血栓弹力图对经皮冠状动脉介入治疗患者预后的预测作用

目的评估经皮冠状动脉介入治疗(PCI)患者术后血栓弹力图(TEG)指标对其预后的预测作用。方法收集115例PCI患者资料,根据其TEG报告中二磷酸腺苷(ADP)诱导的最大血块强度(MA-ADP)将患者分为MA-MDP50 mm组和≥50 mm组,随访观测其1年后心血管不良事件和支架再梗死及再狭窄的发生率。结果根据MA-ADP分组的2组患者的临床基本情况差异无统计学意义(P0.05)。Logistic回归分析显示MA-ADP是PCI术后患者心血管不良事件复发风险的危险因素[OR=3.547(95%CI:1.103~11.412),P=0.034]。与MA-ADP正常(50 mm)的患者相比,MA-ADP升高(≥50 mm)的患者的心血管不良事件和支架内再梗死的发生率均明显升高(P均0.05)。结论 MA-ADP对PCI术后患者的预后有预测作用,MA-ADP=50 mm可作为PCI术后患者心血管不良事件复发风险的判断切点。     

Effect of peripheral arterial disease in patients undergoing percutaneous coronary intervention with intracoronary stents

OBJECTIVE: To compare the short-term and long-term outcomes of patients with coronary artery disease and peripheral arterial disease (PAD) who underwent intracoronary (IC) stent Implantation during percutaneous coronary intervention (PCI) with the outcomes of patients with isolated coronary artery disease but without PAD who underwent IC stent implantation. PATIENTS AND METHODS: We analyzed the outcomes of 7696 patients who underwent IC stent implantation during PCI at the Mayo Clinic in Rochester, Minn, between January 1996 and December 2002. Outcomes of 6299 patients (82%) with Isolated coronary artery disease and without PAD who underwent IC stent implantation (group 1) were compared with outcomes of 1397 patients (18%) with coronary artery disease and PAD (group 2) who underwent PCI with IC stent implantation. RESULTS: Patients in group 2 were older (71.1+/-10.2 years vs 65.0+/-12.0 years; P<.001) and had a higher prevalence of hypertension (79% vs 61%; P<.001), diabetes mellitus (33% vs 20%; P<.001), hyperlipidemia (76% vs 70%; P<.001), and history of smoking (70% vs 63%; P<.001) compared with group 1. Prevalence of multivessel disease was higher in group 2 (79% vs 68%; P<.001). Procedural success was significantly lower In group 2 (95% vs 97%; P<.001). In-hospital complications were higher in group 2: death (3% vs 1%; P<.001), any myocardial Infarction (MI) (8% vs 5%; P<.001), death/MI/coronary artery bypass grafting (CABG)/target vessel revascularization (11% vs 7%; P<.001), and blood loss requiring transfusion (11% vs 5.8%; P<.001). After adjustment for other risk factors, the odds ratio for in-hospital death was 1.84 (95% confidence interval [CI], 1.16-2.90; P=.009), and for death/MI/CABG/target vessel revascularization, the odds ratio was 1.25 (95% CI, 1.00-1.55; P=.048) in patients with PAD treated with IC stents. Median follow-up was 3.1 years. Six-month, 1-year, and 2-year Kaplan-Meier estimates of survival free of death/MI/CABG/target vessel revascularization were 84%, 77%, and 69%, respectively, for group 2 and were significantly worse compared with group 1 (89%, 85%, and 80%, respectively; P<.001). This effect remained after adjustment for other risk factors (hazard ratio, 1.36; 95% CI, 1.22-1.51). CONCLUSIONS: Compared with patients who had isolated coronary artery disease but no PAD, patients with coronary artery disease and PAD had lower procedural success and higher in-hospital major cardiovascular complications, including higher blood loss requiring transfusion, after PCI with stent Implantation. On follow-up, the short-term and long-term outcomes of patients with PAD were worse, with higher mortality, MI, and need for repeated target vessel revascularization.     

