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Objective:To explore the selection of strategies for early reperfusion therapy and its impact on prognosis in patients with acute ST segment elevation myocardial infarction (STEMI).Methods:The treatment data and 3-year follow-up results of acute myocardial infarction (AMI) patients in 49 hospitals in Hebei Province from January to December 2016 were collected. Patients with STEMI who received either intravenous thrombolytic therapy (ITT) or primary percutaneous coronary intervention (PPCI) within 12 hours of onset were enrolled. Baseline data, the time from the first diagnosis to the start of reperfusion (FMC2N for ITT patients and FMC2B for PPCI patients), vascular recanalization rate, in-hospital mortality, 1-year mortality, and 3-year mortality were compared between ITT and PPCI groups. The efficacy and prognosis of ITT and PPCI at different starting time of reperfusion (FMC2N≤30 minutes, FMC2N > 30 minutes, FMC2B≤120 minutes, FMC2B > 120 minutes) were analyzed.Results:A total of 1 371 STEMI patients treated with ITT or PPCI were selected, including 300 patients in the ITT group and 1 071 patients in the PPCI group. 1 055 patients were actually followed up (205 patients in the ITT group and 850 patients in the PPCI group), with a rate of 79.4%. There were no significant differences in age, gender, and previous history between the two groups. The time from the first diagnosis to the start of reperfusion in the ITT group was shorter than that in the PPCI group [minutes: 63 (38, 95) vs. 95 (60, 150), U = -9.286, P = 0.000], but was significantly longer than the guideline standard. Compared with the ITT group, the vascular recanalization rate in the PPCI group was higher [95.5% (1 023/1 071) vs. 88.3% (265/300), P < 0.01], and in-hospital mortality was lower [2.1% (22/1 071) vs. 6.7% (20/300), P < 0.01], but there were no significant differences in the 1-year mortality and 3-year mortality [5.3% (45/850) vs. 4.4% (9/205), 9.5% (81/850) vs. 9.3% (19/205), both P > 0.05]. Between ITT group and PPCI group with different reperfusion starting time, the FMC2N > 30 minutes group had the lowest vascular recanalization rate and the highest in-hospital mortality. Pairwise comparison showed that the vascular recanalization rate of the FMC2B ≤ 120 minutes group and the FMC2B > 120 minutes group were significantly higher than those of the FMC2N > 30 minutes group [95.5% (654/685), 95.6% (369/386) vs. 88.0% (220/250), both P < 0.008], the in-hospital mortality was significantly lower than that of the FMC2N > 30 minutes group [2.0% (14/685), 2.1% (8/386) vs. 7.6% (19/250), both P < 0.008]. There was no significant difference in 1-year mortality (χ 2 = 2.507, P = 0.443) and 3-year mortality (χ 2 = 2.204, P = 0.522) among the four groups. Conclusions:For STEMI patients within 12 hours of onset, reperfusion therapy should be performed as soon as possible. PPCI showed higher infarct related artery opening rate and lower in-hospital mortality compared with ITT, and had no effect on 1-year and 3-year mortality.
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Acute ischemic stroke (AIS) has the characteristics of high morbidity, disability and mortality. Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) for AIS in time window is an effective treatment recommended by domestic and overseas guidelines. However, intravenous thrombolysis has shortcomings, such as short time window, low recanalization rate and high risk of bleeding. Therefore, in recent years, studies on prolonging the time window, using low-dose rt-PA or a new generation of thrombolytic agent, and thrombolysis combined with anti-thrombotic therapy have been carried out worldwide. Based on the studies on intravenous thrombolysis, this paper discusses several issues, including extending time window, low-dose rt-PA thrombolysis, and new generation of thrombolytic agent.
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Stroke is the first cause of death in China, and ischemic stroke is the most common stroke and accounts for 70% of all new stroke cases. The treatment efficiency of acute ischemic stroke is closely related to the health of people in China. Bridging therapy has been proven safe and effective for acute ischemic stroke with anterior circulation large vessel occlusion. The incidence of symptomatic intracerebral hemorrhage is similar in the patients with bridging therapy and intravenous thrombolysis, suggesting that the complication is not due to intra-artery thrombectomy, but rather to intravenous thrombolysis. Thus it has become a research focus whether direct intra-artery thrombectomy is feasible for acute ischemic stroke, skipping intravenous thrombolysis. This paper discusses the related issues.
