Beneficial clinical effect of very early enalapril treatment in patients with acute left ventricular failure complicating myocardial infarction

Acute myocardial infarction (AMI) leads to left ventricular dysfunction, the extent of which predicts mortality. We studied the effect of very early enalapril treatment in patients with left ventricular failure (Killip classification II-III) resulting from AMI. In a double-blind randomized trial, patients on conventional treatment were started on placebo (PL, n = 15) or 2.5 mg enalapril (EN, n = 15) twice daily as early as 24 to 30 h after AMI and were followed up over a period of 21 days. One patient died in each treatment group. There were three dropouts in the placebo group (progressive heart failure requiring antiotensin-converting enzyme inhibition) and one dropout in the enalapril group (malignant ventricular arrhythmias). Plasma atrial natriuretic peptide (ANP) and norepinephrine decreased similarly in both groups from elevated baseline concentrations. The patients with the highest baseline ANP levels died in both groups: EN: 579 fmol/ml (mean 65.3 ± 34.4 fmol/ml), PL: 403 fmol/ml (mean 63.5 ± 37.6 fmol/ml). Killip classification improved in 9 of 13 patients on enalapril but only in 5 of 11 patients on placebo. On echocardiography an increase in fractional shortening (FS) (3.2 ± 7.5%, p < 0.05) was found with enalapril only. Patients on placebo required more diuretics, and plasma aldosterone increased threefold. Thus, very early enalapril treatment may help prevent left ventricular failure after AMI. Extremely high initial plasma ANP concentrations may predict an unfavorable outcome.     

Neurohormonal changes after acute myocardial infarction: Relationships with haemodynamic indices and effects of ACE inhibition

To determine the neurohormonal response to angiotensin-convertingenzyme (ACE) inhibition after acute myocardial infarction, 36patients presenting within 6 h of the onset of chest pain werestudied in a single regional cardiology service. In this double-blindstudy, 13 patients ;were randomized to receive captopril, 12patients received enalapril, and 11 patients received placebo,for 12 months. In patients receiving placebo, acute myocardial infarction wasassociated with activation of the renin-angiotensin-aldosteroneand sympathetic nervous systems, and stimulation of plasma brainnatriuretic peptide and atrial natriuretic peptide levels. ACEinhibition did not significantly alter circulating levels ofnorepinephrine, brain natriuretic peptide or atrial natriureticpeptide. Compared with placebo, enalapril induced a steep declinein plasma ACE activity, and plasma angiolensin II levels werereduced by both ACE inhibitors. Using grouped data, circulating levels of brain natriureticpeptide at the zero sampling time were significantly higherthan atrial natriuretic peptide values. Brain natriuretic peptidelevels at 72 h were significantly correlated with the radionuclideleft ventricular ejection fraction measured 5 days and 3 monthsafter infarction. Similar associations were observed for atrialnatriuretic peptide and norepinephrine. We confirm activation of the renin-angiotensin-aldosterone andsympathetic nervous systems after acute myocardial infarction.The atrial nairiuretic peptide and brain natriuretic peptideand sympathetic nervous system responses to acute myocardialinfarction were not significantly modified by ACE inhibition.Brain natriuretic peptide and atrial natriuretic peptide levelswere sign correlated with the left ventricular ejection fractionmeasured 5 days and again 3 months after myocardial infarction,and may prove a useful prognostic index.     

内皮细胞的损伤与急性心肌梗塞

本研究以循环内皮细胞（ＣＥＣ）作为血管内皮损伤的指示物，以血浆内皮素（ＥＴ－１）反映血管内皮的功能变化，研究了急性心肌梗塞（ＡＭＩ）患者内皮细胞的损伤和功能变化。４１例ＡＭＩ患者分为两组，Ａ组２６例，无梗塞后缺血事件及心力衰竭；Ｂ组１５例，有上述并发症。２１例健康人做为对照。动态测定患者在入院后７２小时的血浆ＥＴ－１水平和ＣＥＣ计数。结果显示：两组患者血浆ＥＴ－１和ＣＥＣ均在ＡＭＩ发病的早期４小时即达峰值，以后随时间推移而下降，但在７２小时内各测定值均高于正常对照组（Ｐ＜０．０１）。两组不同的是：具有合并症的ＡＭＩ患者（Ｂ组），其血浆ＥＴ－１水平和ＣＥＣ计数在各个时间点均高于Ａ组患者（Ｐ＜０．０１）；且随时间下降速度缓慢，在４８小时和７２小时仍呈较高水平，均高于Ａ组患者（Ｐ＜０．０１）；两组患者的ＥＴ－１和ＣＥＣ均呈显著的正相关（Ｐ＜０．００１）。结论：血浆ＥＴ－１水平和ＣＥＣ数量在ＡＭＩ早期显著增加，二者可做为心肌梗塞内皮细胞损伤和功能变化的指示物；在有并发症的ＡＭＩ中二者呈现持续升高，这可能与梗塞后缺血的发生和心脏功能减低有关。     

