微血管性心绞痛诊治进展

1967年Likoff等首先报告了一组女性患者,有典型劳累性心绞痛症状且运动试验阳性,但冠状动脉（冠脉）造影正常。1973年Kemp将冠脉造影正常时出现的劳累性心绞痛称为“X综合征”。1988年Cannon和Epstein经过研究建议将此综合征称为微血管性心绞痛。本病临床上并不少见,其发病机制目前尚不十分清楚,现就此病近几年的诊治进展作一综述。     

20例心脏X综合征的内皮素及一氧化氮变化

X综合征是指一组临床有典型的劳力型心绞痛,心电图运动试验阳性（ST段下降≥1mV）,麦角新碱激发试验前、后冠状动脉造影正常,并排除其他心源性疾病的症候群,此类患者约占临床典型心绞痛患者的10%～30%.X综合征已受到人们重视,但其发病机制及诊断方面的研究都未得到满意结果.有临床研究证实其病理生理学基础可能是细小冠状动脉及心肌内微循环结构或功能异常,冠脉血流储备降低,通过多种机制引起心肌缺血和心绞痛。     

女性绝经前后运动平板试验假阳性率的对比研究

目的分析在胸痛患者中运动平板试验阳性对冠心病的诊断符合率。比较男性组、女性绝经前组、绝经后组运动平板假阳性率的差异。方法运动平板试验均采用Bruce方案,使用美国GE公司CardioSys-CE-0459运动平板机。对268例临床有胸痛症状的运动平板试验阳性患者行冠状动脉（冠脉）造影检查,冠脉狭窄≥50%诊断为冠心病。以冠脉造影结果为金标准,比较男性组（146例）、女性绝经期前组（39例）及绝经期后组（83例）运动平板试验的假阳性率。结果冠脉造影确诊冠心病176例（65.67%）,其中男性105例,女性71例;冠脉造影阴性者92例（34.33%）,男性41例,女性51例。女性绝经后组〔30.12%（25/83）〕与男性组〔28.08%（41/146）〕比较,运动平板的假阳性率差异无统计学意义（χ2=0.107,P=0.428）,绝经前组〔66.67%（26/39）〕与男性组（28.08%）及绝经后组（30.12%）比较差异均有统计学意义（χ2=19.83,P=0.000;χ2=14.57,P=0.000）。结论胸痛患者在冠脉造影前行运动平板试验筛查,阳性者再行冠脉造影可大大提高冠脉造影检查的阳性率。与绝经后组及男性组比较,绝经期前女性运动平板试验假阳性率较高,绝经后女性与男性无明显差异。     

老年左室舒张性心力衰竭的临床研究

对经核素心室造影证实的４０例老年左室舒张性心力衰竭（ＬＶＤＨＦ）和３０例老年左室收缩性心力衰竭（ＬＶＳＨＦ）患者进行临床、超声心动图观察及活动平板运动试验，并以２０例健康老年人作对照，评价左室舒张性心力衰竭临床、超声心动图及运动耐量的特点。结果显示：ＬＶＤＨＦ组心衰时间短，心衰临床表现较轻；超声左房内径扩大，左室内径不大，左室壁厚度增加；左室收缩功能正常，左室舒张功能减低。而ＬＶＳＨＦ组左室内径扩大，左室收缩、舒张功能指标均异常。ＬＶＤＨＦ和ＬＶＳＨＦ两组运动耐量均减退，后者尤为明显。     

冠心病患者SPECT心血池显像与X线左心室造影的比较

X线左室造影（左室造影）是临床测定左室收缩功能最准确的方法，放射性核素心血池显像（心血池显像）检测左室功能在临床上也日益普及，本文以左室造影为标准，旨在对心血池显像测定左室收缩功能的准确性进行探讨。目的：比较20例冠心病患者SPECT心血池显像与X线左心室造影测定左心室功能的价值。方法：采用99mTcSPECT心血池显像和X钱左心室造影的方法分别测定20例冠心病患者的左室射血分数（LVEF）和左室壁运动记分（LVWMS），两种方法测定均在同一周内进行。结果：采用SPECT心血池显像法测得的左室射血分数（LVEF）和左室壁运动记分（LVWMS）分别较X线左心室造影法测得数据LVEF平均低10．2％，LVWMS记分平均低1．7，但两种方法测定的LVEF和LVWMS均有良好的相关性，r值分别为0．N和0．78（P＜0．01）。结论：99mSPECT心血池显像与X线左心室造影在评价冠心病患者心功能方面具有可比性。     

