早发冠心病心肌梗死型与非心肌梗死型危险因素差异分析

目的探讨早发冠心病中心肌梗死型与非心肌梗死型的危险因素差异。方法回顾性分析2004年1月至2009年12月在沈阳医学院附属奉天医院心血管内科住院并确诊的45岁及以下冠心病患者165例,分为急性心肌梗死(AMI)组和非AMI组。对两组患者的相关临床资料及危险因素进行统计分析。结果 AMI组吸烟史比例、男性比率、血浆纤维蛋白原及D-二聚体均高于非AMI组,差异有统计学意义(P<0.05),两组的血脂异常率、血小板计数(PLT)、血小板压积、凝血酶原时间(PT)、国际标准化比值(INR)和活化部分凝血活酶时间(APTT)的差异无统计学意义。结论吸烟、男性性别、血脂水平异常是早发冠心病重要危险因素;血浆纤维蛋白原水平增高对于预测早发冠心病心肌梗死可能具有一定的临床意义。     

Hemodynamic effects of intravenously administered magnesium on patients with ischemic heart disease

Central hemodynamic parameters were registered by right-side heart catheterization before and after intravenous administration of 12 mmol magnesium chloride (MgCl) in 15 patients with chronic ischemic heart disease and heart failure, New York Heart Association classes II and III. Serum magnesium concentrations increased from 0.76 +/- 0.03 (mean +/- SD) to 1.54 +/- 0.05 mmol/l, which resulted in a reduction in mean arterial as well as pulmonary artery pressure by 10% (p less than 0.0001) and 7% (p less than 0.05), respectively. This reduction was caused by a marked decrease in systemic as well as pulmonary vascular resistance (from 1323 +/- 205 to 1132 +/- 158 dyn.s/cm5, p less than 0.001 and from 156 +/- 73 to 133 +/- 72 dyn.s/cm5 (p less than 0.05). Heart rate, cardiac index, stroke volume index, and stroke work index increased slightly, although these differences did not reach statistical significance. Right and left ventricular filling pressures were not influenced, which indicates that the dilatory effect of magnesium, at the dosages used in the present study, is pronounced only at the arterial side of the vascular bed. The observed hemodynamic effects of the magnesium infusions may be beneficial in the setting of an acute myocardial infarction by reducing left ventricular afterload, which, together with the antiarrhythmic effect of magnesium may contribute to the positive effect of magnesium infusions on mortality in patients with acute myocardial infarction.     

雌激素与缺血性心脏病

以往的临床观察证实 ,生育年龄的女性缺血性心脏病的发病率和死亡率明显低于同龄男性。绝经后的妇女服用雌激素与不服用雌激素相比 ,前者心脏病事件少于后者。尽管临床的观察结果还有争议 ,越来越多的临床前期研究表明 ,雌激素对缺血性心脏病具有保护作用。研究结果显示 ,雌激素和其受体调节器是通过减少炎性反应在缺血/再灌注引起心肌损伤时起保护作用的。本文作者就近年的一些研究结果作一综述 ,并就雌激素替代治疗处理心肌缺血及再灌注损伤进行探讨。     

Prevalence and risk factors for heart disease among males with hemophilia

There have been conflicting reports in the literature about the protective effect of hemophilia on the occurrence of ischemic heart disease (IHD). Circulatory disease has been reported as the second most common cause of death in persons with hemophilia in the United States. In addition to diabetes and hypertension, high levels of FVIII, as may occur during factor concentrate infusions, may increase IHD risk in this population. To estimate the prevalence of heart disease and examine factors associated with IHD and other heart diseases among persons with hemophilia, we analyzed data collected from the medical records of 3,422 males with hemophilia living in six U.S. states from 1993 to 1998. Heart disease cases were ascertained from among 2,075 persons who were hospitalized at least once during the 6-year period. Of these, 48 were diagnosed with IHD and 106, with other types of heart disease. The age-specific prevalence of IHD ranged from 0.05% in those under 30 years to 15.2% in those 60 years or older. Hospital discharge rates in males with hemophilia with IHD and other types of heart disease were lower compared to rates in age-matched U.S. males. In our cohort, as in the general population, IHD was independently associated with age, hypertension, diabetes, and hyperlipidemia. Other heart diseases were associated with HIV infection, hypertension, hemophilia B, and diabetes. In summary, persons with hemophilia have unique risk factors such as infusion of factor concentrates and infection with HIV that may predispose them to heart disease as their life expectancy increases.     

