比较不同药物洗脱支架置入后晚期血栓形成的发生率

目的:探讨冠心病患者非选择性病变中即真实世界中(real-world)不同药物洗脱支架(DES)置入后晚期血栓形成的发生率.方法:本研究为单中心DES注册研究,在病变的入选标准上无特殊限制,自2001-12至2008-12共计11352例冠心病患者接受了DES治疗,其中使用雷帕霉素DES(Cypher或Cypher Select支架,美国Cordis公司)3915例(Cypher组),使用紫杉醇DES(TAXUS或TAXUS liberty支架,美国波士顿科技公司)2202例(TAXUS组),使用国产雷帕霉素DES(Fire-bird,中国微创医疗器械有限公司)5235例(Fireblrd组).在上述三种不同的DES中,完成1年临床随访总例数为8626例,其中Cypher组为3012例、TAXUS组为1518例、Firebird组为4096例,完成2年临床随访总例数为5993例,各组例数分别为2187例、1159例、2647例.完成3年临床随访总例数为3378例,各组例数分别为1596例、860例、922例.所有患者PCI术后联合应用阿司匹林与氯吡格雷至少9个月.结果:1年临床随访结果显示晚期血栓发生率在Cypher组、TAXUS组以及Firebird组各自为1.20%,1.25%和0.81%;2年临床随访显示晚期支架内血栓发生率三组分别为1.51%、1.70%、1.02%;3年临床随访显示晚期支架内血栓发生率三组分别1.88、1.86%、1.30%.3组之间各年度比较,其晚期血栓发生率差异均无统计学意义.然而在3组中均可发现,从第一年至第三年间,每年晚期血栓发生率呈递增现象.结论:本研究结果显示应用以上3种DES治疗冠心病无选择性病变均有良好的临床远期疗效,但每年晚期血栓发生率呈递增现象仍应引起高度的重视并提示对于复杂性冠状动脉病变或置入较多支架的患者,双联抗血小板治疗应延长至1年或更长时间为妥.     

Drug-Coated Balloon Angioplasty Versus Drug-Eluting Stent Implantation in Patients With Coronary Stent Restenosis

BackgroundIn patients with coronary in-stent restenosis (ISR) requiring reintervention, it is unclear if the choice of treatment should depend on whether the restenotic stent was a bare-metal stent (BMS) or a drug-eluting stent (DES).ObjectivesThis study aimed to assess the comparative efficacy and safety of the 2 most frequently used treatments — angioplasty with drug-coated balloon (DCB) and repeat stenting DES — in patients with BMS-and DES-ISR.MethodsThe DAEDALUS (Difference in Antirestenotic Effectiveness of Drug-Eluting Stent and Drug-Coated Balloon Angioplasty for the Occurrence of Coronary In-Stent Restenosis) study was a pooled analysis of individual patient data from all 10 existing randomized clinical trials comparing DCB angioplasty with repeat DES implantation for the treatment of coronary ISR. In this pre-specified analysis, patients were stratified according to BMS- versus DES-ISR and treatment assigned. The primary efficacy endpoint was target lesion revascularization (TLR) at 3 years. The primary safety endpoint was a composite of all-cause death, myocardial infarction, or target lesion thrombosis at 3 years. Primary analysis was performed by mixed-effects Cox models accounting for the trial of origin. Secondary analyses included nonparsimonious multivariable adjustment accounting also for multiple lesions per patient and 2-stage analyses.ResultsA total of 710 patients with BMS-ISR (722 lesions) and 1,248 with DES-ISR (1,377 lesions) were included. In patients with BMS-ISR, no significant difference between treatments was observed in terms of primary efficacy (9.2% vs. 10.2%; hazard ratio [HR]: 0.83; 95% confidence interval [CI]: 0.51 to 1.37) and safety endpoints (8.7% vs. 7.5%; HR: 1.13; 95% CI: 0.65 to 1.96); results of secondary analyses were consistent. In patients with DES-ISR, the risk of the primary efficacy endpoint was higher with DCB angioplasty than with repeat DES implantation (20.3% vs. 13.4%; HR: 1.58; 95% CI: 1.16 to 2.13), whereas the risk of the primary safety endpoint was numerically lower (9.5% vs. 13.3%; HR: 0.69; 95% CI: 0.47 to 1.00); results of secondary analyses were consistent. Regardless of the treatment used, the risk of TLR was lower in BMS- versus DES-ISR (9.7% vs. 17.0%; HR: 0.56; 95% CI: 0.42 to 0.74), whereas safety was not significantly different between ISR types.ConclusionsAt 3-year follow-up, DCB angioplasty and repeat stenting with DES are similarly effective and safe in the treatment of BMS-ISR, whereas DCB angioplasty is significantly less effective than repeat DES implantation in the treatment DES-ISR, and associated with a nonsignificant reduction in the primary composite safety endpoint. Overall, DES-ISR is associated with higher rates of treatment failure and similar safety compared with BMS-ISR.     

