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冠脉内溶栓治疗急性心肌梗塞

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中华心血管病杂志 1992年第6期20卷 379-380页

作者：葛洪徐世全周义福张国庆杨丽娜解放军第五一四医院心内科

报告9例急性心肌梗塞早期应用冠脉内溶栓治疗的结果。一、资料及方法 1.临床资料:9例均为男性,平均年龄61岁

关键词：心肌梗死/药物疗法血栓溶解疗法人类

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肌型肌酸激酶亚型对判断急性心肌梗塞溶栓疗效的价值

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中华内科杂志 1991年第12期30卷 775-776页

作者：曾昭耆毛利民黄义明杨振华王玻北京医院内科北京医院检验科

血清肌酸激酶(CK)及其同工酶CK-MB对诊断急性心肌梗塞(AMI)和估计梗塞范围有肯定价值,其峰值前移也是现今判断AMI后溶栓治疗有效的无创性指标之一。但因溶栓治疗需在AMI开始后3～6小时内进行,而有效的溶栓多发生于其后1～2小时,CK高峰... 详细信息

血清肌酸激酶(CK)及其同工酶CK-MB对诊断急性心肌梗塞(AMI)和估计梗塞范围有肯定价值,其峰值前移也是现今判断AMI后溶栓治疗有效的无创性指标之一。但因溶栓治疗需在AMI开始后3～6小时内进行,而有效的溶栓多发生于其后1～2小时,CK高峰又通常见于AMI后18～36小时,与溶栓的过程不同步。肌型肌酸激酶(CK-MM)是目前已知出现最早

关键词：肌酸激酶/血液心肌梗死/药物疗法

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Urocortin protects against ischemic and reperfusion injury via a MAPK-dependent pathway

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JOURNAL OF BIOLOGICAL CHEMISTRY 2000年第12期275卷 8508-8514页

作者： Brar, BK Jonassen, AK Stephanou, A Santilli, G Railson, J Knight, RA Yellon, DM Latchman, DS Univ London Inst Child Hlth London WC1N 1EH England UCL Hosp & Med Sch Hatter Inst Cardiol London WC1E 6DB England Natl Heart & Lung Inst Dept Cyst Fibrosis London SW3 6LR England

Urocortin (UCN) is a peptide related to hypothalamic corticotrophin-releasing hormone and binds with high affinity to corticotrophin-releasing hormone receptor-2 beta, which is expressed in the heart. In this study, we report that UCN prevented cell death when administered to primary cardiac myocyte cultures both prior to simulated hypoxia/ischemia and at the point of reoxygenation after simulated hypoxia/ischemia. UCN-mediated cell survival was measured by trypan blue exclusion, 3'-OH end labeling of DNA (TUNEL), annexin V, and fluorescence-activated cell sorting. To explore the mechanisms that could be responsible for this effect, we investigated the involvement of MAPK-dependent pathways. UCN caused rapid phosphorylation of ERK1/2-p42/44, and PD98059, which blocks the MEK1-ERK1/2-p42/44 cascade, also inhibited the survival-promoting effect of UCN. Most important, UCN reduced damage in isolated rat hearts ex vivo subjected to regional ischemia/reperfusion, with the protective effect being observed when UCN was given either prior to ischemia or at the time of reperfusion after ischemia. This suggests a novel function of UCN as a cardioprotective agent that could act when given after ischemia, at reperfusion.

关键词：细胞死亡/药物作用细胞低氧/药物作用细胞培养的促肾上腺皮质素释放激素/药理学类黄酮物质/药理学心脏/药物作用 MAP激酶信号系统丝裂原激活蛋白激酶类/拮抗剂和抑制剂丝裂原激活蛋白激酶类/代谢心肌梗死/药物疗法心肌缺血/药物疗法心肌再灌注损伤/预防和控制心肌/细胞学心肌/酶学大鼠 Wistar 尿皮质素类动物男(雄)性大鼠

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A double-blind, randomized study of the effect of immediate intravenous nitroglycerin on the incidence of postprocedural chest pain and minor myocardial necrosis after elective coronary stenting

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AMERICAN HEART JOURNAL 2000年第1期139卷 35-43页

作者： Kurz, DJ Naegeli, B Bertel, O Triemli Hosp Dept Internal Med Div Cardiol CH-8063 Zurich Switzerland

