Management of acute coronary occlusion during percutaneous transluminal coronary angioplasty: experience of complications in a hospital without on site facilities for cardiac surgery.

OBJECTIVE--To determine whether percutaneous transluminal coronary angioplasty may be safely performed in cardiology centres in the United Kingdom without immediate on site cardiac surgical cover for complications arising at angioplasty. DESIGN--Retrospective review of coronary angioplasties and complications in a hospital without on site cardiac surgical cover. SETTING--All angioplasties were performed in the catheterisation laboratory of the Belfast City Hospital. Revascularisation surgery for complicated coronary angioplasty was performed in the cardiac surgical unit of the Royal Victoria Hospital, 2.4 km away from the catheterisation laboratory. PATIENTS--540 Coronary angioplasties were performed on 512 patients between late 1982 and November 1988. Indications included stable angina, unstable rest angina, and suitable coronary disease at coronary arteriography after myocardial infarction. MAIN OUTCOME MEASURES--In hospital mortality after complicated coronary angioplasty and delay to surgical revascularisation after acute coronary occlusion at angioplasty. RESULTS--Coronary angioplasty was successful in 444 cases (82%). Acute coronary occlusion occurred in 35 cases (6.5%). Twelve patients required urgent revascularisation surgery and were transferred safely to the surgical unit; none of these patients died. A mean delay of 268 minutes (range 180-390 minutes) occurred before revascularisation compared with 273 minutes (range 108-420 minutes) in the Royal Victoria Hospital, where on site surgical cover was available. The principal cause of delay was the wait for a cardiac operating theatre to become available and not the transfer time between hospitals. Five deaths occurred after coronary angioplasty, a mortality of 0.9%. Three deaths were related to acute coronary occlusion. The absence of immediate surgical help did not influence the outcome in any patient. CONCLUSION--With careful selection of patients coronary angioplasty may be safely performed in a hospital without on site cardiac surgical facilities, provided that these are available at a nearby centre.     

Myocardial blood volume and coronary resistance during and after coronary angioplasty

Animal experiments have shown that the coronary circulation is pressure distensible, i.e., myocardial blood volume (MBV) increases with perfusion pressure. In humans, however, corresponding measurements are lacking so far. We sought to quantify parameters reflecting coronary distensibility such as MBV and coronary resistance (CR) during and after coronary angioplasty. Thirty patients with stable coronary artery disease underwent simultaneous coronary perfusion pressure assessment and myocardial contrast echocardiography (MCE) of 37 coronary arteries and their territories during and after angioplasty. MCE yielded MBV and myocardial blood flow (MBF; in ml · min(-1) · g(-1)). Complete data sets were obtained in 32 coronary arteries and their territories from 26 patients. During angioplasty, perfusion pressure, i.e., coronary occlusive pressure, and MBV varied between 9 and 57 mmHg (26.9 ± 11.9 mmHg) and between 1.2 and 14.5 ml/100 g (6.7 ± 3.7 ml/100 g), respectively. After successful angioplasty, perfusion pressure and MBV increased significantly (P < 0.001 for both) and varied between 64 and 118 mmHg (93.5 ± 12.8 mmHg) and between 3.7 and 17.3 ml/100 g (9.8 ± 3.4 ml/100 g), respectively. Mean MBF increased from 31 ± 20 ml · min(-1) · g(-1) during coronary occlusion, reflecting collateral flow, to 121 ± 33 ml · min(-1) · g(-1) (P < 0.01), whereas mean CR, i.e., the ratio of perfusion pressure and MBF, decreased by 20% (P < 0.001). In conclusion, the human coronary circulation is pressure distensible. MCE allows for the quantification of CR and MBV in humans.     

