急诊胸痛的病因学调查与分析

目的探讨急诊内科胸痛患者就医途径和病因学构成和相关辅助检查完善情况,为进一步制定合理的诊治方案提供依据。方法收集2017年8月至2019年8月因胸痛及胸痛等同症状至应急总医院急诊内科就诊的患者。使用统一表格记录人选患者的一般资料、既往病史、发病时间、到达急诊时间、胸痛特点实验室检查、心电图诊断及影像学结果,初步诊断和急诊的治疗情况,确定诊断和心血管不良事件。所有数据经SPSS25.0统计软件进行统计学处理。结果胸痛患者就医的主要方式为自行前往医院(84.7%),但急性心肌梗死患者以救护车转运的比例(38.6%)高于其他原因胸痛患者(14.7%)。非心源性胸痛(共537例)占胸痛病因比例较高(46.5%),心源性胸痛的主要原因为冠心病(共351例)(30.4%)。冠心病患者疼痛部位中位于胸骨后的患者为152例,位于左侧胸部的患者数量为138例,与非冠心病患者相同疼痛部位的患者数量比较均有统计学意义(P<0.001)。一些常用的急诊铺助检查在急诊胸痛患者中完成程度好,并且表明适用于冠心病的诊断及鉴别诊断中(P>0.05)。结论急诊胸痛患者院前转运和急诊室检查评估均应以科学的研究结果为依据,这不仅可以减少疾病危险性和降低漏诊误诊率,同时能够使患者得到科学的治疗,从而降低病死率和并发症的发生。

The main etiologies for patients presented to ER with chest pain or chest pain equivalent in Beijing,China

Objectives To identify the mian etilogoies for patients presented to the ER with chest pain or chest pain equivalent and further analyze the common presenting symptom of coronary heart disease patients in the ER.Methods We conducted a prospective,cross-sectinal survey of all patinets presented to the ER with chest pain and chest pain equivalent syndrome in 17 medical centre in Beijing,China from Ju ly to August 2009.Data was collected by structured interviews and medical record reviews.The mean follow up period was 30 days.Results A total of 5666 patients entered the study [age(58.09±18.39)years,2663 males and 3303 females]. Their final diagnoses are;Chest pain(4.65%) Coronary heart disease 1506(27.4%),Acute Heart failure 149(2.6%), Pericarditis 4(0.1%),Pulmonary embolism 11(0.2%),Aortic dissection8(0.1%),Acute cerebrovascular disease 431 (7.6%),Non-cardic chest pain 2538(44.9%).We further analyzed the cornary heart disease patients.Eight-eight percent patients with cornary heart disease have symptoms at their presentation.The other 12%? patients without symptom.71% with chest prseur sensation.38.8%with shorness of breath, 23.3%with dyspnea,irritable,1.6%syncope,1.0%Loss of Consciousness 33.2%Palpitation,22.0%dizziness,14.7% nausea and vomiting,19.1%sluggish.Conclusions A quarter of patients(27.4%) presented to the ER with chest pain or chest pain equivalent have defined etiology of coronary heart deisease.Howerer,nearly half(48.8%) of the coronary heart disease patients present with no chest pain and 18.7% CHD patients presents with chest pain equivalent syndrome. This study suggest chest pain is not a prerequisite for the diagnosis of CHD.Therefore,special vigilance and thorough coronary artery evaluation is needed for all patients with chest discomfort or respiratory distress in the ER,even for patients without chest pain complaints.

Effect of Guanxin Danshen Dripping Pills on Coronary Heart Disease Comorbid with Depression or Anxiety: The ADECODE-Real World Study