Background Anginal chest pain without creatine kinase (CK) elevation is frequently observed in the first hours after coronary stenting. Possible causes of ischemic episodes are microembolism, side branch occlusion, coronary vasospasm, and disturbances of microvascular circulation. In a prospective, double-blind, randomized trial, we tested the effect of intravenous nitroglycerin on the incidence of angina and minor myocardial necrosis (MMN), as detected by cardiac troponin I increase, after elective coronary stenting. Methods and Results One hundred patients were randomly assigned to intravenous nitroglycerin (group A: n = 50, goal dose 100 mu g/min) or placebo (group B: n = 50, NaCl 0.9%) during 12 hours after stenting. Patients with acute myocardial infarction, known intolerance to nitrates, and hemodynamic instability during angioplasty were excluded. The 2 groups were comparable in respect to baseline and interventional variables, except for age (group A: 60 +/- 9 years, group B: 56 +/- 10 years;P = .04). The incidence of chest pain was not influenced by nitroglycerin (group A: 18%, group B: 22%;P = not significant). However, the occurrence of MMN was significantly reduced by nitroglycerin (group A: 5%, group B: 19%, P = .036). A rise in CK with significant CK-MB fraction was observed in only 2 patients in group B (both less than twice upper limit). Only 4 of the 10 patients with MMN also had chest pain. Conclusions Routine use of intravenous nitroglycerin after coronary stenting significantly reduced the occurrence of minor myocardial necrosis. However, the incidence of postprocedural chest pain remained unchanged.

关键词：心绞痛/血液心绞痛/预防和控制心绞痛/放射摄影术血管成形术经腔经皮冠状动脉生物学标记/血液冠状血管造影术冠心病/放射摄影术冠心病/治疗双盲法移植物闭塞血管/并发症移植物闭塞血管/药物疗法移植物闭塞血管/放射摄影术心脏/药物作用发病率注射静脉内心肌梗死/药物疗法心肌梗死/病因学心肌梗死/放射摄影术心肌/病理学坏死硝酸甘油/投药和剂量疼痛手术后/血液疼痛手术后/预防和控制疼痛手术后/放射摄影术前瞻性研究支架肌钙蛋白I/血液血管舒张药/投药和剂量女(雌)性人类男(雄)性中年人

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A new regimen for heparin use in acute coronary syndromes

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AMERICAN HEART JOURNAL 1999年第2期138卷 313-318页

作者： Hochman, JS Wali, AU Gavrila, D Sim, MJ Malhotra, S Palazzo, AM De La Fuente, B St Lukes Roosevelt Hosp Ctr Div Cardiol New York NY 10025 USA Columbia Univ New York NY USA

Background Recent trials have demonstrated on association between high activated partial thromboplastin lime (aPTT) and bleeding, intracranial hemorrhage, reinfarction, and death in patients with acute coronary syndromes treated with heparin. Of all the factors that affect aPTT in patients treated with heparin, body weight is most strongly correlated. Methods we compared the efficacy of 2 weight-adjusted heparin regimens (groups 2 and 3) and the standard (group 1) non-weight-adjusted 5000-U intravenous bolus/1000 U/hr infusion to achieve an aPTT between 45 and 70 seconds in a nonrandomized prospective cohort of 80 patients admitted with unstable angina and non-ST elevation myocardial infarction. Results Patients treated with the lower dose of weight-adjusted heparin (60 U/kg intravenous bolus, maximum of 4000 U;12 U/kg/hr, maximum 900 U/kg), group 3, were more often within the target range for aPTT at 6 hours (34% vs 5% vs 0%) and required fewer heparin infusion changes (1.0 +/- 1.0 vs 1.9 +/- 1.0 vs 2.0 +/- 0.9) within the first 24 hours compared with the other regimens. Patients in groups 1 and 2 were overwhelmingly above target range at 6 hours (95% and 84%, respectively, compared with 48% in group 3). Conclusions Traditional heparin dosing regimens result in marked initial overanticoagulation in patients with acute coronary syndromes, which may place these patients at higher risk of adverse outcomes. A lower dose weight-adjusted heparin regimen is superior in achieving early aPTTs within the target range and reducing the need for infusion changes over the ensuing 24 hours.

