不稳定型心绞痛的现代药物治疗

Advanced drug therapies in selected patients with unstable angina pectoris

目的探讨在充分现代药物治疗情况下，不稳定型心绞痛短期及长期的临床转归。方法入选2003年10月至2005年10月我院心内科门诊已确诊的、因各种原因不能或不接受早期血管重建的不稳定型心绞痛患者67例，建立数据库。根据我国2000年发表的《不稳定型心绞痛诊断和治疗建议》，对每例患者进行危险度分层，对劳力心绞痛根据加拿大分级（CCSC）标准进行分级，在门诊或病房进行充分的抗血小板、抗凝、抗缺血、他汀调脂等现代药物治疗，并严格控制危险因素至充分达标，同时给予严格的生活方式干预和二级预防。随访至少3年，记录心绞痛发生频度及程度、危险因素控制达标情况及心脏事件。结果共入选67例患者，3例失访。访期36-60个月。100％的患者接受阿司匹林、他汀类药物及硝酸盐治疗；100％的高危患者及90％的中危患者接受了低分子肝素的治疗；97％的患者接受了B阻滞剂治疗；凡有自发心绞痛的患者100％接受钙拮抗剂治疗；合并高血压的患者100％接受ACEI或ARB治疗。全组患者危险因素获得有效控制。治疗1周，劳力心绞痛CCSC分级下调1级以上的35例，占60％，静息心绞痛消失者14例，占32％。治疗1月后劳力心绞痛CCSC分级下调2级以上的54例，占90％，42例自发心绞痛消失，占91％。1个月内仅1例在治疗1周后停药发生急性心肌梗死。在长达至少3年的治疗随访中，无1例再发生Q波或非Q波心梗。2例顽固性心肌缺血，因症状控制不理想分别于治疗后4个月和6个月接受PCI及搭桥治疗，仅占患者的4．5％。治疗1年仅1例梗死后心绞痛患者行搭桥术，6例在稳定劳力心绞痛的情况下接受介入医生建议行PCI术。结论充分的现代药物治疗可使绝大部分不稳定型心绞痛从急性不稳定期进入稳定状态，并在长期治疗和严格的二级预防中有效地防止远期心脏事件的发生。

Objective The objective of this study is to evaluate the short and long term effects of advanced drug therapies in selected patients with unstable angina pectoris. Methods The study sample consisted of 64 patients with unstable angina from our hospital who cannot or don＇t want to receive early revasculariztion because of various reasons. All patients receive risk stratification and advanced drug therapies according to 《guideline and suggestions for unstable anginer》（China 2000）. The patients were followed up at least three years. The patients clinical symptomatic characteristics, treatments,major events in or out hospital during the period of study were recorded by filling in case report forms. Results 64 patients with unstable angina pectoris without STEMI and NSTEMI were followed up for at least three years. During the period anti-platelet therapy were used in 100% of patients, low-molecular-weight heparins were used in 100% patients with high risk and 90% middle risk, 97% patients were used beta blockers, calcium antagonists were used in 100% of patients with spontaneous angina pectoris;angiotensin-converting enzyme inhibitors or ARB were used in 100% patients with hypertention,and lipidlowering agents-statins were used in all patients respectively. 61% patients downregulated CCSC one grade and 32% patients spontaneous angina pectoris disappeared after having received drug therapies for one week. Only one patient occured acute myocardial infarction after having received treatment for one week when he stoped the drug therapy. Because of stubborn angina two patients received revasculariztion after have received drugs therapy for four months and six months resptctiraly. During the period of long term followed up six patients with stable angina pectoris received PCI after suggested by phycians. Conclusion The results of this prospective descriptive study suggested that morden drug therapies especially collaboration of anti-platelet, anti-thrombotic, anti-myocardial ischemia, anti-inflamation therapies, and intensively control the risk factors such as hypertension, hyperlipidemia, cigarette smoking, diabetes with aspirin, clopidogrel, low-molecular-weight haparins, beta-blockers, calcium, angiotensin-enzyme （ACE） inhibitors, angiotensin receptor blockades could prevent heart attack and achieve maximum reduction in clinical events.