冠心病患者冠状动脉介入治疗后吸烟对临床预后的影响

目的 研究冠心病患者在经皮冠状动脉介入治疗(PCI)后吸烟状态对临床预后的影响.方法 调查592例冠心病患者PCI术前及术后的吸烟状态,根据PCI后吸烟状态将患者分为3组:不吸烟组(n=272)、戒烟组(n=215)及目前吸烟组(n=105),详细记录随访时主要不良心脏事件的发生情况.结果 平均随访19.0个月.术前吸烟率为54.1%,随访时为17.7%.与不吸烟组比较,目前吸烟组患者较年轻(P<0.01),男性较多(P<0.01),高血压病(P<0.05)、糖尿病(P<0.05)较少.病变冠状动脉数(P<0.05)、置人的支架数(P<0.01)也较少,参考冠状动脉的直径较大(P<0.01).与不吸烟组比较,目前吸烟组(0.37%比4.76%,P<0.01)及戒烟组(0.37%比1.40%,P<0.05)的非致死性心肌梗死发生率较高.在校正组间不匹配因素后,logistic多元逐步回归显示随访期间吸烟是PCI术后发生非致死性心肌梗死的危险因素(回归系数为1.28,P<0.01).结论 PCI术后吸烟是术后发生非致死性心肌梗死的危险因素之一.     

药物洗脱支架与金属裸支架对冠状动脉临界病变的远期疗效

目的:评估药物洗脱支架与金属裸支架对于治疗冠状动脉临界病变的远期疗效。方法:自身冠状动脉首次介入治疗病变(在线定量冠状动脉造影分析50%≤管腔狭窄直径≤70%)的患者入选本研究,共计151例患者分为药物洗脱支架组(n=102)和金属裸支架组(n=49),两组的基本临床特征和冠状动脉造影结果差异无统计学意义。术前、术后和随访6～12个月时进行定量冠状动脉造影分析,并在住院期间、30天和6～12个月时观察严重不良心脏事件的发生。结果:151例患者支架置入成功率均为100%。住院期间严重不良心脏事件发生率,在药物洗脱支架组和金属裸支架组差异无统计学意义(0%和2.0%,P=0.15)。在随访30天时,两组均无死亡和支架内血栓形成。6～12个月随访期间,药物洗脱支架组和金属裸支架组比较①严重不良心脏事件发生率(3.9%vs8.1%,P=0.97),②靶病变重复血管重建率(2.9%vs6.1%,P=0.39),③急性心肌梗死发生率(1.96%vs2.04%,P=0.95),差异均无统计学意义。12个月时药物洗脱支架组和金属裸支架组比较,支架内血栓发生率和病死率差异也无统计学意义(1.96%vs0%,P=0.34;0%vs4.08%,P0.05)。定量冠状动脉造影分析显示:远期管腔丢失药物洗脱支架组明显低于金属裸支架组[(0.23±0.73)mmvs(0.95±0.94)mm,P=0.01],两组比较差异有统计学意义;而支架内再狭窄率两组比较差异无统计学意义(12.9%vs25.0%,P=0.34)。结论:药物洗脱支架和金属裸支架对于治疗自身冠状动脉临界病变安全有效,两组远期严重不良心脏事件发生率差异无统计学意义。     

吸烟的冠心病患者冠状动脉病变特点及经皮冠状动脉介入治疗后长期预后评价

目的:评价吸烟的冠心病患者的冠状动脉病变特点及经皮冠状动脉介入治疗(PCI)后的长期预后。方法:本研究人群来自PANDAⅢ临床试验。PANDAⅢ是一项前瞻性、多中心、全人群的随机对照研究,自2013-12至2014-08期间共入选了来自46家中心的2 348例患者,平均年龄(61.2±10.6)岁,男性1 658例(70.6%)。所有受试者均接受PCI,均置入生物可降解聚合物涂层药物洗脱支架。根据入院时吸烟状态将2 348例患者分为非吸烟组(n=1 169),已戒烟组(n=300例)和吸烟组(n=879)。随访2年,主要研究终点为主要不良心血管事件(MACE),定义为全因死亡、心肌梗死和血运重建,次要终点包括支架血栓和靶病变失败(TLF),定义为心原性死亡,靶血管相关心肌梗死和缺血驱动的靶病变血运重建。结果:吸烟组和戒烟组均以男性患者为主,与非吸烟组和已戒烟组相比,吸烟组患者的年龄更小(P0.0001),合并高血压(P=0.0002)、糖尿病(P=0.0052)、既往PCI史(P0.0001)比例更低。吸烟组入院诊断急性心肌梗死比例高达41.3%(363/879),较已戒烟组和非吸烟组明显增高(P0.0001)。非吸烟组、已戒烟组和吸烟组中分别有1 130例(96.7%)、286例(95.3%)和846例(96.2%)患者完成了2年随访。吸烟组、已戒烟组和非吸烟组的MACE发生率分别为11.23%、13.64%和12.21%(P=0.54)。COX多因素分析显示,吸烟不是全因死亡和TLF的独立预测因素(P0.05)。结论:吸烟的冠心病患者急性心肌梗死发生率高,PCI后,吸烟组、戒烟组和非吸烟组的长期MACE无差异。     