关键词：心绞痛不稳定型/药物疗法抗凝药/投药和剂量抗凝药/治疗应用肝素/投药和剂量肝素/治疗应用心肌梗死/药物疗法部分促凝血酶原时间前瞻性研究综合征老年人女(雌)性人类男(雄)性中年人

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Corrected TIMI frame counts correlate with stenosis severity and infarct zone wall motion after thrombolytic therapy

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AMERICAN HEART JOURNAL 2001年第4期141卷 586-591页

作者： Amos, DJ French, JK Andrews, J Ashton, NG Williams, BF Whitlock, RML Manda, SOM White, HD Green Lane Hosp Dept Cardiol Auckland 1030 New Zealand

Background The majority of patients with patent infarct-related arteries after thrombolytic therapy have slower than normal flow, which relates to myocardial perfusion. Methods To evaluate the relationships between blood levels of creatine kinase (CK) and the corrected Thrombolysis in Myocardial Infarction (TIMI) frame count (CTFC), infarct artery stenosis, and left ventricular Function, we studied 397 patients with a first myocardial infarction who underwent angiography at 3 weeks. TIMI flow grades, the CTFC, infarct artery stenosis, and infarct zone wall motion (by contrast ventriculography using the centerline method) were assessed, and CK levels (in units per liter) were measured hourly for the First 4 hours after streptokinase (1.5 x 10(6) U over 30-60 minutes) and then every 4 hours over the next 20 hours, all blinded to treatment and outcome. Results Infarct artery stenosis and the CTFC, assessed as continuous variables, correlated in patients with patent infarct arteries (r = 0.33, P < .001). Also, there was a significant correlation between the CTFC and the sum of hypokinetic chords in the infarct zone (r = 0.15, P = .01). Patients with total occlusion or markedly slowed infarct artery flow (CTFC > 100) had a higher Fraction of chords with wall motion >2 SDs below normal (0.65 [0.41,0.80] vs 0.37 [0.0, 0.67]) compared with patients with normal flow (CTFC <27) (P < .001). The rates of increase of median CK levels with respect to TIMI flow grades were 342 U/L/h for TIMI 3 versus 212 U/L/h for TIMI 2 versus 140 U/L/h for TIMI 0-1 (P < .0001). Conclusions Prolonged corrected TIMI frame counts correlate with stenosis severity in the infarct artery after infarction, infarct zone regional wall motion, and CK levels.

关键词：缩窄病理性冠状血管造影术冠状血管/病理学冠状血管/病理生理学肌酸激酶/血液纤维蛋白溶解药/治疗应用心肌梗死/药物疗法心肌梗死/病理学心肌梗死/病理生理学局部血流链激酶/治疗应用血栓溶解疗法人类

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Drug prescriptions after acute myocardial infarction: Dosage, compliance, and persistence

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AMERICAN HEART JOURNAL 2003年第3期145卷 438-444页

作者： Simpson, E Beck, C Richard, H Eisenberg, MJ Pilote, L Montreal Gen Hosp Div Clin Epidemiol Montreal PQ H3G 1A4 Canada McGill Univ Jewish Gen Hosp Div Cardiol Montreal PQ H3T 1E2 Canada McGill Univ Jewish Gen Hosp Div Clin Epidemiol Montreal PQ H3T 1E2 Canada

Background Although it has been well documented that aspirin, beta-blockers;angiotensin-converting enzyme (ACE) inhibitors, and lipid-lowering drugs are under-prescribed for patients with acute myocardial infarction (Am Heart J 2003;145:438-44.), few studies have examined dosage and long-term compliance and persistence patterns for the use of these drugs after AMI. Methods Using Quebec administrative data on all elderly (aged greater than or equal to65 years) survivors of hospital admissions for AMI between 1996 and 1998 (n = 14,057), we studied the discharge prescriptions, dosages, patient compliance, and per-. sistence during this period for aspirin, beta-blockers, ACE inhibitors, and lipid-lowering drugs. Results Rates of discharge medications were suboptimal (aspirin 65%, beta-blockers 54%, ACE inhibitors 45%, lipid-lowering drugs 21%). Most patients with prescriptions for aspirin and ACE inhibitors were prescribed dosages equivalent to those administered in clinical trials (99% and 88%, respectively). In contrast, only 20% of patients with beta-blocker prescriptions and 48%a of patients with lipid-lowering drug prescriptions were prescribed clinical trial doses. For patients with discharge prescriptions, 1-year compliance rates were high (aspirin 74%, beta-blockers 74%, ACE inhibitors 70%a, lipid-lowering drugs 84%), as were the 1-year persistence rates (aspirin 71%, beta-blockers 72%, ACE inhibitors 69%, lipid-lowering drugs 80%). Conclusion Although cardiac drugs are under-prescribed to patients with AMI, once prescribed, patients are likely to adhere to these prescriptions, with high rates of compliance and persistence.

