腔内影像学指导下急性冠脉综合征发病机制及干预策略进展

<正>急性冠脉综合征(acute coronary syndrome,ACS)是指由于冠状动脉血流突然减少导致急性心肌缺血和/或心肌梗死的一系列现象[1]。ACS包括急性ST段抬高型和非ST段抬高型ACS,其中非ST段抬高型ACS可根据心肌损伤生物标志物(主要是肌钙蛋白cTn)的水平及临床表现,分为急性非ST段抬高型心肌梗死(non ST segment elevation,NSTEMI)和不稳定型心绞痛(unstable angina,UA)。     

组织型纤溶酶原激活物(t-PA)在急性冠脉综合征中的生物标记意义

<正>冠状动脉粥样硬化斑块破裂并继发完全或不完全闭塞性血栓形成是急性冠脉综合征(ACS)的主要病因[1];开发ACS高特异性和高敏感性的确诊标志物是研究的热点。目前利用心肌标志物诊断急性心肌梗死(AMI)临床应用广泛[2]。然而,当心肌标志物发生改变时,部分心肌已发生不可逆的损伤甚至死亡;这些心肌的损伤无法挽回,造成严重后果。相较于心肌梗死的速度及损伤程度,心肌标志物带给我们的预警时间显然不够。一些炎症因子如C反应蛋白     

心肌标志物联合心电图在急性冠脉综合征100例中诊治应用

目的　探讨心肌标志物联合心电图在急性冠脉综合征(ACS)诊治中临床应用价值。方法　对临床诊断为ACS的10 0例患者常规心电图,及血清心肌标志物测定结果进行分析。结果　10 0例Acs患者中,STEMI者4 1例,NSTEMI者2 4例,UA者35例。治后好转出院91例,未愈自动出院6例,死亡3例。结论　心肌标志物联合心电图在急性冠脉综合征(ACS)诊治中有重要价值。     

中性粒细胞淋巴细胞比值与急性冠脉综合征患者住院死亡风险的相关性分析

目的:探讨中性粒细胞与淋巴细胞比值(neutrophil to lymphocyte ratio,NLR)对基层医院急性冠状动脉综合征(acute coronary syndrome,ACS)患者住院死亡风险的判断价值。方法:选择2015-01-2018-12于酉阳土家族苗族自治县人民医院住院治疗的ACS患者253例,收集患者临床血液常规检查等资料,计算NLR。采用受试者工作特征(ROC)曲线评估NLR预测ACS患者住院期间死亡风险的价值,运用多因素logistic回归模型分析ACS患者住院死亡的危险因素。结果:NLR7.79患者住院期间病死率较NLR≤7.79患者更高(P0.05)。ROC曲线显示,NLR的截断值为7.79时,预测ACS患者住院期间死亡风险的灵敏度为87.5%,特异度为62.9%。多因素logistic回归模型显示,NLR是ACS患者住院期间死亡的预测因子(OR=10.95,95%CI:1.20～100.31,P0.05)。结论:NLR可能是基层医院预测ACS患者住院期间死亡风险的有价值的生物标志物。     

急性冠状动脉综合征心电图研究进展

<正>急性冠状动脉综合征(acute coronary syndrome,ACS)是以冠状动脉粥样硬化斑块破裂或侵蚀继发完全,或不完全闭塞性血栓形成为病理基础的一组临床综合征。据报道,全世界每年约有2000万人死于心脏疾病,而ACS是其死亡的主要原因之一[1]。按2000年美国心脏病学会(ACC)及美国心脏协会(AHA)联合发布的ACS的治疗指南,ACS主要包括:不稳定型心绞痛(unstable angina,UA)、非ST段抬高心肌梗     

