Successful emergency surgical intervention in acute non-STsegment elevation myocardial infarction with rupture:A case report

BACKGROUND The incidence of acute myocardial infarction(AMI)is rising,with cardiac rupture accounting for approximately 2%of deaths in patients with acute ST-segment elevation myocardial infarction(STEMI).Ventricular free wall rupture(FWR)occurs in approximately 2%of AMI patients and is notably rare in patients with non-STEMI.Types of cardiac rupture include left ventricular FWR,ventricular septal rupture,and papillary muscle rupture.The FWR usually leads to acute cardiac tamponade or electromechanical dissociation,where standard resuscitation efforts may not be effective.Ventricular septal rupture and papillary muscle rupture often result in refractory heart failure,with mortality rates over 50%,even with surgical or percutaneous repair options.CASE SUMMARY We present a rare case of an acute non-STEMI patient who suffered sudden FWR causing cardiac tamponade and loss of consciousness immediate before undergoing coronary angiography.Prompt resuscitation and emergency open-heart repair along with coronary artery bypass grafting resulted in successful patient recovery.CONCLUSION This case emphasizes the risks of AMI complications,shares a successful treatment scenario,and discusses measures to prevent such complications.

New Cutoff for High Sensitivity Troponin to Better Risk Stratify Patients with Non-ST Elevated Myocardial Infarction

Background: The diagnosis of Non-ST Elevated Myocardial Infarction (NSTEMI) is dependent on elevation of high sensitivity troponin (Hs-troponin). The current cutoff point for Hs-troponin is highly sensitive but not specific for obstructive coronary artery disease (CAD). This study aims to determine the best cutoff point for diagnosing CAD in patients presented with NSTEMI. Methods: Our study included all patients admitted as NSTEMI that underwent coronary angiography (CAG). They were grouped into two groups: A and B. Group A has obstructive CAD of 70% or more stenosis and group B with non-obstructive CAD. Patients were assessed for their demographics, clinical history, laboratory and imaging results. Using SPSS version 22, the pooled cohort of patients were analyzed at significant level < 0.05 and the data were tested for significant correlations between two predetermined groups. Results: Group A comprised 87.6% of the patients and both groups had a median age of 53 years. In Group A, 91% were males, 54% diabetics, 54% hypertensives, and median Hs-troponin was 145 ng/L. While in group B, 88% were males, 39% diabetics, 60% hypertensives, and median Hs-troponin was 54 ng/L. There was significant correlation between the two groups in the percentage of diabetes and median troponin level (p < 0.05). A ROC curve has identified a level of 127 ng/dL as the best cutoff of Hs-troponin in detecting obstructive CAD (p = 0.03). Interestingly, 60% of patients in group B had alternative diagnoses. Conclusion: Hs-troponin is sensitive but less specific for obstructive CAD. However, increasing its cutoff value will improve its specificity.

Reactive protein, plasminogen activator inhibitor type-1 （PAI-1） levels, PAI-1 promoter 4G/5G polymorphism and acute myocardial infarction

Objective To investigate the relationship between CRP, plasminogen activator inhibitor type 1 （PAI-1） levels, PAI-1 gene promoter 4G/5G polymorphism and the type of acute myocardial infarction （ST elevation myocardial infarction, STEMI vs the non-ST elevation Myocardial infarction, NSTEMI）. Methods One hundred seventy-six consecutive patients with AMI were included for the study, of whom 60 had STEMI and 56 had NSTEMI, and 60 adults without cardiovascular and cerebrovascular disease were selected as controls. Blood samples were obtained from patients within 6 h of AMI and the plasma PAI-1, CRP, and the gene polymorphism were measured. Results Plasma levels of PAI- 1 and CRP were higher in AMI groups, compared those in the control group, and plasma levels of PAI-1 were significantly higher in patients with STEMI compared to those with NSTEMI （80.12ng/ml VS.73.01ng/ml, P 〈0.01）, while CRP levels were not significantly different between patient with STEMI and NSTEMI （3.87 ± 0.79 mg/ml VS.4.01 ±0.69mg/ml, P〉0.05）. PAI-1 levels presented a significant correlation with CRP levels in the NSTEMI subjects. However, PAI-1 and CRP levels could explain the lack of a significant relationship between them in control and STEMI subjects.The frequencies of 4G/4G genotype in the AMI group were higher than those in the control group and higher in patient with STEMI than in patient with NSTEMI. Plasma levels of PAI-1 in subjects with 4G/4G genotype were significantly increased as compared to those in subjects with 4G/5G and 5G/5G genotype. Conclusions Plasma PAI-1 levels were associated with different myocardial infarction type, and PAI-1 promoter 4G/5G polymorphisms and CRP may be related to plasma PAI-1 levels

