PCI compared with medical therapy in elderly patients with chronic symptomatic coronary artery disease

Objective The aim of this study was to assess quality of results of elderly patients with coronary disease after medical or revascularisation therapy. Methods In this study, we enrolled 103 patients aged 75 years or older with chronic angina in which 47 patients were assigned coronary angiography and revascularisation and 56 patients with optimised medical therapy. The primary endpoint was quality of life after 6 months, as assessed by questionnaire and the presence of major adverse cardiac events (death, non fatal myocardial infarction, or hospital admission for acute coronary syndrome with or without the need for revascularisation). Results After 6 months follow up, angina severity decreased and measures of quality of life increased in both treatment groups( P <0.05 ); however, these improvements were significantly greater after revascularisation( P <0.01 ). Major adverse cardiac events occurred in 30 ( 53.6% ) of patients in the medical group and 9 ( 19.1% ) in the invasive group ( P <0.01 ).Conclusions Patients aged 75 years or older with angina benefit more from revascularisation than from optimised medical therapy in terms of symptom relief and quality of life. Therefore, these patients should be offered invasive assessment despite their high risk profile followed by revascularisation if feasible.

Atrial fibrillation and coronary artery disease:An integrative review focusing on therapeutic implications of this relationship

The incidence of both atrial fibrillation(AF)and coronary artery disease(CAD)increases with advancing age.They share common risk factors and very often coexist.Evidence points to an intricate relationship between atrial tissue excitability and neuronal remodeling with ischemia at the microcirculatory level.In this review,we delineated this complex relationship,identified a common theme between the two,and discussed how the knowledge of this relationship translates into a positive and meaningful impact in patient management.Recent research indicates a high prevalence of CAD among AF patients undergoing coronary angiography.Further,the incidence of AF is much higher in those suffering from CAD compared to age-matched adults without CAD underlying this reciprocal relationship.CAD adversely affects AF by promoting progression via re-entry and increasing excitability of atrial tissue as a result of ischemia and electrical inhomogeneity.AF in turn accelerates atherosclerosis via endothelial dysfunctional and inflammation and together with enhanced thrombogenicity and hypercoagulability contribute to micro and macrothrombi throughout cardiovascular system.In a nutshell,the two form a vicious cycle wherein one disease promotes the other.Most AF recommendations focuses on rate/rhythm control and prevention of thromboembolism.Very few studies have discussed the importance of unmasking coexistent CAD and how the treatment of underlying ischemia will impact the burden of AF in these patients.Inflammation and endothelial dysfunction remain central to both disease processes and form a handsome therapeutic target in the management of the two diseases.The relationship between AF and CAD is complex and much more than mere coincidence.The two diseases share common risk factor and pathophysiology.Hence,it is impractical to treat them in isolation.Accordingly,we share the implications of managing underlying ischemia and inflammation to positively impact and improve quality of life among AF patients.

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.

Current status of high on-treatment platelet reactivity in patients with coronary or peripheral arterial disease:Mechanisms,evaluation and clinical implications

Antiplatelet therapy with aspirin or clopidogrel or both is the standard care for patients with proven coronary or peripheral arterial disease,especially those undergoing endovascular revascularization procedures. However,despite the administration of the antiplatelet regiments,some patients still experience recurrent cardiovascular ischemic events. So far,it is well documented by several studies that in vitro response of platelets may be extremely variable. Poor antiplatelet effect of clopidogrel or high on-treatment platelet reactivity(HTPR) is under investigation by numerous recent studies. This review article focuses on methods used for the ex vivo evaluation of HTPR,as well as on the possible underlying mechanisms and the clinical consequences of this entity. Alternative therapeutic options and future directions are also addressed.