急性冠状动脉综合征相关新生物标志物研究现状

<正>急性冠状动脉综合征(acute coronary svndrome,ACS)是以冠状动脉粥样硬化斑块破裂或侵袭,血小板聚集、继发完全或不完全闭塞性血栓形成为病理基础的一组临床综合征~[1]。ACS可导致恶性心律失常、心力衰竭及猝死等严重心血管不良事件。近些年ACS发病率及病死率逐年上升,成为威胁人类健康和生命的严重疾病~[2]。研究发现,不稳定性斑块相关生物标志物与炎性生物标志物与ACS的发生、发展有     

血清半乳糖凝集素-3与急性冠状动脉综合征关系研究进展

正急性冠状动脉综合征(acute coronary syndrome,ACS)是心肌急性缺血、缺氧、坏死的一组临床综合征,其主要由动脉粥样斑块不稳定性下降、破裂和(或)糜烂引起冠状动脉内血栓形成而导致,是冠心病中最为严重的类型[1]。临床上根据胸痛时心电图表现分为:ST抬高型ACS及非ST抬高型ACS,前者主要为ST段抬高型心肌梗死(ST elevation myocardial infarction,STEMI),后者主要包括非ST段抬     

急性冠脉综合征患者预后的预测指标及模型

急性冠脉综合征(ACS)患者发生不良事件的危险性较高。全球急性冠状动脉事件注册(GRACE)和心肌梗死溶栓试验(TIMI)等风险评分模型可以对ACS患者进行危险分层,这是制定治疗策略的重要前提。将冠状动脉影像学表现及介入治疗质量与临床资料相结合的危险评分模型,如临床SYNTAX评分模型,可以更准确地预测患者预后。近年来,利用血清生物标志物提高预测模型临床应用价值的研究逐渐增多。研究发现,除了反映心肌损伤坏死的标志物外,反映细胞炎性反应和氧化应激过程的一些小分子蛋白质可以与现有模型联合,用以预测ACS患者的短期及长期预后情况。该文旨在介绍ACS预后风险模型的研究进展,以及与之相关的血清生物标志物的研究情况,以期指导ACS患者预后预测指标及模型的临床选择。     

缺血修饰白蛋白在疑似急性冠脉综合征诊断中的应用

急性冠脉综合征（acute conoary syndrome，ACS）包括不稳定型心绞痛（UA）、非ST段抬高心肌梗死（NSTEMI）、ST段抬高心肌梗死（STEMI）和心源性猝死。现广泛用于临床诊断的心肌损伤标志物如心肌肌钙蛋白T或I（cTnT、cTnI）、肌红蛋白（Mb）和肌酸激酶同工酶（CK—MB）血液浓度均在心肌坏死后才升高，不利于ACS心肌损伤可逆阶段的早期做出诊断。最近研究发现缺血修饰白蛋白（ischemia modified albumin，IMA）具有较理想的缺血标志物特点，能在ACS早期可逆阶段检出，具有极高的灵敏度。     

心肌肌钙蛋白I在急性冠状动脉综合征中的应用

急性冠状动脉综合征(ACS)是指不稳定型心绞痛(UA)、Q波型心肌梗死(QMI)、非Q波型心肌梗死(NQMI)和心源性猝死这样一组临床病征。心肌肌钙蛋白I(cTnI)是新近发展的心肌组织所特有的心肌酶学标志物。本文对cTnI的生物化学特点、检测方法、cTnI与ACS的联系进行评价。cTnI在诊断心肌损害方面敏感性高,特异性强,诊断时间窗口宽,明显优于传统心肌酶,对ACS可进行危险度分层及预后评价,并可预测UA患者复杂冠状动脉形态,值得推广使用。     