阿托伐他汀钙片治疗急性冠脉综合征的临床疗效

目的:探讨阿托伐他片汀治疗急性冠脉综合征(ACS)的临床疗效。方法:选择2013年3月至2013年12月我院收治的156例ACS患者,按随机字数表法分为实验组和对照组各78例,两组均采取常规治疗,实验组在此基础上加用阿托伐他汀钙片,对照组则用辛伐他汀滴丸。对比两组治疗效果及心血管事件发生率。结果:两组治疗后总胆固醇(TC)、甘油三酯(TG)、低密度脂蛋白胆固醇(LDL-C)、血清高敏C反应蛋白(hs-CRP)、纤维蛋白原(Fg)和尿酸水平均明显下降,且实验组下降更明显,比较差异均有统计学意义(P0.05);治疗期间实验组心血管事件发生率率为8.97%(7/78),显著低于对照组的24.36%(19/78),比较差异均有统计学意义(P0.05)。结论:阿托伐他汀片治疗ACS的临床效果优于辛伐他汀滴丸,能有效降低心血管事件的发生,值得的临床推广。     

Efficacy and safety of coronary stenting during diagnostic coronary angiography in patients with stable angina

The authors assessed the in-hospital and long-term (up to 6 months) results of coronary stenting conducted just after diagnostic coronarography during a common procedure in patients with stable angina pectoris on effort. The 2001-2002 study included 2277 patients. The clinical indications for catheterization were Functional Classes II-IV stable angina on effort in 83 % of patients and silent ischemia in 17%. The study excluded patients with previous coronarography, acute coronary syndrome on admission, renal failure, left ventricular ejection fraction <30%, and left trunk stenosis. All the patients received aspirin and clopidogrel before catheterization. RESULTS: 57% of patients had multivessel disease; full revascularization was performed in 59% of the patients with multivessel disease. The coronary intervention was successful in 100% of cases. Significant in-hospital events (myocardial infarction without Q wave) were in 1.2% of cases. The mean length of hospital stay was 2.9 +/- 2.4 days. The rate of stent thrombosis for as long as 30 days was 0.2%. Recurrent angina and/or positive exercise tests were in 12% during 6 months. CONCLUSION: immediate stening is effective and safe in most patients with stable angina during diagnostic catheterization. It does not increase immediate and late complications.     

Acute coronary syndrome frequency in western Herzegovina over the fifteen year period (1987-2001)

All patients who suffered from the acute coronary syndrome in western Herzegovina over the fifteen year period (1987-2001) are included in this retrospective epidemiological study. The population that was undertaken by the study is relative stabile and did not emigrate during the war period. The study compared the time before the war (1987-1991), during the war (1992-1996) and after the war (1997-2001). The data were acquired from the archives of the patients of the Mostar hospital and Clinical hospital Split during the war period. A total of 2022 acute coronary syndrome patients were found, 1305 men and 717 women. More patients were treated during the war compared to the time before the war for both male and female patients (p<0.0005). During the after-war period the number of treated patients was greater (p< 0.0005) compared to the war-time for both sexes. The comparison of the after-war period and the pre-war period reveals a statistically significant difference as the number of treated patients (male and female) is larger in the after-war period. The number of patient who are 65 years old and older than that is greater, and that is statistically significant (p= 0.0005.). We can conclude that the stress caused by the war and other factors have influenced a larger number of treated patients of acute coronary syndrome. Therefore, further epidemiological researches of acute coronary syndrome with the accent on prevention and treatment are needed.     

Reversal of slow flow phenomenon during primary stenting by bail-out administration of abciximab

BACKGROUND: Slow flow or no reflow phenomenon is increasingly being recognized as a serious problem during coronary angioplasty and stenting. This phenomenon is seen more often during angioplasty in highly thrombogenic milieux, especially in a setting of acute myocardial infarction. The treatment of this complication is often not satisfactory. In this study the authors assessed the efficacy of abciximab, a potent antiplatelet drug, in treating slow flow or no reflow phenomenon during primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI). METHODS: Twenty-one instances of persistent slow flow phenomenon were encountered in 131 consecutive patients subjected to primary PTCA for AMI (16%). It was more common in patients presenting with AMI complicated by cardiogenic shock (nine of 21, 43%). Of these 21 cases of slow flow, 10 patients were given injection abciximab during the procedure of primary PTCA as a bail-out measure after encountering the complication of slow flow or no reflow. A pre-discharge coronary angiography was carried out in all patients who survived. RESULTS: In seven of 10 patients in the abciximab group flow had improved to TIMI-3. In contrast, in the non-abciximab group TIMI flow improved in only four of 11 patients. Patients with persistent slow flow had significantly higher mortality at the first 30-day follow-up than patients with TIMI-3 flow (33% versus 1.8%, p<0.001). CONCLUSION: In this small nonrandomized study significant improvement in coronary flow was achieved by using intravenous abciximab after observing slow flow or no reflow phenomenon during primary PTCA. More frequent use of this drug in this milieu might help in preventing the development of this complication. Larger studies are warranted to confirm this life-saving beneficial effect of bail-out administration of abciximab during primary angioplasty.     

