急性心肌梗死心肌蛋白检测的临床评价

目的探讨心肌损伤标志物心肌蛋白检测在急性心肌梗死(AcuteMyocardialInfarction,AMI)诊断时的应用价值,减少急性心肌梗死漏诊、误诊发生率。方法测定35例AMI病人在发病的第4小时、8小时、24小时,5天等四个时间段的血清肌钙蛋白(IcTnI)、肌钙蛋白T(cTnT)及肌红蛋白(Mb)浓度,和对照组30例健康者体检时的血清相应项目数据对比并进行统计学处理。结果AMI患者发病后4￣8小时血清cTnI、cTnT开始上升,24小时达到峰值,5天仍维持在较高水平,其浓度以及阳性率与正常对照组比较均有显著性差异(P<0.05);而血清Mb在4￣8小时上升幅度更大,但24小时后浓度以及阳性率与正常对照组比较差异不显著(P>0.05)。结论在心肌梗死的早期诊断指标中,Mb的优势明显;cTnI、TnT可用于AMI的早期诊断,但更适用于那些因就诊时间较晚、心肌酶已正常的心梗病人。三者联测可更早、更可靠地提高心肌梗死诊断的准确率。     

A randomised, double-blind, placebo-controlled trial of L-carnitine in suspected acute myocardial infarction.

In a randomised, double-blind placebo-controlled trial, the effects of the administration of oral L-carnitine (2 g/day) for 28 days were compared in the management of 51 (carnitine group) and 50 (placebo group) patients with suspected acute myocardial infarction. At study entry, the extent of cardiac disease, cardiac enzymes and lipid peroxides were comparable between the groups, although both groups showed an increase in cardiac enzymes and lipid peroxides. At the end of the 28-day treatment period, the mean infarct size assessed by cardiac enzymes showed a significant reduction in the carnitine group compared to placebo. Electrocardiographic assessment of infarct size revealed that the QRS-score was significantly less in the carnitine group compared to placebo (7.4 +/- 1.2 vs 10.7 +/- 2.0), while serum aspartate transaminase and lipid peroxides showed significant reduction in the carnitine group. Lactate dehydrogenase measured on the sixth or seventh day following infarction showed a smaller rise in the carnitine group compared to placebo. Angina pectoris (17.6 vs 36.0%), New York Heart Association class III and IV heart failure plus left ventricular enlargement (23.4 vs 36.0%) and total arrhythmias (13.7 vs 28.0%) were significantly less in the carnitine group compared to placebo. Total cardiac events including cardiac deaths and nonfatal infarction were 15.6% in the carnitine group vs 26.0% in the placebo group. It is possible that L-carnitine supplementation in patients with suspected acute myocardial infarction may be protective against cardiac necrosis and complications during the first 28 days.     

The management of acute myocardial infarction.

Greater understanding of the underlying pathophysiology of acute myocardial infarction (AMI) has led to more aggressive management and lower mortality, both in-hospital and long term. AMI results mainly from thrombotic occlusion of the infarct-related coronary artery. The ensuing necrosis evolves over a 6-12 h period providing a time window for interventions designed to reduce eventual infarct size. The most appropriate interventions are those which restore coronary artery patency and hence myocardial blood flow as soon as possible. Occasionally, disruption of the occluding thrombus and compression of the underlying atheromatous lesion is best achieved by direct percutaneous transluminal coronary angioplasty. For the vast majority however, revascularisation by drug therapy is more appropriate. As soon as possible, all patients without contraindications should be offered oral aspirin and intravenous thrombolysis, usually with streptokinase but occasionally with tissue plasminogen activator. Patients in whom these agents are contraindicated should be considered for intravenous beta-blockade using atenolol or metoprolol to reduce myocardial demand and hence infarct size. Patients with large infarcts, impaired ventricular function, left ventricular failure or hypertension should be considered for early angiotensin-converting enzyme inhibitor therapy. Other agents may be valuable symptomatically, but have no proven role in reducing infarct size or mortality. After the first 24 h, the main aims of management are to assess the likelihood of later ischaemic events or death (risk stratification) and hence to choose appropriate long term secondary prophylaxis.     

门急诊疑似急性心肌梗死患者临床流行病学研究

目的 调研苏州地区门急诊疑似急性心肌梗死(AMI)患者临床就诊情况,为今后该病防治提供可靠的临床流行病学理论依据。 方法 选取2018年度苏州大学附属第一医院门急诊疑似急性心肌梗死就诊患者为研究对象,以Excel建库并运用SPSS统计学软件回顾性分析疑似患者临床资料与高敏肌钙蛋白T(hs-cTnT)检测结果,进一步明确临床人口分布特点、就诊高峰时间段及hs-cTnT检测临床应用价值等特点。 结果 共纳入门急诊就诊患者13 709例,主要因自感胸痛、胸闷、心悸、呼吸困难等不适而就诊,检出疑似AMI患者3 585例(26.15%),其中男性2 170例(60.53%),女性1 415例(39.47%),男女比例为1.5∶1。年龄从11～100岁不等,中位年龄为72岁,各年龄段人群检出差异有统计学意义(P<0.05),其中青少年人群(≤40岁279例,占7.78%),该组间检出无统计学差异(均P>0.05);在中老年人群[≥41岁3 306例(92.22%),特别是≥61岁2 757例(76.90%)],该组间检出差异有统计学意义(均P<0.05)。季节性检出差异有统计学意义(P<0.05),主要集中于冬季(尤其1～2月)及春季(3～5月),且男性整体检出率始终高于女性患者。患者hs-cTnT水平随年龄增长而不断增高,且同一年龄段男性患者群高于女性,男性患者(≥51岁起)及女性人群(≥61岁起)hs-cTnT检测线高于整体人群基线水平。 结论 我院门急诊疑似AMI检出率较高,以40岁以上中老年人群为主,应加强胸痛、心悸等自觉症状高危人群hs-cTnT季节性筛查力度和范围。      

Follow-up care after acute myocardial infarction.