大鼠实验性脑出血后基质金属蛋白酶2和9的表达

目的探讨大鼠脑出血后基质金属蛋白酶2和基质金属蛋白酶9的表达及其意义。方法采用未抗凝新鲜自体股动脉血注入大鼠尾状核建立脑出血动物模型。用酶谱分析法测定脑出血后6h、12h、24h、3天、6天、10天和15天时基质金属蛋白酶2和基质金属蛋白酶9的表达。结果基质金属蛋白酶2在脑出血后24h开始表达(P<0.05),第6天时达高峰(P<0.01),到第10天仍维持高水平表达(P<0.05);而基质金属蛋白酶9在脑出血后6h开始表达(P<0.05),24h~3天最明显(P<0.01),此后活性逐渐降低,第10天时的活性仍高于对照组(P>0.05),15天时不再表达。结论脑出血后6h~3天出血灶周围脑组织中基质金属蛋白酶9的活性增高,可能与急性期脑水肿的形成有关,而基质金属蛋白酶2的迟发表达可能参与了脑组织的修复过程。     

骨桥蛋白和基质金属蛋白酶-9对经皮冠状动脉介入治疗后支架内再狭窄的诊断价值

目的 :探讨血清骨桥蛋白(OPN)及金属基质蛋白酶-9(MMP-9)水平变化对经皮冠状动脉介入治疗(PCI)后支架内再狭窄(ISR)的诊断价值。方法 :选择142例于我院接受PCI后复查冠状动脉造影检查的患者,根据冠状动脉造影结果分为再狭窄组(n=21)和无再狭窄组(n=121),复查冠状动脉造影时检测两组患者血清OPN、MMP-9等生化指标,比较两组患者临床资料、OPN及MMP-9等临床生化指标水平。结果:再狭窄组患者血清OPN及MMP-9水平显著高于无再狭窄组,差异有显著统计学意义(P0.001);Logistic多因素回归分析显示,OPN及MMP-9升高均是PCI后ISR发生的独立危险因素[优势比(OR)=3.034及OR=2.861,P0.01];在OPN及MMP-9预测ISR能力的受试者工作曲线(ROC)中,其曲线下面积为0.821及0.887,P0.001;当OPN及MMP-9分别取3.68 ng/ml和415.24 ng/ml时,联合检测可增加检测的敏感性(90.48%)和阴性预测价值(98.06%)。结论:PCI后患者血清OPN及MMP-9水平与ISR密切相关,联合检测血清OPN及MMP-9水平对ISR的发生具有一定的预测价值,尤其是其阴性预测价值。     

药物洗脱支架在防治颅内外支架成形术后再狭窄的作用

目前,有症状颅内外动脉狭窄支架置入术多使用裸金属支架,但再狭窄发生率较高。药物洗脱支架治疗冠状动脉粥样硬化病变的研究表明,再狭窄发生率显著降低。虽然颅内外动脉狭窄的药物洗脱支架支架置入术也是安全的,但是还需大样本前瞻性随机对照试验证实其安全性和有效性。     

Late and Very Late Stent Thrombosis in Patients With Second-Generation Drug-Eluting Stents

Background

Second-generation drug-eluting stents (DES) are purported to have a lower risk of stent thrombosis than first-generation DES. However, few studies have examined the frequency of late stent thrombosis (LST) and very LST (VLST) in patients with second-generation DES, and the safety of discontinuation of dual antiplatelet therapy (DAPT) remains controversial.

Methods

We systematically searched MEDLINE, EMBASE, Cochrane Library, and clinicaltrials.gov to identify all reported cases of definite LST and VLST in patients with second-generation DES. Inclusion was restricted to cases with zotarolimus-eluting stents (ZES) and everolimus-eluting stents (EES) in which the time from percutaneous coronary intervention and time from discontinuation of DAPT to LST/VLST was reported.