Progressive left ventricular hypertrophy after withdrawal of long-term ACE inhibition following experimental myocardial infarction

BACKGROUND: Although discontinuation of chronic ACE inhibitor (ACEi) therapy after myocardial infarction (MI) is common in clinical practice, some clinical studies reported an increased incidence of ischemia-related events after withdrawal. To further address this issue, we assessed hemodynamic, neurohormonal and vascular consequences of withdrawing long-term ACEi treatment after experimental MI. METHODS: Rats were subjected to coronary ligation to induce MI, and received quinapril (15 mg/kg/day) from 2 weeks to 14 months post-MI. Subsequently, surviving rats were randomized to sacrifice at 0, 4, and 6 weeks after ACEi withdrawal. Rats were studied for signs of heart failure, hemodynamics and cardiac function, neurohormones, and vascular edothelial function. RESULTS: After discontinuation of ACEi treatment, plasma aldosterone levels increased between 0-4 weeks without further increment thereafter, suggesting persistent RAAS activation. Acetylcholine-induced aortic relaxation was impaired at 4 and 6 weeks, indicating rapid and sustained development of endothelial vasodilator dysfunction after withdrawal. Moreover, 24% of the rats developed heart failure signs (edema, dyspnea), and 3 rats died, all within 4 weeks after withdrawal. Significantly increased N-ANP levels and lung weights at 4, but not at 6 weeks suggest a transient volume overload. Finally, LV/body weight ratios significantly increased between 0-4 as well as 4-6 weeks, indicating progressive LV hypertrophy. CONCLUSIONS: The observed alterations after withdrawing long-term post-MI quinapril treatment in the present study may account for an increased risk for ischemic events. Thus, our findings highlight the potentially harmful effects associated with abrupt discontinuation of long-term post-MI ACE inhibition, and imply careful clinical consideration in this matter.     

血管紧张素转换酶抑制剂对单个心力衰竭心肌细胞收缩特性的实验性研究

目的研究血管紧张素转换酶抑制剂(ACEI)在治疗心力衰竭时,对单个心肌细胞的缩短分数(FS)和收缩力-频率关系(FFR)的影响。方法通过缩窄雄性Wistar大鼠的腹主动脉以制成心力衰竭模型。随机分成培哚普利治疗(CHF-T)组、心力衰竭对照(CHF-C)组和假手术对照(PS)组;测定单个心肌细胞在0.5、1.0、1.5、2.0 Hz刺激时的FS。结果CHF-T、CHF-C和PS组的心肌细胞FS在各刺激频率下差异均有显著性意义。随频率的增加,PS组的FFR呈双向型;CHF-C组的FFR则呈负性;而CHF-T组的FFR则呈平坦型。结论慢性心力衰竭的长程ACEI治疗,能直接改善单个心力衰竭心肌细胞的收缩特性,此为其抗心力衰竭的机制之一。     

急性ST段抬高心肌梗死患者住院期间并发泵衰竭的影响因素分析

目的探讨影响急性ST段抬高心肌梗死（STEMI）患者住院期间并发泵衰竭的因素。方法根据急性心肌梗死泵衰竭Killip临床分级标准将首次发生且发病6h内入院的263例（男203例，女60例，年龄20-90岁）。急性STEMI患者分为心功能异常组和心功能正常组，记录患者临床资料，采用酶联免疫吸附法（ELISA）测定血清白介素6（IL-6）等炎性标记物水平。结果住院期间并发泵衰竭的STEMI患者年龄（P〈0．001）、入院心率（P=0．003）、女性比例（P=0．013）、合并糖尿病史（P=0．023）以及IL-6（P〈0．001）和可溶性白细胞分化抗原40配体（P=0．01）水平均显著高于心功能正常组。Spearman＇s相关分析显示IL-6与肌酸激酶、肌钙蛋白Ⅰ峰值呈显著正相关（均P〈0．05）。多因素Logistic回归分析得出年龄、入院心率和IL-6是影响急性STEMI住院期间并发泵衰竭的独立因素。结论IL-6水平与急性STEMI住院期间并发泵衰竭独立相关，提示IL-6可提供独立于传统危险因素的预后信息辅助急性STEMI的危险分层。     