Objective: To evaluate the efficacy of Guanxin Danshen Dripping Pill(GXDSDP) in treating anxiety and depression in patients with coronary heart disease(CHD). Methods: A total of 1,428 patients diagnosed with CHD screened for anxiety, depression, and quality of life(QOL) at baseline received 0.4 g of GXDSDP treatment 3 times per day and returned for monthly reassessment. Patients were recruited after stable treatment for CHD and received assessment of General Anxiety Disorder-7(GAD-7), Patient Health Questionnaire-9(PHQ-9), and Seattle Angina Questionnaire(SAQ) for evaluating anxiety, depression, and QOL.Patients were followed up 3 times, once every 4 weeks, during outpatient visits for 12 weeks. Results: At the third follow-up(F3), the anxiety symptom of 63.79%(673/1,055) of the patients improved to sub-clinical level, and the GAD-7 score improved significantly(8.11 vs. 3.87, P<0.01);57.52%(585/1,017) patients' depressive symptoms improved to sub-clinical level, with a significant improvement in PHQ-9 score(8.69 vs. 4.41, P<0.01) at F3. All aspects of QOL significantly improved at the end of treatment compared to those at baseline(all P<0.01) as assessed by SAQ: physical limitation(31.17 vs. 34.14), anginal stability(2.74 vs. 4.14), anginal frequency(8.16vs. 9.10), treatment satisfaction(13.43 vs. 16.29), and disease perception(8.69 vs. 11.02). Conclusions: A fixed dosage of GXDSDP may be a potential treatment option for CHD patients comorbid with anxiety or depression.(Registration No. ChiCTR2100051523)

Influence of ambulance use on early reperfusion therapies for acute myocardial infarction

Background Ambulance use expedites the definitive treatment of acute myocardial infarction （AMI）. The aim of this study was to evaluate the effect of ambulance use on the administration of early reperfusion therapies for patients with AMI in Beijing, China. Methods Data were prospectively collected from 498 patients with ST-elevation myocardial infarction （STEMI） who were admitted within 12 hours of symptom onset to 19 hospitals in Beijing between November 1,2005 and December 31, 2006. The baseline characteristics of and the initial management of the ambulance users and the non-ambulance users were compared. Results Only 186 （37.3%） patients used an ambulance as transportation to the hospital. Ambulance users were, on average, older and at relatively higher risk on presentation than the non-ambulance users. After adjustment for patient and hospital characteristics, ambulance use was associated with a greater early reperfusion rate, mainly because of a greater incidence of primary percutaneous coronary intervention. In addition, ambulance users had a significantly shorter median door-to-balloon （120 compared with 145 minutes, P 〈0.001） and symptom onset-to-balloon （223 compared with 300 minutes, P 〈0.001） time than non-ambulance users. Conclusions Ambulances are underused by AMI patients in Beijing. Ambulance use may lead to more frequent and faster receipt of early reperfusion therapies. New public health strategies should be developed to facilitate an increased use of ambulances by AMI patients.

Reference values of brachial-ankle pulse wave velocity for Northern Chinese

Background Brachial-ankle pulse wave velocity （baPWV） is a reliable method for measuring arterial elasticity, but the absence of reference value for baPWV has limited its wide use. We conducted an epidemical study in north China to investigate the reference value of baPWV for Chinese people and its influential factors. Methods A total of 974 identified healthy subjects were recruited in this study. The values of baPWV were evaluated noninvasively with an automatic device. Results For healthy population, the mean value of baPWV was higher for male （P 〈0.001）. Multiple regression analysis demonstrated that both age and systolic blood pressure were positively associated with baPWV for male and female （P 〈0.001）. BaPWV value was higher in male than in female in younger group （〈50 years） but not in older group （P〈-0.001）. The upper limits of baPWV were 1394/1264 cm/s, 1435/1361 cm/s, 1552/1433 cm/s, 1597/1609 cm/s and 1798/1915 cm/s for healthy male/female at 10 years interval （age range 20-70 years）. Conclusions Aging is the most important reason of arterial stiffness, but the effect of age on baPWV augmentation is greater for healthy female than their male counterpart. The reference values of baPWV by sex and age are very useful for clinical and preventive medicine.