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Objective The explore the effect of blood pressure bundle management on prognosis of patients with acute ischemic stroke after intravenous thrombolysis. Methods A total of 286 acute ischemic stroke patients, who received intravenous thrombolytic therapy in Stroke Center of our hospital between Oct. 1, 2015 and Mar. 31, 2018, were included in this study. The patients who received blood pressure bundle management after intravenous thrombolysis were assigned to bundle group, and the patients without blood pressure bundle management were in control group. The baseline data, National Institutes of Health stroke scale (NIHSS) score on admission, blood pressure before thrombolysis, the incidence of symptomatic intracranial hemorrhage and the in-hospital mortality after thrombolysis, and the 90-d modified Rankin scale (mRS) score were compared between the two groups. Multivariate logistic regression analysis was used to explore the effect of blood pressure bundle management, NIHSS score, onset-to-needle time, and blood pressure on prognosis of patients. Results Of 286 patients with acute ischemic stroke, 161 patients were in bundle group, and 125 patients were in control group. There were no significant differences in age, gender, hypertension, diabetes mellitus, atrial fibrillation, NIHSS score on admission or blood pressure before thrombolysis between the two groups (all P0.05). The incidence of symptomatic intracranial hemorrhage was significantly lower in the bundle group than that in the control group (2.48% [4/161] vs 8.00% [10/125], χ2＝4.598, P＝0.032). There was no significant difference in the in-hospital mortality between the two groups (3.73% [6/161] vs 3.20% [4/125], χ2＝0.058, P＝0.810). The 90-d good prognosis (mRS score 0-2) rate was significantly higher in the bundle group than that in the control group (62.11% [100/161] vs 49.60% [62/125], χ2＝4.485, P＝0.034). Successive variation of systolic blood pressure and successive variation of diastolic blood pressure were significantly lower in the bundle group than those in the control group ([13.37±4.92] mmHg [1 mmHg＝0.133 kPa] vs [18.42±3.87] mmHg, t＝2.437, P＝0.025; [11.23±4.02] mmHg vs [15.48±5.16] mmHg, t＝1.842, P＝0.046). Multivariate logistic regression analysis showed that blood pressure bundle management (odds ratio [OR]＝0.798, P＝0.002) and successive variation of diastolic blood pressure≤15 mmHg (OR＝0.816, P＝0.018) were independent predictors for good prognosis of acute ischemic stroke patients with intravenous thrombolysis. Conclusion Blood pressure bundle management can improve blood pressure variation of the patients with acute ischemic stroke after receiving intravenous thrombolysis, reduce the incidence of symptomatic intracranial hemorrhage and improve the prognosis of the patients.
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Objective To explore the prognostic influencing factors of acute cardiogenic ischemic stroke patients treated with alteplase intravenous thrombolysis. Methods Ninety-one patients with acute cardiogenic ischemic stroke, who received intravenous thrombolysis with alteplase in Stroke Center of Changhai Hospital of Navy Medical University (Second Military Medical University) between Sep. 2013 and Sep. 2017, were included in this study. The modified Rankin scale (mRS) score at 3 months after thrombolysis was used as an prognostic indicator, and the patients with mRS score≤2 were good prognosis group (n＝54) and those with mRS score 3-6 were poor prognosis group (n＝37). The age, gender, medical history, baseline National Institutes of Health stroke scale (NIHSS) score, baseline Glasgow coma scale (GCS) score and Alberta stroke program early computed tomograghy score (ASPECTS) before thrombolysis were analyzed in each group. Multivariate logistic regression analysis was used to analyze the prognostic influencing factors. Results The good prognosis rate was 59.3% (54/91) at 3 months after thrombolysis. There were significant differences in age ([66.57±13.46] years vs [75.95±6.06] years), incidence of patent foramen ovale (11.1% [6/54] vs 0.0% [0/37]), baseline NIHSS score (7.5 [3.5, 13.0] vs 18.0 [13.0, 22.0]), baseline GCS score (14.5 [12.0, 15.0] vs 10.0 [8.0, 14.0]), ASPECTS before thrombolysis (10.0 [9.0, 10.0] vs 9.0 [8.0, 10.0]) and incidence of symptomatic intracranial hemorrhage (SICH, 1.9% [1/54] vs 32.4% [12/37]) between the good and poor prognosis groups (t＝3.964, χ2＝4.401, Z＝5.235, Z＝4.079, Z＝2.519, χ2＝16.768; all P0.05). Multivariate logistic regression analysis showed that age (odds ratio [OR]＝3.236, 95% confidence interval [CI] 1.077-9.709, P＝0.036), baseline NIHSS score (OR＝2.874, 95% CI 1.074-6.329, P＝0.034) and SICH (OR＝9.346, 95% CI 1.017-83.333, P＝0.048) were influencing factors for poor prognosis of acute cardiogenic ischemic stroke patients treated with intravenous thrombolysis. Conclusion The age, baseline NIHSS score and SICH are independent factors for poor prognosis of patients with acute cardiogenic ischemic stroke. The patients with elder age, more serious stroke or SICH may have a worse prognosis.