OBJECTIVE: To examine the medical care received by patients following discharge from hospital after acute myocardial infarction (AMI). SETTING AND DESIGN: Community-based cross-sectional survey. PATIENTS: 2836 consecutive patients aged 25-64 years living in the Perth Statistical Division who were admitted to hospital with AMI during 1984-1988. After one reminder the response rate was 71%. RESULTS: Half of all respondents were in full-time employment at the time of their AMI. At follow-up this had fallen to a third. Over 80% of patients visited a cardiologist after AMI, with half remaining under consultant care to the time of survey. However, one in five patients reported no follow-up care at the time of survey. Seventy-three per cent of patients reported undergoing at least one exercise stress test after AMI, with 61% undergoing angiography, 16% angioplasty and 24% coronary bypass surgery. Large proportions of the patients accurately reported being prescribed beta-blockers and antiplatelet agents. The pattern of prescribing at discharge corresponded closely with the use of cardioactive agents at the time of survey and with drugs reported to have been taken continuously since discharge to the time of survey. CONCLUSIONS: These data suggest that follow-up care after AMI is both comprehensive and widespread. Such care may have contributed significantly to the overall decline in mortality from ischaemic heart disease.     

Hemodynamic monitoring in acute myocardial infarction.

The main cause of in-hospital death in patients with acute myocardial infarction is the "power failure syndrome". Hemodynamic monitoring provides precise and current data on the filling and output status of the left ventricle and, when indicated, the right ventricle. The information obtained is used to determine the hemodynamic status more precisely than is possible from conventional clinical assessment. It permits categorization of patients by hemodynamic status; the hemodynamic subset classification of Forrester, Diamond and Swan is a powerful tool in guiding therapy and establishing prognosis in individual patients. In addition to guiding the initiation of therapy, hemodynamic monitoring is useful in the continuing assessment of potent and complex treatment. This therapy is directed at resolving hemodynamic derangements without unfavourably altering the myocardial oxygen supply-demand relationship. Specific clinical indications for hemodynamic monitoring may include confusing or complicated clinical situations in which diagnostic problems exist, complicating mechanical derangements, severe congestive heart failure, cardiogenic shock and clinical research in acute myocardial infarction.     

Tricuspid incompetence complicating acute myocardial infarction.

A case of persistent tricuspid incompetence due to acute myocardial infarction is described. Review of the literature has revealed no similar case.     

Oral disopyramide after admission to hospital with suspected acute myocardial infarction. U. K. Rythmodan Multicentre Study Group.

A multi-centre double-blind randomized study is reported in which the effect on mortality of oral disopyramide (300 mg loading dose, then 100 mg qds) was compared with placebo in 1985 patients entering hospital with suspected acute myocardial infarction. Treatment was commenced with 24 hr of onset of symptoms (mean time to first dose 9 hr) and continued until discharge from hospital or 14 days, whichever came first. Nine-hundred and ninety-five patients were allocated to disopyramide and 990 to placebo. The overall mortality, calculated on an intention-to-treat basis, was 7.2% for the disopyramide and 5.6% for the placebo patients. Among those patients with proven infarction mortality was 9.5% of 687 on disopyramide and 7.4% of 716 on placebo. These differences are not statistically significant. Patients with cardiac failure or hypotension at entry did not fare worse on disopyramide, but those with a conduction defect did. Reinfarction was not significantly influenced by disopyramide. The prophylactic use of disopyramide in patients with suspected acute myocardial infarction does not reduce mortality or the incidence of early reinfarction.     

3D-STI在急性前壁心肌梗死评估中的应用价值

目的:分析3D-STI测量左心室径向应变(RS)、纵向应变(LS)在评价急性前壁心肌梗死左心功能及再灌注中的应用价值。方法:选取2016年1月～2017年4月间如皋市人民医院收治的100例急性前壁心肌梗死患者作为观察组,并同期选择100例健康体检者作为对照组;采用3D-STI技术检查患者RS、LS;以随访结果作为金标准,分析RS、LS在评价急性前壁心肌梗死左心功能及再灌注中的应用价值。结果:观察组3D-STI测量LS及RS的绝对值均高于对照组,且差异有统计学意义(P<0.05);观察组LVEF、LAD水平均低于对照组(P<0.05),且观察组LVESV及LVEDV均高于对照组;3D-STI检测RS指标预测左心功能良好共53例,LS预测良好56例;3D-STI检测RS指标预测心肌再灌注阳性共48例,LS预测阳性49例;3D-STI检测LS、RS预测左心功能及心肌再灌注的灵敏度及特异度均高于85%,且ROC曲线下面积均>0.85。结论:3D-STI测量左心室LS、RS可有效评价并预测急性前壁心肌梗死左心功能及再灌注,其灵敏度及特异度均较高,具有较高的临床应用价值。     

窦性心律震荡对急性心肌梗死后患者危险性的评价

目的 探讨窦性心律震荡(HRT)对急性心肌梗死(AMI)后患者危险性的评价价值.方法 选择2012-2013年我院AMI患者40例设为观察组,选择同期我院非AMI者40例设为对照组,记录两组的HRT的震荡初始(TO)和震荡斜率(TS),评估其对危险性的预测价值.结果 观察组患者TO值明显高于对照组(P＜0.05),TS值明显低于对照组(P＜0.05).死亡者TO值明显高于存活者(P＜0.05),TS值明显低于对照组(P＜0.05).结论 窦性心律震荡对急性心肌梗死后患者危险性的评价价值较大,值得应用.