Prognostic value of GRACE and CHA2DS2-VASc score among patients with atrial fibrillation undergoing percutaneous coronary intervention

AimsThe GRACE and CHA2DS2-VASc risk score are developed for risk stratification in patients with acute coronary syndrome and AF, respectively. We aimed to assess the predictive performance of the GRACE score and CHA2DS2-VASc score among patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).MethodsConsecutive patients with a diagnosis of AF admitted to our hospital for PCI between January 2016 and December 2018 were included and followed up for at least 1 year. The primary endpoint was a composite of major adverse cardiac events (MACEs) including all-cause mortality, repeat revascularization, myocardial infarction, or ischaemic stroke.ResultsA total of 1452 patients were identified. Cox regression demonstrated that the GRACE (HR 1.014, 95% CI 1.008–1.020, p < 0.001) but not the CHA2DS2-VASc score was associated with the risk of MACEs. Both GRACE and CHA2DS2-VASc scores were predictive of all-cause mortality with HR of 1.028 (95% CI 1.020–1.037, p < 0.001) and 1.334 (95% CI 1.107–1.632, p = 0.003). Receiver operating characteristic analyses showed both scores had similar discrimination capacity for all-cause mortality (C-statistic: 0.708 for GRACE vs. 0.661 for CHA2DS2-VASc, p = 0.299). High GRACE score was also significantly associated with increased risk of ischaemic stroke (HR 1.018, 95% CI 1.005–1.031, p = 0.006) and major bleeding (HR 1.012, 95% CI 1.001–1.024, p = 0.039), whereas high CHA2DS2-VASc score was not.ConclusionsHigh GRACE score but not CHA2DS2-VASc score were both associated with an increased risk of MACEs after PCI in patients with AF. The GRACE and CHA2DS2-VASc scores have similar predictive performance for predicting all-cause mortality.

Key messages:

• In patients with AF undergoing PCI, increasing GRACE but not CHA2DS2-VASc scores was independently associated high risk of MACEs.
• The GRACE score could also help identify patients at higher risk of stroke and major bleeding.
• Both GRACE and CHA2DS2-VASc scores showed good ability in the prediction of all-cause mortality.

     

Outcome after coronary artery bypass surgery and percutaneous coronary intervention in patients with atrial fibrillation and oral anticoagulation

Abstract

Aim. This study was planned to compare the clinical characteristics and outcome of patients on warfarin treatment for atrial fibrillation (AF) undergoing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI).

Methods. This is a retrospective analysis of 121 patients who underwent isolated CABG and 301 patients who underwent PCI.

Results. PCI patients were older (mean age, 72.9 versus 69.8 years) and more often had prior cardiac surgery (15.9% versus 1.7%) and acute coronary syndrome (53.8% versus 21.5%). CABG patients more often had two- and three-vessel disease (95.0% versus 60.2%) and left main stenosis (32.2% versus 7.0%). The 30-day outcome was similar after PCI and CABG. At 3 years, PCI was associated with lower overall survival (72.0% versus 86.4%, P = 0.006), freedom from repeat revascularization (85.3% versus 98.2%, P < 0.001), freedom from myocardial infarction (83.4% versus 93.8%, P = 0.008), and freedom from major cardiovascular events (57.4% versus 78.9%, P < 0.001). Propensity score adjusted analysis showed that PCI was associated with increased risk of all-cause mortality (P = 0.016, RR 2.166, CI 1.155–4.060), myocardial infarction (P = 0.017, RR 3.161, 95% CI 1.227–8.144), repeat revascularization (P = 0.001, RR 13.152, 95% CI 2.799–61.793), and major cardiac and cerebrovascular complications (P = 0.001, RR 2.347, 95% CI 1.408–3.914). There was no difference in terms of stroke and bleeding episodes at any time point.

Conclusion. In clinical practice, PCI is the preferred revascularization strategy in these frail patients. Patients selected for CABG have a relatively low operative risk and better mid-term outcome in spite of warfarin treatment. The poor prognosis after PCI may mainly reflect frequent co-morbidities in this patient group.     

盐酸替罗非班在急诊冠状动脉介入术中的应用

报告了盐酸替罗非班在84例急性ST段抬高型心肌梗死(ST elevation acute myocardial infarction,STEMI)患者急诊冠状动脉介入术(PCI)中的应用。46例患者术中、术后使用替罗非班,术后24h及30dMACE的发生率明显低于以往只用PCI的患者,并且提高了梗死相关血管(IRA)心肌灌注血流(TIMI),但使用替罗非班组的患者出血事件稍多。总之盐酸替罗非班应用于急诊PCI术治疗急性STEMI患者效果良好,可减少并发症的发生。     