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Objective To investigate the related factors and clinical features of unexplained early neurological deterioration (END) of acute ischemic stroke (AIS) patients after intravenous thrombolysis. Methods A total of 258 AIS patients, who underwent intravenous thrombolysis treatment within 4.5 h of onset and were registered continuously in Stroke Center of our hospital between Jan. 2016 and Feb. 2018, were included in this study. The unexplained END was defined as the National Institutes of Health stroke scale (NIHSS) score increasing by more than 4 within 24 h of onset compared with that before thrombolysis, with no definite mechanism by imaging examination. The baseline and clinical data were compared between the unexplained END and non-END patients. The clinical features of the AIS patients with unexplained END were analyzed. Results Among the 258 patients enrolled in this study, 243 (94.2%) had no END and 15 (5.8%) had unexplained END. Compared with the patients without END, the proportion of diabetes mellitus in the patients with unexplained END was significantly higher and the door-to-needle time (DNT) was significantly longer (χ2＝6.093, P＝0.048; Z＝2.055, P＝0.040). The NIHSS score of 15 patients with unexplained END before thrombolysis was low (5 [4, 9]). The most common type of trial of Org 10172 in Acute Stroke Treatment (TOAST) classification was small artery occlusion (11 cases, 73.3%). The most common infarction sites were posterior limb of internal capsule (6 cases, 40.0%) and ventromedial pons (6 cases, 40.0%). Conclusion Diabetes mellitus and long DNT may be the risk factors of unexplained END in the patients with AIS after intravenous thrombolysis. Unexplained END usually occurs in the AIS patinets with small artery occlusion and has lower NIHSS score; the common sites of infarction are posterior limb of the internal capsule and ventromedial pons.
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Objective To investigate the clinical characteristics of stroke warning syndrome (SWS) and to explore the effectiveness of intravenous thrombolysis with alteplase. Methods Eleven patients with SWS, who received intravenous thrombolysis with alteplase in Stroke Center of our hospital between Sep. 2013 and Jan. 2018, were selected. The clinical features, imaging findings and therapeutic effects were analyzed. Results There were risk factors of cerebrovascular diseases in the 11 patients with SWS, in which 7 had hypertension, 4 had diabetes mellitus, 2 had hyperlipoidemia, and 1 had gout. In the classification of symptoms, 7 patients were pure motor type and 4 were motor-sense type. Magnetic resonance diffusion weighted imaging showed that 10 patients developed ischemic stroke. The infarction located in the posterior limb of internal capsule, putamen, globus pallidus, corona and pons. Head and neck computed tomography angiography examination found no large vascular stenosis in the patients. The modified Rankin scale scored 0-1 in 9 patients, 2 in 1 patient, and 3 in 1 patient. Conclusion Perforating artery disease is the main pathogenesis of SWS. Intravenous thrombolysis does not prevent SWS to ischemic stroke, but it improves the prognosis of the patients.