A Retrospective Clinical Analysis of 216 Patients With Non-ST Segment Elevation Myocardial Infarction

Objectives To analyze the clinical characteristics of 216 patients with non-ST segment elevation myocardial infarction （NSTEMI）. Methods A retrospective analysis was used. Two hundred and sixteen NSTEMI patients were divided into two groups： （1） according to the age： age 〈65 years group and age ≥65 years group; （2） according to thrombolysis in myocardial ischemia trial （TIMI） lib risk stratification scoring system： score 〈4 group and ≥4 group; （3） according to serum creatinine （sCr） level： sCr level ≤ 178 μmol · L^-1 group and 〉 178 μmol · L^-1 group. Seven hundred and eighty six acute myocardial infarction （AMI） patients during the same period were divided into ST segment elevation myocardial infarction （STEMI） group and NSTEMI group. Clinical characteristics of the patients in the two groups were compared. Results （1） The number of NSTEMI patients in age ≥65 years group is significantly greater than that in age 〈 65 years group. Study revealed that the patients in age ≥ 65 years group were without chest pain, had hypertension, dyslipidemia, atrial fibrillation, cardiac and renal dysfunction （sCr 〉 178 μmol· L^-1 ）and triple vessel disease. Fewer patients in this group received coronary artery angiography （CAG）, percutaneous coronary intervention （PCI） and coronary artery bypass graft （CABG）. More number of deaths in this group compared with the age 〈 65 years group. （2） The number of NSTEMI patients in TIMI score 〉 4 group is significantly greater than that in TIMI score 〈 4 group. Four major complications such as acute left ventricular failure, cardiogenic shock, serious arrhythmia and deaths, increased significantly in TIMI score 〉 4 group comparing with TIMI score ≤〈4 group. （3） Obviously, more number of elderly patients, non-insulin dependant diabetes mellitus （NIDDM）, patients with cardiac troponin T （CTnT） 〉3.0 ng· L^-1 and deaths occurred in sCr 〉 178 μmol · L^-1 group.（4） STEMI and NSTEMI patients were compared in same time frame as follows： fewer NSTEMI patients and more elderly patients had no chest pain, NID- DM, hypertension, dyslipidemia, left main coronary artery （LMCA） disease while CTnT ≥3.0 ng· ml^- ; fewer patients with aneurysm （30 days） underwent CAG, PCI and CABG treatment. However, there were no significant differences in smokers, patients with less than 50% stenosis in any vessel, 1 - 3 vessel disease, acute left ventricle heart failure, cardiogenic shock, serious arrhythmia and deaths. （5） The multivariate logistic regression analysis showed that death in NSTEMI was directly influenced by malignant arrhythmias with age ≥70 years. Conclusions Patients with NSTEMI were older, had more risk factors and presented more serious vessel disease, therefore, less of them could receive standard treatment. Complications and mortality of patients with NSTEMI were similar to that of patients with STEMI. Thus, NSTEMI is a serious disease with poor prognosis. NSTEMI patients may present with atypical chest pain and electrocardiogram changes, so are easily missed or loss diagnosed.

