D-二聚体水平预测房颤患者中血栓栓塞事件

Background: Elevated coagulative molecular markers could reflect the prothromb otic state in the cardiovascular system of patients with non-valvular atrial fi brillation(NVAF). A prospective, cooperative study was conducted to determine wh ether levels of coagulative markers alone or in combination with clinical risk f actors could predict subsequent thromboembolic events in patients with NVAF. Met hods: Coagulative markers of prothrombin fragment 1 +2, D-dimer, platelet fact or 4, and β-thromboglobulin were determined at the enrollment in the prospecti ve study. Results: Of 509 patients with NVAF(mean age, 66.6±10.3 years), 263 pa tients were treated with warfarin(mean international normalized ratio, 1.86), an d 163 patients, with antiplatelet drugs. During an average follow-up period of 2.0 years, 31 thromboembolic events occurred. Event-free survival was significa ntly better in patients with D-dimer level< 150 ng/ml than in those with D-dim er level ≥150 ng/ml. Other coagulative markers, however, did not predict thromb oembolic events. Age(≥75 years), cardiomyopathies, and prior stroke or transien t ischemic attack were independent, clinical risk factors for thromboembolism. T hromboembolic risk in patients without the clinical risk factors was quite low(0 .7%/year) when D-dimer was< 150 ng/ml, but not low(3.8%/year) when D-dimer w as ≥150 ng/ml. It was > 5%/year in patients with the risk factors regardless o f D-dimer levels. This was also true when analyses were confined to patients tr eated with warfarin. Conclusions: D-dimer level in combination with clinical ri sk factors could effectively predict subsequent thromboembolic events in patient s with NVAF even when treated with warfarin.

对扩张型心肌病患者预防性植入埋藏式心脏复律除颤器对左室功能的影响

Background: The value of an implantable cardioverter defibrillator(ICD) for primary prevention in dilated cardiomyopathy(DCM) is unclear, as randomized trials could not show a survival benefit compared to drug therapy. It has not been investigated if patients with a very poor left ventricular function(LVEF) could profit from an ICD. Methods: Consecutive patients with DCM who received an ICD between December 1996 and November 2003 were included in this analysis. Patients were divided in group A(secondary prevention) and group B(primary prevention). Both groups were stratified in subgroups with left ventricular ejection fraction(LVEF) below and above 20% . Results: Fifty eight patients were included(male 50, age 56.4± 12.7 years). Follow-up was 34± 19 months. There was no difference regarding death(18% vs. 11% ), but significant differences(p value< 0.05) regarding any adverse events(55% vs. 22% ), any ICD intervention(48% vs. 17% ) and ICD interventions for life-threatening arrhythmias(27% vs. 0% )between group A and B. LVEF was not predictive for events in group A, whereas in group B only patients with a LVEF< 20% had events(p value 0.02). Over time there was an increase of the LVEF of more than 15% determined by echocardiography in 36% of patients, significantly more often in group B. Conclusions: Indication for primary prevention with an ICD in DCM should be made with caution. Larger studies are needed to determine if patients with LVEF of< 20% might benefit from an ICD.

既往胸部钝性创伤可能是单支冠状动脉病变的原因之一:假设与综述

Prompted by a case where a patient(with no risk factors, and single vessel disease) developed angina pectoris after previous blunt chest trauma, we searched Medline for blunt chest trauma and myocardial ischaemia. We found 77 cases describing AMI after blunt chest trauma, but only one reporting angina pectoris. We focused on the age and sex distribution, type of trauma, the angiography findings and the time interval between the trauma and the angiography. The age distribution was atypical, compared to AMI in general; 82% of the patients with AMI after blunt chest trauma were less than 45 years old, and only 2.5% more than 60 years old. The most common trauma was a road traffic accident, and the LAD was the vessel most often affected. Angiography revealed 12 cases with completely normal vessels, which might be due to spasm or recanalisation; 31 cases showed occlusion but no atherosclerosis, which strongly suggested a causal relation between the trauma and subsequent occlusion. AMI should therefore be considered in patients suffering from chest pain after blunt chest trauma. Because traumatic AMI might often be the result of an intimal tear or dissection, thrombolytic therapy might worsen the situation and acute PCI must be considered preferable. It seems likely that lesser damage could lead to longer-term stenosis we suspect that this sequence is grossly under-reported. This could have medico-legal implications.