两种剂量阿托伐他汀治疗老年急性冠脉综合征的疗效及影响炎症、凝血因子的研究

目的:探讨两种剂量阿托伐他汀治疗老年急性冠脉综合征的疗效及对炎症、凝血因子的影响。方法:选择我院2010年1月~2012年12月收治的120例老年急性冠脉综合征患者作为观察对象,根据住院号随机分为观察组和对照组,每组均60例,两组患者均采用阿托伐他汀治疗,对照组予以10 mg/d,观察组予以20 mg/d,比较两组的临床效果以及炎症因子、凝血因子的变化。结果:治疗后,两组血脂达标率均显著提高,观察组治疗后1个月的血脂达标率为33.3%,治疗后3个月的血脂达标率为46.7%,均显著高于对照组的15.0%、23.3%,差异均具有统计学意义(均P0.05);治疗后1个月和3个月所有患者血浆CRP和TF均显著下降,观察组治疗后1个月和3个月CRP和TF水平均显著低于对照组,差异均具有显著性(均P0.05);观察组治疗后3个月TFPI水平显著高于对照组,差异具有统计学意义(P0.05)。结论:大剂量阿托伐他汀治疗老年急性冠脉综合征患者临床疗效优于小剂量,对炎症因子和凝血因子的影响有利于预后的改善,值得临床进一步推广应用。     

Long-term assessment of clinical parameters in patients with coronary heart disease after balloon angioplasty and stenting balloon angioplasty

The aim of this study was to assess clinical parameters in patients with coronary heart disease (CHD) in the late period after balloon coronary angioplasty (BCA) and intracoronary stenting (ICS). The study included 104 patients who underwent repeated coronary angiography (CA) 2-10 months after successful coronary angioplasty. Clinical parameters were analyzed in 2 groups comparable at the moment of its performance in terms of major clinical characteristics. Group 1 comprised 51 patients following BCA and group 2 included 53 patients after ICS. Six months after the first procedure, repeated coronary angioplasty was performed in 19 (37.2%) and 6 (9.4%) patients after BCA and ICS, respectively (p < 0.05). Recurrent angina pectoris was observed in 42 patients from group 1 and in 25 ones from group 2, which was 82.3 and 47.2%, respectively (p < 0.05). Control CA revealed restenosis of the dilated artery in 22 (43.1%) of the 51 patients of group 1 and in 12 (22.6%) of the 53 patients of group 2. There were no differences between the groups in late postoperative bicycle ergometric and 24-hour ECG monitoring findings. The findings have led to the conclusion that implantation of a stent into the coronary artery greatly prolongs the antiischemic effect of coronary angioplasty and reduces a need for repeated endovascular intervention, which appears as lower incidence rates of restenosis and recurrent angina as compared to routine balloon angioplasty.     