NLR与MSI对急性NSTEMI短期预后判断价值

目的本研究旨在探讨校正休克指数(MSI)和中性粒细胞/淋巴细胞比值(NLR)在判断急性非ST段抬高型心肌梗死(NSTEMI)患者短期内可能出现不良预后的预测能力。方法研究组选择2020年3月到2021年9月期间,首次就诊急诊科明确诊断为急性非ST段抬高型心肌梗死的276例患者。通过快速急诊绿道监测血压与心率,并于急诊科10 min内抽取血常规、床旁心脏彩超等相关化验检查,依据监测及化验结果,研究小组计算了校正休克指数(MSI)和中性粒细胞/淋巴细胞比值(NLR),然后根据统计结果将患者分为2组:NLR≥5.0组(n=75)与NLR﹤5.0组(n=201);(2)MSI≥1.2组(n=57)与MSI<1.2组(n=219)。比较2组一般资料情况,发生不良心血管事件的比例,采用受试者ROC曲线下面积来评估NLR值和MSI值对NSTEMI院内不良心血管事件的预测能力。结果连续入选的276例NSTEMI患者中,发生不良心血管事件52例,占18.8%,心源性休克患者15例,占5.4%,恶性心律失常患者24例,占8.7%,死亡13例,占4.7%。NLR≥5.0与MSI≥1.2值组的心功能、收缩压(SBP)、舒张压(DBP)及心率(HR)分别与NLR<5.0与MSI<1.2组比较,差异有统计学意义(P<0.05);NLR≥5.0与MSI≥1.2组MACE发生率分别高于NLR<5.0组与MSI<1.2组(P<0.05)。此外,NLR和MSI的ROC曲线下面积分别为0.734和0.703,提示NLR和MSI均具有评价急性非ST段抬高型心肌梗死患者短期不良心血管事件发生能力。结论MSI与NLR是评估NSTEMI短期不良预后的两个简单的重要的易获得指标。

Differences in symptoms and pre-hospital delay among acute myocardial infarction patients according to ST-segment elevation on electrocardiogram: an analysis of China Acute Myocardial Infarction (CAMI) registry

Background: Approximately 70% patients with acute myocardial infarction (AMI) presented without ST-segment elevation on electrocardiogram. Patients with non-ST segment elevation myocardial infarction (NSTEMI) often presented with atypical symptoms, which may be related to pre-hospital delay and increased risk of mortality. However, up to date few studies reported detailed symptomatology of NSTEMI, particularly among Asian patients. The objective of this study was to describe and compare symptoms and presenting characteristics of NSTEMI vs. STEMI patients. Methods: We enrolled 21,994 patients diagnosed with AMI from China Acute Myocardial Infarction (CAMI) Registry between January 2013 and September 2014. Patients were divided into 2 groups according to ST-segment elevation: ST-segment elevation (STEMI) group and NSTEMI group. We extracted data on patients' characteristics and detailed symptomatology and compared these variables between two groups. Results: Compared with patients with STEMI (N=16,315), those with NSTEMI (N=5679) were older, more often females and more often have comorbidities. Patients with NSTEMI were less likely to present with persistent chest pain (54.3% vs.71.4%), diaphoresis (48.6% vs.70.0%), radiation pain (26.4% vs.33.8%), and more likely to have chest distress (42.4% vs.38.3%) than STEMI patients (all P<0.0001). Patients with NSTEMI were also had longer time to hospital. In multivariable analysis, NSTEMI was independent predictor of presentation without chest pain (odds ratio: 1.974, 95% confidence interval:1.849-2.107). Conclusions: Patients with NSTEMI were more likely to present with chest distress and pre-hospital patient delay compared with patients with STEMI. It is necessary for both clinicians and patients to learn more about atypical symptoms of NSTEMI in order to rapidly recognize myocardial infarction.