冠状动脉介入诊疗患者抑郁变化研究

目的了解冠心病患者冠状动脉病变严重程度与抑郁的关系,冠状动脉介入诊疗手术前后抑郁的变化。方法行冠状动脉介入手术的患者分别于手术前1~2天、手术后(7±1)天进行抑郁自评量表(SDS)的填写。结果试验期间154例患者行冠状动脉介入手术,其中117例确诊冠心病并完成手术前后SDS评定。不同病变血管支数和不同狭窄程度组间抑郁患病率差异无统计学意义。所有冠心病患者手术前后抑郁患病率、SDS抑郁评分差异无统计学意义;准备接受冠状动脉旁路移植术(CABG)组的患者手术前后抑郁患病率为44.8%、75.9%(P=0.016),SDS抑郁评分为48.75±10.21、52.90±8.29(P=0.008),差异有统计学意义。结论①抑郁不能反应冠状动脉病变严重程度。②冠状动脉介入手术对大多数冠心病患者抑郁患病率及程度无影响,成功再血管化治疗不能减轻抑郁。③冠状动脉造影后准备接受冠状动脉旁路移植术的患者抑郁加重,对这部分患者应给予更多关注。     

Prasugrel in acute coronary syndrome patients undergoing percutaneous coronary intervention

Currently, dual antiplatelet therapy with aspirin and clopidogrel represents the key treatment strategy for the prevention of ischemic events in patients with acute coronary syndrome (ACS) and/or undergoing percutaneous coronary intervention (PCI). However, there is a broad inter-individual response variability to such treatment strategy, and a considerable number of patients persist with inadequate platelet inhibition, which has been associated with an increased risk of ischemic events. Overall, these findings underscore the need for novel antiplatelet agents able to achieve greater platelet inhibition; this can potentially reduce ischemic event rates. Prasugrel (CS-747; LY 640315), a novel third-generation oral thienopyridine, is a specific, irreversible antagonist of the platelet adenosine diphosphate P2Y₁₂ receptor. Laboratory studies have shown prasugrel to be associated with more prompt, potent and predictable degrees of platelet inhibition compared with clopidogrel. In a large-scale clinical study, which was comprised of high-risk ACS patients undergoing PCI, prasugrel was shown to significantly reduce the short- and long-term risk of ischemic events, including stent thrombosis. However, such significant reduction in ischemic events occurred at the expense of a higher risk of bleeding. Recent clinical trial data analyses have led to a better understanding of the efficacy and safety of prasugrel. This article reviews the currently available data regarding the efficacy and safety of prasugrel in ACS patients.     

血管性血友病因子评估经皮冠状动脉介入术后新发心房颤动患者的卒中风险

目的观察血浆血管性血友病因子抗原(v WF:Ag)评估择期经皮冠状动脉介入治疗(PCI)后新发心房颤动(简称房颤)患者的卒中风险。方法选择天津医科大学总医院2016年2月至2017年2月PCI后新发非瓣膜性心房纤维性颤动患者127例(PCI后新发房颤组)、初入院尚未接受PCI的ACS患者50例(ACS对照组)、PCI后未发生房颤的ACS患者50例(PCI对照组)、体检健康者50例(健康人对照组)进行回顾性队列分析。检测上述研究对象血浆v WF:Ag,用ROC曲线评价v WF:Ag预测PCI后新发房颤患者发生卒中风险的性能。用χ2检验评估PCI后新发房颤患者v WF:Ag与临床病理因素的关联。用Kaplan-Meier曲线进行生存分析。结果健康人对照组血浆v WF:Ag测定结果为104.5%(88.0%,133.7%),ACS对照组161.7%(120.7%,270.5%),PCI对照组208.0%(125.2%,360.7%),PCI后新发房颤组284.9%(172.4%,494.2%);其中,PCI对照组高于ACS对照组(U=526.0,P0.01);PCI后新发房颤组高于PCI对照组(U=824.0,P0.01)。血浆v WF:Ag水平预测PCI后新发房颤患者发生卒中风险的ROC曲线下面积为0.882(95%CI:0.811~0.854),v WF:Ag医学决定水平设定为312.0%时,预测PCI后新发房颤患者发生卒中风险的敏感性为94.4%,特异性为60.6%。与低于312.0%的PCI后新发房颤患者比较,高于312.0%的患者在90 d随访期内的卒中累积概率增高(Log-rankχ2=44.308,P0.01)。PCI后新发房颤患者血浆v WF:Ag水平与慢性心力衰竭/左室功能障碍、高血压、年龄、卒中/短暂性脑缺血发作/血栓栓塞病史和血管疾病有关联(P0.01)。接受双联抗栓治疗患者的血浆v WF:Ag水平和卒中事件发生率高于接受三联抗栓治疗的患者(U=1 075.5,P0.01;χ2=10.45,P0.01)。结论血浆v WF:Ag水平能敏感地反映PCI后新发房颤患者的血管内皮细胞损伤状态、卒中风险以及抗凝药物治疗效果。     

