冠脉造影与溶栓再通临床标准的对照研究

冠脉造影与溶栓再通临床标准的对照研究葛堪忆，郭静萱，陈明哲，赵一鸣急性心肌梗塞（ＡＭＩ）的溶栓治疗至今开展已１０年。但溶栓治疗判断梗塞相关血血管再通的标准，目前仍沿用１９９１年中华心血管杂志编委会推荐的参考方案［１］（简称参考方案）。为了解参考方案与...

Delayed asymptomatic progressive aortic dissecting aneurysm in patient with STEMI

An 80-year-old woman visited emergency room because of resting chest pain for one hour. She had history of hypertension for 10 years. The blood pressure was 80/50 mmHg and the pulse rate was 51 beats/min. The electrocardiogram demonstrated Junctional bradycardia and ST elevation in lead Ⅱ, Ⅲ and aVF. Chest X-ray indicated cardiomegaly （Figure 1A）. Coronary angiography revealed near total occlusion of proximal right coronary artery （RCA）. She underwent percutaneous coronary intervention （PCI） for the RCA lesion successfully. Echocardiography showed hypokinesia of RCA territory （Figure 2A）.

Safety and efficacy of intravenous esmolol before prospective electrocardio- gram-triggered high-pitch spiral acquisition for computed tomography coro- nary angiography

Background In order to acquire a high quality image with a low radiation dose, prospective electrocardiogram （ECG）-triggered computed tomography coronary angiography （CTCA） requires a stable heart rate （HR） 〈 65 beats/min. Esmolol has the advantage of reduc-ing HR. The objective of this article is to assess the value of intravenous esmolol treatment before prospective ECG-tr/ggered high-pitch spiral acquisition for CTCA. Methods From March 2013 to June 2013, 313 patients underwent prospective ECG-triggered CTCA. Two hundred and thirty two of them received esmolol before angiography. We retrospectively analyzed clinical characteristics, esmolol dose, radiation exposure dose, and the change in HR and blood pressure in these 232 patients. Results A total of 232 patients with a HR 〉 65 beats/rain before CTCA examination received intravenous esmolol treatment （mean dose of 57.26±15.39 rag）, The mean initial HR （HR1）, slowest HR （HR2）, and the HR 30 min after HR2 （HR3） were 75.06± 5.59, 60.75 ±4.00, and 75.54 ± 5.96 beats/min, respectively （HR1 vs. HR2, P 〈 0.0001; HRI vs. HR3, P = 0.377）. The mean time from esmolol administration to HR2 was 24.25 ± 4.97 s and the mean effective radiation dose was 2.28 ± 0.02 mSv. Conclusions HR could be rapidly controlled at an optimum level with intravenous esmolol before prospective ECG-triggered high-pitch spiral acquisition for CTCA. Consequently, the patients received a very low radiation dose.

Feasibility and Diagnostic Accuracy for Assessment of Coronary Artery Stenosis of Prospectively Electrocardiogram-gated High-pitch Spiral Acquisition Mode Dual-source CT Coronary Angiography in Patients with Relatively Higher Heart Rates: in Comparison wit

Objective To prospectively investigate the diagnostic accuracy for coronary artery stenosis of prospectively electrocardiogram-triggered spiral acquisition mode (high pitch mode) dual-source computed tomography coronary angiography (CTCA) in patients with relatively higher heart rates (HR) compared with catheter coronary angiography (CCA). Methods Forty-seven consecutive patients with relatively higher HR (>65 and <100 bpm) (20 male, 27 female; age 55±10 years) who both underwent dual-source CTCA and CCA were prospectively included in this study. All patients were performed CTCA using high pitch mode setting at 20%-30% of the R-R interval for the image acquisition. All coronary segments were evaluated by two blinded and independent observers with regard to image quality on a three-point scale (1: excellent to 3: non-diagnostic) and for the presence of significant coronary stenoses (defined as diameter narrowing exceeding 50%). Considered CCA as the standard of reference, the sensitivity, specificity, positive predictive value and negative predictive value were calculated. Radiation dose values were calculated using the dose-length product. Results Image quality was rated as being score 1 in 92.4% of segments, score 2 in 6.1% of segmentsand score 3 in 1.5% of segments. The average image quality score per segment was 1.064±0.306. The HR variability of patients with image score 1, 2 and 3 were 2.29±1.06 bpm, 5.17±1.37 bpm, 8.88±1.53 bpm, respectively. The average HR variability of patients with different image scores were significantly different (F=170.402, P=0.001). The sensitivity, specificity, positive and negative predictive values were 92.6%, 97.0%, 87.6%, 98.3%, respectively, per segment and 90.0%, 95.2%, 85.3%, 96.9%, respectively, per vessel and 100%, 63.6%, 90.0%, 100%, respectively, per patient. The effective radiation dose was on average 0.86±0.16 mSv. Conclusion In patients with HR more than 65 bpm and below 100 bpm without cardiac arrhythmia, the prospectively electrocardiogram-gated high-pitch spiral acquisition mode with image acquired timing set at 20%-30% of the R-R interval provides a high diagnostic accuracy for the assessment of coronary stenoses combined with a 1.5% of non-diagnostic coronary segments and a radiation dose below 1 mSv.

