冠脉内逆向精确溶栓和血栓抽吸分别联合支架植入术对STEMI患者的效果

目的 分析冠脉内逆向精确溶栓联合支架植入术、血栓抽吸联合支架植入术在急性ST段抬高型心肌梗死（ST-segment elevation myocardial infarction,STEMI）治疗中的近远期效果。方法 选取本院2018年2月至2019年12月收治的105例STEMI并接受经皮冠脉介入治疗的患者,按照治疗方式分为三组,分别为传统组（n=35）、逆向溶栓组（n=35）、抽吸组（n=35）,传统组采用传统支架植入术治疗,抽吸组采用血栓抽吸联合支架植入术治疗,溶栓组采用冠脉内逆向精确溶栓联合支架植入术治疗,比较三组近期效果、远期效果。结果 三组无复流现象发生率、术后1 h心电图ST段回落率≥50%占比情况比较,差异具有统计学意义（P<0.05）;三组患者TIMI血流分级及住院时间比较,差异无统计学意义（P>0.05）;溶栓组、抽吸组与传统组住院期间不良心血管事件发生情况比较,差异不具有统计学意义（P>0.05）;术后24 h内,溶栓组、抽吸组与传统组左心室舒张末期内径（left ventricular enddiastolic dimension,LVEDD）...     

急性ST段抬高型心肌梗死心肺复苏后溶栓治疗成功1例

患者男,43岁,于2011年8月28日上午7：30活动时突然出现胸痛伴大汗,为持续性,无肩背部放射疼痛,服用速效救心丸10粒后症状缓解不明显,急诊入院.既往体健,否认高血压、糖尿病病史,饮酒20余年,每日饮白酒约150 mL,吸烟指数200年支.患者门诊做心电图检查：窦性心律,Ⅴ1～ Ⅴ5导联ST段弓背向上抬高1～4 mv,Ⅱ、Ⅲ、avF导联ST段压低0.5 ～1.0 mv.诊断为急性前壁ST段抬高型心肌梗死.9：50 AM患者突然出现意识丧失,颜面紫绀,血压测不到,心电监护示：心室颤动,立即给予200 ～ 300 J直流电除颤2次,心电监护转为窦性心律,5 min后转为室性心动过速,予静脉注射胺碘酮150 mg后转为窦性心律,意识恢复,BP 110/66 mmHg,予阿司匹林300mg嚼服,氢氯吡格雷300mg口服,皮下注射吗啡5 mg.关键词：ST段抬高型心肌梗死;静脉溶栓分类号：R542.2＋2 文献标识码：D     

湖北省急性ST段抬高型心肌梗死溶栓治疗专家建议

<正>急性心肌梗死是由于冠状动脉(冠脉)粥样硬化或栓塞、炎症、痉挛导致的冠脉管腔严重狭窄和心肌供血不足引起的急性心肌缺血性坏死,极易导致猝死、恶性心律失常、急性心力衰竭或心源性休克等严重并发症。通常认为急性ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)意味着冠脉完全闭塞。早期积极进行再灌注,即溶栓或直接经皮冠脉介入治疗(percutaneous     

急性前壁心肌梗死患者静脉溶栓后不同时间行经皮冠状动脉介入治疗的对比研究

目的 比较急性前壁心肌梗死静脉溶栓后不同时间窗内行经皮冠状动脉介入治疗(PCI)患者的预后情况.方法 回顾性分析2016年1月至2019年12月于朝阳市中心医院心血管内科就诊,明确诊断为急性前壁心肌梗死的患者156例.根据治疗方式分为行急诊PCI组(PPCI组,n=78)、溶栓后3～24 h PCI组(TE-PCI组,...     

高龄急性ST段抬高心肌梗死患者静脉溶栓21例

冠心病急性心肌梗死的治疗可采用冠脉介入及静脉溶栓方法.但在没有PTCA条件的基层医院,静脉溶栓仍是心肌再灌注首选的治疗手段.因静脉溶栓常见并发症为出血,所以临床上常常将溶栓年龄限制在70岁以下,致使很多高龄的心肌梗死病人失去心肌再灌注机会.本文旨在探讨高龄急性心肌梗死病人静脉溶栓的疗效及安全性.     