Value of notching and slurring of the resting QRS complex in the detection of ischemic heart disease

The resting 12-lead ECG has long been known to be an insensitive marker of underlying ischemic heart disease (IHD). The purpose of this study was to determine if QRS complex notching and slurring is of significant value as a diagnostic discriminator in the detection of IHD. The data from 205 consecutive patients coming to cardiac catheterization for evaluation of probable IHD were initially analyzed. Eighty-three patients were excluded based upon ventricular hypertrophy, bundle-branch block, lack of data, and pacemaker rhythm. The balance, 122 patients (mean age 61.7 years), were evaluated for angiographic evidence of IHD, ECG findings of QRS notching or slurring, and abnormal Q waves. The data revealed a high prevalence of QRS notching or slurring; 62.2% in those patients with IHD, double the prevalence of significant Q waves (33.3%). The two markers had an approximately equal prevalence (QRS notching or slurring 61.7% vs. Q waves 53.2%) in patients with angiographic evidence of infarction; however, in patients with less than infarct criteria for IHD, the prevalence of QRS notching or slurring was 62.8%, while only 11.6% showed abnormal Q waves. Analysis indicated that QRS notching or slurring has a sensitivity of 62.2% and a specificity of 93.8% for the detection of IHD. The study demonstrates that QRS notching or slurring is a moderately sensitive and a very specific marker of ischemic heart disease in selected patients when using the resting ECG, and is of greatest value in those patients with lesser degrees of ischemic myocardial injury where the prevalence of Q waves is low.     

内皮细胞在缺血性心脏病及心力衰竭中的作用

内皮细胞是上皮细胞的一种,广泛分布于心、血管和淋巴管腔面,在人体生理稳态中参与止血、血管调节、血管生成等重要过程.近年来有研究发现,内皮细胞除上述作用外,还促进了缺血性心脏病等多种疾病的病理进展,并且表现出独特的多向分化能力,其中内皮间质转分化能力与心肌纤维化及心力衰竭关系密切.本文主要探讨血管内皮细胞生理特点及在缺血...     

Effect of aprindine on heart rate variability indices in patients with ischemic heart disease

BACKGROUND: Decreased heart rate variability indices (HRV) are associated with untoward outcome of patients with ischemic heart disease (IHD). Most class I antiarrhythmic agents decrease HRV, but aprindine (a new class I antiarrhythmic agent) is reported to increase HRV in patients without ischemia. HYPOTHESIS: The study was undertaken to determine whether apridine might increase HRV in patients with IHD. METHODS: To investigate the effect of aprindine on HRV in patients with IHD, we performed 24-h ambulatory electrocardiogram (ECG) at the end of placebo and aprindine (60 mg daily) treatment phases on 38 patients with IHD and at least isolated premature ventricular contractions (PVC). The study protocol utilized a single blind, 4-week, placebo-controlled design. Heart rate variability from ambulatory ECG included SDNN (ms), SDANN (ms), SD (ms), rMSSD (ms), pNN50 (%); frequency analysis of HRV consisting of total (ms, 0.01-1.00 Hz), low (ms, 0.04-0.15 Hz), and high (ms, 0.15-0.40 Hz) components. RESULTS: Study patients were divided into three groups according to the severity of IHD and antiarrhythmic efficacy of aprindine. Group 1 consisted of 15 patients with angina with single-vessel disease, and Group 2 was composed of 10 patients with either multivessel disease or post myocardial infarction; PVCs decreased in both groups as result of aprindine treatment. Group 3 consisted of 13 patients who showed no decreased PVC after aprindine treatment. RMSSD increased, and pNN50 and high-frequency spectra tended to increase in Group 1, while SD, rMSSD, pNN50, and total and low-frequency spectra decreased in Group 3; no significant changes were observed in Group 2. Aprindine significantly augments vagal activity, as reflected by the increase of rMSSD, pNN50, and high-frequency spectra in mild IHD. CONCLUSION: These salutary effects are less in more severe IHD, but aprindine does not aggravate HRV. Thus, if there are salutary effects on arrhythmias and no proarrhythmic effects, aprindine could be prescribed to patients with IHD without concern about decreasing HRV.     