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.

Positive correlation between plasma PCSK9 and tissue factors levels in patients with angiographically diagnosed coronary artery disease and diabetes mellitus

Background Pro-protein convertase subtilisin/kexin type 9 （PCSK9） is a secreted protein that influences plasma levels of low-density lipoprotein cholesterol （LDL-C）. Both oxidized LDL and tissue factor （TF） contributed to the development of prothrombofic state. The pre- sent study aims to explore the relationship between plasma level of PCSK9 and that of TF in patient with coronary artery disease （CAD）. Methods From July 2013 to March 2014, we enrolled 197 consecutive patients who underwent coronary angiography because of suspected CAD at Beijing Anzhen Hospital in this study. All patients had no history of using lipid-lowering medication. Of these 197 patients （1B 1 male and 66 female, mean age 56.9 ± 11.8 years）, 81 had angiographically diagnosed CAD. Clinical data were collected. Plasma PCSK9 and TF were measured using enzyme-linked immunosorbent assay （ELISA）. Levels of plasma PCSK9 and TF were compared and their correlation analyzed among different patient groups. Results Both plasma levels of PCSK9 （279.8 ± 60.4μg/L vs. 216.5 ± 45.3μg/L, P 〈 0.01） and TF （156.4 ± 26.6 μg/mL vs. 112.1 ± 38.3 μg/L, P 〈 0.01） were significantly higher in patients with CAD, as compared with those with- out CAD. Correlation analysis showed plasma level of PCSK9 was significantly correlated with that of TF in both patients with and without CAD. However, multivariate regression analysis after adjustment for age, gender, smoking, alcohol, hypertension and hyperlipidemia showed that only in CAD patients with type 2 diabetes mellitus, there was significant positive correlation between plasma levels of PCSK9 and TF （β = 0.353, P 〈 0.01）. Coneluslons The plasma level of PCSK9 is independently and positively associated with that of TF in CAD patients with diabetes mellitus, but not in those without diabetes mellitus. Further study is needed to investigate the underlying mechanism.

Cardiac catheterisation in nonagenarians： Single center experience

Objective To explore the treatment, procedure related risks, and outcomes of patients older than 90 years of age undergoing cardiac catheterization. Methods We retrospectively studied 32 patients ≥ 90 years （93.0 ± 1.2 years） who underwent cardiac catheterisation in a tertiary specialist hospital （0.2% of 14,892 procedures during three years）. The results were compared to a patient cohort younger than 90 years of age. Results Baseline characteristics revealed a higher prevalence of diabetes （P 〈 0.001）, chronic obstructive pulmonary disease （P 〈 0.04）, previous myocardial infarction （P 〈 0.02）, and complex coronary anatomy （SYNTAX score 33 vs. 19） in nonagenarians. Patients 〈 90 years of age showed more hyperlipidemia （P 〈 0.01） and previous percutaneous coronary interventions （P 〈 0.015）. Nonagenarians underwent coronary angiography more often for acute coronary syndrome （ACS） （P 〈 0.003）, were presented more often in cardiogenic shock （P 〈 0.003）, and were transferred faster to coronary angiography in cases ofACS （P 〈 0.0001）. The observed in-hospital mortality rate （13% study group vs. 1% control group; P 〈 0.003） in nonagenarians was lower than the calculated rate of thrombolysis in myocardial infarction （TIMI） and global registry of acute cardiac events （GRACE） mortality and strongly influenced by the severity of clinical presentation and the presence of co-morbidities. Conclusion Despite the common scepticism that cardiac catheterisation exposes patients 〉 90 years to an unwarranted risk, our data demonstrate an acceptable incidence of complications and mortality in this group of patients.

Factors Associated with Coronary Artery Disease in Young Population(Age≤40):Analysis with 217 Cases