急性心肌梗死溶栓治疗中ST段再抬高的意义

目的探讨急性心肌梗死静脉溶栓治疗中ST段再抬高产生的原因和意义.方法通过回顾性分析31例首发急性心肌梗死病人,按静脉溶栓治疗中有无ST段再抬高分为A、B两组,比较两组间伴发疾病、再通率、CK峰值水平、梗死后心绞痛,冠脉造影结果.结果A、B两组患者各项指标均有显著性差异(P＜0.05).结论静脉溶栓治疗时ST段再抬高与病人合并糖尿病、高血压病、高脂血症及再灌注损伤有关,原因可能是冠状动脉存在多支病变及梗塞血管狭窄程度严重.     

经皮冠状动脉介入治疗与溶栓治疗急性ST段抬高心肌梗死的疗效比较

<正>急性ST段抬高型心肌梗死(ST segment elevation acute myocardial infarction,STEMI)是一种较为常见的临床急性病症,严重威胁人类的生命健康[1,2]。早期再灌注治疗是挽救STEMI患者生命、改善其预后及生存质量的重要手段[3]。大量临床研究表明,采取早期再灌注治疗可大幅度降低STEMI患者的死亡率并显著改善幸存者的心功能[4]。再灌注治疗方法主     

尿激酶溶栓治疗发病2h内急性ST段抬高型心肌梗死的疗效

急性ST段抬高型心肌梗死(STEMI)再灌注治疗的重要策略是经皮冠脉介入治疗(PCI)和静脉溶栓。虽然STEMI急性期行直接PCI已成为首选方法,但溶栓治疗具有快速、简便、经济、易操作等特点,在无条件行直接PCI的基层医院,仍然是STEMI再灌注治疗的重要手段〔1,2〕。本文通过对尿激酶溶栓治     

急性ST段抬高型心肌梗死患者溶栓后经皮冠状动脉介入治疗时机的选择

目的:探讨急性心肌梗死静脉溶栓后紧急转诊经皮冠状动脉介入治疗(PCI)模式的科学性、有效性及安全性。方法:5例急性ST段抬高型心肌梗死(STEMI)患者在外院行静脉溶栓后经绿色通道直接送至我院心导管室行紧急PCI术,观察转运途中的安全性、术中及术后的并发症,术后即刻疗效及出院后短期随访效果。结果:溶栓后立即转诊至我院并紧急PCI的5例患者均顺利完成PCI术,住院期间未见再发缺血事件,也未见明显出血并发症,缩短了患者的住院时间,术后短期随访未见明显不良事件发生。结论:在具备抢救设备及医护人员陪同的条件下,外院STEMI患者溶栓后立即转诊实施紧急PCI术是安全的,且对患者有益,手术时间应在溶栓3h之后,根据术中情况决定术后抗血小板聚集和抗凝治疗。     

不同类型急性心肌梗死冠状动脉病变特点的观察

目的:从临床角度更深入理解急性ST段抬高性心肌梗死(STEMI)或急性非ST段抬高性心肌梗死(NSTEMI)的冠状动脉病变特点。方法:入选2003年12月至2006年9月间,症状发作24小时内行冠状动脉造影的急性心肌梗死(AMI)患者,选择造影结果提示梗塞相关血管为次全闭塞或未闭塞的患者为急性STEMI组(42例),与梗塞相关血管为完全闭塞的患者为急性NSTEMI组(16例)比较两组患者病变特点。结果:急性STEMI组的梗塞相关血管均为主支血管,而急性NSTEMI组梗塞相关血管非主支血管较多,急性STEMI组与急性NSTEMI组相比,有显著性差异[0例vs6例(37.5%),P<0.05]。急性STEMI组梗塞相关血管病变位于主支血管的近段或中段较急性NSTEMI组为多,有显著性差异[38例(90.5%)vs7例(43.8%),P<0.05]。梗塞相关血管造影可见侧支者,急性STEMI组较急性NSTEMI组少,有显著性差异[10例(23.8%)vs10例(62.5%),P<0.05]。结论:与急性NSTEMI患者相比,急性STEMI患者中,梗塞相关血管病变位于主支冠状动脉及其近中段者较多,而侧支循环较少。     

Further elevation of the ST segment during the first hour of thrombolysis: A possible early marker of reperfusion

