Abstract】Objective To observe the efficacy of thrombolytic therapy with urokinase in patients with AMI combined with diabetes mellitus and the vascular analysis of lesions after elective PCI after thrombolysis. The aim was to investigate the efficacy and safety of early intravenous thrombolysis in patients with acute myocardial infarction with or without combined diabetes mellitus and the vascular lesions after PCI. Methods: All 200 patients with indications for thrombolysis and no contraindications were given the same thrombolytic agent for thrombolysis, and PCI was performed via femoral artery puncture at an elective stage after stabilization. Results: The revascularization rate was 52.2% and 74.7% in the group with and without diabetes mellitus, respectively (P<0.05); the five-week mortality rate was 13.1% and 4.8%, respectively (P<0.05); the incidence of adverse events such as mild bleeding was 8.7% and 6.8%, respectively (P<0.05); the cardiac ejection fraction EF was 53.44±11.1 and 62.9±10.2, respectively (P<0.05). (P<0.05); single-branch lesion 42.9% and 45.2% (P>0.05); double-branch lesion 33.3% and 34.1% (P>0.05); triple-branch lesion 14.3% and 12.6% (P>0.05); and normal coronary rate 9.5% and 8.1% (P>0.05), respectively, in the group with and without diabetes mellitus via PCI. Conclusion Thrombolysis in patients with AMI combined with diabetes mellitus resulted in a significantly lower rate of infarct vessel recanalization than in patients without diabetes mellitus, and their recent prognosis was also worse than the latter; there was no significant difference in lesioned vessels analyzed by PCI. Wei Feng, Department of Cardiology, Bengbu First People’s Hospital
【Key words】 Acute myocardial infarction (AMI); diabetes mellitus (DM); percutaneous coronary intervention (PCI); thrombolytic therapy
Acute myocardial infarction (AMI) refers to severe myocardial ischemia and necrosis due to acute stenosis or occlusion of coronary arteries. The main pathophysiological mechanism is the acute stenosis or occlusion of coronary arteries due to some mechanical reasons induced by plaque rupture and secondary thrombosis of coronary atheroma. Acute myocardial infarction is currently the most critical acute event in cardiovascular disease, with diverse clinical manifestations and complex therapeutic measures. Early opening of the infarct-related coronary artery (IRA) to achieve reperfusion is the most important treatment strategy for myocardial infarction. Whether mechanical (PCI or CABG) or pharmacological thrombolysis is used, it can effectively save myocardium, reduce infarct size, improve left ventricular function, and improve prognosis. This reality is now widely recognized and used as one of the guidelines to guide clinical practice [1].
1 Data and methods
1.1 Clinical data Two hundred patients with acute myocardial infarction who were hospitalized in our cardiology department between January 2000 and December 2008 and were eligible for thrombolysis (including 40 cases with combined diabetes) were selected (i) those whose thrombolysis was ≤12 hours from the onset and who had no contraindications to thrombolysis. The AMI+DM group and the AMI group were basically similar in terms of gender and age and were comparable.
1.2 Treatment Urokinase (UK) 1.5 million U intravenous 30 min drip, thrombolysis with oral aspirin 300 mg, Bolivar 150 mg , whole blood coagulation time (ACT) measured 6-12 h after thrombolysis, recovery to 150 s subcutaneous injection of low molecular heparin sodium 0.4 mg/12 h. The rest of the treatment after thrombolysis was performed according to the conventional treatment of AMI. The thrombolytic drug UK was a product of Guangdong Tianpu Biochemical Pharmaceutical Co. Clinical judgment of thrombolysis recanalization and coronary angiography patency was performed according to the criteria in the relevant guidelines. Judgment of recurrent myocardial ischemic events after thrombolysis: (1) recurrent precordial pain; (2) ECG: ST-segment elevation ≥0.1 mV in the infarct site; (3) re-elevation of already decreased cardiac enzymes. Cardiac function was measured by 2D echocardiography at about 2 weeks after onset of the disease to determine left ventricular ejection fraction (LVEF): the area-long-axis method was used. All coronary angiography was performed by transfemoral artery puncture.
1.3 Statistical methods Data were expressed as mean±standard deviation, and t-test was used for measurement data and chi-square test was used for count data, and P<0.05 was considered as statistically significant difference.