胰岛素敏感性的改善对胰岛素抵抗患者择期冠状动脉介入治疗术后心血管事件的影响

目的:探讨胰岛素敏感性的改善对非糖尿病、非肥胖患者,择期经皮冠状动脉介入治疗术(PCI)后心血管事件的影响。方法:连续入选2013年1月至2014年1月间,因心绞痛住院并接受择期PCI治疗的非糖尿病、非肥胖胰岛素抵抗(HOMA-IR≥2.92)患者147例。所有患者术后接受规范的药物治疗和生活方式指导。根据术后6个月HOMA-IR结果将患者分为IR改善组(n=45)和IR持续组(n=102)。随访1年,观察两组患者主要心血管事件(死亡、非致死性心肌梗死、再次血运重建及支架血栓)的发生率。结果:与IR持续的患者相比,IR改善的患者靶血管(12.7%vs.2.2%,P=0.05)和靶病变(11.8%vs.2.2%,P=0.06)血运重建的发生率低;心血管事件的发生率(22.5%vs.13.3%,P=0.20)差异无统计学意义。多因素Cox比例危险度模型分析显示,持续吸烟是PCI术后心血管事件的独立预测因素(HR=7.68,95%CI:3.63~16.22,P0.00)。结论:短期胰岛素敏感性的改善对PCI术后心血管事件无显著影响,持续吸烟是预测PCI术后心血管事件的独立危险因素。     

国产与进口药物洗脱支架治疗前降支开口病变的临床疗效比较

目的:比较国产与进口药物洗脱支架治疗前降支开口病变的临床疗效。方法:回顾性分析95例前降支开口病变的患者置入国产支架(国产支架组,n=68)和进口支架(进口支架组,n=27),所有患者均行临床随访,部分患者进行了冠状动脉造影(CAG)复查。结果:国产支架组的急性心肌梗死患者多于进口支架组,但无统计学差异(46%vs.33%)。两组的介入成功率均为100%。国产支架组的冠脉钙化率、偏心斑块率和C型病变率均高于进口支架组(分别为20%vs.4%;14%vs.0%;28%vs.7%,均P0.05)。两组CAG随访的支架内和血管段再狭窄率无统计学差异;两组的主要不良事件发生率也无统计学差异。结论:国产药物洗脱支架治疗前降支开口病变是安全的,与进口药物洗脱支架具有相似的良好疗效。     

无保护左主干病变合并急性冠状动脉综合征介入与手术治疗对比研究

目的:探讨急性冠状动脉综合征(ACS)合并无保护左主干病变患者经桡动脉介入治疗(TRI)与冠状动脉旁路移植术(CABG)二者的疗效。方法:连续入选2008年3月至2010年12月,于北京安贞医院行经桡动脉介入治疗(n=236)或冠状动脉旁路移植术(n=354)的无保护左主干病变合并ACS患者。对于患者的临床基线特征及冠状动脉病变特征纳入倾向性评分模型进行匹配,得到154对患者。结果:平均随访时间27个月。经过倾向性评分模型进行校正,两组患者的基线资料及病变特征无显著差异。结果显示TRI与CABG两组全因病死率(4.5%vs.6.5%;P=0.454)及心肌梗死发生率(5.2%vs.7.8%;P=0.355)并差异无统计学意义。CABG组患者脑卒中发生率显著增加(零vs.2.6%;P=0.044),而TRI组靶血管重建率(TVR)显著增加(13.0%vs.5.2%;P=0.017)。两组患者复合终点(死亡/心肌梗死/靶血管重建),差异无统计学意义(7.1%vs.12.3%;P=0.124)。结论:对于ACS合并无保护左主干病变患者TRI与CABG的临床复合终点事件风险相似,然而尽管应用药物洗脱支架CABG组患者靶血管重建率仍显著低于介入治疗组。     

