介入治疗心肌桥和心肌桥并发严重冠状动脉粥样硬化病变的疗效观察

目的:探讨冠脉内药物支架置入治疗心肌桥及心肌桥并发严重冠状动脉粥样硬化病变的疗效。方法:对14例急性心肌梗死的心肌桥患者(冠状动脉造影示心肌桥均位于前降支,心脏收缩时血管狭窄75%～95%,病变长度为10～22mm。8例并发心肌桥近端冠状动脉粥样硬化伴狭窄和完全闭塞,5例为心肌桥以外冠状动脉粥样硬化伴狭窄和完全闭塞,1例为单纯心肌桥。)行吉威雷帕霉素药物支架于冠状动脉粥样硬化伴狭窄和完全闭塞及部分患者心肌桥处。结果:术中即刻造影示冠状动脉粥样硬化狭窄和闭塞处及置入支架的心肌桥压缩影像消失,血流恢复,TIMI3级,管腔无残余狭窄。随访3～18个月有3例再发心绞痛,经药物治疗后症状缓解。结论:对有心肌桥和心肌桥并发严重冠状动脉脉粥样硬化病变的患者,可以选择药物支架置入治疗,但远期疗效仍需更多的病例研究证实。

急诊冠脉搭桥初步经验

目的:探讨急诊冠状动脉搭桥术的手术指征、并发症及围术期处理方法。方法:回顾18例急诊冠脉搭桥手术患者围术期危险因素及死亡原因。入选病例均符合ACC/AHA有关冠心病手术指南中急诊冠状动脉搭桥术适应证。不稳定性心绞痛16例,经皮冠状动脉成形术失败2例。结果:16例恢复出院,2例术后死亡,病死率11%。5例出现围术期并发症,占28%。结论:急诊冠脉搭桥手术是治疗冠心病一种有效且安全的方法。

曲美他嗪与比索洛尔联用在冠心病合并充血性心衰治疗机制中的实验研究

目的系统研究曲美他嗪与比索洛尔联用于冠心病(CHD)合并充血性心衰(CHF)的治疗效应及其作用机制。方法根据入选标准将2015.01~2016.10于内蒙古自治区人民医院就诊的CHD合并CHF患者共79例纳入研究,按双盲随机原则分为两组,即联合组(n=39例)与对照组(n=40例),进行为期12周的分类治疗实验;其中对照组仅执行包括β-Blocker、ACEI/ARB及醛固酮拮抗剂+降脂药等为基础的常规标准治疗方案,联合组则在常规治疗基础上给予曲美他嗪+比索洛尔渐进剂量下联用应用。加强治疗期随访观察,主要评价策略为:(1)以t2DE为指针行心脏彩超监测,记录2组治疗前后主要心功能指标的改变并观察24h室性心律失常、心率变化;(2)根据AHA指南比较2组治疗效果。结果 2组实验对象入组前LVEDD、LVESD、EF、HR、ARR等指标的差异性不显著(P均﹥0.05),12周实验期结束时,2组实验对象各项观察指标均较入组前改善明显(P﹤0.05及P﹤0.01);其中联合组各项指标的改善程度优于对照组(P﹤0.05);疗效分析显示,联合组治疗总有效率及显效率均高于对照组(P﹤0.05)。结论在常规治疗基础上增加曲美他嗪+比索洛尔的用药方案,其治疗作用明显增强,在冠心病合并充血性心衰治疗中建议尽早应用此方案以加快患者心功能及预后的改善进程。

Cardiac evaluation of liver transplant candidates

Physicians previously thought that heart disease was rare in patients with end stage liver disease. However, recent evidence shows that the prevalence of ischemic heart disease and cardiomyopathy is increased in transplant candidates compared to most other surgical candidates. Investigators estimate that up to 26% of all liver transplant candidates have at least one critical coronary artery stenosis and that at least half of these patients will die perioperatively of cardiac complications. Cardiomyopathy also occurs in greater frequency. While all patients with advanced cardiac disease have defects in cardiac performance, a larger than expected number of patients have classical findings of dilated, restrictive and hypertropic cardiomyopathy. This may explain why up to 56% of patients suffer from hypoxemia due to pulmonary edema following transplant surgery. There is considerable controversy on how to screen transplant candidates for the presence of heart disease. Questions focus upon, which patients should be screened and what tests should be used. This review examines screening strategies for transplant candidates and details the prognostic value of common tests used to identify ischemic heart disease. We also review the physiological consequences of cardiomyopathy in transplant candidates and explore the specific syndrome of "cirrhotic cardiomyopathy".

