33 patients with fascicular block, 18 had persistent (group 1) and 15 had transient (group 2) fascicular blocks. When the 2 groups with fascicular block were compared, group 1 had significantly more asynergic segments than group 2 (4.7 +/- 1.2 vs 3.7 +/- 1.6, respectively), whereas pericardial rubs were observed significantly more in group 2 (67%) than in group 1 (28%). Therefore, the inflammatory process of AMI was 1 of the mechanisms related to the occurrence of a transient fascicular block and a more extensive myocardial necrosis was associated with a persistent fascicular block.     

Cardiac troponin I in acute pericarditis

OBJECTIVES: This study was designed to investigate the prognostic value of cardiac troponin I (cTnI) in viral or idiopathic pericarditis. BACKGROUND: Idiopathic acute pericarditis has been recently reported as a possible cause of nonischemic release of cTnI. The prognostic value of this observation remains unknown. METHODS: We enrolled 118 consecutive cases (age 49.2 +/- 18.4 years; 61 men) within 24 h of symptoms onset. A highly sensitive enzymoimmunofluorometric method was used to measure cTnI (acute myocardial infarction [AMI] threshold was 1.5 ng/ml). RESULTS: A cTnI rise was detectable in 38 patients (32.2%). The following characteristics were more frequently associated with a positive cTnI test: younger age (p < 0.001), male gender (p = 0.007), ST-segment elevation (p < 0.001), and pericardial effusion (p = 0.007) at presentation. An increase beyond AMI threshold was present in nine cases (7.6%), with an associated creatine kinase-MB elevation, a release pattern similar to AMI, and echocardiographic diffuse or localized abnormal left ventricular wall motion without detectable coronary artery disease. After a mean follow-up of 24 months a similar rate of complications was found in patients with a positive or a negative cTnI test (recurrent pericarditis: 18.4 vs. 18.8%; constrictive pericarditis: 0 vs. 1.3%, for all p = NS; no cases of cardiac tamponade or residual left ventricular dysfunction were detected). CONCLUSIONS: In viral or idiopathic acute pericarditis cTnI elevation is frequently observed and commonly associated with young age, male gender, ST-segment elevation, and pericardial effusion at presentation. cTnI increase is roughly related to the extent of myocardial inflammatory involvement and, unlike acute coronary syndromes, is not a negative prognostic marker.     

Increased pericardial fluid level of matrix metalloproteinase-9 activity in patients with acute myocardial infarction: possible role in the development of cardiac rupture.

BACKGROUND: In an animal model of acute myocardial infarction (AMI), deletion of matrix metalloproteinase (MMP)-9 results in suppression of the development of cardiac rupture. The present study sought to clarify how myocardial MMP-9 activity is related to the pathophysiologies of AMI and cardiac rupture in humans. METHODS AND RESULTS: Levels of interleukin-8 (IL-8), polymorphonuclear leukocyte (PMN) elastase, monocyte chemotactic protein-1 (MCP-1) and MMP activity were measured in the pericardial fluid obtained from 28 patients with angina pectoris (AP group) and 16 patients with AMI (AMI group) undergoing cardiac surgery. In the AMI group, 5 were complicated with ventricular septal perforation (VSP) and the remaining 11 were not (non-VSP). Levels of IL-8, PMN elastase, MMP-2 and MMP-9 activity were all higher in the AMI group than in the AP group. In the AMI group, all levels other than MMP-2 activity were further elevated in cases with VSP compared with those in the non-VSP group. There was no significant difference in MCP-1 among the groups CONCLUSIONS: Markers of neutrophil activation in the infarcted cardiac tissue seem to be elevated in AMI. Highly elevated levels of MMP-9 activity, which may be derived from neutrophils, and PMN elastase may be related to the pathophysiology of VSP or cardiac rupture in AMI.     