冠心病患者运动试验中微伏T波电交替的分析

目的分析冠心病患者运动试验中的微伏T波电交替（MTWA）。方法118例疑似冠心病患者行运动平板试验及选择性冠脉造影，在运动平板试验过程中检测MTwA，对运动平板试验结果、MTWA检测值及选择性冠脉造影结果进行分析。结果（1）男性冠心病患者运动中MTWA的平均值明显高于男性冠脉正常组（P=0．004），男性ST段压低伴MTWA〉7．6μV诊断冠心病的敏感性、特异性均比单纯ST段压低明显增高（P=0．003）；（2）女性冠心病患者运动中MTWA平均值与冠脉正常组比较无统计学差异（P=0．640）。结论MTWA值与冠心病的相关性有性别差异；运动平板试验中参考MTWA检测值可提高运动试验筛查冠心病的效率。     

运动平板试验与冠状动脉造影诊断冠心病的对比研究

目的用冠状动脉造影对比运动平板试验评价运动平板试验对冠心病的诊断价值。方法对符合运动平板试验适应症的临床可疑冠心病100例，行12导联平静心电图、运动平板试验及冠脉造影，并进行对比分析。结果（1）运动平板试验阳性者36例（36％），冠脉造影有改变者26例（71．4％）；运动平板试验阴性者64例（64％），冠脉造影有改变者21例（32．7％）。运动平板试验与冠脉造影对比假阳性率与假阴性率分别为27．7％和32．8o／．（2）平静心电图可疑心肌缺血80例（80％），冠脉造影有改变者40例（50％）；平静心电图正常者20例（20％）冠脉造影有改变者7例（35％）。（3）运动平板试验终止后即刻～2min心电图异常出现阳性者19例（52．8％），冠脉有狭窄者13例（73．7％）；即刻～6min阳性者6例（16．7％），冠脉造影有改变者4例；即刻～8min阳性者2例（5．6％），均为单支病变。各组病变程度差异有显著性（P〈0．05）。结论运动平板试验与冠脉造影对比存在一定的假阳性率与假阴性率，不能只凭运动平板试验肯定与否定冠心病；运动平板试验结束后其阳性出现时间愈早，冠脉病变愈重而且双支及3支病变较多；无创性检查中运动平板试验敏感性较高。     

代谢综合征与冠心病发病的关系

目的：探讨代谢综合征（MS）与冠心病（CAD）发病的关系。方法：分析167例临床诊断可疑冠心病患者临床资料如体重指数、腹围、血压、血脂、血糖等情况与冠状动脉造影情况。结果：82例冠脉造影阳性患者中代谢综合征阳性52例占65.0%,30例代谢综合征阴性占35.0%。85例冠脉造影阴性患者中代谢综合征阳性21例占24.7%,代谢综合征阴性64例占75.3%,两组间有显著性差异（P〈0.001）。73例代谢综合征阳性中,冠脉重度病变40例,冠脉轻度病变20例,冠脉造影正常13例;而代谢综合征阴性94例中,冠脉重度病变仅19例,冠脉轻度病变29例,冠脉造影正常46例,两组间有显著性差异（P〈0.001）。结论：代谢综合征是冠心病发病的危险因素,而且与冠状动脉病变的的严重程度呈正相关。     

冠脉侧支循环对冠脉病变程度与左室功能关系的影响

冠心病患者的冠脉病变程度与左室功能的关系，至今仍无一致性的结论。有研究提示冠脉病变程度与左室功能相关，而更多的研究发现这两者间无相关。但以上的研究在探讨二者的关系时，均未考虑例支循环对左室功能的影响。为此，本文探讨了冠脉病变程度与左室功能的关系及测支循环的建立对这一关系的影响。36例冠心病患者作冠状动脉造影和左室造影，结果显示Leaman冠脉记分和冠脉病变支数均与左室射血分数及左室壁运动记分无显著相关，但在无侧支循环建立的亚组，leaman冠脉记分与左室射血分数呈显著负相关（r=-0.64P＜0.01），与左至壁运动记…     

女性冠心病的临床特征

目的：探讨女性冠心病的临床特征。方法：比较我院心内科住院并经冠脉造影证实的83例女性冠心病患者与同期住院的281例男性冠心病患者的临床资料，分析其临床特征。结果：女性冠心病的发病年龄较男性晚（P〈0．05）；绝经为女性冠心病的特殊危险因素；女性不典型心绞痛多于男性，而劳累性心绞痛少于男性；女性急性非ST段抬高型心肌梗死多于男性，急性ST段抬高型心肌梗死少于男性；女性冠脉病变以多支为主，男性病人以双支病变为主（P〈0．05）；女性选择介入治疗者明显少于男性（P〈0．05）。结论：女性冠心病患者具有发病年龄晚、典型症状少、三支病变多、介入治疗少等临床特征。     