Objective To investigate the relevant factors of coronary artery disease （CAD） in young people under 40 years of age. Methods The study population was 292 young patients accepting coronary angiography in Fuwai Hospital from July to December 2006, including 272 men and 20 women, with the mean age being 36.7±3.7 years. The diagnosis of CAD was made in the cases presenting ~ 50% stenosis in coronary lumen in coronary angiography. Based on the diagnosis, 217 patients （204 men, 13 women） were assigned to CAD group, and 75 （68 men, 7 women） to non-CAD group. Clinical data and metabolic characteristics of the patients were collected and analyzed using t-test, Z2 test, and multinomial logistic regression with SPSS 8.0 software. Results Most study subjects were current smokers （209/292, 71.6%）, and more than half had body mass index （BMI）〉24 kg/m2 （230/292, 78.8%） and usually took high-fat diet （162/292, 55.5%）. The proportion of heavy smokers （smoking history ≥10 years and t〉20 cigarettes per clay） were significantly higher in the CAD group than in the non-CAD group [20.7% （45/217） vs. 9.3% （7/75）, P=0.015）]. Heavy smoking [odds ratio （OR）, 1.89; 95% confidence interval （CI）, 1.74-2.05], hypertension （OR, 1.56; 95% CI, 1.48-1.65）, alcohol （OR, 1.37; 95% CI, 1.30-1.46）, type 2 diabetes mellitus （OR, 1.37; 95% CI, 1.25-1.50）, high-fat diet （OR, 1.35; 95% CI, 1.28-1.43）, and BMI〉24 kg/m2 （OR, 1.09; 95% CI, 1.03-1.17） were factors related to CAD in the young patients （all P〈0.05）. Total cholesterol （4.56_±1.46 mmol/L vs. 4.09_±1.00 mmol/L）, low-density lipoprotein cholesterol （2.38±1.11 mmol/L vs. 2.14±0.63 rnmol/L）, lipoprotein a （134.97±109.70 mg/L vs. 101.58±58.39 mg/L）, uric acid （359.89_±100.09 μmol/L vs. 336.75±94.36 μmol/L）, erythrocyte sedimentation rate （9.98± 12.19 ram/hour vs. 4.89_±4.92 mm/hour）, high-sensitivity C-reactive protein （3.42±4.39 mg/L vs. 2.80±_3.77 mg/L） and Big endothelin-1 （1.41±1.50 fmol/mL vs. 0.77_±1.13 fmol/mL） in plasma were significantly increased in the CAD group compared with the non-CAD group （all P〈0.05）. Conclusions Heavy smoking, hypertension, alcohol consumption, type 2 diabetes mellitus, high-fat diet and BMI〉24 kg/m2 were significantly related to CAD in patients aged ≤40, with heavy smoking presenting the highest OR. Metabolic syndrome and inflammation were also more common in young CAD patients than in non-CAD patients.

Comparison of the low-density lipoprotein cholesterol target value and the preventive effect of statins in elderly patients and younger patients

Objective To assess whether the low-density lipoprotein cholesterol （LDL-C） target value and preventive effect of statins are different between elderly and younger patients. Methods We investigated 304 patients with previous percutaneous coronary intervention who underwent coronary angiography from January 2007 to December 2016 for examination of recurrent ischemia beyond the early restenosis. Patients were classified into two groups： age ≥ 75 years （elderly group： n = 140） and 〈 75 years （younger group： n = 164）. Relationships between the achieved LDL-C level, incidence of late coronary events, and the effectiveness of statins were evaluated. Results During follow-up, 179 patients underwent late coronary revascularization. Recurrent ischemia presenting as acute coronary syndrome （ACS） occurred in 83 cases. Kaplan-Meier curve analysis revealed that in the younger group, recurrent ACS was significantly lower in patients with LDL-C 〈 70 mg/dL than in those with LDL-C ranging from 70 to 〈 100 mg/dL （P = 0.035）; however, there was no difference between these in the elderly group （P = 0.863）. Instead, recurrent ACS was less frequent in patients with LDL-C ranging from 70 mg/dL to 〈 100 mg/dL than in those with LDL-C ≥ 100 mg/dL in the elderly group （v = 0.033）. Statin use was associated with decreased recurrent ACS （P = 0.005）; moreover, only using statins was an independent predictor in the elderly group （HR： 0.375; P = 0.007）. Conclusions Strict control of LDL-C to 〈 70 mg/dL was effective for reducing the incidence of recurrent ACS in younger patients. However, LDL-C 〈 100 mg/dL might be sufficient as the target value of LDL-C-lowering therapy for secondary prevention of ischemic events in Japanese elderly patients.

Screening for significant atherosclerotic renal artery stenosis with a regression model in patients undergoing transradial coronary angiography/intervention

Objective:Early detection of atherosclerotic renal artery stenosis (ARAS) is clinically important with respect to blood pressure control, prevention of renal insufficiency, and even improving survival. We investigated whether the presence of significant ARAS (luminal diameter narrowing ≥70%) could be predicted using a logistic regression model before coronary angiography/intervention. Methods:Initially, we developed a logistic regression model for detecting significant ARAS based upon clinical and angiographic features and biochemical measurements in a cohort of 1 813 patients undergoing transfemoral coronary and renal angiography. This model was then prospectively applied to an additional 495 patients who received transradial renal angiography to ascertain its predictive accuracy for the presence of significant ARAS. Results:Multivariate regression analysis revealed that older age (≥65 years), resistant hypertension, type 2 diabetes, creatinine clearance (Ccr) ≤60 ml/min, and multivessel coronary disease were independent predictors for significant ARAS. A logistic regression model for detecting ARAS by incorporating conventional risk factors and multivessel coronary disease was generated as:P/(1 P)=exp( 2.618+1.112[age≥65 years]+1.891[resistant hypertension]+0.453[type 2 diabetes]+0.587[Ccr≤60 ml/min]+2.254[multivessel coronary disease]). When this regression model was prospectively applied to the additional 495 patients undergoing transradial coronary and renal angiography, significant ARAS could be detected with a sensitivity of 81.2%, specificity of 88.9%, and positive and negative predictive accuracies of 53.8% and 96.7%, respectively. Conclusions:The logistic regression model generated in this study may be useful for screening for significant ARAS in patients undergoing transradial coronary angiography/intervention.