冠状动脉旁路移植术后患者左乳内动脉桥血管和自身血管置入药物洗脱支架长期疗效的对比

目的:冠状动脉(冠脉)旁路移植术(CABG)后的患者左乳内动脉(LIMA)桥血管与自身冠脉血管药物洗脱支架长期疗效比较。方法:选择我院2004-06至2012-12 CABG后因LIMA桥血管病变致前壁心肌缺血而行经皮冠脉介入治疗的患者151例,回顾分析其置入药物洗脱支架的临床、冠脉造影和随访资料。依靶血管的不同将患者分为两组,即LIMA组(n=40)和自身血管组(n=111)。自身血管组的靶血管包括左主干—前降支各节段。研究的终点事件包括靶病变血运重建、靶病变失败(包括由心原性死亡、与靶血管相关的非致死性心肌梗死和靶病变血运重建等构成的复合事件)和主要不良心血管事件(包括由死亡、非致死性心肌梗死和任何新的血运重建等组成的复合事件)。使用Cox比例风险模型分析致各终点事件发生的独立预测因子。结果:所有病例随访时间的中位数为30(范围10~100)个月。LIMA组和自身血管组靶病变血运重建率(15.0%vs 11.7%,log-rank P=0.65)和靶病变失败率(17.5%vs 13.5%,log-rank P=0.63)差异均无统计学意义。主要不良心血管事件发生率LIMA组比自身血管组显著增高(35.0%vs 18.0%,log-rank P=0.043),主要为新的血运重建中非靶血管(包括右冠脉、回旋支和大隐静脉桥血管)血运重建率在LIMA组显著增高(17.5%vs 4.5%,log-rank P=0.014)。Cox多变量分析发现,靶病变支架长度是靶病变血运重建[风险比(HR)=1.03,95%CI:1.00~1.06,P=0.01)、靶病变失败率(HR=1.03,95%CI:1.00~1.05,P=0.02)的唯一独立预测因子;而LIMA桥血管介入治疗则是主要不良心血管事件发生的唯一独立预测因子(HR=3.09,95%CI:1.28~7.60,P=0.012)。结论:LIMA桥血管与自身血管病变药物洗脱支架治疗相比,靶病变血运重建率和靶病变失败率结果没有差异,但主要不良心血管事件发生率在LIMA组显著增高,值得进一步研究。     

吸烟和戒烟对冠状动脉旁路移植术后远期结果的影响

目的 探讨吸烟和戒烟对冠状动脉旁路移植术(CABG)后远期结果的影响。方法 随访2004年1月1日至2005年12月30日在阜外心血管病医院行CABG的患者2541例。根据术前有无吸烟史,将患者分为不吸烟组和吸烟组,吸烟组又进一步分为术前戒烟亚组,术后戒烟亚组,持续吸烟亚组。观察患者的死亡、主要不良心脑血管事件以及心绞痛的发生情况。采用Cox回归模型分析各组患者发生不良事件的风险。结果 随访4.27 ～6.41年（平均随访5.09年）。CABG术后持续吸烟患者的比例为22.1％。Cox多因素回归分析显示：与不吸烟组比较,吸烟组肿瘤原因死亡(RR：2.38,95％ CI:1.06 ～5.36)、主要不良心脑血管事件（RR:1.26,95％ CI:1.01 ～ 1.57）和心绞痛（RR：1.29,95％CI:1.04 ～ 1.59)的发生风险较高;与不吸烟组比较,持续吸烟亚组全因死亡(RR:2.60,95％ CI:1.53～4.46)、心因死亡（RR:2.51,95％ CI:1.32～4.78）、肿瘤原因死亡（RR:5.12,95％ CI:2.08 ～12.59）、主要不良心脑血管事件（RR:1.83,95％ CI:1.42 ～2.34）和心绞痛(RR:1.69,95％ CI:1.33 ～2.16)的发生风险较高;术前戒烟亚组和术后戒烟亚组的死亡、主要不良心脑血管事件和心绞痛的发生风险与不吸烟组相似（均P＞ 0.05）。结论 CABG术后患者持续吸烟比例较高。CABG术后持续吸烟会增加死亡率,主要不良心脑血管事件和心绞痛发生率,戒烟可减少不良事件的发生。     