Clinical characteristics and one year outcomes in Chinese atrial fibrillation patients with stable coronary artery disease： a population-based study

Background Atrial fibrillation （AF） and coronary artery disease （CAD） often coexist, however, the clinical characteristics and the impact of stable CAD on the outcomes in Chinese patients with AF has not been well understood. Methods Consecutive AF patients in 20 hospitals in China from November 2008 to October 2011 were enrolled. The primary endpoints included 1-year all-cause mortality, stroke, non-central nervous system （non-CNS） embolism, and major bleeding. Results A total of 1947 AF patients were analyzed, of whom 40.5% had stable CAD. The mean CHADS2 scores in CAD patients were significantly higher than that of non-CAD patients （2.4 - 1.4 vs. 1.4 - 1.2, P 〈 0.001）. During follow-up period, warfarin use is low in both groups, with relatively higher proportion in non-CAD patients compared with CAD patients （22.3% vs. 10.7%, P 〈 0.001）. Compared with non-CAD patients, CAD patients had higher one-year all-cause mortality （16.8% vs. 12.9%, P = 0.017） and incidence of stroke （9.0% vs. 6.4%, P = 0.030）, while the non-CNS embolism and major bleeding rates were comparable between the two groups. After multivariate adjustment, stable CAD was independently associated with increased risk of 1-year all-cause mortality （HR = 1.35, 95% CI： 1.01-1 .80, P = 0.040）, but not associated with stroke （HR = 1.07, 95% CI： 0.72-1.58, P = 0.736）. Conclusions Stable CAD was prevalent in Chinese AF patients and was independently associated with increased risk of 1-year all-cause mortality. Chinese AF patients with stable CAD received inadequate antithrombotic therapy and this grim status of antithrombotic therapy needed to be improved urgently.

Long-term effect of stenting in unprotected left main coronary artery disease in the elderly

Objective To evaluate the feasibility,safety and efficacy of percutaneous stent implantation for treating left main coronary artery(LMCA)stenosis.Methods Consecutive patients with unprotected left main coronary artery disease treated by stent-based percutaneous intervention(PCI)at 6 medical centers in China were enrolled.Procedural data and clinical outcomes were obtained from all patients.Results From January 2001 to December 2004,138 patients(79 males and 59 females;mean age:69.7±5.8 years)underwent PCI for LMCA stenosis.Bare metal stents(BMS)were implanted in 51 patients with non-bifurcational lesions and in 5 patients with bifurcational lesions from January of 2001 to June of 2003(BMS group);.Drug eluting stents(DES)were used unselectively to cover both bifurcational and non-bifurcational lesions in 86 patients from July of 2003 to December of 2004(DES group).Procedural success rate of the 138 cases was 98%(135/138).One patient(0.7%)with bifurcation lesion who was treated with DES died from severe heart failure 2 weeks after the procedure.During a mean follow up period of 21.3±5.6 months,one patient died from renal failure,one from sudden cardiac death,4 underwent target lesion revascularization(TLR)in the BMS group,which all occurred in patients with bifurcational lesions;whereas in the DES group no deaths occurred and only one patient with bifurcational lesion had TLR.Conclusions(1)PCI is feasible and relatively safe to treat unprotected left main coronary artery disease in elderly patients at medical centers with experienced professionals.(2)BMS and DES have similar immediate and long-term efficacy in the treatment of ostium and shaft lesions of the LMCA.(3)DES are strongly suggested in the therapy of distal bifurcation lesion of unprotected LMCA.

Safety and efficacy of dual antiplatelet therapy after percutaneous coronary interventions in patients with end-stage liver disease