OBJECTIVES: To evaluate the clinical implications of early electrocardiographicchanges during thrombolysis in a randomized study in patientswith an acute myocardial infarction. BACKGROUND: Re-elevation of a rapidly resolving ST segment during thrombolysisis currently interpreted as a sign of re-occlusion, but a furtherelevation at very early stages of lytic therapy may not necessarilyhave the same implications. METHODS: In 214 patients with a first transmural acute myocardial infarctionof 4 h randomized to fibrinolytic (streptokinase group, n: 110)vs non fibrinolytic medical therapy (control group, n: 104),a standard 12 lead ECG was continuously recorded during thefirst 60 min and at 2, 4, 10, 16 and 24 h. Serial enzymes weremeasured during 72 h, and in 156 patients (73%) a coronary angiogramwas performed at 10–15 days. RESULTS: Within the first 20–40 min there was an additional STsegment elevation in 50 patients (45%) from the streptokinasegroup and in 19 from control group (18%) (P<0·0001)but the increment was greater in the streptokinase group (1·2± 1·4 vs 0·3 ± 1·4 mm, P<0·0001).In the streptokinase group, the interval from onset of painto peak creatine kinase MB was shorter in patients with additionalST segment elevation than in those without it (699 ±193 vs 856 ± 299 min, P<0·01). Moreover, in-hospitalmortality tended to be lower in patients whose ST segment waselevated than in those without such elevation (2150, 4%, vs6160, 10%). Incidence of recanalization was high but comparablein these two subsets. In recanalized patients, with or withoutadditional ST segment elevation, the ST segment declined significantlyat 1 h (– 1·0 ± 1·7, P<0·001,vs 0·1 ± 1·5 mm, ns). CONCLUSIONS: Additional ST segment elevation is frequently observed duringthe first hour of intravenous thrombolysis with streptokinase.Its association with a subsequent early decline of ST elevation,reduced mortality, a shorter time interval to peak creatinekinase, and a high rate of late recanalization, suggest thatin some patients it is one of the earliest markers of reperfusion.     

Further elevation of the ST segment during the first hour of thrombolysis: A possible early marker of reperfusion

OBJECTIVES: To evaluate the clinical implications of early electrocardiographicchanges during thrombolysis in a randomized study in patientswith an acute myocardial infarction. BACKGROUND: Re-elevation of a rapidly resolving ST segment during thrombolysisis currently interpreted as a sign of re-occlusion, but a furtherelevation at very early stages of lytic therapy may not necessarilyhave the same implications. METHODS: In 214 patients with a first transmural acute myocardial infarctionof 4 h randomized to fibrinolytic (streptokinase group, n: 110)vs non fibrinolytic medical therapy (control group, n: 104),a standard 12 lead ECG was continuously recorded during thefirst 60 min and at 2, 4, 10, 16 and 24 h. Serial enzymes weremeasured during 72 h, and in 156 patients (73%) a coronary angiogramwas performed at 10–15 days. RESULTS: Within the first 20–40 min there was an additional STsegment elevation in 50 patients (45%) from the streptokinasegroup and in 19 from control group (18%) (P<0.0001) but theincrement was greater in the streptokinase group (1.2 ±1.4 vs 0.3 ± 1.4 mm, P<0.0001). In the streptokinasegroup, the interval from onset of pain to peak creatine kinaseMB was shorter in patients with additional ST segment elevationthan in those without it (699 ± 193 vs 856 ± 299min, P<0.01). Moreover, in-hospital mortality tended to belower in patients whose ST segment was elevated than in thosewithout such elevation (2150, 4%, vs 6160, 10%). Incidence ofrecanalization was high but comparable in these two subsets.In recanalized patients, with or without additional ST segmentelevation, the ST segment declined significantly at 1 h (–1.0 ± 1.7, P<0.001, vs 0.1 ± 1.5 mm, ns). CONCLUSIONS: Additional ST segment elevation is frequently observed duringthe first hour of intravenous thrombolysis with streptokinase.Its association with a subsequent early decline of ST elevation,reduced mortality, a shorter time interval to peak creatinekinase, and a high rate of late recanalization, suggest thatin some patients it is one of the earliest markers of reperfusion.     

Electrocardiographic criteria for predicting total occlusion of the proximal left anterior descending coronary artery in anterior wall acute myocardial infarction