关键词：降血脂药/投药和剂量降血脂药/治疗应用阿司匹林/投药和剂量阿司匹林/治疗应用用药计划表坚持准则医院记录心肌梗死/药物疗法病人依从病人出院医师诊疗模式魁北克女(雌)性人类男(雄)性

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Depression but not anxiety influences the autonomic control of heart rate after myocardial infarction

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AMERICAN HEART JOURNAL 2001年第5期141卷 765-771页

作者： Pitzalis, MV Iacoviello, M Todarello, O Fioretti, A Guida, P Massari, F Mastropasqua, F Dello Russo, G Rizzon, P Univ Bari Policlin Inst Cardiol I-70124 Bari Italy Univ Bari Inst Psychiat 2 I-70124 Bari Italy Cardiol S Maugeri Fdn Ist Recerca & Cura Carettere Sci Bari Italy

Aims It has been previously hypothesized that the adverse outcome observed in depressed patients after myocardia infarction might be due to an imbalance in autonomic nervous system activity. The aim of this study was to define the role of depressive and anxious symptoms in influencing autonomic control of heart rate after myocardial infarction. Methods and Results The SD of RR intervals, baroreflex sensitivity, and depression and anxiety (Zung's scales) were assessed before discharge in 103 patients with acute myocardial infarction;32 were found to be depressed. Among the patients who were not taking beta -blockers, those with depression had significantly lower SDs of RR intervals and baroreflex sensitivity than did those without depression (96.3 +/- 22.2 ms vs 119.5 +/- 37.7 ms, P = .016;8.6 +/- 6.2 ms vs 11.8 +/- 6.5 ms/mm Hg, P = .01, respectively). No differences were Found when anxiety was considered or when beta -blockers were given. Among the patients not taking beta -blockers, there was a significant correlation between depression levels and both the SD of RR intervals (r = -0.47) and baroreflex sensitivity (r = -0.40). Conclusions In patients with myocardial infarction, depression but not anxiety negatively influences autonomic control of heart rate. beta -Blockers modify these influences.

关键词：肾上腺素能β受体拮抗剂/治疗应用焦虑/病因学焦虑/病理生理学自主神经系统/药物作用自主神经系统/病理生理学压力感受器反射/药物作用压力感受器反射/生理学昼夜节律抑郁/病因学抑郁/病理生理学心电描记术/药物作用心率/药物作用心肌梗死/并发症心肌梗死/药物疗法心肌梗死/病理生理学预后回顾性研究老年人女(雌)性人类男(雄)性中年人

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Platelet glycoprotein inhibitors in patients with medically managed acute coronary syndrome: Does the enthusiasm exceed the science?

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ANNALS OF EMERGENCY MEDICINE 2001年第3期38卷 249-255页

作者： Schriger, DL Herbert, ME Univ Calif Los Angeles Sch Med Ctr Emergency Med Los Angeles CA 90024 USA Univ Calif Los Angeles Sch Nursing Los Angeles CA 90024 USA Olive View UCLA Med Ctr Dept Emergency Med Los Angeles CA USA