冠脉内注射替罗非班不同给药方式对急性心肌梗死介入治疗术中血流异常的影响

目的：比较急性心肌梗死介入治疗中冠脉内常规给予以及必要时给予血小板膜糖蛋白（GP）Ⅱb／Ⅲa受体拮抗剂替罗非班两种给药方式对冠脉血流异常的影响,寻找较好的替罗非班用药方式。方法：入选九四医院2005年1月至2008年10月急性心肌梗死直接PCI患者58例,随机分成常规给药组（血管开通前所有患者冠状动脉内均注射替罗非班,n=30）与必要时给药组（血管开通后即时造影显示TIMI血流≤2级者冠脉内注射替罗非班,TIMI血流3级者不给药,n=28）,观察支架植入后30分钟TIMI血流、30天内主要不良心血管事件（MACE）、出血以及血小板减少情况。结果：必要给药组冠脉内给药可显著改善冠脉血流（TIMI3级给药前46．4％,给药后75％,P〈0．05）,常规给药组支架植入后30分钟TIMI3级获得率高于必要给药组（96．7％比75％,P〈0．05）,MACE、出血和血小板减少事件两组之间差异无统计学意义。结论：冠脉内给予替罗非班可有效降低急性心肌梗死PCI术中血流异常情况,血管开通前冠脉内常规给药方式优于必要时给药方式。     

Lipid management after acute coronary syndrome

PURPOSE OF REVIEW: Despite advances in medical therapy and percutaneous revascularization, patients with acute coronary syndrome face a high risk of early, recurrent cardiovascular events. Interventions targeting atherogenic lipoproteins may favorably modify this risk. RECENT FINDINGS: Two randomized clinical trials, MIRACL and PROVE-IT, demonstrated efficacy of early, intensive statin therapy after acute coronary syndrome. Recent observational and meta-analyses corroborate the findings of these trials. The benefit of intensive statin treatment appears to apply broadly to elderly as well as younger patients, and to patients with or without diabetes or metabolic syndrome. Randomized trials demonstrating the efficacy of early, intensive statin treatment after acute coronary syndrome employed fixed statin dosages, and there does not appear to be an initial or achieved LDL-cholesterol level below which benefit is absent. As such, broad application of intensive statin therapy after acute coronary syndrome may be preferable to titration of statin dose to achieve specific LDL goals. Low HDL-cholesterol predicts risk after acute coronary syndrome; therefore, pharmacologic interventions to raise HDL concentration or mimic its function may help reduce that risk. SUMMARY: Early, intensive statin therapy is safe and effective after acute coronary syndrome. Future research will determine whether drugs that raise or mimic HDL-cholesterol are effective adjuncts to statin therapy.     

Design of a randomized controlled trial of comprehensive rehabilitation in patients with myocardial infarction, stabilized acute coronary syndrome, percutaneous transluminal coronary angioplasty or coronary artery bypass grafting: Akershus Comprehensive Cardiac Rehabilitation Trial (the CORE Study)

Objectives  

1. To assess the long-term effectiveness of a comprehensive cardiac rehabilitation programme on quality of life and survival in patients with a large spectrum of cardiovascular diseases (myocardial infarction, acute coronary syndrome, percutaneous transluminal coronary angioplasty and coronary artery bypass grafting). 2. To establish the degree of correlation between expected improvement of health-related quality of life and improvement in physical function attributable to rehabilitation in the intervention group, in comparison with similar changes in the conventional care group.     

Comparison of ReoPro((R)) (abciximab) versus intracoronary thrombolysis for early coronary stent thrombosis

AIMS: This study evaluated the treatment of early coronary stent thrombosis with intracoronary urokinase or the platelet glycoprotein IIb/IIIa receptor inhibitor ReoPro (abciximab). METHODS AND RESULTS: Seventy-four patients (126 stents) were treated immediately after identification of early (0-30 days) coronary stent thrombosis. Twenty-nine patients were treated with intracoronary urokinase (UK) (UK alone in 19; UK and additional balloon angioplasty in 10) and another 45 patients were given ReoPro((R)) (abciximab) (0.25 mg/kg as a bolus alone in 26, abciximab with additional balloon angioplasty in 19) within 30 days of stent implantation. TIMI grade 3 flow was obtained in 23 patients (79%) in the UK group and in 38 (84%) in the abciximab group (nonsignificant). Three patients (10%) in the UK group and one (2%) in the abciximab group underwent repeat percutaneous transluminal coronary angioplasty (PTCA) (nonsignificant). Five patients (17%) in the UK group and three (7%) in the abciximab group were referred for urgent coronary artery bypass graft surgery (CABG) because of residual thrombus and refractory ischemia (nonsignificant). Repeat revascularization was necessary in eight patients (28%) in the UK group versus four (9%) in the abciximab group (p < 0.05). Five patients (17%) in the UK group and eight (18%) in the abciximab group developed myocardial infarction (nonsignificant). Five patients (17%) in the UK group (cardiogenic shock (three), cerebral hemorrhage (one) and pneumonia (one)) and three (6.6%) in the abciximab group (cardiogenic shock (two), heart failure (one)) died within 30 days (nonsignificant). Overall, noncardiac complications (bleeding including surgical repair of groin) were observed in 11 patients (38%) in the UK group and three (7%) in the abciximab group (p < 0.001). CONCLUSION: Compared to urokinase, abciximab reduced the need for repeat revascularization procedures and the risk of noncardiac events, including bleeding complications in patients with early coronary stent thrombosis.     