Hybrid minimally invasive coronary artery revascularization

Background Hybrid coronary revascularization(HCR) is an alternative coronary revascularization strategy that combines a minimally invasive, survival advantage of the left internal mammary artery(LIMA)-left anterior descending(LAD) coronary artery bypass with less-invasive percutaneous coronary intervention(PCI)to non-LAD coronary lesions by using drug-eluting stents. We report our experience of hybrid minimally invasive approach in 15 patients. Methods From December 2012 to October 2013, 15 patients underwent revascularization of the left anterior descending artery through minimally invasive coronary artery bypass grafting(MIDCAB). All patients by endoscopic assist beating heart coronary artery bypass grafting. Seven patients were scheduled for a hybrid procedure. Percutaneous coronary intervention of non- LAD was performed 3 to 5 days preoperatively. Demographic data, perioperative outcome, and annual follow-up were obtained from all the patients. Results In-hospital mortality was 6.67%. The rate of conversion to full median sternotomy was 13.3%. Ventilation time was 6.9 ± 5.1 h. Blood loss volume was 241 ± 67.8 mL. ICU stay was21.3 ± 10.8 h. Hospital postoperative stay lasted for 7.5 ± 1.3 days. Prior to PCI patients showed 100% patent LIMA(Tables 3 and 4). A mean follow-up was 8.5 months. One year graft patency rate was 100%(8 / 8patients for 254-slice tomography). Two patients required reintervention. Conclusions Minimally invasive hybrid coronary revascularization is a safe, feasible and efficacious approach with good results and should be performed in selected patients by surgeons with experience in minimally invasive bypass surgery plus collaboration with cardiologists. eluting stents.     

cOptical coherence tomography application as guiding in percutaneous coronary intervention procedure one year follow up survey

Background Optical coherence tomography （OCT） is increasingly used in the process of percutaneous coronary intervention （PCI）, but there is still lack of data about the significance of OCT in the process of PCI. The study aimed to investigate the long term value of OCT in the procedure of PCI. Methods One hundred sixty-five patients with coronary artery disease and implanted drug eluting stents were enrolled in the retrospective study. OCT was performed after stent implantation to detect the complications in 82 patients, who were named as OCT group. And the other 83 patients without OCT application served the control group. Incidence of the angina pectoris, acute myocardial infarction, revascularization and cardiac sudden death was observed in the two groups during one year follow-up. Results At one year clinical follow-up, the incidences of angina and revascularization in OCT group were significantly lower than those in control group （angina： 3.66% vs. 18.07%, P 〈 0.05; revascularization： 2.44% vs. 12.04%, P 〈 0.05）, the incidence of acute myocardial infarction was not significantly different （2.44% vs. 4.82%, P 〉 0.05）. Conclusions OCT is a feasible technique for guidance of coronary interventions, and its application during PCI procedure can improve the clinical outcome.     

Ministernotomy for minimally invasive coronary artery bypass grafting

Background Through a ministernotomy ＂J shaped approach, left internal mammary artery （LIMA） bypass grafting to the left anterior descending artery （LAD） can be performed safely off-pump. To achieve a complete revascularization, percutaneous coronary interventions （PCI） with drug eluting stent implantation to other coronary arteries was used. We reported outcomes of the treatment of multivessel coronary artery disease with minimally invasive coronary artery bypass （MICAB） and PCI. Methods Between January 2009 and Dec 2012, 14 patients （11 males, 3 females, mean age was 64.8 _ 10.1 years. Two-vessel disease account for 35.7% （5/14） of these patients, three-vessel disease 64.2% （9/14） （Table 1）. All patients underwent a minimally invasive coronary artery bypass grafting via mini-sternotomy ＂J＂ shaped approach. Seven patients were followed by PCI, 7 for obtuse marginal circumflex, 5 for right coronary artery （RCA）. Angiographic assessment of graft patency was performed in all patients during the PCI procedure. The clinical follow-up period lasts from 11-24 months. Results The in-hospital mortality was 0%. There was neither conversion to a full median sternotomy nor intraoperative complications. Ventilation time was 6.6 ＋_ 4.1 h. Blood loss ranged 341 ＋_ 78.8 mL. ICU stay ranged 22.3 _ 12.8 h. Hospital postoperative stay lasted for 6.5 ＋ 1.6 days. Prior to PCI patients showed 100% patent left internal mammary artery. One patient had mediastinitis （Tables 2-3）. Rate of freedom from cardiac reintervention during the follow-up period was 92.8% （13/14）. Conclusions The inferior J-shaped sternotomy is simple, reproducible, and the safest technique for performing minimally invasive coronary bypass surgery. MICAB ＋ PCI is also safe, feasible and efficacious.     