Guidelines from the American Heart Association and the American College of Cardiology, as well as numerous review articles, have strongly and enthusiastically recommended that platelet glycoprotein IIb/IIIa inhibitors be used in patients with medically managed unstable angina or non-ST-segment myocardial infarction (UA/NSTEMI). We explore whether there is sufficient experimental evidence to justify these recommendations. We review the 4 large randomized trials of US Food and Drug Administration-approved platelet glycoprotein IIb/IIIa inhibitors that included medically managed UA/NSTEMI patients, first taking each trial's results at face value and then in the context of likely biases. The risk differences, unadjusted for potential biases, are 2.5% (0.6%, 4.4%) for the Platelet Receptor Inhibition in Ischemic Syndrome Management (PRISM) study, 2.3% (-1.9%, 6.5%) for the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) study (tirofiban plus heparin), 0.9% (-0.9%, 2.8%) for the Platelet Glycoprotein IIb/IIIa in Unstable Angina Receptor Suppression Using Integrilin Therapy (PURSUIT) trial, -0.2% (-1.7%, 1.3%) for the least harmful treatment arm of the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-IV) trial, and -1.9% (-6.8%, 3.0%) for the PRISM-PLUS study (tirofiban alone) (positive numbers indicate benefit). The 95% confidence interval produced by combining the studies using a random effects model is -1.3% to 3.2% (mean 0.9%);this is consistent with drugs providing a small benefit, no benefit, or causing harm. Confounding caused by the nonrandom selection of patients for percutaneous transluminal coronary angioplasty and coronary artery bypass grafting in all trials except GUSTO-IV and problems arising from the fact that enrolled patients were much sicker than typical UA/NSTEMI patients are likely to have biased the studies away from t

关键词：心绞痛不稳定型/药物疗法心绞痛不稳定型/经济学心绞痛不稳定型/死亡率费用效益分析循证医学心肌梗死/药物疗法心肌梗死/经济学心肌梗死/死亡率血小板聚集抑制剂/经济学血小板聚集抑制剂/治疗应用血小板糖蛋白GPⅡb-Ⅲa复合物/拮抗剂和抑制剂危险性评估存活率人类

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Accuracy and clinical effect of out-of-hospital electrocardiography in the diagnosis of acute cardiac ischemia: A meta-analysis

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ANNALS OF EMERGENCY MEDICINE 2001年第5期37卷 461-470页

作者： Ioannidis, JPA Salem, D Chew, PW Lau, J New England Med Ctr Div Clin Care Res Evidence Based Practice Ctr Boston MA 02111 USA

Study objective: We sought to evaluate quantitatively the evidence on the diagnostic performance of out-of-hospital ECG for the diagnosis of acute cardiac ischemia (ACI) and acute myocardia[ infarction (AMI) and the clinical effect of out-of-hospital thrombolysis. Methods: We conducted a systematic review and meta-analysis of the English-language literature published between 1966 and December 1998 on the diagnostic accuracy of out-of-hospital ECG and the clinical effect of out-of-hospital thrombolysis. Both prospective and retrospective studies qualified for the assessment of diagnostic performance. For clinical effect, data from prospective nonrandomized studies were synthesized separately from data from randomized trials. Diagnostic performance was assessed by using estimates of test sensitivity, specificity and diagnostic odds ratios and was summarized by using summary receiver-operating characteristic curves, Measures of clinical effect included time savings, early ventricular function, early mortality, and long-term survival. Results: Diagnostic accuracy was evaluated in 11 studies with a total of 7,508 patients. Data were available for ACI in 5 studies and for AMI in 8 studies. For ACI, the random-effects pooled sensitivity was 76% (95% CI, 54% to 89%), the specificity was 88% (95% CI, 67% to 96%), and the diagnostic odds ratio was 23 (95% CI, 6.3 to 85). The respective figures for AMI were sensitivity of 68% (95% CI, 59% to 76%), specificity of 97% (95% CI, 89% to 92%), and diagnostic odds ratio of 104 (95% CI, 48 to 224). Both in nonrandomized (n=4, total 1,531 patients) and randomized (n=9, total 6,643 patients) studies, out-of-hospital thrombolysis shortened the time from onset of symptoms to thrombolytic treatment by 40 to 60 minutes. Data on shortterm ejection fraction were sparse. Hospital mortality was reduced by 16% (95% CI, 2% to 27%) among randomized trials, and a similar estimate of effect was seen in nonrandomized studies. There was no clear effec

关键词：急性病偏倚(流行病学) 心电描记术/标准急救医疗服务/方法急救医疗服务/标准循证医学纤维蛋白溶解药/治疗应用医院死亡率心肌梗死/诊断心肌梗死/药物疗法心肌梗死/死亡率心肌缺血/诊断心肌缺血/药物疗法心肌缺血/死亡率比值比前瞻性研究可重复性结果研究设计回顾性研究敏感性与特异性存活率分析时间因素治疗结果心室功能/药物作用人类

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