2 Results
(1) Forty patients with combined diabetes mellitus (AMI+DM) and 160 patients without diabetes mellitus (AMI) had no difference between the two groups before thrombolysis (P>0.05). (2) The rate of revascularization by thrombolysis was significantly lower in the AMI+DM group than in the patients without diabetes (AMI) (P<0.05); the incidence of adverse effects such as myocardial ischemia, mortality and mild bleeding after 5 weeks was higher than in the latter group (P<0.05), and cardiac function was also lower than in the group without diabetes (P<0.05) (see Table 1). (3) Twenty-one patients in the AMI+DM group and 135 patients in the AMI group underwent PCI via femoral artery puncture under local anesthesia, and there was no significant difference in the lesioned vessels by analysis (P>0.05) (see Table 2).
Table 1 Comparison of the efficacy and recent prognosis after thrombolysis in the two groups
AMI+DM
AMI
Thrombolytic revascularization rate (%)
52.2 (12/23)
74.7 (109/146)
Incidence of adverse events such as mild bleeding (%)
8.7 (2/23)
6.8 (10/146)
Incidence of severe bleeding and stroke (%)
4.3 (1/23)
4.8 (7/146)
Incidence of five-week myocardial ischemia (%)
21.7 (5/23)
8.9 (13/146)
Five-week mortality (%)
13.1 (3/23)
4.8 (7/146)
EF value
53.44±11.1
62.9±10.2
Table 2 Comparison of diseased vessels after PCI in both groups
AMI+DM
AMI
Single vessel lesion rate (%)
42.9 (9/21)
45.2 (61/135)
Double-branch vasculopathy rate (%)
33.3 (7/21)
34.1 (46/135)
Three-vessel lesion rate (%)
14.3 (3/21)
12.6 (17/135)
Normal coronary rate (thrombolytic recanalization, autolysis, spasm, etc.)
9.5 (2/21)
8.1 (11/135)
3 Discussion
There are many common risk factors for cardiovascular disease [2], with more than 300 overall, but only a dozen of the most important ones. In the current more consistent classification, diabetes is classified as a major (traditional) risk factor. In the development of ischemic cardiovascular disease (coronary heart disease and ischemic stroke), 3% is attributed to diabetes [3].
Diabetes mellitus is an independent risk factor for poor prognosis of acute myocardial infarction [4]. It has been statistically shown that diabetic patients are two to four times more likely to develop coronary heart disease than non-diabetic patients,and mortality in acute myocardial infarction is two to three times higher than in non-diabetic patients [5–6]. Hyperglycemia usually adversely affects ischemic myocardium through the following mechanisms [7]: it decreases myocardial collateral circulation and thus increases infarct size; it affects endothelium-mediated collateral coronary diastole; it exacerbates vascular inflammatory response and increases prothrombotic factor activity; it is associated with oxidative stress and impaired immune response, etc.
The results of this study showed that: (i) the rate of revascularization after thrombolysis was lower in patients with AMI+DM than in patients with AMI alone (P<0.05), which may be related to the above mechanisms; (ii) the incidence of adverse events such as mild bleeding was slightly higher in patients with AMI+DM than in non-diabetic patients with thrombolysis. However, the incidence of severe bleeding and stroke did not increase, indicating that thrombolytic therapy is still relatively safe for AMI+DM patients; (3) the recurrent myocardial ischemic events during hospitalization were significantly higher in AMI+DM patients than in patients without diabetes (P<0.05), and their occurrence may be related to vascular endothelial insufficiency and autonomic dysfunction in diabetic patients; (4) the 5-week mortality rate was significantly higher in AMI+DM patients than in patients without DM. The 5-week mortality rate of AMI+DM patients was significantly higher than that of AMI patients without DM (P<0.05), and the EF value was also lower than that of the latter (P<0.05), and the author believes that the reason for the high mortality rate of the former is related to their reduced cardiac function; ⑤ The analysis of the lesioned vessels observed in the two groups of patients undergoing PCI at a later stage was not statistically significant (P>0.05). However, it is worth suggesting that the findings of lesion vessel analysis obtained in this data are not consistent with the literature that suggests that double and triple coronary artery lesions are more common in diabetic myocardial infarction than in non-diabetic patients [8], whether this is related to the insufficient number of samples collected in this paper is to be explored. In conclusion, the rate of revascularization with thrombolytic therapy was significantly lower in patients with AMI+DM than in those without diabetes, and their immediate prognosis was worse than that of the latter; there was no significant difference in the lesioned vessels analyzed by PCI.
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Correspondence should be addressed to WEI Feng
Address: Department of Cardiology, Bengbu First People’s Hospital, No. 229 Tushan Road, Bengbu, Anhui Province, China (233000)