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Objective To investigate and analyze the clinical analysis and nursing intervention of intravenous thrombolysis with urokinase in the treatment of acute myocardial infarction. Methods 40 patients with acute myocardial infarction treated in Hangzhou Hospital of Zhejiang Medical and Health Group from February 2015 to August 2016 were selected and randomly divided into the control group and the experimental group, with 20 patients in each group. The control group received routine treatment, intravenous drip of nitroglycerin and subcutaneous injection of low molecular weight heparin. On this basis, the experimental group was given urokinase intravenous thrombolysis treatment. Two groups of patients were given reasonable nursing intervention measures to improve the quality of care. The therapeutic effects of the experimental group and the control group were compared and analyzed. Results After the corresponding treatment, the effective number of patients in the experimental group was 19 cases (95.0%). In the control group, the effective number of treatment was 13 cases (65.0%). The effective rate of treatment in the experimental group was significantly higher than that in the control group, with statistical difference (P<0.05). The remission time of the chest pain in the control group was (15.32±7.21) h, and the remission time of the chest pain in the experimental group was (2.72±0.67) h. The improvement time of chest pain in the experimental group was significantly shorter than that in the control group, with statistical difference (P<0.05). In addition, the probability of complications in the experimental group was 10%, which was significantly lower than that in the control group (40.0%), and there was a statistical difference (P<0.05). Conclusion Intravenous thrombolysis with urokinase in treatment of acute myocardial infarction treatment effect is ideal, can improve clinical symptoms in a large extent, improve the efficiency of treatment, the treatment of high safety, with the further promotion of the clinical significance.
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Objective To investigate and analyze the clinical analysis and nursing intervention of intravenous thrombolysis with urokinase in the treatment of acute myocardial infarction. Methods 40 patients with acute myocardial infarction treated in Hangzhou Hospital of Zhejiang Medical and Health Group from February 2015 to August 2016 were selected and randomly divided into the control group and the experimental group, with 20 patients in each group. The control group received routine treatment, intravenous drip of nitroglycerin and subcutaneous injection of low molecular weight heparin. On this basis, the experimental group was given urokinase intravenous thrombolysis treatment. Two groups of patients were given reasonable nursing intervention measures to improve the quality of care. The therapeutic effects of the experimental group and the control group were compared and analyzed. Results After the corresponding treatment, the effective number of patients in the experimental group was 19 cases (95.0%). In the control group, the effective number of treatment was 13 cases (65.0%). The effective rate of treatment in the experimental group was significantly higher than that in the control group, with statistical difference (P<0.05). The remission time of the chest pain in the control group was (15.32±7.21) h, and the remission time of the chest pain in the experimental group was (2.72±0.67) h. The improvement time of chest pain in the experimental group was significantly shorter than that in the control group, with statistical difference (P<0.05). In addition, the probability of complications in the experimental group was 10%, which was significantly lower than that in the control group (40.0%), and there was a statistical difference (P<0.05). Conclusion Intravenous thrombolysis with urokinase in treatment of acute myocardial infarction treatment effect is ideal, can improve clinical symptoms in a large extent, improve the efficiency of treatment, the treatment of high safety, with the further promotion of the clinical significance.