In-hospital delay to primary angioplasty for patients with ST-elevated myocardial infarction between cardiac specialized hospitals and non-specialized hospitals in Beijing, China

Background Evidence indicates that early reperfusion therapy in patients with ST-elevation myocardial infarction （STEMI） reduces complications. This study was undertaken to compare the in-hospital delay to primary percutaneous coronary intervention （PPCI） for patients with STEMI between specialized hospitals and non-specialized hospitals in Beijing, China. Methods Two specialized hospitals and fifteen non-specialized hospitals capable of performing PPCI were selected to participate in this study. A total of 308 patients, within 12 hours of the onset of symptoms and undergoing PPCI between November 1, 2005 and December 31, 2006 were enrolled. Data were collected by structured interview and review of medical records.Results The median in-hospital delay was 98 （interquartile range 105 to 180） minutes, and 16.9% of the patients were treated within 90 minutes. Total in-hospital delay and ECG-to-treatment decision-making time were longer in the non-specialized hospitals than in the cardiac specialized hospitals （147 minutes vs. 120 minutes, P〈0.001; 55 minutes vs. 45 minutes, P=0.035）. After controlling the confounding factors, the non-specialized hospitals were independently associated with an increased risk of being in the upper median of in-hospital delays.Conclusions There were substantial in-hospital delays between arrival at the hospital and the administration of PPCI for patients with STEMI in Beijing. Patients admitted to the cardiac specialized hospitals had a shorter in-hospital delay than those to the non-specialized hospitals because of a shorter time of ECG-to-treatment decision-making.

Guanxin Danshen Dripping Pills Improve Quality of Life and Cardiovascular Prognoses of CHD Patients after PCI with Anxiety or Depression(GLAD Study):A Randomized Double-Blind Placebo-Controlled Study

Objective:To assess the efficacy and safety of Guanxin Danshen Dripping Pills(GXDS)in the treatment of depression or anxiety in patients with coronary heart disease(CHD)after percutaneous coronary intervention(PCI).Methods:From September 2017 to June 2019,200 CHD patients after PCI with depression and anxiety were included and randomly divided into GXDS(100 cases)and placebo control groups(100 cases)by block randomization and a random number table.Patients in the GXDS and control groups were given GXDS and placebo,respectively,0.4 g each time,3 times daily for 12 weeks.The primary outcomes were scores of Patient Health Questionnaire-9(PHQ-9),Generalized Anxiety Scale(GAD-7)and the Seattle Angina Pectoris Scale(SAQ).The secondary outcomes included 12 Health Survey Summary Form(SF-12)scores and the first onset time and incidence of major adverse cardiovascular events(MACEs).Other indices including blood pressure,blood lipids,microcirculation and inflammatory-related indices,etc.were monitored at baseline,week 4,and week 12.Results:In the full analysis set(200 cases),after treatment,the PHQ-9 and GAD-7 scores in the GXDS group were considerably lower than those in the control group(P<0.05).Compared with the baseline,the total PHQ-9 scores of the experimental and control groups decreased by 3.97 and 1.18,respectively.The corrected mean difference between the two groups was–2.78(95%CI:–3.47,–2.10;P<0.001).The total GAD-7 score in the GXDS group decreased by 3.48%compared with the baseline level,while that of the placebo group decreased by 1.13%.The corrected mean difference between the two groups was–2.35(95%CI:–2.95,–1.76;P<0.001).The degree of improvement in SAQ score,SF-12 score,endothelin and high-sensitive C-reactive protein levels in the GXDS group were substantially superior than those in the placebo group,and the differences between the two groups were statistically significant(P<0.05).Similar results were obtained in the per protocol population analysis of 177 patients.Three cases of MACES were reported in this study(1 in the GXDS group and 2 in the placebo group),and no serious adverse events occurred.Conclusions:GXDS can significantly alleviate depression and anxiety,relieve symptoms of angina,and improve quality of life in patients with CHD after PCI.(Registration No.ChiCTR1800014291)

Factors influencing ambulance use in patients with ST-elevation myocardial infarction in Beijing, China