青年男性急性心肌梗死88例临床分析

目的:探讨青年男性急性心肌梗死(AMI)患者的临床病变特点。方法:回顾性分析1578例不同年龄和不同性别AMI患者临床特征及冠状动脉造影结果。结果:≤40岁男性AMI患者88例。主诉多为胸痛,AMI梗死范围以前壁多见。与老年男性比较,危险因素以超重和吸烟为著。冠状动脉正常者较多,以单支病变为主,合并左主干病变较少。经皮冠状动脉介入(PCI)是主要的治疗手段,患者预后较好。结论:AMI发病年轻化,青年AMI患者中男性占绝大多数,病因以冠状动脉粥样硬化为主,其危险因素和冠状动脉病变特点与老年男性不同,临床医生应加以重视。     

急性心肌梗死并发泵衰竭的影响因素

目的:探讨急性心肌梗死（AM I）患者并发泵衰竭的影响因素。方法:以1999年4月至2004年7月收住我院冠心病监护病房（CCU）的176例AM I患者为对象,对比分析泵衰竭组（66例）与对照组（110例,无泵衰竭）患者的病史、临床表现、并发症等特点,以Logistic多因素逐步回归分析AM I并发泵衰竭的影响因素。结果:泵衰竭组陈旧性心肌梗死病史、前壁或多部位AM I、肺部湿罗音、白细胞计数≥10×109/L、左心室射血分数≤0.5、肺炎发生率、下壁、侧壁或非Q波AM I、心肌酶峰值、住院期间病死率均与对照组有显著性差异（P<0.05或P<0.01）。Logistic多因素逐步回归分析表明,陈旧性心肌梗死病史、前壁或多部位AM I、高龄及并发肺炎是AM I患者并发泵衰竭的独立影响因素。结论:AM I患者有陈旧性心肌梗死病史、前壁或多部位AM I、高龄及并发肺炎是AM I并发泵衰竭的独立危险因素。     

Effect of enalapril initiated early after acute myocardial infarction on heart failure parameters,with reference to clinical class and echocardiographic determinants

Background and hypothesis: Although the angiotensin-converting enzyme inhibitor enalapril has recently been shown to reduce mortality and the need for hospitalization in patients with left ventricular dysfunction and congestive heart failure, this drug was found to have no significant impact on short-term mortality after acute myocardial infarction (AMI) in the CONSENSUS II trial. The effect of enalapril initiated early after AMI on clinical and echocardiographic determinants of left ventricular (LV) function was studied in a subset of patients from CONSENSUS II Methods: Symptoms and signs of heart failure were classified as NYHA and dyspnea classes. Echocardiography included LV end-systolic volumes (ESV) and end-diastolic volumes (EDV), as well as ejection fraction (EF). wall motion index (WMI), and mitral flow indices. In all, 428 patients were included and followed for an average of 5.1 months by serial examinations, starting 2–5 days after myocardial infarction (MI) and repeated after 1 month and at the completion of the study. Results: There was no beneficial effect of enalapril on clinically determined function. Changes (i.e. changes in NYHA class) in the functional status remained correlated with changes in echocardiographic determinants throughout the study in patients belonging to the placebo group: EDV index (r=0.36, p = 0.002, ESV index (r = 0.49, p < 0.001), EF (r = -0.41, p < 0.001), and WMI (r=0.29, p = 0.008). In a stepwise logistic regression model, the best baseline parameters to predict NYHA class at final visit in all patients were age (p = 0.014) and ESV index (p = 0.001). Conclusion: Enalapril treatment for an average period of 5.1 months following MI resulted in no clinically significant beneficial effects on NYHA and dyspnea class. Changes in clinical function class were correlated with changes in echocardiographic determinants in placebo-treated patients, but not in patients given enalapril.     

