房颤患者中充血性心力衰竭的发生率和死亡风险:一项超过20年的社区研究

Aims: We sought to determine whether the incidence of and survival following congestive heart failure(CHF) in patients with atrial fibrillation(AF) have changed over time. Methods and results: Olmsted County, Minnesota residents diagnosed with first AF during 1980-2000 were identified and followed in medical records to 2004. The trends of incidence and survival of CHF over time were assessed. Of the 3288 subjects(mean age 71±15 years) diagnosed with first AF and without CHF prior to or at AF diagnosis, 790(24%) developed a first CHF during a mean follow-up of 6.1±5.2 years(unadjusted incidence, 44 per 1000 person years). Age-and sex-adjusted CHF incidence was unrelated to calendar year of AF diagnosis(P=0.86). The age-and sex-adjusted mortality risk following CHF was higher than that in patients without CHF(hazard ratio 3.4, 95%confidence interval 3.1-3.8, P< 0.0001). There were no detectable changes over time with respect to the absolute(P=0.94) or the relative(P=0.68) mortality risk after CHF diagnosis. Conclusion: In this study spanning two decades, there appeared to have been no significant reduction in terms of the incidence and mortality risk of CHF following first AF diagnosis.

因急性心肌梗死行直接血管成形术的患者中侧支血流对心肌再灌注和梗死面积的影响

背景:在接受直接经皮冠状动脉介入(PCI)的患者中,基线时梗死相关动脉(IRA)的侧支血流的预后意义仍存在争论。作者旨在观察在因急性心肌梗死(AMI)行直接PCI的患者中基线IRA侧支血流对再灌注成功率、

急性心肌梗死患者梗死动脉定位、心外膜血流以及直接经皮血运重建后心肌灌注之间的关系

Background: The association between infarct artery location, reperfusion success, and clinical outcomes after primary percutaneous coronary intervention(PCI) has not been characterized. We examined the infarct artery-specific impact of epicardial and myocardial flow and reperfusion after primary PCI for acute myocardial infarction. Methods: Among 2082 patients undergoing primary PCI in the CADILLAC trial, myocardial blush grade, TIMI flow grade, ST-segment resolution, and clinical outcomes were analyzed according to the infarct artery. Results: Baseline clinical characteristics did not significantly differ between patients experiencing infarction in the left anterior descending(LAD, 37%) versus left circumflex(18%) and right coronary artery(46%) distributions. Baseline left ventricular function was reduced, and collateral flow was less commonly present in patients with infarction involving the LAD. Achievement of final TIMI-3 flow, grade 3 myocardial blush, and ST-segment resolution >70%was also significantly less common in anterior infarction. Patients with anterior versus nonanterior infarction had significantly higher mortality at 30 days(3.4%vs 1.3%, P=.0006) and 1 year(6.5%vs 2.9%, P< .0001) and had increased 1-year rates of reinfarction(3.6%vs 1.7%, P=.009) and ischemic target vessel revascularization(16.1%vs 11.7%, P=.006). By multivariate analysis, LAD infarction was a powerful independent predictor of 1-year mortality(odds ratio 2.45, P=.009). Conclusions: Acute myocardial infarction involving the LAD distribution is associated with reduced left ventricular function, less frequent collateral flow, impaired myocardial perfusion and decreased reperfusion success, findings associated with reduced survival, and increased major adverse cardiac events compared with other vascular territories. These data provide mechanistic insights to the adverse prognosis of patients with anterior infarction.

1980—2000年确诊为首次心房纤颤患者缺血性卒中发生率和死亡率的时间趋势:社区研究报道

Background and Purpose -With the changes in management of atrial fibrillation (AF) over time, it is possible that the time trends of post-AF stroke incidenc e and mortality have changed. We sought to determine whether the incidence and survival of ischemic stroke after AF diagnosis have improved. Methods -We identified the Olmsted County, Minn, residents who developed first AF from 1980 to 2000 and followed them in medical records to 2004. The outcomes were first ischemic stroke and death. Results -Of the 4117 subjects diagnosed with first AF and without previous stroke, 446 (11%) sustained a first ischemic stroke during a mea n follow-up time of 5.5±5.0 years. The age-and sex-adjusted incidence of str oke decreased, on average, by 3.4%per year (P=0.0001), concurrent with an increase in warfarin and aspirin use (both P < 0.0001) and reduction of systolic blood pressure (P < 0.001). The age-adjusted ischemic stroke incidence was higher in women (P=0.039), but not after adjusting for systolic blood pressure (P=0.41). Compared with the general Minnesota white population, the relative mortality hazard ratio was 1.88 for men and 1.84 for women without stroke and 3.03 for men and 3.80 for women (P < 0.05)with stroke. The relative mortality hazard did not vary by age or calendar year of AF diagnosis. Conclusions -Post-AF ischemic stroke incidence decreased significantly from 1980 to 2000, during which time a substantial increase in the use of antithrombotic therapy and reduction of systolic blood pressure was evident. The relative mortality risk of stroke, however, had not improved over time.

急性心肌梗死后室性心律失常:一项20年的社区研究

Background: Although myocardial infarction(MI) severity is declining, the occurrence of ventricular arrhythmia(VA) after MI and its effect on outcome is unknown. This study was undertaken to examine the frequency and timing of VA and the effect of VA on mortality after MI. Methods: Myocardial infarctions recorded between 1979 and 1998 were validated. Baseline characteristics, occurrence of VA, and survival were determined. Ventricular arrhythmias were categorized as primary ventricular fibrillation(VF), nonprimary VF, and ventricular tachycardia(VT). Logistic regression was used to analyze associations between VA and baseline characteristics. Temporal trends were assessed with the Mantel-Haenszel χ2. Survival was analyzed with the Kaplan-Meier method. Proportional hazards regression was used to examine the association between death and occurrence of VA. Results: Among 2317 persons with incident MI, 7.5%experienced VA(3.6%nonprimary VF, 2.1%primary VF, 1.8%VT). Ventricular arrhythmia-associated factors were younger age, female sex, higher Killip class, ST elevation, and atrial fibrillation. Ventricular arrhythmias were associated with increased risk of death at 30 days. Conclusions: Ventricular arrhythmias after MI are relatively common, particularly among persons with more severe MI and no prior history of coronary disease. Over time, the incidence of VF declined, whereas VT did not change. Ventricular arrhythmia after MI was associated with a 6-fold increase in morality. Thus, identification of highrisk MI survivors and prevention of VA could markedly improve outcomes. Further studies are needed to determine the cause of the shift in distribution of VA subtype.