Background Emergency medical service plays a key role in the early recognition and treatment of ST-elevation myocardial infarction （STEMI）, but studies indicate that the patients experiencing STEMI symptoms often fail to call an ambulance as recommended. This study aimed to examine the current ambulance transport frequency and ascertain predictors and reasons for not choosing ambulance transportation by the patients with STEMI in Beijing. Methods A prospective, cross-sectional survey was conducted from January 1,2006 through until June 30, 2007 in two tertiary hospitals in Beijing and included consecutive patients with STEMI admitted within 24 hours of onset of symptoms. Data were collected by structured interviews and medical records review. Results Of the 572 patients, only 172 （30.1%） used an ambulance, and the remaining 400 （69.9%） presented by self-transport. Multivariate analysis showed that age 〈65 years （OR： 1.220; 95% CI： 1.001-2.043）, lower education level （OR： 1.582; 95% CI： 1.003-2.512）, presence of pre-infarction angina （OR： 1.595; 95% CI： 1.086-2.347）, and attribution of symptoms to non-cardiac origin （OR： 1.519; 95% CI： 1.011-2.284） were independent predictors for not using an ambulance. However, history of coronary artery disease （CAD）, dyspnea, perceiving symptoms to be serious, and knowing the meaning of cardiopulmonary resuscitation appeared to be independent predictors of ambulance use. The main reasons for not using an ambulance were convenience and quickness of self-transport and the decreased severity of symptoms. Conclusions A large proportion of patients in Beijing do not call for an ambulance after onset of STEMI symptoms. Several factors including demographics, previous CAD, symptoms and cognitive factors of patients are associated with the ambulance use. The public should be educated that an ambulance is not merely a transportation modality and that it also provides rapid diagnosis and treatment.

Impact of patients＇ symptom interpretation on care-seeking behaviors of patients with acute myocardial infarction

Background Delay in seeking medical care in patients with acute myocardial infarction （AMI） is receiving increasing attention. This study aimed to examine the association between expected symptoms and experienced symptoms of AMI and its effects on care-seeking behaviors of patients with AMI. Methods Between November 1, 2005 and December 31, 2006, a cross-sectional and multicenter survey was conducted in 19 hospitals in Beijing and included 799 patients with ST-elevation myocardial infarction （STEMI） admitted within 24 hours after onset of symptoms. Data were collected by structured interviews and medical record review. Results The median （25%, 75%） prehospital delay was 140 （75, 300） minutes. Only 264 （33.0%） arrived at the hospital by ambulance. The most common symptoms expected by patients with STEMI were central or left chest pain （71.4%）, radiating arm or shoulder pain （68.7%）, shortness of breath or dyspnea （65.5%）, and loss of consciousness （52.1%）. The most common symptoms experienced were central or left chest pain （82.1%）, sweats （71.8%）, shortness of breath or dyspnea （43.7%）, nausea or vomiting （32.3%）, and radiating pain （29.4%）. A mismatch between symptoms experienced and those expected occurred in 41.8% of patients. Patients who interpreted their symptoms as noncardiac in origin were more likely to arrive at the hospital by self-transport （86.5% vs. 52.9%, P 〈0.001） and had longer prehospital delays （medians, 180 vs. 120 minutes, P 〈0.001） compared to those who interpreted their symptoms as cardiac in origin. Conclusions Symptom interpretation influenced the care-seeking behaviors of patients with STEMI in Beijing. A mismatch between expectation and actual symptoms was associated with longer prehospital delay and decreased use of emerqency medical service （EMS）.

Predictive value of serum uric acid on cardiovascular disease and all-cause mortality in urban Chinese patients

Background The association between increased serum uric acid （SUA） levels and cardiovascular risk has been debated for decades. Several large studies have provided conflicting results regarding the clinical significance of elevated SUA levels in cardiovascular disease （CVD） or cerebrovascular disease. The aim of this study was to investigate the relationship between SUA and CVD and all-cause mortality and their potential diagnostic value. Methods A total of 3570 in-patients ranging in age from 56 to 95 years （mean （67.36_＋11.36） years） were selected from 20 hospitals in Beijing and Shanghai. A carefully designed questionnaire was used to gather baseline data of each patient All patients were divided into two main groups according to their SUA levels： high SUA and normal SUA groups. Serum indices and other important parameters were measured. Results Compared with normal SUA group, high SUA group had significant difference in systolic blood pressure （SBP）, total cholesterol （TC）, triglyceride （TG）, high density lipoprotein cholesterol （HDL-C）, body mass index （BMI）, and age （P 〈0.05 or P 〈0.01）. High SUA prevailed in female and patients with history of essential hypertension, while history of smoking and diabetes showed no significant difference between two groups. All-cause and CVD mortality occurred more frequently in high SUA group than in normal SUA group. In the accumulative survival analysis, high SUA group had lower survival rate than normal SUA group both in CVD and all-cause mortality. COX regression analysis indicated that the history of smoking, age and high SUA were independent risk factors for the development of CVD. Conclusions These preliminary observations suggest that patients with high SUA levels would face higher risk of mortality. SUA measurement may be applied as a routine predictor for clinical assessment.