糖尿病急性冠状动脉综合征患者药物洗脱支架与裸金属支架1年心血管预后的比较

目的比较糖尿病急性冠状动脉综合征患者药物洗脱支架与裸金属支架1年心血管预后。方法收集2009年1月至2012年12月鹤壁煤业公司总医院收治的糖尿病急性冠状动脉综合征患者药物洗脱支架与裸金属支架治疗的资料。结果与裸金属支架组(n=575)相比,药物洗脱支架组(n=199)住院心源性休克发生率显著降低(1.5%vs 4.9%,P=0.037),急性心力衰竭(0.5%vs 4.5%,P=0.008)、1年全因死亡率(5.0%vs 8.9%,P=0.048)、1年主要不良心脏事件(MACEs)(20.0%vs 24.4%,P=0.006)亦然;靶血管重建率差异无统计学意义(6.0%vs 7.3%,P=0.395)。随访1年,裸金属支架组具有显著高的危险校正全因死亡率(HR=2.4,95%CI 1.0～5.7;P=0.048)、MACE(HR=2.2,95%CI 1.2～3.9;P=0.011),靶血管重建和非致死性心肌梗死两组相似。结论药物洗脱支架与裸金属支架应用于糖尿病急性冠状动脉综合征患者,前者的总体死亡率和MACEs降低,1年的靶血管重建无显著增加。     

雷帕霉素洗脱支架治疗急性冠状动脉综合征临床观察

目的:评价在非选择的急性冠状动脉综合征(ACS)患者中置入雷帕霉素洗脱支架(SES)的安全性和临床疗效。方法:选择224例接受冠状动脉内支架术治疗的ACS患者,其中103例接受普通支架治疗(普通支架组),121例接受SES治疗(SES组)。记录一般临床情况、手术成功率和术后随访心脏事件发生率,包括:心原性死亡、再梗死、心绞痛复发等。结果:两组支架术的手术成功率相似。与普通支架组比较,SES组30天内心脏事件发生率无显著差异(0%比1.94%,P=0.210)。平均随访(9.1±3.6)个月,SES组心肌缺血症状复发率较普通支架组明显减低(4.96%比20.39%,P=0.001)。两组9个月无心脏事件生存率SES组与对照组分别为95.04%和77.67%(P=0.001)。结论:ACS患者中SES支架术安全有效,且远期临床疗效明显改善。     

Three layer functional model and energy exchange concept of aging process

Relying on a certain degree of abstraction, we can propose that no particular distinction exists between animate or living matter and inanimate matter. While focusing attention on some specifics, the dividing line between the two can be drawn. The most apparent distinction is in the level of structural and functional organization with the dissimilar streams of ‘energy flow’ between the observed entity and the surrounding environment. In essence, living matter is created from inanimate matter which is organized to contain internal intense energy processes and maintain lower intensity energy exchange processes with the environment. Taking internal and external energy processes into account, we contend in this paper that living matter can be referred to as matter of dissipative structure, with this structure assumed to be a common quality of all living creatures and living matter in general. Interruption of internal energy conversion processes and terminating the controlled energy exchange with the environment leads to degeneration of dissipative structure and reduction of the same to inanimate matter, (gas, liquid and/or solid inanimate substances), and ultimately what can be called ‘death.’ This concept of what we call dissipative nature can be extended from living organisms to social groups of animals, to mankind. An analogy based on the organization of matter provides a basis for a functional model of living entities. The models relies on the parallels among the three central structures of any cell (nucleus, cytoplasm and outer membrane) and the human body (central organs, body fluids along with the connective tissues, and external skin integument). This three-part structural organization may be observed almost universally in nature. It can be observed from the atomic structure to the planetary and intergalactic organizations. This similarity is corroborated by the membrane theory applied to living organisms. According to the energy nature of living matter and the proposed functional model, the decreased integrity of a human body's external envelope membrane is a first cause of the structural degradation and aging of the entire organism. The aging process than progresses externally to internally, as in single cell organisms, suggesting that much of the efforts towards the restoration and maintenance of the mechanisms responsible for structural development should be focused accordingly, on the membrane, i.e., the skin. Numerous reports indicate that all parts of the human body, like: bones, blood with blood vessels, muscles, skin, and so on, have some ability for restoration. Therefore, actual revival of not only aging tissue of the human body's membrane, but the entire human body enclosed within, with all internal organs, might be expected. We assess several aging theories within the context of our model and provide suggestions on how to activate the body's own anti-aging mechanisms and increase longevity. This paper presents some analogies and some distinctions that exist between the living dissipative structure matter and inanimate matter, discusses the aging process and proposes certain aging reversal solutions.     