Effects of Late Reperfusion on Left Ventricular Function and Its Relationship With Viable Myocardium After Acute Myocardial Infarction in Patients With or Without Diabetes

Objectives To compare the different effects of late successful reperfusion with PCI on left ventricular function and its relationship with viable myocardium after acute anterior wall myocardial infarction in patients with or without diabetes. Methods A total of 125 consecutive subjects with acute anterior wall myocardial infarction were selected, and divided into diabetes mellitus （DM） group （ n = 43） and Non-DM group （ n = 82） according to WHO diabetes diagnosis criteria. All patients received successful PCI at 12 ± 8 days from onset. Ischemic viable myocardium was detected with low-dose dobutamine echocardiography, and left ventricular function and wall motion abnormality were also assessed with echocardiography before PCI. The data of clinical manifestations and angiograms before and after PCI were analyzed. Levels of creatinine kinase-MB （CK-MB）, and troponin T （TnT） before PCI, 6 hours and 24 hours after PCI were assessed. All patients received clinic and echocardiography follow-up for 6 months. Results Higher rate of TIMI 2 flow, and lower rate of TIMI 3 flow in DM group were demonstrated immediately after PCI, and the rate of serum CK-MB and/or TnT levels were higher in DM group, compared with Non-DM group（P 〈 0.05）. 63% of DM patients and 56% of non-DM patients had viable myocardium before PCI（ P 〉 0. 05）. There were no significant differences of left ventricular ejection fraction （LVEF）, left ventricular end diastolic volume index （LVEDVI）, left ventricular end systolic volume index （LVESVI）, and wall motion score （WMS） between two groups at baseline before PCI（P 〉 0.05）. After six months, WMS was decreased and LVEF was increased in Non-DM group, but the WMS and the LVEF did not changed, and the LVEDVI was increased in DM group compared with baseline; the LVEDVI, LVESVI, LVEF, and WMS were significantly different between two groups （P 〈 0.05 or P 〈 0. 01 ）. Conclusions Compared with non-diabetics, delayed successful revascularization with PCI in diabetics patient with acute myocardial infarction has less benefitial effect on the improvement of late phase left ventricular function, and it may be because the insufficient reperfusion or reperfusion injury to myocardium but not the viable myocardium contributing to the poor result. （S Chin J Cardiol 2009; 10（4） ： 196 -203）     

心绞痛患者PCI术前大剂量阿托伐他汀对围手术期心肌损伤的影响

经皮冠状动脉介入治疗（percutaneous coronary intervention,PCI）是所有采用经皮穿刺方法减轻冠状动脉狭窄的各种心导管技术的总称,早期PCI术主要是指经皮冠状动脉内血管成形术（percutaneous transluminal coronary angioplasty,PTCA）.自从1977年Gruzentig在瑞士完成世界上第一例PTCA后,心血管造影的临床应用日趋广泛,成为临床上判断冠状动脉病变部位和程度的＂金标准＂.     

Prasugrel versus clopidogrel in acute coronary syndrome patients undergoing percutaneous coronary intervention： A meta-analysis of randomized controlled trials