BACKGROUND: Patients with occlusion of the left anterior descending coronary artery (LAD) proximal to both the first septal branch and the first diagonal branch may benefit most from early reperfusion therapy due to extensive area at risk. HYPOTHESIS: The aim of the study was to examine whether 12-lead electrocardiograms (ECGs) in the acute phase of acute myocardial infarction (AMI) could identify total occlusion of the LAD proximal to both the first septal and the first diagonal branch. METHODS: A 12-lead electrocardiogram was recorded on admission in 128 patients with anterior AMI within 12 h from symptom onset. Patients were divided into three groups according to the culprit lesion: 33 patients had total occlusion of the LAD proximal to both the first septal perforator and the first diagonal branch (Group P), in 51 it was proximal to either the first septal perforator or the first diagonal branch (Group D-a), and in 44 it was distal to both the first septal perforator and the first diagonal branch (Group D-b). RESULTS: Sensitivity and specificity of a greater degree of ST-segment depression in lead III than that of ST-segment elevation in lead aVL were 85 and 95%, respectively, which was better than the results derived by all other ECG criteria (p< 0.001). CONCLUSIONS: We conclude that a greater degree of ST-segment depression in lead III than that of ST-segment elevation in lead aVL is a useful predictor of proximal LAD occlusion in patients with anterior AMI.     

ST段抬高型急性心肌梗死溶栓后心电图改变的临床意义

目的通过分析急性心肌梗死抬高的ST段下降幅度,评价溶栓治疗过程中ST段改变对患者心功能的预测价值。方法96例ST段抬高型急性心肌梗死患者,入院后行溶栓治疗,并计算溶栓后2h内ST段抬高振幅总和(ΣSTE)的下降幅度。结果溶栓治疗2h后,ΣSTE较溶栓治疗前下降大于50%时,病人自觉胸痛症状消失,心功能得到较好保护。而ΣSTE较治疗前下降小于50%时,患者心功能不同程度受损。结论ST段抬高型急性心肌梗死的患者经早期溶栓治疗后,其抬高的ST段下降幅度可作为心肌血供能否恢复的间接预测指标,从而能较准确地反映心肌再灌注情况及预测心功能状态。     

Dose of urokinase for intracoronary thrombolysis in patients with acute myocardial infarction

Intracoronary thrombolysis is a logical therapeutic method and one of the challenging new treatments of acute myocardial infarction. However, a wide dose range of urokinase has been reported, and the optimal dose has not yet been established. In this study the fibrinolytic activity in patients with recanalized coronary arteries was compared with that in those with nonrecanalized arteries. The mean doses of urokinase in the recanalized and non-recanalized groups were 910,700 +/- 161,730 international units (IU) and 1,008,000 +/- 151,800 IU, respectively. The fibrinolytic activity was measured with alpha 2-plasmin inhibitor, alpha 2-macroglobulin, fibrinogen, plasminogen, and fibrin degradation products. No significant difference was observed in the fibrinolytic activity between the recanalized and nonrecanalized groups. Because the fibrinolytic activity in the two groups was thought to be activated sufficiently and to a similar degree, it appears that 1,000,000 IU of urokinase is adequate for intracoronary thrombolysis and larger doses cannot be expected to result in a higher rate of recanalization.     

急性ST段抬高心肌梗死的最佳支架植入时机:即刻与延迟植入比较的Meta分析

目的:收集比较有关发生急性ST段抬高心肌梗死(STEMI)时即刻植入支架(IS)和延迟植入支架(DS)的随机对照和队列研究,对其结果进行系统评价和Meta分析,比较IS和DS的安全性和有效性。方法:在PubMed、Cochrane Library、中国知网3大数据库检索2017年5月前关于比较IS和DS安全性和有效性的文章,将IS患者作为实验组(IS组),DS患者组作为对照组(DS组),以主要心脏不良事件(MACE)发生率、慢血流/无复流发生率、远端栓塞发生率、靶病变血管开通率(TIMI 3级)、靶血管再次血运重建(TVR)率、主要出血发生率、再次心肌梗死发生率作为观察指标,使用Review Manager 5.3软件进行Meta分析,计算对应的OR值和95%CI,并分析异质性及其来源。结果:最终有8篇文献纳入Meta分析,包括2 181例患者,其中IS组1 262例,DS组919例。与IS相比,DS能够显著降低慢血流/无复流发生率(OR=4.55,95%CI:2.14~9.68)、远端栓塞发生率(OR=9.14,95%CI:3.47~24.10),提高靶病变血管开通率(TIMI 3级)(OR=0.22,95%CI:0.12~0.43);然而两组在MACE发生率、TVR率、再次心肌梗死发生率、主要出血发生率方面相比无明显差异。结论:在STEMI患者中,DS与IS在MACE发生率、TVR、再次心肌梗死发生率与主要出血发生率方面无明显差异;DS慢血流/无复流发生率与远端栓塞发生率均较IS低,靶病变血管开通率(TIMI 3级)较IS高。     