Stress Doppler echocardiography in the evaluation of ischemic heart disease

Doppler echocardiography enables convenient, noninvasive evaluation of global, systolic performance at rest and during exercise. Early studies suggested that Doppler parameters of systolic function were sensitive to exercise-induced myocardial ischemia and could identify patients with severe coronary artery disease. Subsequent investigation, however, has identified several factors in addition to myocardial ischemia that can significantly influence exercise Doppler study results. Thus, in order to obtain reliable information, the many factors that can influence Doppler measurements of aortic flow velocity and acceleration must be accounted for. Further work in this area is likely to produce results that encourage greater application of this technique in experimental and clinical research. At present, the role of stress Doppler echocardiography in the evaluation of ischemic heart disease remains uncertain.     

微小RNA-缺血性心脏病治疗新的靶点

当前,缺血性心脏病（IHD）是世界主要死亡原因之一。IHD是指因冠状动脉不同程度的受阻引起冠状血流和心肌耗氧需求之间不平衡而导致的心肌损害,最终形成充血性心力衰竭。心脏缺血损伤后,非缺血部位的心肌出现心肌重构,如心肌间质纤维化和心肌肥厚。心肌的重构过程可使心脏功能进一步恶化,更容易诱发心律失常。微小RNA(microRNAs,miRNAs)是一类长约22个核苷酸的非编码小分子RNA,通过与靶蛋白 mRNA 3′端非编码区的不完全互补结合,抑制靶 mRNA 转录后的表达。最近大量研究显示,miRNA 在心脏病理、生理过程中发挥着重要的调控作用,尤其与心肌梗死和梗死后心脏重构的发生、发展密切相关。本文将从miRNAs在IHD中的调控作用进行阐述,并探讨以miRNAs为靶点改善IHD患者的临床转归。     

Increased ventricular sialylation in patients with heart failure secondary to ischemic heart disease

Background: Elevated serum sialic acids are associated with increased cardiovascular mortality, but sialic acid levels have not been studied in cardiac tissue. Methods: Myocardial samples were obtained at the time of transplantation from 23 patients (age 54 ± 12 years) with heart failure secondary to ischemic heart disease and 16 patients (age 51 ± 7 years) with idiopathic dilated cardiomyopathy (DCM). A control group comprised postmortem samples obtained from 14 patients (age 70 ± 5 years) who died of non-cardiovascular causes. Ventricular sialylation was quantitated using the sialic acid-specific lectins Maackia amurensis agglutinin (MAA) and Sambucus nigra agglutinin (SNA) using a chemiluminescence assay. Results are expressed as the percentage (± standard error of the mean) of the binding of lectin to a standardized control sample of human myocardium. Results: Ventricular sialylation recognized by MAA was 55 ± 7% in patients with heart failure secondary to ischemic heart disease compared with 26 ± 7% for DCM (p = 0.006) and 32 ±8% for controls (p = 0.04), and that recognized by SNA was 69 ± 7% in patients with heart failure secondary to ischemic heart disease compared with 42 ± 6% for DCM (p = 0.006) and 38 ± 7% for controls (p = 0.006). No significant difference in ventricular sialylation was observed between patients with DCM and controls. Conclusion: Myocardial levels of sialic acids are significantly increased in patients with heart failure secondary to ischemic heart disease compared with patients with idiopathic dilated cardiomyopathy and controls. Our findings are important in view of recent reports of an association between serum sialic acid concentration and cardiovascular mortality and require further investigation.     

卡维地洛与美托洛尔治疗缺血性心脏病心力衰竭的疗效观察

目的:观察卡维地洛和美托洛尔对缺血性心脏病心力衰竭患者的临床疗效。方法:缺血性心脏病心力衰竭患者80例,左室射血分数（LVEF）≤0.45,心功能（NYHA）ⅡⅣ级,常规治疗基础上随机分为卡维地洛组和美托洛尔组,治疗3月后,观察两种药物对心功能及运动耐量的影响。应用心脏彩色超声仪测定心功能基线值及3月后的变化。用6 m in步行距离测定运动耐量的改善程度。结果:经过3月的治疗,卡维地洛组与美托洛尔组心率、血压、运动耐量改善程度及心功能均有明显改善,且卡维地洛组6 m in步行试验结果,收缩压、舒张压变化及左室收缩末容积（LVESV）、左室舒张末容积（LVEDV）、LVEF改善程度明显优于美托洛尔组（P<0.01）。结论:在常规治疗基础上卡维地洛、美托洛尔对缺血性心脏病的治疗均有显著效果,前者在改善运动耐量、LVEDV、LVESV及心室射血方面更优。     