Short-term Prognosis of Fragmented QRS Complex in Patients with Non-ST Elevated Acute Myocardial Infarction

Background：There remains significant debate as to the relationship between fragmented QRS （fQRS） complexes on electrocardiogram （ECG） and acute myocardial infarction （AMI）.Few studies have reported on this relationship in non-ST elevated AMI （NSTEMI）,and thus,we attempt to assess this relationship and its potential short-term prognostic value.Methods：This was a single-center,observational,retrospective cohort study.A total of 513 consecutive patients （399 men,114 women） with NSTEMI within 24 h who underwent coronary angiography at our department,between January 1,2014,and December 31,2014.Patients were divided into 2 groups according to the presence or absence of fQRS complex on the admission ECG.fQRS complexes were defined as the existence of an additional R＇ or crochetage wave,notching in the nadir of the S wave,RS fragmentation,or QS complexes on 2 contiguous leads.All patients were followed up for 6 months,and all major adverse cardiac events （MACE） were recorded.Results：In this study,there were 285 patients with fQRS ECG in the 513 patients with NSTEMI.The number of patients with 0-2 coronary arteries narrowed by ≥50% in fQRS group were less while patients with 3 narrowed arteries were more than in the non-fQRS group （P =0.042）.There were fewer Killip Class Ⅰ patients in the fQRS group （P =0.019）,while Killip Class Ⅱ,Ⅲ,and Ⅳ patients were more in the fQRS group than in the non-fQRS group （P =0.019）.Left ventricular ejection fraction levels were significantly lower in the fQRS group （P =0.021）.Baseline total cholesterol,low-density lipoprotein,creatinine,creatine kinase,homocysteine,high-sensitivity C-reactive protein （CRP）,and red blood cells distribution width levels were significantly higher in the fQRS group.Total MACE （MACE,P =0.028）,revascularization （P =0.005）,and recurrent angina （P =0.005） were also significantly greater in the fQRS group.On final logistic regression analysis,after adjusting for baseline variables,the following variables were independent predictors of fQRS：Coronary artery narrowing （P =0.035）,Killip classification （P =0.026）,and total cholesterol （P =0.002）.The following variables were found to be independent predictors of preoperative MACE：Hemoglobin （P =0.000）,gender （P =0.026）,fQRS （P =0.016）,and time from myocardial infarction to balloon or coronary artery bypasses grafting （P =0.013）.Conclusions：The fQRS complexes are commonly present in NSTEMI and the fQRS complexes are an independent predictor of MACE in NSTEMI patients.The number of narrowed coronary arteries,Killip classification,and total cholesterol are all independent predictors of the fQRS complexes.

NSTEMI患者PCI术后再入院风险预测模型的建立及验证

目的:探讨急性非ST段抬高型心肌梗死(NSTEMI)患者行直接PCI术后再入院的影响因素,并建立预测模型。方法:选取166例NSTEMI患者为研究对象,依据患者PCI术后1年内是否因心梗及心肌梗死并发症再入院分为再入院组(n=110)和未再入院组(n=56)。分析NSTEMI患者行直接PCI术后再入院的独立影响因素,并构建其风险预测模型列线图,绘制受试者工作特征(ROC)曲线来评估模型区分度,采用Hosmer-Lemeshow对模型进行拟合优度检验,绘制校准曲线评估模型准确度。结果:心率、有无肺炎病史、病变血管数、甘油三酯、B型利钠肽为NSTEMI患者经直接PCI术后再入院的独立预测因素(P<0.05)。构建预测模型列线图,ROC曲线显示,曲线下面积(AUC)为0.773,敏感度为70.9%,特异度为76.8%,Hosmer-Lemeshow拟合优度检验显示,差异无统计学意义(χ^(2)=8.329,P=0.351)。通过模型校准曲线提示列线图模型的实际曲线接近理想曲线。结论:心率、有无肺炎病史、病变血管数、甘油三酯、B型利钠肽为NSTEMI患者直接PCI术后再入院的独立预测因素,以此建立的预测模型列线图可直观、快捷的对该类患者再入院的风险进行评估。