急性心肌梗死介入治疗后临床预后与白细胞介素-6的关系

目的观察急性心肌梗死(AMI)介入治疗后,白细胞介素6(IL-6)水平、白细胞计数和单核细胞比及高敏C反应蛋白(hs-CRP)与心脏收缩功能及心脏事件的关系。方法32例首次前壁AMI行急诊介入治疗患者,记录患者AMI介入治疗后24 h白细胞计数、单核细胞比及hs-CRP水平,AMI后第3天测定患者血浆IL-6水平,随访6个月。25例无冠心病病史,且超声心动图检查正常者为对照组。结果AMI组IL-6水平高于对照组(P<0.05);IL-6水平与心功能Killip分级呈正相关(r=0.64,P<0.01);与AMI后3个月及6个月时左室射血分数呈负相关,r值分别为-0.59及-0.47(均P<0.01);Killip分级≥2级、严重心律失常、心包积液患者的IL-6水平明显高于无心脏事件的患者,P<0.05;Killip分级≥2级的患者hs-CRP水平明显高于Killip分级1级的患者。结论IL-6是AMI左室收缩功能严重受损以及发生心脏事件的预测因子。     

Echocardiographical demonstration of a progressively expanding left ventricular aneurysm preceded by endomyocardial tearing

A 70-year-old woman with acute myocardial infarction (AMI) had a narrow necked left ventricular (LV) aneurysm and pericardial effusion. Although there had been no obvious sign of pseudoaneurysm at the first operation on the 13th day after onset, LV volume increased so dramatically that dyspnea on mild exertion was induced only 2 months after the onset of AMI. She underwent Dor's operation for the expanded LV aneurysm. The histological findings of the resected tissue, which were fibrotic epicardial lesion with small myocyte islands, indicated a true aneurysm. The ultrasound manifestation of a narrow necked aneurysm with abrupt thinning of the myocardium at the hinge point may be a valuable predictor of free wall rupture in the early phase and severely progressive LV remodeling in the late phase. Such aneurysms need to be considered as high risk.     

Simultaneous papillary muscle avulsion and free wall rupture during acute myocardial infarction. Intra-aortic balloon pump: a bridge to survival

Mechanical complications of acute myocardial infarction (AMI) are rare, but often fatal. Medical therapy does not provide adequate risk reduction, and surgical correction is recommended when feasible. Supplemental hemodynamic support utilizing intra-aortic counterpulsation with a balloon pump provides an improvement in morbidity and mortality when combined with a corrective surgical approach. We report a case of an elderly male with a progressive 2-week history of ischemic symptoms presenting with acute pulmonary edema, hypotension and an inferior wall ST-elevation MI. His hospital course was complicated by ischemic mitral regurgitation (MR) and cardiogenic shock, which resulted in a papillary muscle rupture/avulsion from the inferolateral myocardial wall, and a communication for blood from ventricle to pericardial space. Initial management included mechanical ventilation, pharmacologic inotropic support, percutaneous revascularization of the culprit lesion and intra-aortic balloon counterpulsation. The patient underwent further successful cardiovascular surgical correction of his incompetent mitral valve, free wall rupture and other obstructive coronary arteries, leading to discharge and survival. Mechanical complications from AMI and the role of intra-aortic balloon support are discussed.     

Sequential changes of hepatocyte growth factor in the serum and enhanced c-Met expression in the myocardium in acute myocardial infarction

A 68-year-old male with acute myocardial infarction (AMI) was admitted to the hospital with chest pain that had started 1 day earlier. The serum levels (ng/ml) of hepatocyte growth factor (HGF) were 1.06, 1.22, 1.05, 0.72 and 0.64 on days 2, 3, 4, 5 and 6 postinfarction, respectively. He died suddenly due to cardiopulmonary arrest on day 6. At autopsy, approximately 400 ml of bloody pericardial fluid, caused by rupture of the left ventricle, was detected and the c-Met expression in the myocardium was immunohistochemically found to be most intense in the border zone of the infarcted and non-infarcted region. Although there was no c-Met expression in the infarcted myocardium, it was increased in the myocardial cells surrounding the blood vessels. This is the first report to show sequential changes of HGF in the serum, as well as c-Met expression in the myocardium, in a patient with AMI.     