Community-wide survey of physicians＇ knowledge of cholesterol management

Background An elevated serum lipid is one of the major risk factors for coronary heart disease （CHD）. Physicians＇ awareness contributes to successful adoption of practice guidelines. Community medical centers are the primary defense against chronic disease. This study aimed to investigate community physicians＇ awareness of cholesterol guidelines and their utilization.Methods Six hundred and one community physicians were randomly selected from four different regions, and completed a confidential and semi-structured questionnaire. Four hundred and ninety-one completed the questionnaire, and 486 valid questionnaires were available.Results The physicians＇ fundamental knowledge of lipids was astonishingly poor, while the awareness of cholesterol guidelines was low. Only 24% and 14% of the physicians reported the right optimal low-density lipoprotein cholesterol （LDL-C） level for CHD and diabetes patients respectively. More than half of the physicians （55.8%） mistakenly considered elevated transaminases to be the lethal side effect of statins. More than half of the physicians （51.9%） would give up statin treatment in the case of transaminase elevation.Conclusion Educational interventions to improve cholesterol knowledge and to publicize standard treatment are needed among Chinese community physicians.

In vitro anticoagulation monitoring of low-molecular-weight heparin

Background Although low-molecular-weight heparin has replaced unfractionated heparin to become the primary anticoagulation drug for treatment of acute coronary syndrome, there is no convenient bedside monitoring method. We explored the best laboratory monitoring method of low-molecular-weight heparins （enoxaparin, dalteparin, and nadroparin） by use of the Sonoclot coagulation analyzer to monitor the activated clotting time. Methods A total of 20 healthy volunteers were selected and 15 ml of fasting venous blood samples were collected and incubated. Four coagulants, kaolin, diatomite, glass bead, and magnetic stick, were used to determine the activated clotting time of the low-molecular-weight heparins at different in vitro anti-Xa factor concentrations. A correlation analysis was made to obtain the regression equation. The activated clotting time of the different low-molecular-weight heparins with the same anti-Xa factor concentration was monitored when the coagulant glass beads were applied. Results The activated clotting time measured using the glass beads, diatomite, kaolin, and magnetic stick showed a linear correlation with the concentration of nadroparin （r = 0.964, 0.966, 0.970, and 0.947, respectively）. The regression equation showed that the linear slopes of different coagulants were significantly different （glass beads 230.03 s/IU, diatomite 89.91 s/IU, kaolin 50.87 s/IU, magnetic stick could not be calculated）. When the concentration of the anti-Xa factor was the same for different low-molecular-weight heparins, the measured activated clotting time was different after the application of the glass bead coagulant. Conclusions The glass bead coagulant is most feasible for monitoring the in vitro anticoagulation activity of nadroparin The different effects of different low-molecular-weight heparins on the activated clotting time may be related to the different anti-11a activities.

Crush stenting in treating coronary bifurcate lesions： paclitaxel eluting stents versus sirolimus eluting stents

Background Because no data regarding the comparison of crush stenting with paclitaxel （PES） or sirolimus eluting stents （SES） for coronary bifurcate lesions have been reported, we compared the clinical outcomes of these two types of stents. Methods Two hundred and thirty patients with 242 bifurcate lesions were enrolled in a prospective, nonrandomized trial Primary endpoints included myocardial infarction, cardiac death and target vessel revascularization at 8 months. Results All patients were followed up clinically and 82% angiographically at 8 months. Final kissing balloon inflation was performed in 72% in the PES and 75% in the SES groups （P〉0.05）. Compared to the SES group, PES group had a higher late loss and incidence of restenosis （P=0.04） in the prebifurcation vessel segment. The postbifurcation vessel segment in the PES group had a greater late loss （（0.7±0.6） mm vs （0.3±0.4） mm, P〈0.001） and higher restenosis in the side branch （25.5% vs 15.6%, P=0.04） when compared to the SES group. There was significant difference of insegment restenosis in the entire main vessel between PES and SES groups （P=0.004）. Target lesion revascularization was more frequently seen in the PES group as compared to the SES group （P=0.01）. There was significant difference in the accumulative MACE between these two groups （P=-0.01）. The survival rate free from target lesion revascularization was significantly higher in the SES group when compared to the PES group （P〈0.001）. Conclusion SES is superior to PES in reducing restenosis and target lesion revascularization by 8-month follow-up after crush stenting for bifurcate lesions.