Adenosine provokes diastolic dysfunction in microvascular angina

Adenosine stress echocardiography was performed in nine patients (58 (±3) years, eight women) with documented microvascular angina. Global ventricular function was assessed by Tc^99m blood pool imaging and Doppler, whereas longitudinal ventricular function was assessed by simultaneous tissue Doppler echocardiography of the lateral mitral annulus. Adenosine was infused incrementally to onset of chest pain in all patients. There was no significant change in global or longitudinal systolic function. Adenosine induced global diastolic dysfunction, demonstrated by blood pool imaging and by Doppler of the transmitral flow. All patients had long axis diastolic dysfunction at peak adenosine, revealed by a ratio of early to late diastolic velocity of lateral mitral annulus <1, which was absent at rest. Adenosine, as a stress agent, provokes regional and global diastolic dysfunction in microvascular angina, which may be a consequence of subendocardial ischaemia. Long axis diastolic dysfunction can be easily revealed by tissue Doppler of the lateral annular motion.     

Role of the vascular endothelium in patients with angina pectoris or acute myocardial infarction with normal coronary arteries

Chest pain with normal coronary angiograms is a relatively common syndrome. The mode of presentation of this syndrome includes patients with syndrome X and patients with an acute myocardial infarction and angiographically normal coronary arteries. Different mechanisms have been proposed to elucidate the exact cause and to explain the various clinical presentations in these patients. Abnormalities of pain perception and the presence of oesophageal dysmotility have all been reported in patients with syndrome X. In situ thrombosis or embolization with subsequent clot lysis and recanalization, coronary artery spasm, cocaine abuse, and viral myocarditis have been described as potential mechanisms responsible for an acute myocardial infarction in patients with angiographically normal coronary arteries. Recent data suggest that both microvascular and epicardial endothelial dysfunction may play an important role in the pathophysiological mechanism of the syndrome of stable angina or acute myocardial infarction with normal coronary arteries.     

HMG-CoA还原酶抑制剂对X综合征血管内皮功能的影响

目的 :通过应用HMG -CoA还原酶抑制剂 (普伐他汀 )对x综合浆内征患者的血管内皮功能的影响 ,观察微血管病变引起的心肌缺血的改善作用。方法 :严格筛选 17例临床表现为胸痛并已作冠脉造影正常的患者服用普伐他汀 10mg。每晚睡前服 1次 ,疗程 3个月 ,用药前后进行血浆内皮素 (ET)的检测及活动平板运动试验 ,比较用药前后各项指标的变化情况。结果 :血浆ET水平较治疗前明显降低 (P <0 .0 1) ,运动出现心绞痛ST段改变的时间明显延长 (P <0 .0 5 ) ;ST段恢复时间显著缩短 (P <0 .0 5 )运动后 4分时相各导联运动诱发的ST段缺血型下降之和 (∑ST)明显减少。结论 :HMG -CoA还原酶抑制剂 (普伐他汀 )可显著改善X综合征患者的血管内皮功能异常 ,减轻心肌缺血 ,对X综合征有治疗作用     

Coronary flow reserve and oesophageal dysfunction in syndrome X.

The relative prevalence of abnormalities of coronary flow reserve and oesophageal function was ascertained in 32 syndrome X patients with typical angina chest pain, a positive exercise test, and normal coronary arteries. Coronary flow reserve in response to a hyperaemic dose of papaverine was measured using an intracoronary Doppler catheter positioned in the left anterior descending coronary artery. An abnormal coronary flow reserve was defined as being < 3.0. Patients were investigated for oesophageal dysfunction by manometry and 24-hour pH monitoring. Thirteen patients had an impaired coronary flow reserve (group 1) and 19 patients had a normal flow reserve (group 2). Eight of the 13 group 1 patients (62%) and 13 of the 19 group 2 patients (68%, p = NS) had evidence of oesophageal dysfunction on either manometry or pH studies. Therefore, a total of 26 (81%) syndrome X patients had either an abnormality of coronary flow reserve or oesophageal dysfunction suggesting that chest pain in these patients may be due to myocardial ischaemia or oesophageal dysfunction, thus confirming the heterogeneous nature of this syndrome. The prevalence of oesophageal abnormalities was independent of any abnormalities of coronary flow reserve.     