ST段压低在急性左主干病变中的诊断价值

目的探讨ST段压低在急性左主干病变中的诊断价值。方法选取2000年1月～2007年3月间因急性心肌梗死住院的患者134例,经冠状动脉造影证实其中16例左主干病变(LMCA组)、85例前降支病变(LAD组)和33例右冠状动脉病变(RCA组)。患者入院即刻描记12导联心电图,分析各组患者ST段压低情况。结果单因素分析发现,II、III、aVF和V2～V6导联ST段压低在LAD和LMCA组间差异有统计学意义,II、III、aVL、aVF、V2和V6导联ST段压低在LMCA和RCA组间比较,差异有统计学意义。多因素判别分析结果表明,与LAD组相比,II、aVF和V2导联ST段压低对左主干病变有良好的诊断价值,敏感性31.3%,特异性可达98.8%,阳性预测价值83.3%;与RCA组相比时,aVF和V6导联ST段压低亦有良好的预测价值,敏感性62.5%,特异性和阳性预测价值均为100%。结论12导联心电图ST段压低在急性左主干病变诊断中有较高的特异性和阳性预测价值。     

老年急性ST段抬高心肌梗死患者介入联合替罗非班治疗临床疗效的观察

目的前瞻性研究老年急性ST段抬高心肌梗死(ASTEMI)患者急诊介入治疗早期联合应用替罗非班临床疗效的有效性及安全性。方法入选沈阳军区总医院2004年5月1日至2006年6月30日经冠状动脉造影证实为单支血管病变且行介入治疗的231例老年ASTEMI患者,年龄65～85岁,平均(72±9.3)岁,随机分为替罗非班治疗组(n=116)和对照组(n=115),对比观察两组术中靶血管开通情况、TIMI3级血流获得情况,术后90min内ST段回落情况,96h活化凝血时间(ACT)、肌酸激酶同工酶(CK-MB)酶峰时间,术中及术后重要脏器出血情况,术后30d不良心血管事件、持续ST段抬高情况及左心室射血分数(EF)。结果两组靶血管经皮冠状动脉介入(PCI)成功率无显著差异,术中及术后出血事件发生情况无显著差异;治疗组术中TIMI3级血流获得率、术后90min内ST段回落比例及30dEF值均优于对照组(94.0%vs83.5%,85.3%vs73.0%,65.3%±2.4%vs54.7%±7.0%,P<0.05),治疗组术后持续ST段抬高>0.2mV患者的比例明显低于对照组(1.7%vs12.2%,P<0.05),术后治疗组CK-MB酶峰时间较对照组提前(8.3h±0.6hvs12.1h±0.3h,P<0.05),30d治疗组不良心血管事件发生率明显少于对照组(心绞痛发生率2.6%vs13.9%,心肌梗死再发率0.9%vs8.7%,心源性死亡率0vs5.2%,P<0.05)。结论老年ASTEMI患者急诊介入治疗早期联合应用替罗非班安全有效。     

Myocardial damage after successful thrombolysis is associated with the duration of ST re-elevation at reperfusion

The purpose of this study was to investigate the significance of ST re-elevation at reperfusion using strict criteria for patient inclusion and exclusion. Twenty-nine patients who had a first anterior infarction with single-vessel disease, successful recanalization by intracoronary thrombolysis (ICT) with urokinase, and an angiographically confirmed patent infarct-related artery after 4 weeks, were divided into three groups according to the deviation of the ST segment at reperfusion: Group A, 10 patients with sustained ST re-elevation; Group B, 10 patients with transient ST re-elevation; and Group C, 9 patients with ST reduction. Left ventricular (LV) function was evaluated from cineventriculograms performed in the 30° right anterior projection 4 weeks after ICT. LV ejection fraction and regional wall motion of the infarct area, evaluated by the centerline method (SD/chords), were significantly lower in Group A (44 ± 10%, -3.2 ± 0.4) than in Group B (61 ± 9%, -1.9 ± 0.7) and Group C (60 ± 5%, -2.0 ± 0.4) (p < 0.01). Peak creatine kinase (CK) activity was significantly higher in Group A (5848 ± 2112 IU) than in Group B (2485 ± 1254 IU) and Group C (1889 ± 1525 IU) (p < 0.05). These data suggest that a sustained ST re-elevation at reperfusion was strongly associated with marked LV dysfunction and higher peak CK activity. It was concluded that sustained, not transient, ST re-elevation associated with successful reperfusion indicates extensive myocardial damage.