hs-cTnT、BNP、eGFR水平与老年NSTEMI患者短期预后的关系

目的研究血清高敏心肌肌钙蛋白(hs-c Tn T)、全血B型钠尿肽(BNP)、估算肾小球滤过率(e GFR)水平与老年急性非ST段抬高心肌梗死(NSTEMI)短期(住院期间及出院90 d内)转归的关系。方法回顾性分析我院心内科年龄≥65岁的急性NSTEMI住院患者,记录此次住院期间最高hs-c Tn T、BNP及最差e GFR水平;将患者分为无不良心脑血管事件组(A组)、复合不良心脑血管事件组(B组),比较两组间hs-c Tn T、BNP、e GFR水平。结果共310例患者入选,其中男性158例,占51.0%;平均年龄(81.32±6.72)岁;平均住院(14.60±7.05)d;短期不良心脑血管事件发生率为47.7%。hs-c Tn T、BNP、e GFR水平两组相比P=0.391、P=0.001、P=0.001;预测出现复合不良心脑血管事件ROC曲线下面积为0.527、0.723、0.675;Logistic回归分析发现高BNP水平为患者出现复合不良心脑血管事件的独立预测因子。结论老年NSTEMI患者最高hs-c Tn T水平与是否发生不良心脑血管事件及死亡无明显相关性;BNP、e GFR水平对预测发生不良心脑血管事件有一定相关性;BNP水平增高为发生复合不良心脑血管事件独立危险因素。

合并2型糖尿病的老年NSTEMI患者应用替罗非班的疗效和安全性研究

目的观察在应用常规抗血小板聚集、抗凝药物的基础上合用替罗非班治疗合并2型糖尿病的老年非ST段抬高型心肌梗死(NSTEMI)患者的临床疗效和安全性。方法选取合并2型糖尿病的老年NSTEMI患者80例,随机分成替罗非班治疗组40例和对照组40例。对照组患者应用阿司匹林、氯吡格雷、低分子肝素钙联合治疗7d;治疗组在对照组用药的基础上,加用替罗非班静脉注射。观察两组治疗7d内全因死亡、梗死后心绞痛、再发心肌梗死的发生率,出血情况和血小板计数变化。结果治疗组较对照组7d内全因死亡、梗死后心绞痛、再发心肌梗死的发生率显著下降,两组比较差异有统计学意义(P<0.05)。两组患者均无严重出血,轻中度出血的发生率比较差异无统计学意义(P>0.05);治疗组患者血小板计数较用药前无明显下降(P>0.05),与对照组比较差异无统计学意义(P>0.05)。结论在使用常规抗血小板聚集、抗凝药物基础上合用替罗非班治疗合并2型糖尿病的老年NSTEMI患者安全有效。

SCAMI-NSTEMI评分优化NSTEMI患者死亡风险预测及院前急救策略的临床研究

目的在非ST段抬高型心肌梗死(NSTEMI)人群中对基于中国急性心肌梗死(AMI)注册研究建立的简化NSTEMI(SCAMI-NSTEMI)评分进行验证,并与全球急性冠状动脉事件(GRACE)评分进行比较,探索其对院前急救策略的影响。方法入选2019年1月至2019年12月NSTEMI患者279例,收集患者的基线资料和死亡等数据,分别计算每例患者的SCAMI-NSTEMI评分和GRACE评分,并利用受试者工作特征(ROC)曲线下面积(AUC)和净重新分类指数(net reclassification imporvement,NRI)等方法对评分进行验证和比较。结果与GRACE评分比较,SCAMI-NSTEMI评分表现出更优秀的分辨能力[AUC=0.789,95%置信区间(CI):0.734~0.834]和分类能力(NRI=43.61%,P<0.0001),并且更准确、有效地识别高危患者。结论SCAMINSTEMI评分能够改善NSTEMI患者死亡风险的预测,并在此基础上指导优化NSTEMI患者院前急救策略。

NSTEMI患者血清hs-CRP、cTnI和D-D检测的临床评价

目的:探讨非ST抬高型急性心肌梗死(NSTEMI)患者血清hs-CRP、cTnI和D-D水平变化的临床意义。方法:应用免疫比浊法、生化法和酶联法对66例疑NSTEMI患者进行了血清hs-CRP、cTnI和D-D检测,并根据临床诊断分成观察组和对照组,进行统计学分析。结果:NSTEMI患者血清hs-CRP、cTnI和D-D水平均非常显著地高于对照组(P<0.01),且血清hs-CRP水平与cTnI和D-D水平呈显著的正相关(r=0.5782、0.6134,P<0.01)。结论:血清hs-CRP、cTnI和D-D水平升高与NSTEMI密切相关,对NSTEMI的预测、诊断和预后均有一定的临床价值。