Predictors of new-onset atrial fibrillation in elderly patients with coronary artery disease after coronary artery bypass graft

Objective To identify the factors associated with the development of postoperative atrial fibrillation （POAF） after coronary artery bypass graft （CABG） in elderly patients with coronary artery disease （CAD）. Methods A total of 81 patients with CAD who underwent CABG were enrolled in the study. Patients were divided into two groups： Group 1, without postoperative atrial fibrillation （59 patients, 74.6% men, mean age 65.8 ~ 4.0 years）; Group 2, with early new-onset atrial fibrillation after CABG （22 patients, 90.9% men, mean age 67.7 ＋ 5.4 years）. Interleukin （IL）-6, IL-8, IL-10, C-reactive protein （CRP）, fibrinogen, superoxide dismutase （SOD）, N-terminal pro-B-type natriuretic peptide （NT-proBNP）, and troponin I were studied. Results During the observation period, atrial fibrillation occurred in 27.2% cases, an average of 4.9 ±3.8 days after surgery. In group 2, the left atrium （LA） dimension was larger than in group 1 （43.9 ± 3.4 mm vs. 37.6 ±3.9 rnm, P 〈 0.001）. Patients with POAF had significantly higher IL-6 （72.7 ±60.8 pg/mL vs. 38.0 ± 34.6 pg/mL, P = 0.04）, IL-8 （11.9 ± 6.0 pg/mL vs. 7.7± 5.4 pg/mL, P = 0.01） and SOD （2462.0 ± 2029.3 units/g vs. 1515.0 ± 1292.9 units/g, P = 0.04） compared with group without POAF. The multivariate analysis showed that the odds ratio （OR） for POAF development in patients with left atrium more than 39 mm was 2.1 [95% confidence interval （CI）： 1.2-3.8, P = 0.0004], IL-6 levels more than 65.18 pg/mL-1.4 （95% Ch 1.1-2.7, P = 0.009）, IL-8 levels more than 9.67 pg/mL-1.2 （95% CI： 1.1-3.7, P ： 0.009）, SOD more than 2948 units/g-1.1 （95% Ch 1.01-2.9, P = 0.04）. Conclusions In our study, the independent predictors of postoperative atrial fibrillation after CABG in elderly patients were left atrium dimension and the increased postoperative concentration of IL-6, IL-8 and superoxide dismutase.

Is there any link between homocysteine and atherosclerosis？

I have read with interest the paper by Hart, et al. re- porting that homocysteine （Hey） is an independent risk fac- tor for non-culprit coronary lesions progression after 12 months of follow-up in elderly patients who has undergone percutaneous coronary stenting. Hcy-mediated increased lipid peroxidation and generation of free radicals results in in- flammation and endothelial dysfunction, which triggers atherosclerotic process. Coronary artery disease is also as- sociated with higher levels of Hcy.

The impact of optimal medical therapy at discharge on mortality in patients with coronary artery disease

Objective To analyze the current usage of optimal medical therapy （OMT）, influencing factors, and the predictive value of OMT for all-cause mortality in coronary artery disease （CAD） patients with different subgroups. Methods A total of 3176 CAD patients confirmed by coronary angiography were included. OMT was defined as the combination of anti-platelet drugs, statins, beta blockers, and angiotensin converting enzyme inhibitors or angiotensin receptor blockers. Factors for OMT and its prognostic value were analyzed in CAD patients across different subgroups. Results Out of 3176 patients, only 39.8% （n = 1265） were on OMT at discharge. Factors associated with OMT at discharge were pre-admission OMT and discharge department. All-cause mortality occurred in 6.8% （n = 217） of patients. Multivariate analyses indicated that OMT was significantly associated with reduced all-cause mortality （HR： 0.65, 95% CI： 0.45~0.95; P = 0.025）. Sub-group analyses indicate that male acute coronary syndrome （ACS） patients were more likely to receive survival benefits with OMT at discharge. The positive impact of OMT at discharge was more apparent after 24 months, regardless of revascularization therapy. Four-drug combination of OMT was superior to 3-drug combination therapy in ACS patients but not in stable patients. Conclusions OMT was asso- ciated with significant improvement in survival in patients with CAD. The positive impact of OMT was distinct in the CAD patients with different characteristics.

Polymorphisms in the genes for coagulation factor II,V,VII in patients undergoing coronary angiography

Objective: To determine whether polymorphisms in the genes for coagulation factor II,V, VII could predispose an individual to increase risk for coronary artery disease (CAD) and/or myocardial infarction (MI) in Chinese. Methods: We screened coagulation factor II(G20210A),V(G1691A),VII (R353Q and HVR4) genotype in 374 patients undergoing coronary angiography by polymerase chain reaction and restriction fragment length polymorphism (PCR RFLP) assay. Results: The R353Q and HVR4 genotype of the factor VII distribution was in accordance with Hardy Weinberg equilibrium. The frequencies of FVII genotype or allele did not show statistically significant differences between CAD group and controls or between male and female. The frequencies of the Q allele and (RQ+QQ) genotype were significantly higher among the CAD patients without myocardial infarction (MI) history than among those with MI history ( P <0.05). However, HVR4 polymorphism was not significantly different within groups. We only find one normal control of factorII(G20210A) mutation. No coagulation factor V(G1691A) mutation was found in the CAD patients and controls. Conclusion: The factor II(G20210A),V(G1691A) mutation is absent and may not be a major genetic factor for CAD and/or MI; the Q allele of the R353Q polymorphism of the factor VII gene may be a protective genetic factor against myocardial infarction in Chinese.