B型利钠肽在先天性心脏病患儿中的诊断价值

Aims: To examine the diagnostic value of B-type natriuretic peptide(BNP) plasma concentration in congenital heart disease. Methods and results: BNP was measured in 288 consecutive patients(mean age 6.0± 6.4 years) with left-to-right shunt, left or right heart obstruction, tetralogy of Fallot, functionally univentricular heart, or impaired left ventricular function and compared with age- and gender-specific normal values, and to haemodynamic and echocardiographic data. BNP increased with decreasing left ventricular shortening fraction(r=-0.80; P< 0.001). In patients with left-to-right shunt, BNP was increased(mean SDS + 1.64; P< 0.001) and positively correlated(P< 0.001) to shunt volume(r=0.66), systolic right ventricular pressure(r=0.69), mean pressure of the pulmonary artery(r=0.66), and pulmonary resistance(r=0.59). There was no correlation between BNP and invasive pressure gradient or extent of ventricular hypertrophy in patients with left or right heart obstruction. In patients with tetralogy of Fallot, BNP was not significantly increased. Patients with functionally univentricular heart had elevated BNP plasma levels(mean SDS + 1.39; P< 0.001)without decrease after volume unloading by cavopulmonary connection. Conclusion: In children with congenital heart defects, plasma BNP correlates closely to ventricular function. BNP plasma levels do not reflect directly the extent of ventricular pressure or volume work, but mirror the impairment of the loaded ventricles. Normal BNP cannot exclude pathology, but reflects a compensated status of the heart.

中年体重指数与老年住院和死亡的关系

Context: Abundant evidence links overweight and obesity with impaired health. However, controversies persist as to whether overweight and obesity have additional impact on cardiovascular outcomes independent of their strong associations with established coronary risk factors, eg, high blood pressure and high cholesterol level. Objective: To assess the relation of midlife body mass index with morbidity and mortality outcomes in older age among individuals without and with other major risk factors at baseline. Design: Chicago Heart Association Detection Project in Industry study, a prospective study with baseline(1967- 1973) cardiovascular risk classified as low risk(blood pressure ≤ 120/≤ 80 mm Hg, serum total cholesterol level < 200 mg/dL[5.2 mmol/L], and not currently smoking); moderate risk(nonsmoking and systolic blood pressure 121- 139 mm Hg, diastolic blood pressure 81- 89 mm Hg, and/or total cholesterol level 200- 239 mg/dL[5.2- 6.2 mmol/L]); or having any 1, any 2, or all 3 of the following risk factors: blood pressure ≥ 140/90 mm Hg, total cholesterol level ≥ 240 mg/dL(6.2 mmol/L), and current cigarette smoking. Body mass index was classified as normal weight(18.5- 24.9), overweight(25.0- 29.9), or obese(≥ 30). Mean follow-up was 32 years. Setting and Participants: Participants were 17 643 men and women aged 31 through 64 years, recruited from Chicago-area companies or organizations and free of coronary heart disease(CHD), diabetes, or major electrocardiographic abnormalities at baseline. Main Outcome Measures: Hospitalization and mortality from CHD, cardiovascular disease, or diabetes, beginning at age 65 years. Results: In multivariable analyses that included adjustment for systolic blood pressure and total cholesterol level, the odds ratio(95% confidence interval) for CHD death for obese participants compared with those of normal weight in the same risk category was 1.43(0.33- 6.25) for low risk and 2.07(1.29- 3.31) for moderate risk; for CHD hospitalization, the corresponding results were 4.25(1.57- 11.5) for low risk and 2.04(1.29- 3.24) for moderate risk. Results were similar for other risk groups and for cardiovascular disease, but stronger for diabetes(eg, low risk: 11.0[2.21- 54.5] for mortality and 7.84[3.95- 15.6] for hospitalization). Conclusion: For individuals with no cardiovascular risk factors as well as for those with 1 or more risk factors, those who are obese in middle age have a higher risk of hospitalization and mortality from CHD, cardiovascular disease, and diabetes in older age than those who are normal weight.

介入后同型半胱氨酸水平不能作为支架内再狭窄的生化预测指标

Objectives: Purpose of our study was to determine if homocysteine plasma levels are related to the risk of in-stent restenosis after percutaneous coronary stent implantation in de novo lesions. Background: The putative role of homocysteine as a predictive cardiovascular biomarker of coronary artery disease is well established. The impact of homocysteine levels in the development of in-stent restenosis, however, is controversially discussed. Methods: A total of 177 patients with stable angina pectoris undergoing stent implantation in coronary de novo lesions were included. Laboratory determination comprised blood sample evaluation for homocysteine and other conventional risk factors before baseline coronary intervention and prior to six months control catheterization. Binary restenosis, late lumen loss, and late loss index after six months were assessed by quantitative coronary angiography. Endpoints included target lesion and target vessel failure, homocysteine levels as well as major adverse cardiac events. Results: There was a significant correlation between the length of the implanted stent(p< 0.006), the percentage of stenosis(p< 0.003) and the pre-interventional luminal diameter(p< 0.0001) with late loss index. Linear regression analysis demonstrated no significant impact of the initial or six months homocysteine levels on angiographic restenosis, late lumen loss, or late loss index. Conclusions: In contrast to homocysteine levels, luminal diameter, stent length and percentage of stenosis correlated with the appearance of restenosis. Taking our data into consideration, we hypothesise that homocysteine may not serve as a safe and independent biomarker of in-stent restenosis after a six months period following percutaneous coronary stenting.

NEW ENGL．ZMED．2005 353／17．18新英格兰医学杂志

成年后发生冠状动脉事件者的儿童期生长轨迹;呼吸困难对接受心脏负荷试验患者的预后意义;