循环血外泌体miR-320对NSTEMI的鉴别诊断价值研究

目的探讨循环血外泌体miR-320对非ST段抬高心肌梗死(NSTEMI)的鉴别诊断价值。方法连续纳入2017年1月~2019年7月医院收治的NSTEMI患者112例作为观察组训练集,同期纳入非心肌梗死患者37例作为对照组,纳入2019年8月~2020年12月医院收治的NSTEMI患者75例作为观察组测试集,同期纳入非心肌梗死患者21例作为对照组,提取两组患者外周血外泌体并通过实时荧光定量PCR检测miR-320表达水平,使用皮尔逊线性相关分析miR-320表达和高敏心肌肌钙蛋白(hs-TnI)水平的相关性;使用受试者工作特征曲线(ROC)及其曲线下面积(AUC)评估其诊断效能。结果观察组miR-320表达量与hs-TnI水平相关系数为0.831(95%可信区间0.782~0.871,P<0.001),对照组miR-320表达量与hs-TnI水平相关系数为 0.383 (95%可信区间 0.138~0.583,P<0.01);miR-320 诊断 NSTEMI 的 AUC值为 0.899 (95%可信区间 0.839~0.943),高于hs-cTnI的0.739(95%可信区间0.661~0.808),差异有统计学意义(Z=3.100,P<0.01),根据ROC曲线确定的miR-320和hs-cTnI最佳灵敏度和特异度下截断值分别为1.14和0.18 ng/ml,测试集中miR-320诊断NSTEMI的灵敏度、特异度、阳性似然比、阴性似然比及正确指数分别为73.3%、90.5%、7.70、0.29、0.64。结论循环血外泌体miR-320能有效区分NSTEMI与病毒性心肌炎和急性肺栓塞患者,对NSTEMI的鉴别诊断有较好应用前景。

NSTEMI患者血清IL-6、cTnI和TNF-α检测的临床评价

目的:探讨非ST抬高型急性心肌梗死(NSTEMI)患者血清IL-6、cTnI和TNF-α水平的变化的临床意义。方法:应用放射免疫分析和生化法对62例怀疑NSTEMI患者进行了血清IL-6、cTnI和TNF-α检测,并根据临床诊断分成观察组和对照组,进行统计学分析。结果:NSTEMI患者血清IL-6、cTnI和TNF-α水平均非常显著地高于对照组。且血清IL-6水平与cTnI和TNF-α水平呈显著正相关(r=0.5782、0.6024,P<0.01)。结论:血清IL-6、cTnI和TNF-α水平升高与NSTEMI的预测、诊断和预后均有一定的临床价值。

Routine Primary PCI;Whether and When Necessary for the Management of NSTEMI—An Evidence Based Evaluation

Non ST elevated myocardial infarction (NSTEMI) accounts for a significant portion of the hospitalizations due to acute coronary syndromes worldwide and is posing a huge challenge towards the health care cost globally. This signifies the need for proper triage and management stratification for the best utilization of the health care resources. Primary Percutaneous Coronary Intervention (PCI) with early revascularization is a new emerging invasive technique and application of this technique is increasing tediously among the clinicians. However, the current body of evidences is divided between the efficacy, need and critical timing of PCI compared to conservative management in the treatment protocol for NSTEMI. A review of trials done comparing the early use of PCI versus conservative management indicates inconsistent finding with strong evidence towards early use of PCI in moderate to high-risk NSTEMI patients.