Adjunctive therapy after reperfusion therapy in acute myocardial infarction

The current era has witnessed dramatic improvement in the treatment of acute myocardial infarction, due in large part to the more widespread use of thrombolytic therapy aimed at quickly restoring perfusion in the infarct-related artery. This review addresses the role of adjunctive pharmacologic therapy in the thrombolytic era, recognizing that much of the available clinical trial data supporting the role of adjunctive pharmacologic treatment strategies was conducted in patient populations not widely exposed to reperfusion therapy. This review, therefore, explores the data supporting the incremental benefit of therapy with beta blockers, nitrates, angiotensin-converting enzyme inhibitors, or magnesium in addition to thrombolytic therapy. Heparin and aspirin will not be discussed.     

Characteristics and prognosis of patients with acute myocardial infarction in relation to occurrence of congestive heart failure

Congestive heart failure is one of the major symptoms accompanyingacute myocardial infarction (AMI). The study aimed to describethe occurrence, characteristics and prognosis of congestiveheart failure in AMI and to compare post-MI patients with andwithout congestive heart failure. The methods used includedbaseline characteristics, initial symptoms, electrocardiogram(ECG), mortality during hospitalization and one year follow-upin consecutive patients with AMI admitted to Sahlgrenska Hospital,Göteborg, Sweden. Congestive heart failure was observed in 51% of the cases. Patientswith congestive heart failure were older, more frequently hada history of previous cardiovascular disease, and, less frequentlyhad chest pain on admission to hospital. They had a higher occurrenceof life-threatening ventricular arrhythmias during initial hospitalization,and their mortality during one year follow-up was 39% as comparedto 17% in patients without congestive heart failure (P<0.001).This difference remained significant when correcting for differencesat baseline. Patients with severe congestive heart failure hada one year mortality of 47% vs 31% in patients with moderatecongestive heart failure (P<0.01). Signs and symptoms of congestive heart failure occur in everysecond patient admitted to hospital due to AMI, and indicatea bad prognosis, which is directly related to the severity ofcongestive heart failure.     

70岁以上老年人急性心肌梗死临床特点

目的探讨年龄因素对急性心肌梗死（ＡＭＩ）疾病过程及预后的影响。方法将１９～９６岁４８８例ＡＭＩ住院患者按年龄分组，从发病特点、诱发因素、临床过程及疾病转归等方面进行对比。结果随年龄增长，≥７０岁组女性患者的比率明显增高；≥７０岁组发病与慢性心肌缺血史、高血压、糖尿病明显有关，起病时多无典型胸痛，仅表现为呼吸困难、胃肠道反应、意识障碍等症状，出现心律失常、心力衰竭、心源性休克等并发症及病死率均明显高于１９～５９岁及６０～６９岁两组。结论年龄因素是决定老年ＡＭＩ患者预后的重要指标之一。     

长期抗神经内分泌治疗对高血糖心肌梗死患者左心室功能的影响

目的观察长期抗神经内分泌治疗对高血糖心肌梗死患者神经内分泌激素及左心室功能的影响。方法将入选的65例心肌梗死患者,分为血糖正常组(34例)和高血糖组(31例),给予美托洛尔加血管紧张素转换酶抑制剂(ACEI)治疗,分别于治疗前和治疗后6个月采血检测血浆神经内分泌激素的水平。随访2年分别于治疗前和治疗后行超声心动图检测,观察两组患者在用药前后心室重构的逆转、左心室功能的变化。结果使用美托洛尔并ACEI可以降低血糖正常组和高血糖组患者的血浆肾素、血管紧张素Ⅱ水平,血浆肾素活性、血管紧张素Ⅱ浓度降低,差异有显著性意义(P<0.05)。血糖正常组患者治疗后左心室射血分数(LVEF)好转(P<0.05),高血糖组患者LVEF虽有好转,但差异无显著性意义。结论抗神经内分泌治疗可以降低心肌梗死患者的血浆肾素、血管紧张素Ⅱ水平。     

Beneficial effects of long-term treatment with enalapril on cardiac function and heart rate variability in patients with old myocardial infarction