Acute coronary syndrome in the older adults

Coronary heart disease remains the leading cause of death in the developed world. Advanced age is the single strongest risk factor for coronary artery disease （CAD） and independent predictor for poor outcomes following an acute coronary syndrome （ACS）. ACS refers to a spectrum of conditions compatible with acute myocardial ischemia and/or infarction due to various degrees of reduction in co- ronary blood flow as a result of plaque rupture/erosion and thrombosis formation or supply and demand mismatch.

Patients ≥ 75 years with acute coronary syndrome but without critical epicardial coronary disease： prevalence, characteristics, and outcome

Objective Absence of significant epicardial coronary artery disease （CAD） in patients with acute onset of chest pain and elevation of myocardial necrosis markers is occasionally observed. The aim of this study was to analyse the clinical characteristics and outcome of such patients with advanced age. Methods We retrospectively analysed 4,311 patients with acute onset of chest pain plus necrosis marker elevation. Two hundred and seventy two patients without CAD on angiogram （6.3%） were identified. Out of them, 50 （1.2%） patients 〉 75 years （Group Ⅰ） were compared with （1） 222 acute coronary syndrome （ACS） patients without CAD on angiogram 〈 75 years （Group Ⅱ）, and （2） 610 consecutive patients ≥ 75 years with Non-ST-elevation Myocardial Infarction （NSTEMI） undergoing percutaneous coronary intervention （Group Ⅲ）. Results Group 1 compared to Group III patients made up for more females （64.0% vs. 49.2%; P 〈 0.0001）, and had more severe anginal symptoms on presentation [Canadian Cardiovascular Society （CCS） class Ⅰ/Ⅱ, 26.0% vs. 49.8%; P = 0.02]. Group I patients also had lower troponin levels （0.62 ± 0.8 ng/mL vs. 27 ± 74 ng/mL; P 〈 0.02）, lower leukocyte count （9.4 ± 3.13 × 10^9 vs. 12 ± 5.1 × 10^9; P = 0.001 ） and better preserved left ventricular function （56.7% ± 14.3 % vs. 45% ± 1 1%; P 〈 0.0001 ）. Event-free survival （cardiac death, myocardial infarction, recurrent angina, and re-hospitalisation） was more frequent in Group Ⅰ and Ⅱ patients compared to Group III patients （64.9%, 66.7%, and 41.6%, respectively; P 〈 0.0001）. Conclusions ACS in patients 〉 75 years without CAD is very infrequent, associated with a （1） similar outcome compared to ACS patients 〈 75 years without CAD, and （2） significant better outcome compared to NSTEMI patients 〉 75 years.

Red blood cell level is increased in obese but not in non-obese patients with coronary heart disease

Objective To examine the changes of red blood cell levels in the obese and non-obese patients with coronary heart disease （CHD） and its clinical significance. Methods 230 cases of coronary heart disease were selected and divided into the obese group and the non- obese group. Obesity and non-obesity were defined based on the body mass index （BMI if 28.0kg/m2）, or waist-hip ratio （men〉 0.9, women〉 0.85）. In addition, 130 healthy subjects were recruited as controls. The pathological status of coronary lesions was quantita- tively analyzed according to the Coronary Vascular Image Segmentation Evaluation Criteria （American Heart Association 1984） and the Gensini scoring system. Results of the changes of both the hemoglobin levels and the red blood cell count in the obese group, the non- obese group with CHD and the control group were compared. Besides, Multivariant Logistic Regression Analysis was applied to assess the correlation between the red blood cells and the coronary artery disease. Results The red blood cell count and the level of hemoglobin in the obese group with CHD was higher than that in the non-obese group with CHD [（4.35 ± 0,55） and （4.13 ± 0.56） 10^9/L; （136.71± 15.87） and （129.96 ±16.23） g/L, P 〈 0.05 in both]; the proportion of acute coronary syndrome in the obese group with CHD was higher in the obese group with CI-/D than that in the non-obese group with CHD （P〈0.05）; Multivariant logistic regression analysis also showed that the red blood cell count was positively correlated with obesity with CHD.Conclusion The red blood cell count and the level of hemoglobin in the obese group were higher than those in the non-obese group; the increase of red blood cell count and hemoglobin level is one of the independent risk factors for the obese patients with CHD.

Stent supported coronary angioplasty in patients with severe ventricular dysfunction

OBJECTIVE: To assess the immediate- and long-term outcomes of stent supported coronary angioplasty in patients with severe left ventricular dysfunction. METHODS: Seventy-four consecutive patients with angiographic left ventricular ejection fractions or = 1 was seen in 29 (73%) of 40 successfully treated congestive heart failure patients at 6 months after the procedure. During long-term follow-up, 58 (87.9%) of 66 patients with clinical success were alive, including 44 (68.6%) free from cardiac events. CONCLUSIONS: Patients with severe left ventricular dysfunction treated with stent supported PTCA experience a high rate of success, low procedure related mortality and satisfactory long-term survival.