The prevalence of coronary artery disease(CAD)increases in patients with endstage liver disease,with part of them receiving the percutaneous coronary intervention(PCI)as a treatment option.Dual antiplatelet therapy(DAPT),a standard of care after PCI,could result in catastrophic consequences in this population.Before PCI and the start of DAPT,it is recommended to assess patient bleeding risk.Based on novel findings,liver cirrhosis does not necessarily lead to a significant increase in bleeding complications.Furthermore,conventional methods,such as the international normalized ratio,might not be appropriate in assessing individual bleeding risk.The highest bleeding risk among cirrhotic patients has a subgroup with severe thrombocytopenia(<50×10^(9)/L)and elevated portal pressure.Therefore,every effort should be made to maintain thrombocyte count above>50×10^(9)/L and prevent variceal bleeding.There is no solid evidence for DAPT in patients with cirrhosis.However,randomized trials investigating short(one month)DAPT duration after PCI with new drug-eluting stents(DES)in a high bleeding risk patient population can be implemented in patients with cirrhosis.Based on retrospective studies(with older stents and protocols),PCI and DAPT appear to be safe but with a higher risk of bleeding complications with longer DAPT usage.Finally,novel methods in assessing CAD severity should be performed to avoid unnecessary PCI and potential risks associated with DAPT.When indicated,PCI should be performed over radial artery using contemporary DES.Complementary medical therapy,such as proton pump inhibitors and beta-blockers,should be prescribed for lower bleeding risk patients.Novel approaches,such as thromboelastography and“preventive”upper endoscopies in PCI circumstances,warn clinical confirmation.

Comparative Nursing Study of Patients Undergoing Coronary Intervention Therapy in Different Ways

Purpose: To compare the surgical indicators, perioperative complications and postoperative psychological status of patients with coronary interventional therapy (CIT) by radical artery and femoral artery puncture approaches. Methods: 120 patients with CIT were divided into femoral artery group (FAG) and radial artery group (RAG) according to the operation ways. The interventional operation was performed by the same surgeon team and methods. Data of surgical indicators and perioperative complications were recorded and collected. The psychological questionare survey was made within 48 hours the after surgery by the hospital anxiety and depression scale (HAD), and the results were scored by the psychiatrist. Results: The age, sex, ethnicity, education level, disease type, and combined diseases of the two groups had homogeneity without statistical difference. There was no obvious difference in X-ray exposure time, contrast agent usage and operation time in two ways (P > 0.05). The success rate of one-time catheterization was higher in FAG than in RAG (P Conclusion: CIT via radial artery can reduce the incidence of postoperative complications, postoperative physical discomfort and psychological problems such as anxiety and depression of patients.

Spontaneous diffuse vasospasm simultaneously found at left main trunk, left anterior descending, left circumflex and right coronary arteries

Coronary artery spasm （CAS） is found not only in Asian but also in white patients. CAS can lead to angina pecto- ris, myocardial infarction, ventricular arrhythmias and sud- den cardiac death. But CAS diagnosis is not necessarily easy, and it also remains highly challenging to therapy and prevention. We present a spontaneous extensive-CAS case with typical clinical features of acute myocardial infarction, despite the regular vasodilator treatment.

Clinical follow up of patients with premature coronary artery disease (PCAD) implanted with drug-eluting stents

Background: Drug-eluting stents (DESs) are associated with lower restenosis rates. However, minimal data on the follow up results of premature coronary artery disease (PCAD) treated with DESs exist. This study was to evaluate clinical characteristics and one- year prognosis of PCAD implanted with DESs in a Chinese population. Methods: 282 patients with PCAD, of which 177 implanted with DESs and 105 prescribed medicine alone were enrolled and analyzed. Major adverse cardiovascular events (MACEs) and the use of medications for secondary prevention were collected and analyzed. Results: Compared with those receiving medicine alone, patients implanted with DESs had higher ratios of males than females, they also had acute coronary syndromes, multi-vessel disease, higher values of cardiac troponin I, longer hospital stays, higher aspirin and clopidogrel use (all P β-blockers and statins use during follow-up, they had higher ratios of recurrent angina and composite MACEs during one-year follow- up (all P y syndrome (OR 1.716, 95% CI: 1.011 - 2.913) and reduced left ventricular ejection fraction (OR 2.539, 95% CI: 1.180 - 5.463) predict MACEs in a one-year follow-up among patients with PCAD. Conclusions: PCAD patients implanted with DESs have more unstable clinical phenotypes and higher MACEs during a one-year follow-up period, though they were prescribed higher ratios of optimal therapeutic medicine. Further enhanced strategies should be made for secondary prevention.