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Objective The aim of this study was to investigate the application of low molecular weight heparin combined with alteplase for thrombolysis in patients with acute myocardial infarction(AMI),and to compare its thrombolysis effect with traditional anticoagulant-general heparin. Methods 35 AMI patients with alteplase intravenous thrombolytic therapy were divided into two groups,among which 15 cases in the study group were treated with 30 mg enoxaparin instant intravenous injection before thrombolysis,40 mg enoxaparin hypodermic injection 15 minutes after thrombolysis,40 mg enoxaparin hypodermic injection every 12 hours for 5 days. The other 20 cases were assigned to the control group and treated with 4 000 u(or 60 u/kg)general heparin instant intravenous injection,then pumped general heparin intravenously in the rate of 800-1 000 u/h. Meanwhile,detected coagulation convention every 3 hours and adjusted the dose of heparin according to the activated partial thromboplastin time(APTT)to keep APTT value within 1.5 to 2.0 times(50-70 s)the standard value. 48 hours later,patients in the control group was given hypodermic injection of 40 mg enoxaparin every 12 hours for 5 days. All cases were given regular treatment as guidelines recommended. Results The patency rate of infarct-related coronary artery assessed by unified clinical criteria was 86.66% and 65.00%,and the average recanalization time was(1.62±0.36)h and(1.81±0.33)h in the study and control groups,respectively. There were no significant differences on patency rate and recanalization time between the two groups(P > 0.05). One case of bleeding complication occurred in the study group(6.66%),while five cases occurred in the control group(25.00%). In the two groups,no cases appeared intracranial hemorrhage and other serious or fatal bleeding occurred. Conclusion The clinical efficacy of low molecular weight heparin was non-inferior to general heparin in AMI patients with alteplas thrombolysis. The application of low molecular weight heparin was simple and easy to operate. It can optimize the procedure of thrombolysis,reduce repetitive coagulation index monitoring and lessen clinical workload,which is worth being promoted to primary hospital and the emergency systems.
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Objective To observe the efficacy and safety of recombinant tissue type plasminogen activa-tor (rt-PA)for the treatment of the patients with wake-up ischemic stroke (WUS)under the guidance of multimode CT. Methods Eighteen patients with WUS (a thrombolytic group)suitable for intravenous thrombolysis after multimode CT imaging screen at the Department of Neurology,Shiyan Hospital of Integrated Traditional and Western Medicine,Hubei Province from October 2012 to October 2014 were enrolled retrospectively. Twenty patients with WUS (a control group)who underwent multimode CT imaging screen were suitable for intravenous thrombolysis,but because of exceeding time window or rejecting thrombolysis and other reasons without having intravenous thrombolysis from February 2012 to February 2014 were enrolled retrospectively. The control group was treated with conventional therapy and the thrombolytic group was treated with rt-PA (0. 9 mg/kg)intravenous thrombolytic therapy. The indicators including fibrinogen (Fib),coagulation function (prothrombin time [PT ]),activated partial thromboplastin time (APTT ), platelet (PLT ),high-sensitivity C-reactive protein (hs-CRP ),National Institute of Health Stroke Scale (NIHSS )scores,and activities of daily living scores (Barthel index)at before treatment and 24 h,7 and 14 days after treatment were observed respectively. The adverse events and complications were documented and compared with the control group. Results There were no significant differences in Fib,PT,APTT, PLT,hs-CRP,NIHSS score and Barthel index before treatment between the thrombolytic group and the con-trol group (all P>0. 05);at day 7 and 14 after treatment in the thrombolytic group,compared with before treatment,Fib (14 d after treatment),PLT,and hs-CRP were decreased,PT and APTT were prolonged,the NIHSS scores were decreased,and Barthel indexes were increased. There were significant differences (all P<0. 05). At day 14 after treatment,there were significant differences in Fib,PT,APTT,hs-CRP,NIHSS scores,and Barthel indexes (Fib:3. 25 ± 0. 38 g/L vs. 3. 55 ± 0. 28 g/L;PT:15. 7 ± 3. 2 s vs. 12. 9 ± 2. 5 s;APTT:42. 7 ± 3. 5 s vs. 38. 7 ± 2. 6 s;PLT:[189 ± 26]× 109/L vs. [201 ± 23]× 109/L;hs-CRP:5. 7 ± 0. 6 mg/L vs. 11. 3 ± 2. 2 mg/L;NIHSS scores:5. 6 ± 2. 4 vs. 9. 2 ± 4. 5;and Barthel indexes:68 ± 15 vs. 47 ± 5)between the two groups (all P <0. 05). Except 1 patient occurred symptomatic intracerebral hemorrhage after thrombolysis,no other serious complications were observed in the thrombolytic group. One patient in the control group had stress gastric ulcer and bleeding,no symptomatic intracerebral hemorrhage occurred. Conclusion Multimode CT guidance can be used as a reliable imaging evidence for patients with WUS expanding intravenous thrombolytic time window. Under the multimode CT guidance, using rt-PA for intravenous thrombolytic therapy has a certain efficacy.