Contemporary antiplatelet therapy in patients undergoing percutaneous coronary intervention

The proper use of antiplatelet agents in the cardiac catheterization laboratory is important for ensuring optimal results in patients undergoing percutaneous revascularization. Understanding the mechanisms by which these drugs exerts their effects is important for both interventional and non-interventional cardiologists. The effects of these agents on platelet function can be assessed and monitored using a variety of commercially available laboratory assays but so far these tests have not been adopted in routine clinical practice. Currently, aspirin, thienopyridines and glycoprotein IIb/IIIa inhibitors are the primary types of antiplatelet drugs being utilized. The use of these drugs and of several newer antiplatelet drugs in the treatment of patients undergoing percutaneous revascularization in the cardiac catheterization laboratory will be discussed, especially in the light of the recently published guidelines.     

药物洗脱支架植入治疗早发冠心病的近期临床随访研究

目的研究接受药物洗脱支架治疗的早发冠心病(PCAD)患者近期预后。方法收集290例PCAD患者(男<55岁,女<65岁)和227例非冠心病对照者临床资料,对PCAD中行药物洗脱支架(西罗莫司或紫杉醇洗脱支架)植入治疗的180例患者(单支病变组62例及多支病变组118例)进行6个月随访研究。结果 PCAD组男性、高血压、糖尿病、吸烟、肥胖及饮酒比例及总胆醇、低密度脂蛋白胆固醇、载脂蛋白B、脂蛋白(a)及空腹血糖水平均高于非冠心病对照组(P均<0.05)。药物洗脱支架治疗多支病变组糖尿病比例高于单支病变组(P<0.01)。接受药物洗脱支架治疗的PCAD单支病变组及多支病变组术后6个月单一及复合心血管事件差异无统计学意义(P>0.05)。结论 PCAD患者临床心血管危险因素多,接受药物洗脱支架治疗后的近期预后较好。     

矫正型大动脉转位一例

患者女,40 岁,因妇科子宫肌瘤入院治疗,入院后手术前常规检查心电图.患者述近1 年来时有心悸、气短、乏力,既往体健无不适.查体:二尖瓣听诊区可闻及Ⅲ～Ⅳ/6 级收缩期杂音.心电图检查(图1):窦性心律,Ⅰ度房室传导阻滞,异常Q 波(Ⅲ、avF、V1),不完全性左束支传导阻滞,间歇性预激综合征(A 型).     

ICU治疗的老年急性冠脉综合征患者行急诊经皮冠状动脉介入术后新发房颤的预测因素

目的评价在我院ICU行急诊经皮冠状动脉介入(PCI)手术治疗的老年急性冠脉综合征(ACS)患者术后新发房颤(NOAF)的预测因素.方法选取2016年5月至2019年4月在泉州市第一医院老年病科ICU进行急诊PCI手术治疗的老年ACS患者440例.根据患者术后是否发生NOAF将患者分为NOAF组与非NOAF组,收集并比较两组患者人口统计学资料、合并症、病史、超声与血管造影特征、治疗情况、术前实验室指标.对患者进行6个月隧访,比较两组患者预后指标.采用多变量分析评价患者发生NOAF及6个月死亡的独立预测因素.采用受试者工作特征(ROC)曲线分析相关预测因素敏感度、特异度.结果共有77例(17.5%)发生NOAF(NOAF组,n=77),363例(82.5%)未发生NOAF(非NOAF组,n=363).68例(15.5%)死亡.多变量Logistic回归分析表明,心肌梗死(MI)病史(OR=4.510,95%CI1.680~12.107,P=0.004)与单核细胞/高密度脂蛋白比值(MHR,OR=1.103,95%CI1.055~1.153,P<0.001)是老年ACS患者急诊PCI术后发生NOAF的独立预测因素.MHR的ROC曲线下面积为0.750,MHR预测NOAF的截断值为15.873,敏感度为75.98%,特异度为65.03%.多变量Cox比例模型分析表明,NOAF(HR=2.330,95%CI2.489~8.625,P=0.019)与Killip分级Ⅲ/Ⅳ级(HR=2.951,95%CI 1.219~7.137,P=0.017)是老年ACS患者急诊PCI术后6个月死亡的独立预测因素.结论MI病史和MHR是老年ACS患者急诊PCI术后发生NOAF的独立预测因素,NOAF与Killip分级Ⅲ/Ⅳ级是老年ACS患者急诊PCI术后6个月死亡的独立预测因素.     