Correlates of bundle-branch block in patients undergoing primary angioplasty for acute myocardial infarction.

BACKGROUND: Early reperfusion therapy has reduced the infarct size and mortality rate in patients with acute myocardial infarction (AMI). The occurrence of bundle-branch block in AMI is related to the amount of myocardial damage and the insult to the conduction system. HYPOTHESIS: To evaluate the clinical and angiographic factors related to the occurrence of bundle-branch block (BBB) in patients with primary percutaneous transluminal coronary angioplasty (PTCA), we investigated consecutive series of patients with their first Q-wave AMI and successful PTCA. METHODS: Coronary angiogram at the time of admission, electrocardiogram, and echocardiogram were evaluated in 279 patients with their first Q-wave AMI and successful PTCA. RESULTS: Bundle-branch block was detected in 26 patients (9%); 16 patients had transient and 10 patients had persistent block, while 16 patients had bifascicular block and 10 patients had right BBB. The patients with BBB had a significantly larger number of left ventricular asynergic segments, higher incidence of total occlusion of infarct-related artery, angiographic no reflow, and pericardial rub than those without BBB. When the multivariate analysis was performed using five clinical markers of infarct severity, angiographic no reflow (F = 20.2, p < 0.001) and total occlusion of infarct-re-lated artery (F = 4.2, p = 0.04) were found to be the significant variables related to BBB. CONCLUSIONS: Despite successful primary PTCA, absence of antegrade flow in the infarct-related artery at the onset of AMI and/or angiographic no reflow resulted in more severe transmural myocardial damage and, hence, the occurrence of BBB.     

Detection of recent myocardial infarction by spin-echo MRI. Value of the third echo

Seventeen patients underwent MRI spin-echo imaging (Magniscan 5000) 7 to 21 days after acute myocardial infarction (10 anterior, 7 inferior--average 13.1 +/- 3.7 days). The success rate of visualisation of AMI evaluated independently by a qualitative score (from 0 to 4) based on the brilliance of the myocardial signal after taking steps to eliminate the brillance of pericardial fat and subendocardial flow signals, was 3.1 +/- 0.87 in anterior AMI (10 out of 10) and 1.28 +/- 1.25 (4 out of 7) in inferior AMI (p less than 0.007). The diagnostic sensitivity was increased when images of the third echo were used (13 out of 17) compared to those of the second echo (8 out of 17, p less than 0.016). The value of the 3rd echo is explained and emphasised. Abnormal intramyocardial signals were not recorded in a control group of 10 patients under similar conditions of multi-echo imaging. Finally, significant correlations were observed between peak CPK concentrations and the MRI score (r = 0.62; p less than 0.01) and between peak CPK and the number of sections in which the hyperbrilliant signal was observed (r = 0.74; p less than 0.001): this may open the day to quantification of myocardial necrosis by MRI.     

急性心包填塞25例临床分析

本文对２５例急性心包填塞的病因、诊断、临床表现、抢救措施及死因进行探讨，认为心包转移性肿瘤是本病最常见的原因。如肿瘤患者在病程中突然出现呼吸困难等类似心力衰竭症状，或感染性疾病突然出现休克综合征，应考虑为急性心包填塞。鉴别的最可靠方法是超声心动图检查。及时、可靠的心包穿刺引流是缓解急性心包填塞最有效的方法。     

Pericardial tamponade and systemic sclerosis

We report a case with systemic sclerosis (scleroderma) presented with an acute pericarditis and pericardial tamponade with haemodynamic impairment that required pericardial drain. The frequency of pericardial disease in scleroderma is high, but the clinical recognition is rare, and tamponade with haemodynamic impairment requiring aspiration for relief is exceptional, but should be considered in patients with scleroderma that present an acute pericarditis. It is suggested that pericardial fibrosis in scleroderma may predispose to pericardial tamponade.     