Background Clopidogrel is beneficial after acute coronary syndrome. Recent studies suggest the superiority of prasugrel compared with clopidogrel. The enhanced platelet inhibition with prasugrel lead to a reduction in major adverse cardiovascular events in patients with moderate to high risk acute coronary syndrome scheduled for PCI. However, prasugrel showed signs of increased bleeding potential. We performed a meta-analysis to assess clinical safety and efficacy of prasugrel in patients with acute coronary syndrome. Methods We systematically searched PubMed, ISI Web of Knowledge, Cochrane Central Register of Controlled Trials, clinicaltrials. gov, proceedings of major US and European cardiology meetings, China National Knowledge Infrastructure (CNKI) databases 2000-2010 and reviews, reference lists of relevant articles. The search strategy paired the term "prasugrel" "clopidogrel" with the following: "acute coronary syndrome" "percutaneous coronary intervention" We conducted a meta-analysis of randomized double-blind trials that evaluated clinical outcomes in patients with acute coronary syndrome. Two reviewers independently assessed the trials. Differences were resolved by consensus. Results A total of 2 trials with 14512 patients were available for analysis. Overall, prasugrel appeared significantly superior to clopidogrel for the risk of MACE (OR = 0.820.74-0.90, P ﹤0.0001), stent thrombosis (OR = 0.470.35-0.62, P 0.00001), death(OR = 0.850.78-0.93, P = 0.0003), and myocardial infarction (OR = 0.760.68-0.85, P﹤0.00001), without any significant difference in stroke (P = 0.85). However, major bleeding associated with non coronary artery bypass grafting Thrombolysis in Myocardial Infarction related to prasugrel (OR = 1.321.03-1.67, P = 0.03). Conclusions Prasugrel is superior to clopidogrel for acute coronary syndrome, while causing more bleedings.     

A Comparative Study on Post-intervention Use of Tirofiban or Enoxaparin in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Objectives To evaluate the efficacy and safety of post procedure use of platelet glycoprotein Ⅱb/Ⅲ a receptor in- hibitor （PGI） or low molecular weight heparin （LMWH） in patients with acute coronary syndrome （ACS） undergoing dual anti-platelet loading therapy and percutaneous coronary intervention （PCI）. Methods This was a prospective randomized grouping controlled study in 174 patients with ACS received aspirin 300 mg plus clopidogrel 600mg loading before PCI. After procedure, patients were randomized to intravenous tirofiban for 12 -24 hours （tirofiban group） or subcutaneous enoxaparin for 5 days （enoxaparin group）. Cardiac ischemic events, major bleeding complications, minor bleeding complications, thrombocytopenia, and vascular access complications in both groups were investigated. Results Cardiac ischemic events, major bleeding complications, minor bleeding complications, thrombocytopenia, and vascular access complications in tirofiban group were 8.0% , 3.4% , 6.8% , 3.4% , and 3.4% , respectively. In enoxaparin group, aforementioned event rates were 7%, 2. 3%, 6. 0%, 2. 3%, and 5.8%, respectively. No statistical significance was found between two groups. Conclusions In the setting of dual anti-platelet medication loading and PCI for the treatment of ACS, it is effective to use tirofiban or enoxaparin for aggressive post procedure antithrombotic therapy. It comes with a very low major bleeding complication rate. Use of GPI for 12 to 24 hours was comparable to use of LMWH for 5 days in efficacy and safety.     

急性冠脉综合征抗血小板治疗新进展

急性冠脉综合征（acute coronary syndromes,ACS）是以冠状动脉粥样硬化斑块破溃,继发完全或不完全闭塞性血栓形成为病理基础的一组临床综合征。     

入院即刻血糖与急性冠脉综合征

入院即刻血糖可能反映机体在应激性刺激过程中产生的应激反应的强烈程度。入院即刻血糖的水平与体内炎症反应强度、血容量、血小板聚集及黏附等存在相关性。对入院即刻血糖的研究可以为评估急性冠脉综合征（acute coroary syndrome,ACS）患者的预后提供新的指标。现就入院即刻血糖的特性与急性冠脉综合征的关系作一综述。     

心肌血流储备分数在冠心病诊断及介入治疗中的应用研究进展

冠状动脉造影（CAG）是目前诊断冠心病最常用和最重要的手段,是进一步行经皮冠状动脉介入治疗（PCI）或冠脉搭桥术（CABG）的金标准。但是随着对冠脉血流动力学及病理学研究的不断深入,单纯冠脉造影提供的形态学已不能满足临床对狭窄病变解剖特征和生理功能评价的需要。