时间的重要性:对比较急性心肌梗死患者接受直接经皮冠状动脉介入术和院内溶栓治疗的随机化临床试验的汇总分析

Aims: Although outcomes after acute myocardiat infarction(AMI) seemed to be superior with primary percutaneous coronary intervention(PPCI) relative to fibrinolysis(FL), the extent to which treatment delay modulates this treatment effect is unclear. Methods and results: Twenty-five randomized trials(n=7743) testing the efficacy of PPCI vs. FL were identified in journal articles and abstract listings published between 1990 and 2002. Of these, individual patient data from 22 trials(n=6763) were pooled, and multi-level logistic regression assessed the relationship among treatment, treatment delay, and 30-day mortality. Treatment delay was divided into ‘ presentation delay’ [symptom onset to randomization; FL: median 143(IQR: 91-225) min; PPCI: 140(91-220) min] and hospital-sp3ecific ‘ PCI-related delay’ [median time from randomization to PPCI minus median time to FL per hospital; median 55(IQR: 37-74) min]. PPCI was associated with a significant 37% reduction in 30-day mortality [adjusted OR, 0.63; 95% CI(0.42-0.84)]. Although, there was no heterogeneity in the treatment effect by presentation delay(pBreslow-Day=0.88), the absolute mortality reduction by PPCI widened over time(1.3% 0-1 h to 4.2% >6 h after symptom onset). When the PCI-related delay was< 35min, the relative(67 vs. 28% pBreslow-Day=0.004) and absolute(5.4 vs. 2.0% ) mortality reduction was significantly higher than those with longer delays. Conclusion: PPCI was associated with significantly lower 30-day mortality relative to FL, regardless of treatment delay. Although logistic and economic constraints challenge the feasibility of ‘ PPCI-for-all’ , the benefit of timely treatment underscores the importance of a comprehensive, unified approach to delivery of cardiac care in all AMI patients.

Euroheart急性冠状动脉综合征调查中急性冠状动脉综合征患者的年龄、临床表现和预后

Aims: Age is one of the most powerful determinants of prognosis in myocardial infarction, but there is comparatively little recent data across the whole spectrum of acute coronary syndromes(ACS). We examined the impact of increasing age on clinical presentation and hospital outcome in a large sample of patients with ACS. Methods and results: Patients(n=10 253) from the Euroheart ACS survey in 103 hospitals in 25 countries were investigated. There was a significant inverse association between the age and the likelihood of presenting with ST-elevation. For each decade of life, the odds of presenting with ST-elevation decreased by 0.82 [95% confidence interval(CI) 0.79-0.84];P< 0.0001. Elderly patients were considerably less often treated by cardiologists, less extensively investigated, and, when presenting with ST-elevation ACS, less likely to be treated with reperfusion. Compared with patients< 55 years, the odds ratios of hospital mortality were 1.87(1.21-2.88) at age 55-64, 3.70(2.51-5.44) at age 65-74, 6.23(4.25-9.14) at age 75-84, and 14.5(9.47-22.1)among patients ≥ 85 years, with no major differences across different types of admission or discharge diagnoses. Conclusion: Elderly ACS patients were less likely to present with ST-elevation but had substantial in-hospital mortality, yet they were markedly less intensively treated and investigated.

咖啡因降低运动诱导的心肌血流储备

OBJECTIVES: We studied the acute effect of caffeine on myocardial blood flow(MBF) at rest and exercise in healthy volunteers at normoxia and during acute exposure to simulated altitude. BACKGROUND: Caffeine is a widely consumed stimulant, although its cardiovascular safety remains controversial and its effect on MBF is unknown. METHODS: 15O-labeled H2O and positron emission tomography(PET) were used to measure regional MBF at rest and immediately after supine bicycle exercise in healthy volunteers at normoxia(n=10; mean workload, 175 W; 98% predicted; mean age, 27± 6 years) as well as during hypoxia, simulating an altitude of 4,500 m by inhalation of a mixture of 12.5% oxygen(n=8; 148 W; 78% predicted; mean age, 29± 4 years). Measurements were repeated 50 min after oral ingestion of caffeine(200 mg). Myocardial flow reserve(MFR) was calculated as the ratio of hyperemic to resting MBF. RESULTS: Resting MBF was not affected by caffeine at normoxia(1.05± 0.36 ml/min/g vs. 1.17± 0.27 ml/min/g; p=NS), although it was significantly increased at hypoxia(1.71± 0.41 ml/min/g vs. 2.22± 0.49 ml/min/g; p < 0.001). By contrast, exercise-induced hyperemic MBF decreased significantly at normoxia(2.51± 0.58 ml/min/g vs. 2.15± 0.47 ml/min/g; p< 0.05) and hypoxia(5.15± 0.79 ml/min/g vs. 3.98± 0.83 ml/min/g; p< 0.005 vs. baseline; p< 0.005 vs. normoxia). The MFR decreased by 22% at normoxia(2.53± 0.69 to 1.90± 0.49; p< 0.01) and by 39% at hypoxia(3.13± 0.60 to 1.87± 0.45, p< 0.005; p< 0.05 vs. normoxia). CONCLUSIONS: In healthy volunteers, a caffeine dose corresponding to two cups of coffee(200 mg)signif icantly decreased exercise-induced MFR at normoxia and was even more pronounced during exposure to altitude.