Shortened dual antiplatelet therapy in contemporary percutaneous coronary intervention era

Percutaneous coronary intervention with stenting is followed by a duration of dual antiplatelet therapy(DAPT)to reduce stent thrombosis and avoid target lesion failure.The period of DAPT recommended in international guidelines following drug-eluting stent implantation is 12 mo for most patients with acute coronary syndrome,and 6 mo for patients with chronic coronary syndrome or high bleeding risk.The new generation of drug-eluting stents have metallic platforms with thinner struts,associated with significantly less stent thrombosis.Shortened DAPT has been investigated with these stents,with evidence from randomised clinical trials for some individual stents showing non-inferior safety and efficacy outcomes.This has to be balanced by the effect of DAPT on secondary prevention of systemic cardiovascular disease especially in high-risk populations.This review will outline the current evidence for individual stents with regards to DAPT duration for both acute coronary syndrome and chronic coronary syndrome and discuss further directions for research and personalised medicine in this contemporary percutaneous coronary intervention era.

Preventing Heart Disease via Coronary Artery Calcium Scoring to Make a Definitive Diagnosis of Atherosclerosis

Purpose: Cardiovascular disease is the number one cause of death in the Western world. The purpose of this manuscript is to compare the benefits and deficiencies of coronary artery calcium scanning versus computer generated risk equations in identifying atherosclerotic cardiovascular disease. These two approaches provide significantly different cardiovascular risk assessments and often lead to therapeutic differences in recommendations from the physician to the patient. Methods: Pertinent medical literature is reviewed concerning both risk assessment approaches (i.e., coronary artery scanning and computer generated risk equations). The strengths and weaknesses of both approaches are discussed, and recommendations are provided based upon available data. Results: Cardiovascular risk equations are simple and readily obtained at no charge by physicians. However, their drawbacks are several, including non-applicability to specific populations, disagreements among different cardiovascular society risk equations, wide ranges of risk outputs (e.g., intermediate 10-year risk is between 5% and 20%), inability to definitively identify coronary artery plaques, and lack of definitive anatomical coronary disease. Alternatively, coronary artery calcium scanning costs approximately $100/scan (if not covered by insurance), requires time and effort by the patient, and exposes the patient to a minimal amount of radiation. However, coronary calcium scanning identifies specific atherosclerotic coronary disease and provides additional information about the anatomical location (i.e., coronary artery) of the atherosclerotic plaque. Conclusion: Based on the published literature, coronary artery calcium scanning is the preferred approach for identifying atherosclerotic cardiovascular disease. Although there are minor drawbacks, overall it provides superior clinical information compared with computer generated risk equations.

Optimization of the pharmacological therapy in patients with polyvascular disease: A multidisciplinary approach

The recent shift of the concept of cardiovascular disease as a chronic progressive condition,potentially involving multiple districts,has driven attention to the optimal management of patients with concomitant coronary and peripheral artery disease,representing a subset of patients with an increased risk of events and impaired survival.Recent pharmacological achievements in terms of antithrombotic therapy and lipid-lowering drugs allow multiple therapeutical combinations,thus requiring optimizing the treatment in a tailored fashion according to patients’risk profiles.Nevertheless,data dedicated to this specific subset of patients are still modest.We summarize currently available strategies and indications for the management of antithrombotic and lipid-lowering drugs in patients with the poly-vascular disease.