休克指数及中性粒细胞/淋巴细胞比值对急性非ST段抬高心肌梗死患者短期预后的预测价值

目的研究休克指数(SI)与中性粒细胞/淋巴细胞比值(NLR)对急性非ST段抬高心肌梗死(NSTEMI)患者短期预后的判断价值。方法选取2016年3月至2018年3月首诊承德医学院附属医院急诊科的NSTEMI患者516例。根据患者SI、NLR水平及NSTEMI患者10 d内主要不良心脏事件(MACE)发生情况分组:①SI<0.7与SI≥0.7组;②NLR<5.0组与NLR≥5.0组;③MACE组与非MACE组。比较各组临床资料及MACE发生例数。采用受试者工作特征曲线(ROC曲线)分析比较NLR与SI对NSTEMI患者MACE发生的预测能力。结果纳入NSTEMI患者516例,其中92例(17.8%)发生MACE,包括4.3%全因病死22例、5.2%心源性休克27例和8.3%致命性心律失常43例。而且,SI≥0.7并NLR≥5.0患者56例,其中19例发生MACE,占33.92%;NLR≥5.0并SI<0.7患者104例,其中30例发生MACE,占28.88%;SI≥0.7并NLR<5.0患者48例,其中9例发生MACE,占18.75%.NLR≥5.0组患者MACE发生例数及SI水平高于NLR<5.0组(均P<0.05)。SI≥0.7组患者MACE发生例数及NLR水平高于SI<0.7组(均P<0.05)。与非MACE组比较,MACE组患者NLR与SI水平明显升高(均P<0.05),NLR、SI的ROC曲线下面积为0.734和0.681。结论NLR和SI对预测NSTEMI患者短期内MACE的发生均具有较高的价值,NLR的预测能力优于SI.

银杏酮酯联合常规抗血小板方案在急性冠脉综合征患者经皮冠脉介入术后氯吡格雷抵抗的应用价值

目的:评价银杏酮酯联合常规双联抗血小板方案在急性冠脉综合征(ACS)患者经皮冠状动脉介入治疗(PCI)术后氯吡格雷抵抗时的应用价值。方法:选取2017年1月至12月在首都医科大学附属北京潞河医院共有1 560例ACS患者行PCI手术,按就诊顺序纳入489例经血栓弹力图证实存在氯吡格雷抵抗的患者进行临床观察,根据不同抗血小板方案将其分为A组(n=127)、B组(n=209)和C组(n=153)。A组采用阿司匹林+氯吡格雷强化的抗血小板治疗方案,B组采用阿司匹林+替格瑞洛的抗血小板治疗方案,C组采用阿司匹林+氯吡格雷+银杏酮酯的抗血小板治疗方案。调整用药后2周复查TEG,观察3组腺苷二磷酸抑制率(ADP%)、花生四烯酸抑制率(AA%),比较用药期间药物不良反应发生率(ADR)、3组抗血小板治疗的药物总费用(元),考察随访6个月时主要不良心血管事件(MACE)发生率。结果:调整用药后2周复查TEG发现,3组ADP%、AA%均较其调整用药前明显改善(P<0.05),3组组间比较差异有统计学意义(P>0.05),其中C组改善最佳(P<0.05)。3组抗血小板治疗药物总费用分别是:A组440.30元,B组305.20元,C组307.44元。与B组比较,C组药物总费用没有明显增加。持续随访6个月,3组总ADR发生率分别是:A组为14.38%(22/127),B组为30.62%(61/209),C组为7.19%(11/153),3组比较差异有统计学意义(P<0.05),其中C组皮肤黏膜轻度出血发生率更低(P<0.05)。3组MACE发生率分别是:A组4.72%(6/127),B组0.48%(1/209),C组0.65%(1/153),3组比较差异无统计学意义(P>0.05)。结论:银杏酮酯联合常规阿司匹林和氯吡格雷双联抗血小板治疗可有效改善ACS患者PCI术后出现的氯吡格雷抵抗,可显著降低血小板的聚集活性、降低出血率及近期MACE事件,且不会增加药物费用,故推荐这一方案在临床合理应用。