急性冠状动脉综合征介入治疗预后的性别差异

目的探讨性别对急性冠状动脉综合征(ACS)介入治疗预后的影响。方法分析比较363例ACS患者(男性244例,女性119例)的临床和冠状动脉造影病变特征、介入治疗的造影成功率、院内和随访(22±13)个月主要心脏不良事件(MACE)的发生率和病死率。结果女性年龄较大,合并高血压的比例较大,血胆固醇和低密度脂蛋白的平均浓度较高,但吸烟和既往心肌梗死的比例较低。男性多支病变的比例较高(50.4%vs 36.1%,P=0.010),侧支循环较多,而女性双支病变的比例较高(25.8%vs 36.1%,P=0.042),钙化病变较多。两组介入治疗的造影成功率(91.4%vs 94.1%,P=0.361)、院内MACE(5.7%vs 5.9%,P=0.956)和随访期间MACE(13.3%vs 13.4%,P=0.982)相似。但在年龄低于65岁的患者中,女性随访期间的病死率显著高于男性(0.7%vs 7.7%,P=0.029)。结论性别不是影响ACS患者介入治疗术后院内和长期MACE的重要因素,但在年龄低于65岁的患者中,女性长期病死率较高。     

择期行经皮冠状动脉介入治疗病人术前饮食指导

[目的]评价择期经皮冠状动脉介入治疗术（PCI）术前饮食指导的改进对减少病人不适临床表现及并发症的效果。[方法]将择期PCI病人432例随机分为对照组216例和实验组216例,对照组采用传统术前6h禁食、2h禁饮,实验组采用改进新方法全程指导饮食,比较两组病人不适临床表现及并发症发生情况。[结果]实验组较对照组口渴、饥饿、心悸、大汗、心率变化、低血压、低血糖的发生率低（P〈O．05）。[结论]通过对择期PCI病人术前饮食指导的改进,可明显减少病人不适及并发症的发生。     

Anticoagulant and/or antiplatelet treatment in patients with atrial fibrillation after percutaneous coronary intervention. A single-center experience

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia sustained and frequently occurs in patients with coronary heart disease. Thus, a large number of patients requiring percutaneous coronary intervention (PCI) also suffer from AF. An anticoagulant regimen has not been standardized for patients with AF after coronary stent implantation. PATIENTS AND METHODS: The authors investigated data from 159 patients with AF who underwent PCI in their department. Baseline variables and incidence of a combined endpoint (stroke, myocardial infarction, cardiovascular death, severe bleeding) were compared in patients receiving clopidogrel and acetylsalicylic acid (ASA; group 1) versus patients receiving the combination of clopidogrel and ASA with low-molecular-weight heparin (LMWH; group 2) versus patients receiving the combination of clopidogrel and ASA with oral anticoagulation (OAC; group 3) at discharge. RESULTS: Patients discharged with triple therapy including OAC seemed to be at higher risk: patients in group 3 had decreased left ventricular ejection fraction and increased inflammatory state as measured by plasma fibrinogen and C-reactive protein. Moreover, previous OAC treatment and strokes were found more often in this subgroup of patients. In a median follow-up of 1.4 years, two severe bleeding events (both in group 1), four myocardial infarctions (all in group 1), 13 strokes (nine in group 1, four in group 2), and nine cardiovascular deaths (three in group 1, five in group 2, one in group 3) occurred. CONCLUSION: In this analysis, no treatment regimen seemed to be clearly superior. It underlines the importance of prospective, randomized trials to investigate the optimal antithrombotic/antiplatelet treatment for patients with AF after PCI.     

择期行经皮冠状动脉介入治疗病人术前饮食指导

[目的]评价择期经皮冠状动脉介入治疗术(PCI)术前饮食指导的改进对减少病人不适临床表现及并发症的效果.[方法]将择期PCI病人432例随机分为对照组216例和实验组216例,对照组采用传统术前6h禁食、2h禁饮,实验组采用改进新方法全程指导饮食,比较两组病人不适临床表现及并发症发生情况.[结果]实验组较对照组口渴、饥饿、心悸、大汗、心率变化、低血压、低血糖的发生率低(P＜0.05).[结论]通过对择期PCI病人术前饮食指导的改进,可明显减少病人不适及并发症的发生.