BACKGROUND: The beneficial effects of the early use of angiotensin-converting enzyme inhibitors (ACEis) in patients with acute myocardial infarction (MI) are well documented. However, the effects of ACEis in patients with an old MI and preserved cardiac function have not yet been studied. We examined the effects of 12 months of enalapril treatment in patients with previous MI. METHODS AND RESULTS: Thirteen patients with an old MI and no overt congestive heart failure (CHF), aged 70 +/- 2 years, were treated with enalapril for 12 months. We also included 13 age- and sex-matched control patients who had a similar clinical background but were not treated with enalapril. Holter electrocardiography and echocardiography were performed at entry and after 12 months of treatment. Heart rate variability, low- and high-frequency powers (LF and HF), and the ratio between LF and HF (LF/HF) were analyzed. Changes from baseline to 12 months in HF, LF/HF, left ventricular end-diastolic dimension (LVEDD), and end-systolic dimension (LVESD) were significantly different in the enalapril group (HF, 8.1 +/- 0.9 to 9.3 +/- 0.9 milliseconds: LF/HF, 1.65 +/- 0.11 to 1.53 +/- 0.16; LVEDD, 57.2 +/- 1.6 to 54.7 +/- 1.6 mm; LVESD, 40.0 +/- 2.4 to 36.3 +/- 1.9 mm) compared with the control group (HF, 8.9 +/- 0.9 to 8.5 +/- 0.7 milliseconds; LF/HF, 1.78 +/- 0.18 to 1.88 +/- 0.15; LVEDD, 52.3 +/- 2.5 to 55.9 +/- 2.2 mm; LVESD, 32.5 +/- 2.6 to 36.1 +/- 2.6 mm; P < .05). The delta change (delta) in LVESD between the end and the start of study correlated inversely with deltaHF (r = -0.56; P < .05) and positively with deltaLF/HF (r = 0.65; P < .01). CONCLUSION: Our results suggest possible ongoing structural changes in patients with old MI even in the absence of overt CHF. Enalapril seemed to prevent such changes and to restore cardiac autonomic tone toward normal. Further prospective studies using a larger sample size are warranted to confirm potential beneficial effects of ACEis in patients with previous MI and preserved left ventricular function.     

米力农治疗急性心肌梗死并发急性左心衰竭的临床观察

目的评价米力农治疗急性心肌梗死并发急性左心衰竭的疗效及安全性。方法2005年1月2006年4月在沈阳军区总医院心内科诊断急性心肌梗死并发急性左心衰的住院患者120例,随机分为2组,每组60例,心功能均为Killip ⅢⅣ级,对照组给予常规抗心衰治疗,米力农组在常规治疗的基础上加用米力农0.5μg/（kg.min）静脉滴注5 h,每日1次,应用7 d。观察患者用药前后的症状变化、心功能级别及不良反应。结果米力农组心功能改善总有效率为88%,对照组为70%,两组总有效率有显著差异（P<0.05）。米力农组无明显药物不良反应。结论米力农治疗急性心肌梗死并发急性左心衰疗效确切、安全可靠。     

急性下壁ST段抬高型心肌梗死患者左心衰竭的危险因素分析

目的 探讨急性下壁ST段抬高型心肌梗死患者发生左心衰竭的影响因素,为临床防治措施的制定提供依据.方法 将沧州市人民医院2013年1月至2018年1月收治的534例急性下壁ST段抬高型心肌梗死患者作为此次研究对象,回顾性分析这些患者的临床病历资料,并查阅患者病史等,将发生心力衰竭的患者(162例)作为观察组,将未发生心力...     

Management and risk factors for mortality in very elderly patients with acute myocardial infarction