急性心肌梗死冠脉介入治疗前TyG及心率变异性的监测价值及预后影响因素分析

目的 探讨急性心肌梗死(AMI)冠脉介入治疗前后甘油三酯葡萄糖指数(TyG)及心率变异性的监测价值及预后影响因素。方法 选取2020年3月到2023年3月佳木斯市中心医院收治的90例AMI患者进行回顾性分析,所有患者均采取冠脉介入治疗,对所有患者进行1年门诊复查随访,分析其治疗情况及预后,并对比其治疗前后TyG及心率变异性变化,建立受试者操作特征(ROC)曲线,分析治疗后TyG及心率变异性指标对AMI后不良心血管事件的诊断价值。随后将术后1年发生心血管不良事件的20例患者分为预后不良组,其余为预后良好组。多因素Logistics回归分析影响AMI介入治疗预后的因素。结果 90例AMI患者27例行急诊PCI,63例行择期PCI,单支血管病变患者42例,2支及以上48例,通过对患者进行1年随访,20例患者发生不良心血管事件。治疗后TyG为7.28±1.49,低于治疗前,治疗后全程相邻R-R间期差值均方根值(rMSSD)、全部正常窦性心搏R-R间期标准差(SDNN)及5 min心搏间期均值标准差(SDANN)分别为(37.62±6.24) ms、(120.51±12.37) ms、(126.62±16.66) ms,均高于治疗前,差异均有统计学意义(P<0.05)。TyG联合心率变异性指标的诊断敏感度为71.57%,特异度为83.56%,联合诊断明显高于单一指标诊断;预后良好组与预后不良组患者性别、体重指数、饮酒史、PCI治疗时机、左心室射血分数、预后危险(TIMI)评分比较,差异均无统计学意义(P>0.05),预后良好组与预后不良组患者年龄、发病到PCI时间、合并基础疾病、Killip心功能分级、吸烟史、冠脉病变支数、TIMI评分、TyG、rMSSD、SDNN、SDANN比较,差异均有统计学意义(P<0.05)。结果显示,年龄、发病到PCI时间、Killip心功能分级、TyG、rMSSD、SDNN、SDANN是影响AMI介入治疗预后的独立危险因素(P<0.05)。结论 AMI采取冠脉介入治疗术后1年不良心血管事件发生率达22.22%,通过冠脉介入治疗可降低患者机体TyG水平,改善心率变异性;治疗后采用TyG联合心率变异性指标和提升对不良心血管事件的诊断价值;进一步分析发现,年龄、发病到PCI时间、Killip心功能分级、TyG及心率变异性为其预后不良的影响因素。

心脏体外震波治疗对冠心病患者心肌灌注及心电图的影响

目的探讨心脏体外震波治疗(CSWT)对冠心病患者负荷心肌灌注扫描及心电图结果的影响。方法纳入2016年12月至2022年8月因冠心病在北京医院住院诊治并行CSWT的患者。CSWT为3个月方案,共9次治疗。收集冠心病患者行CSWT前后的临床基本资料、心肌灌注扫描数据和心电图数据。比较CSWT前后心肌灌注扫描结果和心电图参数的变化。结果共有55例冠心病患者,其中男43例,平均年龄为(67.45±8.96)岁。CSWT前后12导联心电图ST段最大位移均无明显变化,心肌灌注扫描显示左心室整体负荷灌注总分(P=0.031)和整体可逆灌注总分(P=0.024)显著改善,静息左心室整体缺血面积显著缩小(P=0.034),差异均有统计学意义。靶节段负荷灌注评分(P=0.002)、靶节段可逆灌注评分(P=0.002)、靶节段负荷缺血面积(P=0.001)明显改善,差异均有统计学意义。结论CSWT对冠心病难治性心绞痛患者心电图ST段最大位移无影响,有助于改善心肌血流灌注,缩小缺血范围。

冠状动脉斑块旋磨术联合血管内碎石术治疗冠状动脉严重钙化3例

冠状动脉钙化(coronary artery calcification,CAC)常见于糖尿病、代谢综合征及慢性肾脏病患者,其进展可反映全身炎症状态,且与经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)支架内血栓形成或再狭窄等不良结局有关。CAC增加PCI难度,通常需修饰钙化灶以保证顺利输送和扩张药物洗脱支架。