Clinical trends in stent treatment of simple and complex coronary disease

This is a retrospective analysis of a consecutive group of patients from a single medical center who underwent stent implantation. It describes 316 patients who constituted 53% of the angioplasty procedures carried out in a single year. The authors describe the complications and their 1-year follow-up. We aimed to study the short and long-term results of stenting in our centre in relation to multiple clinical and angiographic variables. During 1996, 316 consecutive patients were treated with stent implantation for a total of 381 coronary lesions. The pharmacological protocol methods of stent implantation and patient characteristics were used. Clinical variables were: age 59.1 3 10.7 years, diabetes mellitus 25.3%, hypertension 33.0% and angina pectoris 88.7% (unstable in 44.1%). Previous coronary surgery had been undergone by 9.2%. Multivessel disease was present in 56% of the patients. The indications for stenting were: primary 58.5%, suboptimal results 33.0% and threatened or acute occlusion 8.5%. Angiographic success was 98.9% and clinical success 96.8%. The major in-hospital complications were acute myocardial infarction (2.2%), acute revascularization (0.3%) and major bleeding (0.6%). All occurred within 24 h of revascularization. Repeated angiography was performed in 115 cases (30.2%) at 160.3 3 109.4 days after stent procedure for unstable angina (38.7%), stable angina (26.1%) and other causes (35.2%). The restenosis rate in those catheterized was 38.1%, with an overall clinical restenosis rate of 11.3% during the follow-up period. Restenosis was more prevalent among diabetic patients (17.9 vs 9.15%, P 3 0.02) and patients with prior balloon angioplasty (18.6 vs 9.75%, P 3 0.046). Clinical follow-up was available in 90.8% of the patients for 291 3 112 days. The actuarial survival at the end of the follow-up period was 93.8%. Death/myocardial infarction was associated with unstable angina pectoris (P 3 0.006), hypertension (P 3 0.001), smoking (P 3 0.046) and threatened or acute occlusion (P < 0.001). In the first year of extensive stent use, stenting is associated with high technical and clinical success rates. Long-term results after stent implantation are associated with the occurrence of acute or threatened occlusion, and the in-hospital complications diabetes mellitus and hypertension.     

灯盏细辛口服液对急性冠状动脉综合征患者外周血C-反应蛋白、MCP-1 和MMP-9 水平的影响

目的:探讨灯盏细辛口服液对急性冠状动脉综合征患者外周血C-反应蛋白、1-甲基环丙烯和9-基质金属蛋白酶水平的影响。方法:选取我院心内科已确诊为急性冠状动脉综合征的患者110例,随机分为实验组和对照组,对照组行常规药物治疗,实验组在对照组的基础上口服灯盏细辛口服液。比较两组患者治疗前后外周血C-反应蛋白变化情况及MCP-1及MMP-9水平及临床疗效。结果:与治疗前相比,两组患者治疗后MCP-1、MMP-9及C-反应蛋白水平降低(P0.05),与对照组相比,实验组患者MCP-1、MMP-9及C-反应蛋白较低(P0.05);与对照组相比,实验组总有效率较高(P0.05)。结论:灯盏细辛口服液对急性冠状动脉综合征患者具有较好的疗效,这可能与其降低外周血中C-反应蛋白、MMP-9和MCP-1水平具有一定的关系。     

