直接血管成形术前血栓抽吸有助于改善急性心肌梗死患者的心肌再灌注:DEAR-MI(去除血栓以增加心肌梗死患者的急性再灌注)研究

目的:本研究旨在验证以下假说,即在直接经皮冠状动脉介入(PPCI)前应用一种新型人工血栓抽吸装置去除血栓与标准PPCI治疗相比,改善了ST段抬高型急性心肌梗死(STEMI)患者的心肌再灌注。

药物负荷超声心动图在已知或疑似冠状动脉疾病的糖尿病及非糖尿病患者中的预后价值

OBJECTIVES: We sought to compare the prognostic value of pharmacological stress echocardiography(SE) in diabetic and nondiabetic patients with known or suspected coronary artery disease. BACKGROUND: Although SE is a useful tool for risk stratification of patients with diabetes, it has not been established whether it retains the same prognostic information in diabetic patients compared with nondiabetic patients. METHODS: A total of 5,456 patients(749 diabetics) undergoing dipyridamole(n=3,306) or dobutamine(n=2,150) SE were prospectively followed up for the occurrence of hard events(death and/or nonfatal myocardial infarction). RESULTS: During a median time of 31 months, 411 deaths and 236 infarctions occurred. There were 132 events in diabetic patients and 515 in nondiabetic patients(18% vs. 11% , respectively; p< 0.0001). Moreover, 1,607(29% ) patients underwent coronary revascularization and were censored. Ischemia at SE, resting wall motion score index, and age were independent predictors of death and hard events in both diabetic and nondiabetic patients. Compared with a normal test, ischemia and scar test patterns were associated to significantly lower age- corrected five- year hard event- free survival in diabetic as well as nondiabetic patients. However, a normal test was associated with a greater than two- fold annual event rate in diabetic patients as compared with nondiabetics who were either younger(2.6% vs. 1.0% ) or older(5.5% vs. 2.2% ) than 65 years of age. CONCLUSIONS: Stress echocardiographyis equally effective in risk stratifying diabetic and nondiabetic patients independently of age. However, the normal test result predicts a less favorable outcome in diabetic than in nondiabetic patients.

药物洗脱期对急性心肌梗死后进行运动试验患者的影响

Study objectives: Pharmacological therapy can reduce diagnostic and prognostic accuracy of exercise stress testing. However, the risk of withdrawing drugs ear ly after myocardial infarction (MI) has not been established. We assessed safety and clinical implications of drug withdrawal in patients undergoing stress test ing after uncomplicated MI. Methods: A total of 362 MI patients underwent ECG Ho lter recording before and after withdrawing beta blockers, calcium antagonists and nitrates. QRS(QRS/h) and ventricular premature beats(VPB/h) count per hour, repetitive ventricular arrhythmias, ST segment changes and patient complaints w ere evaluated for reproducibility using kappa statistics and Bland Altman metho d. Results: No major complications occurred. Forty three patients complained of >1 symptom on and 37 off therapy. QRS/h and VPB/h count were significantly(p< 0 .0001) higher off therapy but correlated with the corresponding values on therap y. A mean heart rate increase of 8 beats/min (agreement range -8 to +14 beats/ min) and a fivefold increase in VPB/h(agreement range -141 to +151) were obser ved after withdrawing therapy. Repetitive ventricular arrhythmias and ST changes were also more frequent off therapy but intra patient reproducibility was poor : kappa 0.12(95%confidence interval(CI)-0.01 to 0.25) for arrhythmias, -0.02( 95%CI-0.46 to 0.39) for ST depression and -0.01(95%CI-0.66 to 0.64) for ST elevation. Conclusions: The withdrawal of therapy is well tolerated soon after u ncomplicated MI; however, a generic but not individual risk of ventricular arrhy thmias and/or transient myocardial ischemia has to be taken into account.

采用门控单光子发射CT进行左室灌注和左室功能联合评估,以对高危高血压患者风险分层

Objective: This study was aimed at verifying whether combined information on l eft ventricular perfusion and function by electrocardiogram-gated single-photo n emission computed tomography(SPECT) retains its known prognostic value in pati ents with systemic hypertension. Methods: A total of 415 hypertensive patients u nderwent rest and stress(exercise in 278 and dipyridamole in 137) gated 99mTc-s estamibi SPECT and prospective follow-up for the composite endpoint of death an d acute coronary syndrome. Patients undergoing revascularization were censored. The individual effect of clinical and stress imaging data on outcome was evaluat ed by Cox regression analysis. Model validation was performed using bootstrap me thods adjusted by the degree of optimism in estimates. Survival analysis was per formed using the product-limit Kaplan-Meier method. Results: During a median f ollow-up of 24 months, 12 cardiac deaths and 32 acute coronary syndromes occurr ed. After adjusting for the most significant covariates, age[hazard ratio(HR) 1. 62, 95%confidence interval(CI) 1.02-2.57], diabetes(HR 7.51, 95%CI 1.61-35.2 ), summed stress score(HR 2.06, 95%CI 1.07-4), and peak end-systolic volume(H R 3.62, 95%CI 1.35-9.69) were multivariable predictors of outcome. The normal perfusion pattern was associated with a low event rate independently of peak end -systolic volume. Conversely, in the case of moderate to severe perfusion abnor malities, a peak end-systolic volume greater than 74 ml was able to identify an increased risk of adverse outcome. Moreover, peak end-systolic volume was sign ificantly higher among patients who died of a cardiac cause compared with those with different outcomes. Conclusion: A combined assessment of left ventricular p erfusion and function by gated SPECT significantly improves risk strati fication in hypertensive patients.

运动心电图结果阴性的患者中负荷恢复指数与常规心电图标准的预后价值比较

为了确定负荷恢复指数(SRI)是否有助于对根据常规标准判定为运动心电图(ECG)结果阴性的患者的风险分层,测定连续708例运动ECG结果阴性患者的SRI。将全因死亡以及死亡或非致死性心肌梗死的联合事件作为目标终点。利用各变量组单独模型的Cox回归分析来评估临床和运动试验数据各自对预后的影响。通过校正评估满意度的bootstrap法来验证模型。