Results

A total of 26 cases (15 ZES and 11 EES) in 11 publications were included. We identified 17 cases of LST and 9 cases of VLST. The median time from percutaneous coronary intervention to LST/VLST in ZES patients was 121 days (interquartile range [IQR], 89-292) and in EES patients was 364 days (IQR, 269-504). For the 5 patients who discontinued taking acetylsalicylic acid and clopidogrel simultaneously, the median time to event was 20 days (IQR, 10-60). For the 7 patients who discontinued taking clopidogrel but continued taking acetylsalicylic acid, the median time to event was 190 days (IQR, 135-303).

Conclusions

With only a few reported cases of LST/VLST in the literature, available data suggest that thrombotic events might be rare with second-generation DES. Moreover, LST/VLST appears to occur later after DAPT discontinuation in patients with second-generation DES than in those with first-generation DES.     

原发性高血压患者血清基质金属蛋白酶9及其抑制因子水平

目的　研究原发性高血压患者血清中基质金属蛋白酶 9(MMP— 9)及其抑制剂 ,金属蛋白酶组织抑制因子 1(TIMP— 1)水平的变化和左室肥厚的关系。方法　用酶联免疫吸附法对 4 0例经治疗或未治疗的原发性高血压患者进行血清MMP— 9和TIMP— 1水平测定 ,与 2 8例健康对照组进行比较。并对高血压患者进行心脏彩色多谱勒检查 ,计算左室重量指数。结果　 1、高血压组血清MMP - 9较正常对照组明显降低(2 96 38± 15 9 2 3ng ml-1、4 99 6 2± 334 80ng ml-1,P <0 0 0 1)而TIMP - 1水平较正常对照组明显升高 (35 5 99± 114 95ng ml-1、2 0 5 4 5± 38 77ng ml-1,P <0 0 0 1) ;2、高血压心肌肥厚组与无肥厚组MMP - 9无显著性差异(332 71± 186 70ng ml-1、2 82 5 9± 14 9 10ng ml-1,P >0 0 5 ) ,但TIMP - 1水平心肌肥厚组明显升高 (491 2 7±75 0 3ng ml-1,2 98 4 7± 4 2 98ng ml-1P <0 0 0 1)。结论　原发性高血压患者存在基质金属蛋白酶 - 9及其抑制剂 - 1代谢异常 ,血清TIMP - 1水平可能成为反映高血压左室肥厚的指标。     

阻塞性睡眠呼吸暂停综合征患者颈动脉粥样硬化与血清基质金属蛋白酶-9水平的关系

阻塞性睡眠呼吸暂停综合征(OSAS)患者的颈动脉粥样硬化程度和血清基质金属蛋白酶(MMP)-9水平均随着呼吸暂停程度的加重而增高,而MMP-9在颈动脉粥样硬化发展过程中发挥着重要作用.文章对OSAS患者颈动脉粥样硬化与血清MMP-9水平的关系进行了综述,以分析OSAS患者发生颈动脉粥样硬化的可能机制.     

原发性高血压患者血清基质金属蛋白酶9与升主动脉弹性的关系

目的探讨原发性高血压(EH)患者血清基质金属蛋白酶9(MMP-9)与大动脉弹性的相关关系。方法选择EH患者119例,分为单纯高血压组59例,高血压合并颈动脉粥样硬化组(硬化组)60例;另选取同期我院体检健康者38例(对照组)。检测血压、身高、体质量、体质量指数(BMI)及生化指标。酶联免疫吸附法检测血清MMP-9水平,用超声心动图在主动脉瓣上3 cm处测量心脏收缩期和舒张期升主动脉内径,并计算出Peterson弹性指数(Ep)、僵硬度指数(β)、扩张性。结果对照组、单纯高血压组、硬化组的ln Ep(Ep的自然对数)、β、血清MMP-9依次升高;扩张性依次降低[(0.91±0.47)×10-6比(0.63±0.42)×10-6比(0.38±0.21)×10-6cm2/dyn,P<0.01]。偏相关分析显示,ln Ep、β与血清MMP-9呈正相关(r=0.43,P<0.01;r=0.44,P<0.01),扩张性与MMP-9呈负相关(r=-0.30,P<0.01)。多元逐步回归分析显示,血清MMP-9是大动脉弹性的独立影响因素之一。结论EH患者血清MMP-9的升高与大动脉弹性的减退有相关性。