频域心电图与放射性核素心室造影评价冠心病左心室功能的比较

56例经冠脉造影的病人和20例正常人接受FCG和RNV检查。FCG与RNV评价冠心病人左心室功能的敏感度,特异度和准确度分别为87.5％、77.8％、82.9％与92.5％、88.9％、90.8％(P>0.05)。FCG计分与LVEF(r=0.586,P<0.01)及TS(r=-0.679,P<0.01)呈中度负相关。此结果提示FCG评价冠心病左心室功能有一定价值。     

Smoking and hyperlipidemia are important risk factors for coronary artery spasm

Objective To investigate the role of coronary artery spasm in the etiology of chest pain lacking significant coronary stenosis and to identify the clinical risk factors related to coronary artery spasm.Methods Two hundred and seventy five patients with chest pain, but without significant coronary artery stenosis underwent the intracoronary acetylcholine test. Coronary artery spasm was diagnosed while coronary artery stenosis increased to 90% and was accompanied by the usual chest pain with or without ischemic changes on electrocardiogram. Logistic regression was employed to investigate the relationships between coronary artery spasm and sex, age, hypertension, diabetes mellitus, smoking,hyperlipidemia and results of electrocardiographic treadmill stress test. Left ventricular ejection fraction and end diastolic pressure were compared between spasm group and non-spasm group.Results Coronary artery spasm was detected in 103 out of 271 patients, a rate of 38%. Logistic regression analysis showed that smoking and hyperlipidemia increased the relative risk of coronary artery spasm 4.2 times and 2.3 times, respectively. There was a significantly negative relationship between diabetes mellitus and coronary artery spasm. Furthermore, there was no coronary artery spasm detected in left ventricular ejection fraction and end diastolic pressure.Conclusions Coronary artery spasm was one of the important etiological factors for patients with chest pain but no coronary artery stenosis. Smoking and hyperlipidemia were the main clinical risk factors for coronarv arterv spasm.     

Tako-tsubo心肌病诊断与发病机制的研究进展

Tako-tsubo心肌病,是指患者具有急性冠状动脉综合征表现而冠状动脉正常。发病前常有情绪或机体应激。临床症状为突发胸痛,新出现的心电图改变;一过性的室壁运动异常和左心室射血分数明显降低。心肌酶通常正常或轻度升高。潜在的机制可能包括:冠状动脉多支血管痉挛;冠状动脉微循环功能障碍或痉挛;儿茶酚胺介导的心肌功能障碍等。     

An audit of activity and outcome from a daily and a weekly "one stop" rapid assessment chest pain clinic

Objectives: The recent National Service Framework for coronary heart disease advocates the establishment of rapid assessment clinics for chest pain. But how should these clinics be organised and do they fulfil their objectives? The aim of this study was to compare referral patterns to a daily and a weekly "one stop" rapid access chest pain clinic (RACPC), and to examine clinical outcome in patients attending these clinics. Design: Patients were prospectively categorised into one of the following subgroups: "acute coronary syndrome", "stable coronary heart disease", or "low risk/non-coronary chest pain". Fatal and non-fatal outcomes were audited over eight months. Setting: Both RACPCs were situated within the cardiology departments of two large Glasgow teaching hospitals. Patients were seen by a cardiologist, and underwent non-invasive testing. Participants: A total of 633 patients with chest pain who were referred by their general practitioner; 500 came to the daily and 133 to the weekly clinic. Forty four (7%) were categorised as having an acute coronary syndrome, 267 (42%) as stable coronary artery disease, and 322 (51%) as low risk/non-coronary chest pain. Results: Referral patterns to the two clinics differed significantly. Compared with the weekly clinic, more patients with an acute coronary syndrome (7.8 v 3.8%) and low risk/non-coronary chest pain (55.2 v 35.6%), but fewer patients with stable coronary disease (37.0 v 61.6%) were referred to the daily clinic (p<0.00001). During follow up eight (1.3%) patients died from a cardiac cause, and eight (1.3%) patients suffered a myocardial infarction. None of these patients were classified as low risk/non-coronary chest pain. Conclusions: (1) RACPCs do provide an effective tool for the early assessment of patients with possible angina. (2) The frequency with which clinics are scheduled may be an important factor in determining how the service is utilised in practice.     

心血管X综合征13例临床分析

目的：分析心血管X综合征临床特点，并探讨其发病机制。方法：回顾性总结13例x综合征临床特点，有创及无创检查情况。结果：心血管X综合征临床表现、无创检查结果与冠心病相同，但冠状动脉造影正常。结论：冠状动脉造影对此病诊断十分重要，冠状动脉微小血管病变及血管内皮功能损伤是心血管X综合征发病机制。     

麝香保心丸联合尼可地尔对冠状动脉微循环障碍患者微循环阻力指数的影响

目的 观察麝香保心丸联合尼可地尔治疗冠状动脉微循环障碍患者的效果.方法 选取2017年2月—2021年6月山东中医药大学附属医院心血管内科诊治冠状动脉微循环障碍患者78例,根据随机数字表法分为对照组(n=39)、观察组(n=39).对照组予尼可地尔等西药常规治疗,观察组在对照组基础上予麝香保心丸治疗.观察2组临床疗效,...