碎裂QRS波群对老年非ST段抬高性心肌梗死患者临床诊断及冠状动脉病变程度的预测价值

目的探究碎裂QRS（fQRS）波群对老年非sT段抬高性心肌梗死（NSTEMI）患者临床诊断及冠状动脉病变程度的预测价值。方法采用回顾性研究方式，选取2016—02—2017-02石河子大学医学院第-附属医院住院治疗的194例老年NSTEMI患者进行研究。根据标准12导联心电图（ECG）检查结果，分为fQRs波阳性组112例和fQRs波阴性组82例。计算fQRS波和病理性Q波发生率，以及敏感度和特异度，并分析两组患者冠脉病变数和冠脉狭窄程度。结果两组患者性别、吸烟史、高血压病、高脂血症、糖尿病、总胆固醇（TC）和低密度脂蛋白（LDL）水平比较差异无统计学意义（P〉0．05）。两组患者年龄差异有统计学意义（P〈0．05），fQRS波阳性组患者冠心病病史例数和Gensini评分明显高于fQRs波阴性组患者（P〈0．05）。fQRS波发生率明显高于病理性Q波发生率（P〈0．05），fQ·RS波诊断敏感度明显高于病理性Q波（P〈0．05），fQRS波与病理性Q波诊断特异度差异无统计学意义（P〉0．05）。fQRS波阳性组患者单支血管病变率明显低于fQRs波阴性组患者（P〈0．05），但双支及多支血管病变率fQRs波阳性组要明显高于fQRs波阴性组（P〈0．05），fQRs波阳性组患者冠状动脉狭窄程度明显高于fQRs波阴性组患者（P〈0．05）。对具有统计学意义单因素指标进行Logistic回归分析，老年NSTEMI患者年龄i〉70岁、既往冠心病史、冠脉病变支数≥2支、Gensini评分≥50分与心电图出现fQRS波具有相关性（P〈0．05）。结论fQRs波群对老年NSTEMI患者诊断敏感度较高，对预测患者冠脉病变支数和冠脉狭窄程度有-定价值，是诊断NSTEMI的-个非常重要指标，具有很大的临床应用价值。

非ST段抬高型心肌梗死患者介入治疗时机的选择临床分析

目的探讨不同类型非ST段抬高型心肌梗死(non-ST segment elevated myocardial infarction,NSTEMI)患者可靠临床治疗时机。方法选取该院收治的NSTEMI患者228例为研究对象,按照患者合并症情况进行分组,分成高血压组(110例)和糖尿病组(118例),比较两组患者采用不同治疗时机后的相关临床情况。结果合并糖尿病的NSTEMI患者中,早期介入治疗组患者平均血糖水平较高(P<0.05)。在再发心绞痛、再发心肌梗死、心衰等不良心脏事件发生情况上,合并高血压NSTEMI患者中早期介入治疗组优于择期介入治疗组(均P<0.05);合并糖尿病NSTEMI患者中早期介入治疗组效果差于择期介入治疗组,且差异均具有显著性(均P<0.05)。结论在临床针对非ST段抬高型心肌梗死患者实施介入治疗的过程中,对于合并高血压的患者应实施早期介入治疗,对于合并糖尿病的患者应实施择期介入治疗更可靠。

3种药联合盐酸替罗非班治疗急性冠状动脉综合征患者的疗效观察

目的探讨阿司匹林、氯吡格雷、低分子肝素联合替罗非班治疗急性冠状动脉综合征(ACS)患者的临床疗效和安全性。方法选择2008年2月至2010年5月该院收治的ACS患者120例,其中观察组61例,对照组59例。两组患者均用阿司匹林、氯吡格雷相同剂量。观察组在应用盐酸替罗非班期间同时皮下注射低分子肝素,对照组患者则单用低分子肝素。结果观察组与对照组比较8 d内全因死亡、顽固性心肌缺血的发生率明显下降(P<0.05)。观察组患者血小板聚集率在给药后明显降低(P<0.01)。两组轻度出血比较差异有统计学意义(P<0.05),观察组患者的血小板计数与用药前相比稍有下降(P<0.05),但数值没有超出正常范围,活化部分凝血时间(APTT)在用药后虽有所升高(P<0.05),但未超过正常值的1倍以上。结论在应用阿司匹林、氯吡格雷、低分子肝素的基础上合用盐酸替罗非班治疗ACS患者是有效并安全的。