Comparative study of 4Fr catheters using the ACIST variable rate injector system versus 6Fr catheters using hand manifold in diagnostic coronary angiography via transradial approach

Background The transradial approach is regarded as a useful vascular site for coronary procedures. The aim of this study was to test whether 4Fr catheters assisted by ACIST variable rate injector system can produce comparable angiographic quality and reduce the risk of radial artery injury compared to hand manifold 6 Fr catheters. Methods A total of 1816 patients were studied consecutively, among whom 856 patients received coronary angiography by 4 Fr catheters （4Fr group） and 960 patients by 6 Fr catheters （6Fr group）. Angiographic and procedural characteristics were observed and recorded. The luminal inner radial arterial diameter before and after the procedure were collected. Results The baseline clinical characteristics were similar in both groups. There were no significant differences in procedure time, radiation dose and quality scores in both groups （P 〉0.05）, but more contrast media was delivered in the 6Fr group （P 〈0.001）. The mean radial arterial diameter six months after the procedure in the 6Fr group reduced significantly compared to that measured one day prior to the procedure （P 〈0.001）. Conclusions Coronary angiography using the 4Fr catheters with Acist power injection system can achieve an acceptable diagnostic quality while at the same time minimizing radial artery injury and contrast media consumption.

A giant cyst-like mass： an unusual morphous of left atrial myxoma

Primary cardiac neoplasms are very rare as compared to metastatic tumors; 70% to 80% of them are benign myxomas. Myxomas are polypoid, round, or oval. They are gelatinous with a smooth or lobulated surface, usually white, yellowish, or brown. We report a case of left atrial myxoma with approximate cystis in morphous.

Reasons for the upsetting cholesterol level during the community investigation from residents, physicians, and social aspects： The China Cholesterol Education Program （CCEP）

Background The community medical center is the first barrier for lipid control. We aimed to survey the residents＇ cholesterol condition in the community, and pursue the reasons for the upsetting results from various aspects.Methods Residents and physicians were recruited from four community centers. Residents completed questionnaires and a physical examination as well as biochemical analysis. Physicians were also asked to complete a questionnaire,some of which were about basic knowledge of lipids.Results About 37.0% male and 48.1% female had elevated cholesterol levels. Residents＇ blood pressure （BP）, fasting glucose （FG）, body mass index （BMI）, and waist circumference （WC） were positively associated with their low-density lipoprotein cholesterol （LDL-C） and total cholesterol （TC）. Framingham risk scoring （FRS） was strongly related to cholesterol （P 〈0.001 for LDL-C and TC）. Residents＇ higher education grade was positively related to a normal cholesterol condition （P〈0.001）, while personal income was negatively related to it. Rural residents had higher percent of population with normal cholesterol level （normal cholesterol rate） than their city counterpart （P 〈0.001）. Although physicians with college education had a much higher lipid knowledge level themselves, the physicians＇ factors had almost no relationship with the residents＇ cholesterol levels.Conclusions Management of hypercholesterolemia should be an important component of health strategy in Beijing.Education is imperative for residents as well as for physicians.

A multi-center, double-blind, randomized, parallel group study to evaluate the effects of two different doses of losartan on morbidity and mortality in Chinese patients with symptomatic heart failure intolerant of angiotensin converting enzyme inhibitor treatment

Background There have been no mortality/morbidity endpoint studies with Iosartan in Chinese heart failure patients. The objective was to evaluate the effects of high-dose vs. low-dose Iosartan on clinical outcomes in Chinese subjects with heart failure.