Access to catheterisation facilities in patients admitted with acute coronary syndrome: multinational registry study

Objective To investigate the relation between access to a cardiac catheterisation laboratory and clinical outcomes in patients admitted to hospital with suspected acute coronary syndrome.Design Prospective, multinational, observational registry.Setting Patients enrolled in 106 hospitals in 14 countries between April 1999 and March 2003.Participants 28 825 patients aged ≥ 18 years.Main outcome measures Use of percutaneous coronary intervention or coronary artery bypass graft surgery, death, infarction after discharge, stroke, or major bleeding.Results Most patients (77%) across all regions (United States, Europe, Argentina and Brazil, Australia, New Zealand, and Canada) were admitted to hospitals with catheterisation facilities. As expected, the availability of a catheterisation laboratory was associated with more frequent use of percutaneous coronary intervention (41% v 3.9%, P < 0.001) and coronary artery bypass graft (7.1% v 0.7%, P < 0.001). After adjustment for baseline characteristics, medical history, and geographical region there were no significant differences in the risk of early death between patients in hospitals with or without catheterisation facilities (odds ratio 1.13, 95% confidence interval 0.98 to 1.30, for death in hospital; hazard ratio 1.05, 0.93 to 1.18, for death at 30 days). The risk of death at six months was significantly higher in patients first admitted to hospitals with catheterisation facilities (hazard ratio 1.14, 1.03 to 1.26), as was the risk of bleeding complications in hospital (odds ratio 1.94, 1.57 to 2.39) and stroke (odds ratio 1.53, 1.10 to 2.14).Conclusions These findings support the current strategy of directing patients with suspected acute coronary syndrome to the nearest hospital with acute care facilities, irrespective of the availability of a catheterisation laboratory, and argue against early routine transfer of these patients to tertiary care hospitals with interventional facilities.     

Early and long-term outcome of elective stenting of the infarct-related artery in patients with viability in the infarct-area: Rationale and design of the Viability-guided Angioplasty after acute Myocardial Infarction-trial (The VIAMI-trial)

BACKGROUND: Although percutaneous coronary intervention (PCI) is becoming the standard therapy in ST-segment elevation myocardial infarction (STEMI), to date most patients, even in developed countries, are reperfused with intravenous thrombolysis or do not receive a reperfusion therapy at all. In the post-lysis period these patients are at high risk for recurrent ischemic events. Early identification of these patients is mandatory as this subgroup could possibly benefit from an angioplasty of the infarct-related artery.Since viability seems to be related to ischemic adverse events, we initiated a clinical trial to investigate the benefits of PCI with stenting of the infarct-related artery in patients with viability detected early after acute myocardial infarction. METHODS: The VIAMI-study is designed as a prospective, multicenter, randomized, controlled clinical trial. Patients who are hospitalized with an acute myocardial infarction and who did not have primary or rescue PCI, undergo viability testing by low-dose dobutamine echocardiography (LDDE) within 3 days of admission. Consequently, patients with demonstrated viability are randomized to an invasive or conservative strategy. In the invasive strategy patients undergo coronary angiography with the intention to perform PCI with stenting of the infarct-related coronary artery and concomitant use of abciximab. In the conservative group an ischemia-guided approach is adopted (standard optimal care).The primary end point is the composite of death from any cause, reinfarction and unstable angina during a follow-up period of three years. CONCLUSION: The primary objective of the VIAMI-trial is to demonstrate that angioplasty of the infarct-related coronary artery with stenting and concomitant use of abciximab results in a clinically important risk reduction of future cardiac events in patients with viability in the infarct-area, detected early after myocardial infarction.     