老年冠心病患者的介入治疗

冠心病是目前中国老年人心脏病住院和死亡的第一位原因。由于年龄因素及合并其他慢性疾病,老年冠心病患者的治疗往往更加困难。随着技术的进步和经验的积累,越来越多的老年患者接受经皮冠状动脉介入治疗,且取得了很好的疗效。本期专栏所刊登的文章重点向大家介绍了我国老年急性心肌梗死和慢性完全闭塞病变等危重冠心病患者介入治疗方面的进展,以及血管内超声在老年冠心病患者介入诊治中的应用。因此,老年危重冠心病患者可以从介入治疗中受益。     

Alcohol,ischemic heart disease,and the french paradox

Many studies have shown either an inverse relation between alcohol intake and ischemic heart disease or a U-shaped curve in which the equivalent of two drinks per day of any kind of alcohol is associated with a decreased incidence of coronary disease compared with no drinks, while higher doses result in an increased risk of infarction and stroke. Although the cardioprotective effects of most alcoholic beverages are probably due to an elevation of high-density lipoprotein as well as the ability of alcohol to prevent platelet aggregation and increased fibrinolysis, there is an increased favorable effect of red wine. The unique cardioprotective properties of red wine reside in the action of flavonoids which are absent in white wine (with the exception of champagne) and sparse in beer (with the exception of dark beers). The best researched flavonoids are resveritrol and quercetin, which confer antioxidant properties more potent than alpha-tocopherol. Grape juice has about half the amount of flavonoids by volume as does red wine.     

The effects of captopril on training in patients with ischemic heart disease.

We studied a group of 30 patients to determine the effect of captopril on the exercise training response after a period of training in patients with ischemic heart disease but without cardiac failure. The study was a double-blind placebo-controlled comparison of captopril and placebo. The patients studied were 28 men and 2 women, mean age 53.6 +/- 6.9 years. All were 8 to 12 weeks postmyocardial infarction or coronary artery bypass surgery. These patients underwent an organized exercise training program consisting of exercise training sessions 3 times weekly for a period of 8 weeks. On commencement and completion of the program patients were assessed for exercise tolerance using submaximal exercise stress testing. Patients were assessed in the untreated state. Both groups showed a statistically significant training effect with increased exercise duration, decreased heart rate for equal workload, increased energy expenditure, and reduced functional aerobic impairment. There was no statistically significant change in systolic blood pressure, but the captopril group alone showed a significant reduction in diastolic blood pressure (p less than 0.001). The change in heart rate at rest over the 8-week period was not significant in both groups. In summary, this study shows that treatment with captopril does not affect the exercise training response in patients with ischemic heart disease undergoing an organized exercise training program.     

TRENDS IN ISCHEMIC HEART DISEASE MORTALITY AND MORBIDITY IN PERTH STATISTICAL DIVISION

Trends in mortality from Ischemic Heart Disease (IHD) and other principal causes of death, and in hospital admission rates for Acute Myocardial Infarction (AMI) have been studied in residents aged 35–64 years of the Perth Statistical Division for the period 1968–1982. Death rates were based on data abstracted from official statistics or computer tapes of unit death records. Hospital admission rates were derived from the computer tapes of the Western Australian Hospital Inpatient Survey, 1968–1982. Since 1968, mortality from IHD has fallen in the Perth Statistical Division in both males and females by 30% and 33%, respectively. This fall has occurred principally in deaths occurring out-of-hospital and has been accompanied by similar fails in mortality from other vascular diseases and in total mortality. Hospital admission rates for Acute Myocardial Infarction (AMI) in the Perth Statistical Division have fallen since 1971 by 17% in males and 27% in females. These findings taken together suggest that the improvement in IHD mortality in Western Australia has been due mainly to a fall in the incidence of acute manifestations of IHD (sudden death and AMI), rather than improvements in case fatality. The possible underlying mechanisms responsible for this are discussed.     