Aim: Elderly patients often remain underrepresented in clinical trials. The aim of our study was to analyze the treatment, clinical outcome and risk factors for mortality in patients aged ≥85 years with ST‐segment elevation myocardial infarction (STEMI). Methods: From 2005–2011, 102 patients aged ≥85 years with STEMI admitted to a coronary care unit were retrospectively reviewed. Clinical data, treatment and outcome were recorded. Reperfusion strategy and its influence in hospital morbidity and mortality were evaluated. Morbidity was defined as the presence of heart failure (Killip–Kimball >1), arrhythmias, mechanical complications, stroke or major bleeding. Risk factors for mortality were assessed by multivariate analysis. Results: The mean age was 87.5 ± 2.5 years (range 85–96). Therapeutic strategy on admission was: primary‐angioplasty (PCI) for 33 patients (32.3%) fibrinolysis for 30 patients (29.4%) and conservative treatment for 35 patients (34.3%). In the four remaining patients, rescue angioplasty was required. A total of 29 patients (28.4%) died, and morbidity was seen in 63 patients (61.7%). The morbidity and mortality rates in the conservative treatment group (77.1% and 48.5%) were higher than that found in the reperfusion strategy group (primary‐PCI and fibrinolysis; 53.7% and 17.9%; P = 0.02 and P = 0.002, respectively). Regarding mortality, the univariate analysis showed that heart failure on admission (P = 0.0001) and previous coronary artery disease (P = 0.01) were prognostic variables. Only heart failure was an independent risk factor for mortality (odds ratio = 3.64, 95% CI 0.78–21.87, P < 0.0001). Conclusions: Mortality and morbidity in very elderly patients with STEMI are very high, especially in those not receiving reperfusion therapies. Heart failure on admission was an independent risk factor for hospital mortality. Geriatr Gerontol Int 2013; 13: 146–151 .     

急性下壁梗死伴或不伴右心室心肌梗死患者临床特征的比较

目的：比较急性下壁心肌梗死（IWMI）伴或不伴右心室心肌梗死（RVMI）患者的临床特征差异。方法纳入2006年10月~2012年12月总参保健处发病12 h内入院的急性下壁心肌梗死（IWMI）患者256例,根据冠状动脉造影（CAG）结果将患者分为IWMI不合并RVMI组（n=167）和IWMI合并RVMI组（n=89）,比较两组患者冠心病发病主要危险因素（包括吸烟、高血压、糖尿病、高脂血症、冠心病家族史）、临床表现、并发症和治疗用药的差异。结果两组患者冠心病主要危险因素无差异（P＞0.05）。IWMI合并RVMI患者出现低血压（80.0% vs.19.8%,P＜0.05）、颈静脉怒张（50.6%vs.1.8%）和Kussmaul征（51.7%vs.1.2%）的比例明显增加（P均＜0.01）,需要更多地应用正性肌力药物（60.7%vs.16.2%）来维持血压,且病死率较高（77.9%vs.0.6%,P＜0.05）。结论在IWMI基础上伴RVMI多合并右心功能障碍,可导致预后不良。     

Anaemia is an independent predictor of mortality in patients with left ventricular systolic dysfunction following acute myocardial infarction

BACKGROUND: In patients with chronic heart failure (HF), mortality is inversely related to haemoglobin (hgb) concentration. We investigated the prognostic importance of anaemia in patients with acute myocardial infarction (AMI) and left ventricular systolic dysfunction (LVSD) with and without HF. METHODS AND RESULTS: We studied 1731 patients with AMI and left ventricular ejection fraction 相似文献   

急性心肌梗死合并心房颤动患者的临床特点分析

目的 探讨急性心肌梗死(AMI)合并心房颤动(AF)患者的临床特点。方法 纳入2014年1月至2017年12月华中科技大学同济医学院附属协和医院心内科收治的AMI住院患者777例。根据患者既往史及住院期间心电图诊断是否合并AF,将其分为AMI并AF组(78例)和AMI无AF组(699例)。收集2组患者的基本情况、心血管危险因素、生物化学指标、心脏超声、冠状动脉造影等资料,进行统计分析,比较2组患者临床特点的差异。结果 AMI并AF组患者的年龄、吸烟史、卒中史、慢性肾脏病史、室性心律失常的发生率均显著高于AMI无AF组(P＜0.05)。AMI并AF组血红蛋白、红细胞计数、甘油三酯、估算的肾小球滤过率显著低于AMI无AF组,而血尿酸、尿素氮、肌酐、胱抑素C、脑钠尿肽、高敏C反应蛋白水平均显著高于AMI无AF组(P＜0.05)。心脏超声结果显示,与AMI无AF组相比,AMI并AF组左心房内径和右心房内径明显增大(P＜0.01),左心室射血分数显著降低(P＜0.05)。2组冠状动脉造影检查结果无显著差异(P＞0.05)。结论 AMI合并AF患者室性心律失常、心力衰竭发生率高,易合并贫血及慢性肾脏病。