心力衰竭患者的依从性:知识水平和信念的重要性

Aims: Non- compliance in patients with heart failure(HF)contributes to worsening HF symptoms and may lead to hospitalization. Several smaller studies have examined compliance in HF, but all were limited as they only studied either the individual components of compliance and its related factors or several aspects of compliance without studying the related factors. The aims of this study were to examine all dimensions of compliance and its related factors in one HF population. Methods and results: Data were collected in a cohort of 501 HF patients. Clinical and demographic data were assessed and patients completed questionnaires on compliance, beliefs, knowledge, and self- care behaviour. Overall compliance was 72% in this older HF population. Compliance with medication and appointment keeping was high(>90% ). In contrast, compliance with diet(83% ), fluid restriction(73% ), exercise(39% ), and weighing(35% ) was markedly lower. Compliance was related to knowledge(OR=5.67; CI 2.87- 11.19), beliefs(OR=1.78; CI 1.18- 2.69), and depressive symptoms(OR=0.53; CI 0.35- 0.78). Conclusion: Although some aspects of compliance had an acceptable level, compliance with weighing and exercise were low. In order to improve compliance, an increase of knowledge and a change of patient’ s beliefs by education and counselling are recommended. Extra attention should be paid to patients with depressive symptoms.

基于一项大型随机试验的患者队列,预测稳定型心绞痛患者死亡、心肌梗死和脑卒中的风险评分

Objective: To derive a risk score for the combination of death from all causes, myocardial infarction, and disabling stroke in patients with stable symptomatic angina who require treatment for angina and have preserved left ventricular function. Design: Multivariate Cox regression analysis of data from a large multicentre trial. Setting: Outpatient cardiology clinics in western Europe, Israel, Canada, Australia, and New Zealand. Participants: 7311 patients with all required data available. Main outcome measure: Death from any cause or myocardial infarction or disabling stroke during a mean follow-up of 4.9 years. Results: 1063 patients either died from any cause or sustained myocardial infarction or disabling stroke. The five year risk of this composite ranged from 4% for patients in the lowest tenth of risk to 35% for patients in the highest tenth. The risk score combines 16 routinely available clinical variables(in order of decreasing contribution): age, left ventricular ejection fraction, smoking, white blood cell count, diabetes, casual blood glucose concentration, creatinine concentration, previous stroke, at least one angina attack a week, coronary angiographic findings(if available), lipid lowering treatment, QT interval, systolic blood pressure ≥ 155 mm Hg, number of drugs used for angina, previous myocardial infarction, and sex. Fitting the same model separately to all cause death, myocardial infarction, and stroke gave similar results. The risk score did not seem to predict the nature of the event(death in 39% , myocardial infarction in 46% , and disabling stroke in 15% ) or the incidence of angiography or revascularisation, which occurred in 29% of patients. Conclusion: This risk score is an objective aid in deciding on further management of patients with stable angina with the aim of reducing serious outcome events. The score can also be used in planning future trials.

美国医学杂志

聚合体紫杉醇洗脱支架和裸金属支架在复杂冠状动脉疾病患者中的应用比较：一项随机对照研究。接受溶栓治疗的ST段抬高心肌梗死患者行经皮冠状动脉介入术前氯吡格雷预处理的作用：PCI—CLARITY研究.