Systemic and cardiac catecholamines during elective PTCA and during immediate PTCA for acute myocardial infarction

This study investigated arterial and coronary venous catecholamine concentrations in patients undergoing either elective coronary angioplasty (PTCA) or direct PTCA for acute myocardial infarction. We included 17 patients with stenoses of the left anterior descending coronary artery (LAD) and 10 patients with acute anterior myocardial infarction (AMI) undergoing PTCA. During the initial balloon dilatation arterial and coronary venous plasma concentrations of norepinephrine and epinephrine were determined. In elective PTCA, coronary occlusion (2 min) resulted in a transient increase of arterial concentrations of norepinephrine (2.04±0.30 vs. 1.26±0.13 nmol/L before dilatation) and epinephrine (0.52±0.08 vs. 0.34±0.04 nmol/L) in the first minute of reperfusion, whereas coronary venous concentrations of catecholamines were not changed after dilation. Among the 10 patients with AMI, immediate reperfusion of the LAD (TIMI grade 3) was achieved in 6 patients. In these patients, baseline arterial concentrations for norepinephrine (3.91±1.16 nmol/L) and epinephrine (4.68±2.07 nmol/L) were elevated and no transcardiac gradient for catecholamines was found. In the first minute after successful reopening of the LAD we detected a distinct rise of the transcardiac norepinephrine gradient from –0.10±0.53 to 85.02±24.64 nmol/L, which declined in the fifth minute of reperfusion to 4.36±2.30 nmol/L. Conversely, venous epinephrine and arterial concentrations for both catecholamines remained unchanged within the observation period. In the four patients with incomplete (TIMI 0–2) reopening of the LAD, we found no cardiac washout of norepine phrine. In summary, a transient rise of systemic catecholamines, but no cardiac release of norepinephrine was observed in patients after brief coronary occlusion. Conversely, a massive washout of norepinephrine from the infarcted myocardium occurred during AMI.Presented in part at the 67th Annual Scientific Sessions of the American Heart Association, Dallas, Texas, November 1994     

Adult stem cells in the treatment of acute myocardial infarction

Stem cell therapy has emerged as a novel therapeutic treatment alternative for early and end stage LV dysfunction. The rapid translation into clinical trials has left many questions unanswered. Moreover, results of randomized trials in the setting of acute myocardial infarction are controversial, emphasizing a need for further basic and translational research to improve understanding of cell functionality. This review attempts to summarize some of the functional issues related to cell therapy and also evaluate the current status of stem cell clinical trials. Although results to date have shown modest improvement in left ventricular function, the progress should follow a coordinated, multidisciplinary, and well designed path to address issues of cell homing, cell retention, and also look at outcomes beyond physiological parameters. © 2010 Wiley‐Liss, Inc.     

冠状动脉粥样硬化性心脏病与缺血性脑卒中相关性研究进展

冠状动脉粥样硬化性心脏病(冠心病)和缺血性脑卒中是动脉粥样硬化性疾病中最主要的2种疾病,二者可以单独或合并发生,是引起死亡和功能缺陷的重要病因。2种疾病存在一些共同的危险因素,在疾病发生上有一定的联系。明确二者之间的相关性有助于动脉粥样硬化性疾病的预防及治疗,减轻疾病不良预后引起的负担,提高国民生存质量。目前有诸多研究致力于探究二者在发病机制、疾病进展、预后以及影像学表现上的关联,其中某些研究结果之间存在差异。现将相关最新研究结果综述如下。     

Stable ischemic heart disease in the older adults

Ischemic heart disease (IHD) is caused by atherosclerotic and/or thrombotic obstruction of coronary arteries. Clinical spectrum of IHD expands from asymptomatic atherosclerosis of coronary arteries to acute coronary syndromes (ACS) including unstable angina, acute myocardial infarction (non-ST elevation myocardial infarction and ST elevation myocardial infarction). Stable IHD (SIHD) refers to patients with known or suspected IHD who have no recent or acute changes in their symptomatic status, suggesting no active thrombotic process is underway. These patients include those with i) recent-onset or stable angina or ischemic equivalent symptoms, such as dyspnea or arm pain with exertion; ii) post-ACS stabilized after revascularization or medical therapy; and iii) asymptomatic IHD diagnosed by abnormal stress tests or imaging studies. This review summarizes clinical features and management of SIHD in the older adult. ACS in older adults is not considered in this review.