Role of coronary artery bypass grafting during the acute and subacute phase of ST-elevation myocardial infarction

Background/Objectives. We aimed to investigate the incidence and clinical outcome of coronary artery bypass grafting (CABG) performed in contemporary patients with ST-elevation myocardial infarction (STEMI) within 30 days after presentation. Methods. All 1071 patients enrolled in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS) were included in this analysis. CABG was indicated for both ischaemic and anatomical reasons according to the current treatment guidelines for STEMI. For all surgical as well as non-surgical patients, clinical outcome was assessed at both 30 days and one year. Results. CABG was performed within 30 days of presentation in 59/1071 (5.5%) patients, in 13 (22%) within 24 hours, in eight (14%) between one and three days, and in 38 (64%) between four and 30 days. Compared with non-surgical patients, surgical patients required more initial intra-aortic balloon pump support (33 vs. 5%, p<0.001) and more often had multi-vessel disease (p<0.001). Overall, rethoracotomy was performed in 9/59 (15%) patients. In patients operated within three days, the rethoracotomy rate was markedly higher than after three days (33 vs. 5%, p=0.004). Cardiac mortality at 30 days and one year was 1.7% in the surgical group and 3.2 and 5.3%, respectively, in the non-surgical group. Conclusion. STEMI patients treated with CABG within three days after presentation are at increased risk of rethoracotomy. However, despite this higher incidence of surgical complications and multiple high-risk features at presentation, surgical management during the acute and subacute phase is associated with excellent 30-day and one-year survival. (Neth Heart J 2010;18:348-54.)     

Severe acute coronary spasm following intracoronary radiation for in-stent restenosis: A case report

Intracoronary radiation therapy is currently the only available treatment for the prevention of recurrence of in-stent restenosis. We report a case of severe coronary spasm after excimer laser angioplasty, balloon angioplasty, and intracoronary gamma radiation in the right coronary artery (RCA) that resulted in an acute myocardial infarction. Treatment with 600 μg of intracoronary nitroglycerin resulted in minimal improvement; therefore, diltiazem 400 μg was administered intracoronary with total resolution of the spasm, restoring normal coronary blood flow without trace of acute dissection or thrombus inside the artery.     

小剂量重组组织纤溶酶原激活剂治疗急性心肌梗死临床研究概况

1990年代中期以来,国内130多家医院入组9378例急性心肌梗死患者,其中用小剂量（50mg）重组组织纤溶酶厚激活剂（rt-PA）治疗6693例,阻塞相关血管开通5318俐,开通率为79.46％;死亡293倒,病死率为4.38％;出血550俐,出血率勾8.22％,其中重度出血7例,颅内出血21例（0.31％）,再次梗塞60例（0.90％）。超过40家医院对rt-PA（50mg）与尿激酶治疗急性心肌梗死疗效进行了比较,共计入组3449倒急性心肌梗死患者,rt-PA治疗1689例,先静脉推注8mg,其余42mg在30或60和90min滴注;尿激酶治疗1760例,150万U位滴注30min。结果显示,阻塞相关冠脉血管开通率分别为79.40％（1341例）和5733％（1009例）,相差非常显著（P〈0.001）。12家医院研究了rt-PA50-9100mg治疗急性心肌梗死的效果,共计入组1054例患者,其中50mg组487例,100mg组567例,阻塞相关血管开通率分别为78.85％和82.36％。另有22家医院入组1017倒病人,行rt-PA50mg30rain给药临味试验,冠脉开通率达80.53％;18家医院行rt-PA50mg 60min给药临床试验,入组942例病人,阻塞相关血管开通率为77.92％;50家医院用rt-PA50mg 90min给药方案治疗急性心肌梗死患者,入组2768例患者,冠脉开通率为77.89％。6家医院对用rt-PA（50mg）与链激酶治疗急性心肌梗死的疗效进行了对比,结果表明相关血管开通率分别为81.4％和65.2％22家医院比较了小剂量rt-PA对急性心肌梗死患者症状发作不同时间的治疗效果,表明症状发作时间越短,用药的溶栓效果越好。刘光对入院前和入院后用小剂量rt-PA溶栓进行了比较研究,证明入院前溶栓比入院后效果好。对冠脉内输注rt-PA（50mg）和2次静脉推注小剂量rt-PA治疗急性心肌梗死的效果也进行了探索。