Subacute left ventricular free-wall rupture in early course of acute myocardial infarction. Clinical report of two cases and review of the literature

Left ventricular free wall rupture (LVFWR) may complicate an acute myocardial infarction (AMI); its frequency ranges from 1 to 6 percent. In the era of coronary care units, LVFWR is the second cause of in-hospital death, after pump failure. The subacute presentation accounts for 2-3 percent of total hospital admissions for AMI. Heart rupture may not be suddenly fatal and sometimes there is enough time for surgical repair. Electromechanical dissociation is neither the only nor the main clinical presentation. More subtle symptoms occurring hours or days before the final event include unexplained hypotension and transient bradycardia and some ECG features such as persistent ST-segment elevation with T-waves failing to invert in the same leads. On echocardiographic subcostal view, pericardial effusion of more than 5-10 mm, with echo-dense masses overlying the heart independently of cardiac tamponade, is highly suggestive of heart rupture. If pericardiocentesis yields hemorrhagic fluid, surgical intervention is mandatory, providing both diagnostic confirmation and definitive treatment. Medical management strategies (prolonged bed rest, beta-blockade therapy) are still experimental but could become suitable for particular subsets of patients (elderly patients and patients at a high surgical risk). We report two cases of subacute LVFWR and review the currently available literature.     

Pericardial effusion in acute myocardial infarction: clinical feature and significance]

To determine the incidence and clinical significance of pericardial effusion after acute myocardial infarction, two-dimensional echocardiography was serially performed in 137 consecutive patients. Pericardial effusion was observed in 45 patients (33%), of whom 22 were followed until they recovered and were discharged. Pericardial effusion was more frequent in patients with anterior acute infarction than those with inferior acute infarction, and so it was in non-recanalized patients than in recanalized ones. Patients with pericardial effusion had higher peak levels of creatine kinase, higher wall motion score indices, and higher defect scores of thallium imagings. The improvement of regional wall motion at an infarct zone in patients with pericardial effusion was less regardless of the successful early recanalization. These results show that pericardial effusion is a common event in patients with acute myocardial infarction and observation of transition of pericardial effusion is important for predicting prognosis.     

应用切割球囊结合支架术治疗冠状动脉分叉处病变89例

目的 :评价经皮冠状动脉腔内切割球囊成形术 （PTCBA）结合支架术治疗冠脉分叉处病变的安全性及疗效。方法 :对 89例冠心病患者主支病变应用 PTCBA预扩张后置入支架、分支病变单行 PTCBA而不置入支架 ,观察其冠脉病变特点、手术过程相关因素、手术成功率、并发症和近、中期随访结果。结果 :89例患者中分叉处病变位于前降支 /对角支占 71% ,回旋支 /钝圆支占 2 5 % ,右冠脉 /后降支或后侧支占 4%。对分支血管行 PTCBA后 1例因残余狭窄 >5 0 %而植入支架 ,1例因并发轻度钙化且分支成角较大切割球囊未通过 ,改用常规 PTCA球囊扩张成功。病变 PTCBA成功率达 97.8% ;无院内死亡、急性心肌梗死 （AMI）、急性心包填塞及急诊冠脉搭桥术等严重并发症。对手术成功的 87例术后临床随访 3～ 2 6个月 ,无死亡及 AMI等心脏事件发生。临床心绞痛复发率 17.2 %。复查冠脉造影 （CAG）率 5 6.3 % ,示 49处分叉病变主支支架内再狭窄率 14.3 % ,分支血管再狭窄率 18.4%。结论 :PTCBA结合支架术治疗冠脉分叉处病变是一种安全、有效的介入治疗技术 ,其成功率高、并发症少 ,近、中期疗效满意