冠状动脉粥样硬化性心脏病炎症机制及抗炎治疗研究进展

冠状动脉粥样硬化性心脏病(CAD)是人类死亡的主要原因之一,其发病机制是由于冠状动脉血管发生动脉粥样硬化病变而引起血管腔狭窄或阻塞,造成心肌缺血、缺氧或坏死而导致的心脏病。在动脉粥样硬化的发生发展过程中,炎症起着至关重要的作用。炎症是冠心病发病机制研究中的一大热点。抗炎治疗药物能否对炎症进行靶向干预并对冠心病患者的预后产生积极的影响日益引起人们的重视。本文扼要综述了介导冠心病发病的关键炎症分子及抗炎药物治疗冠心病的研究进展。

基于XGBoost算法结合光电容积脉搏波与临床特征变量对冠心病患者出血风险的预测研究

目的基于机器学习(machine learning,ML)结合光电容积脉搏波(photoplethysmography,PPG)与临床特征变量构建冠状动脉粥样硬化性心脏病(coronary artery disease,CAD)患者抗栓治疗期间发生出血事件的预测模型。方法选取冠心病患者抗栓治疗云端数据库中2018年1月至2019年10月在中国人民解放军总医院经冠状动脉造影诊断的冠心病并至少上报1例出血事件的冠心病患者,收集PPG及临床特征数据。将PPG-临床特征数据集按8∶2随机划分为训练集与验证集,训练集分别以随机森林、支持向量机及XGBoost算法构建CAD-出血事件预测模型;通过SHAP(SHapley Additive exPlanations)可解释模型对最佳ML预测模型纳入的临床变量进行筛选;最后用验证集数据从敏感性、特异性、受试者工作特征曲线的曲线下面积(AUC)三个方面对筛选后的预测模型进行评价。结果共纳入155例CAD患者临床资料及PPG数据,XGBoost模型在训练集中表现出最佳预测性能(AUC=0.927)。对临床特征变量筛选后发现,导致CAD患者抗栓治疗期间发生出血事件的预测因子有收缩压、糖尿病史、降糖药物使用等12个。最后使用验证集数据对纳入PPG-临床数据集特征与单用PPG特征变量构建CAD-出血事件预测模型进行比较,PPG-临床数据集构建的预测模型预测性能较好(AUC=0.892),敏感度及特异度均高于单用PPG特征的预测模型。结论基于XGBoost算法结合PPG与临床特征变量的冠心病患者出血预测模型表现出较好的预测性能。在此基础上,应用便携式可穿戴PPG设备有望进一步实现对冠心病抗栓治疗患者出血风险的准确的居家动态监测,从而改善这些患者的长期临床结局。

家庭医生团队模式干预对冠心病患者用药依从性和LDL-C达标率的影响

目的:探索家庭医生团队干预对CAD患者用药依从性和LDL-C达标的影响。方法:采集2021年6月-8月社区574例CAD患者,平均年龄(73.0±6.2)岁,对照组和研究组各287例。研究采用随机双盲对照方法。对照组采用传统门诊方式对患者进行诊疗、用药建议与宣教,研究组采用家庭团队模式对CAD患者重点管理。分析患者抗血小板、降脂类药物使用依从性和影响因素以及LDL-C达标率。结果:多因素Logistic回归分析结果显示,高龄、初中及以下文化程度是CAD患者未使用抗血小板药物的独立危险因素,PCI/CABG史是CAD患者未使用抗血小板药物的保护因素(均P<0.05);女性、高龄、超重是CAD患者未使用降脂类药物的独立危险因素,糖尿病史和PCI/CABG史是CAD患者未使用降脂类药物的保护因素(均P<0.05)。研究组患者的抗血小板和降脂药物使用率和LDL-C达标率均高于对照组(P<0.05)。结论:通过家庭医生团队模式进行干预管理,能有效提高社区CAD患者用药依从性和LDL-C的达标率。