Unusual responses of nocturnal pineal melatonin synthesis and secretion to swimming: Attempts to define mechanisms

Abstract: The effect of swimming at night on rat pineal melatonin synthesis was compared with that of light exposure at night. Rats were forced to swim at 0030 hr (lights out at 2000 hr) and sacrificed by decapitation 15 and 30 min later, immediately after swimming. Other groups of animals were exposed to white light (650μW/cm²) for 15 and 30 min at same time. Swimming caused a rapid and highly significant drop in the melatonin content in the pineal gland; however, the activity of N-acetyltransferase (NAT), the supposed rate limiting enzyme in the melatonin production, was not changed. Despite the drop in pineal melatonin levels, serum concentrations of the indole remained elevated in the rats that swam. In contrast, melatonin levels in the pineal and serum of light exposed rats fell precipitously, accompanied by a significant suppression of NAT activity. Since we anticipated that the strenuous exercise associated with swimming may induce release of artrial natriuretic peptide (ANP) from the heart, which in turn could cause the release of pineal melatonin, in a second study we injected physiological saline intravenously to stretch the cardiac muscle and release ANP. Three milliliters of normal saline was injected during the day into the jugular vein of anesthetized rats that were pretreated with isoproterenol to stimulate pineal melatonin production. Animals were killed 15 min after the saline injection, and pineal NAT activity and pineal melatonin levels were measured. The saline injections caused no alteration in the elevated levels of either NAT or melatonin. These data suggest that the disparity in pineal NAT activity (which was high) and pineal melatonin (which was low), in animals swum at night, may not be caused by ANP which is released during strenuous exercise such as swimming.     

Melatonin and photoperiodic time measurement: Seasonal breeding in the sheep

Abstract: Well-established circadian physiology supports the view that photoperiodic time measurement utilizes the coincidence between the presence of light and a photosensitive phase of a 'biological clock' to alter reproductive status—the so-called external coincidence model of seasonal breeding. In this review, we examine the mechanism whereby photoperiod interacts with presumed suprachiasmatic nuclei activity to allow endogenous melatonin to normally synchronize reproductive activity to the optimal time of year. The Romney Marsh sheep is particularly explored as an experimental model. It is suggested that the on/off activity of seasonal reproduction may be a robust mechanism able to be predictably manipulated by the judicious use of the light/dark cycle and exogenous melatonin, but firmly based on circadian principles.     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Serological survey of HIV and syphilis in pregnant women in Madagascar

Objectives Peripartal transmission of human immunodeficiency virus (HIV) and Treponema pallidum, the causative agent of syphilis, leads to severe consequences for newborns. Preventive measures require awareness of the maternal infection. Although HIV and syphilis testing in Madagascar could be theoretically carried out within the framework of the national pregnancy follow‐up scheme, the required test kits are rarely available at peripheral health centres. In this study, we screened blood samples of pregnant Madagascan women for HIV and syphilis seroprevalence to estimate the demand for systemic screening in pregnancy. Methods Retrospective anonymous serological analysis for HIV and syphilis was performed in plasma samples from 1232 pregnant women that were taken between May and July 2010 in Ambositra, Ifanadiana, Manakara, Mananjary, Moramanga and Tsiroanomandidy (Madagascar) during pregnancy follow‐up. Screening was based on Treponema pallidum haemagglutination tests for syphilis and rapid tests for HIV, with confirmation of positive screening results on line assays. Results Out of 1232 pregnant women, none were seropositive for HIV and 37 (3%) were seropositive for Treponema pallidum. Conclusions Our findings are in line with previous studies that describe considerable syphilis prevalence in the rural Madagascan population. The results suggest a need for screening to prevent peripartal Treponema pallidum transmission, while HIV is still rare. If they are known, Treponema pallidum infections can be easily, safely and inexpensively treated even in pregnancy to reduce the risk of transmission.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.