美国医学会杂志

急性心肌梗死伴心源性休克患者的治疗和预后发展趋势；社区内不同年龄段成人高血压的预后及控制；急性冠状动脉综合征后接受β受体阻断剂治疗的患者中β2肾上腺素能受体基因型与生存率的关系；充血性心衰和肺动脉导管术有效性评估研究。

对于行直接或补救性经皮冠状动脉介入治疗的急性心肌梗死患者,入院血糖浓度可独立预测近期和远期死亡率

Background: In patients with acute myocardial infarction(MI), increased plasma glucose levels at hospital admission are associated with worse outcome. We aimed to assess the predictive value of admission glucose concentrations on short- and long-term mortality in patients with acute MI undergoing primary or rescue percutaneous coronary intervention(PCI). Methods: We analyzed the 30-day and long-term(mean follow-up 3.7 years)outcome of 978 patients prospectively included in a single-center registry of patients with acute MI treated with PCI within 24 hours after onset of symptoms. Patients were classified according to plasma glucose levels at admission:< 7.8 mmol/L(group I, n=322), 7.8 to 11 mmol/L(group II, n=348), and >11.0 mmol/L(group III, n=308). Results: Mortality at 30 days was 1.2% in group I, 6.3% in group II, and 16.6% in group III(P< .001). After multivariate adjustment for age, the presence of cardiogenic shock, and TIMI 3 flow after PCI, the association of mortality with glucose classification remained significant(P value for trend=.003). The relative risk of death at 30 days for group III versus group I was 3.9(95% CI 1.2- 13.2). During long-term follow-up, mortality was similar in groups I and II. However, in group III adjusted mortality remained significantly increased compared with group I(relative risk 1.76, CI 1.01- 3.08). Conclusions: In patients undergoing emergency PCI for acute MI, glucose levels at hospital admission are predictive for short- and long-term survival. Knowledge of admission glucose levels may improve initial bedside risk stratification.

不同风险水平的稳定型冠状动脉疾病患者中培哚普利的治疗效应

Aims: Patients with stable coronary artery disease(CAD) are at increased risk. Estimation of individual risk is difficult. We developed a cardiovascular risk model based on the EUROPA study population and investigated whether benefit of long-term administration of the angiotensin-con- verting enzyme(ACE)-inhibitor perindopril was modified by risk level. Methods and results: A total of 12218 patients with stable CAD were treated with 8 mg perindopril or placebo. Baseline patient characteristics were assessed for association with 1091 cardiovascular deaths or non-fatal myocardial infarction(MI). Risk factors were age over 65 years, male gender [hazard ratio(HR) 1.2], previous MI(HR 1.5), previous stroke and/or peripheral vascular disease(HR 1.7), diabetes, smoking, angina(all HR 1.5), and high serum cholesterol and systolic blood pressure. Treatment benefit by perindopril was consistent among high, intermediate, and low risk patients(HRs 0.88, 0.68, and 0.83, respectively). Risk reduction was thus not modified by absolute risk level. Conclusion: Risk factors such as age, male gender, smoking, total cholesterol, and blood pressure continue to play an important role once clinical sequellae of coronary heart disease have developed. Patients at moderate-to-high risk because of uncontrolled risk factors and those with other indications for ACE-inhibitors have the most to gain from ACE-inhibition.

不同类型阵发性房颤的频率分析

OBJECTIVES: This study sought to investigate the regional frequency distributi on from multiple bi-atrial sites in different types of paroxysmal atrial fibril lation(AF). BACKGROUND: A previous study showed a left atrium(LA) to right atriu m(RA) frequency gradient in patients with paroxysmal AF. METHODS: Forty-four pa tients(age=60±16, male patients=27) with paroxysmal AF originating from the pul monary veins(PVs)(n=31) or superior vena cava(SVC)(n=13) were included. Frequenc y analysis was performed on the intracardiac electrograms(7 s, 1 kHz/channel) re corded from PV, posterior LA, coronary sinus(CS), posterolateral RA, and SVC. Th e largest peak frequency was identified as the dominant frequency(DF). RESULTS: In the PV-AF patients, there was a frequency gradient from the PV ostium to the LA, RA, and SVC(8.5±3.3 Hz vs. 5.9±1.1 Hz vs. 5.2±0.85 Hz vs. 5.5±0.48 Hz, respectively, p< 0.001). The highest DFs were mostly located at the arrhythmogen ic PV ostium(58%). The DFs of the arrhythmogenic PV and PV ostium were signific antly higher than those of the non-arrhythmogenic PVs and PV ostia(p< 0.05). In the SVC-AF patients, there was a frequency gradient from the SVC to the RA, LA , and PV(8.0±2.4 Hz vs. 5.9±1.1 Hz vs. 5.9±0.7 Hz vs. 5.8±0.7 Hz, respective ly, p=0.001). The highest DFs were mostly located inside the SVC(77%) instead o f the SVC ostium(as compared with PV-AF patients, p=0.035). CONCLUSIONS: The lo cation of the highest DF depended on the arrhythmogenic PV or SVC. A frequency g radient was present between the arrhythmogenic thoracic vein and atrium in all p atients.

内科学年鉴

Framingham心脏研究中发展为肥胖的估测风险；12月份住院的急性心肌梗死患者的循证治疗和死亡率。