强化延续护理在急性冠脉综合征二级预防中的应用研究

目的观察强化延续护理对急性冠脉综合征患者二级预防的影响。方法将108例急性冠脉综合征患者按居住地不同分为观察组和对照组,观察组出院后予强化延续护理,对照组予常规随访,观察时间1年,比较两组患者规范服药率、吸烟率、合理膳食率、运动锻炼率和体质指数、低密度脂蛋白、血压、糖化血红蛋白达标率及再次入院率、患者满意度。结果观察组患者各项指标达标情况优于对照组,患者满意度对照组84.0%、观察组98.1%,P均0.05。结论强化延续护理对急性冠脉综合征患者二级预防效果明显。     

Antiplatelet options for secondary prevention in acute coronary syndromes

Current guidelines recommend dual antiplatelet therapy, a combination of aspirin and a P2Y₁₂ inhibitor, for 6–12 months after percutaneous coronary intervention with drug-eluting stent implantation in all patients and for 1 year in all patients after an acute coronary syndrome (ACS), irrespective of revascularization strategy. Clopidogrel has a pharmacokinetic and pharmacodynamic profile that results in a delayed and/or subtherapeutic antiplatelet effect, and wide variability in antiplatelet response. New P2Y₁₂ inhibitors, such as prasugrel and ticagrelor, have favorable pharmacodynamics and clinical efficacy over clopidogrel and offer an alternative antiplatelet treatment strategy in specific patients. Prasugrel has more potent, rapid, and consistent effects on inhibiting ADP-induced platelet aggregation than clopidogrel. Ticagrelor also appears to have more rapid and consistent antiplatelet effects than clopidogrel. The higher levels of antiplatelet inhibition provided by prasugrel and ticagrelor compared with standard-dose clopidogrel result in improved ischemic outcomes in patients with ACS. Despite an increase in bleeding risk, prasugrel and ticagrelor appear to have a better net clinical benefit, especially in higher-risk patients with ACS.     

Antiplatelet options for secondary prevention in acute coronary syndromes

Current guidelines recommend dual antiplatelet therapy, a combination of aspirin and a P2Y(12) inhibitor, for 6?12 months after percutaneous coronary intervention with drug-eluting stent implantation in all patients and for 1 year in all patients after an acute coronary syndrome (ACS), irrespective of revascularization strategy. Clopidogrel has a pharmacokinetic and pharmacodynamic profile that results in a delayed and/or subtherapeutic antiplatelet effect, and wide variability in antiplatelet response. New P2Y(12) inhibitors, such as prasugrel and ticagrelor, have favorable pharmacodynamics and clinical efficacy over clopidogrel and offer an alternative antiplatelet treatment strategy in specific patients. Prasugrel has more potent, rapid, and consistent effects on inhibiting ADP-induced platelet aggregation than clopidogrel. Ticagrelor also appears to have more rapid and consistent antiplatelet effects than clopidogrel. The higher levels of antiplatelet inhibition provided by prasugrel and ticagrelor compared with standard-dose clopidogrel result in improved ischemic outcomes in patients with ACS. Despite an increase in bleeding risk, prasugrel and ticagrelor appear to have a better net clinical benefit, especially in higher-risk patients with ACS.     

Depression, anxiety and stress in women following acute coronary syndrome: Implications for secondary prevention.

OBJECTIVE: To document incidence of depression, anxiety, and stress in women more than 6 months following an acute coronary syndrome. DESIGN: Participants were identified from a coronary care unit database. The Depression Anxiety Stress Scales 21 (DASS 21) was sent to potential participants via postal survey. SETTING: A metropolitan teaching hospital in Melbourne, Australia. PARTICIPANTS: The cohort of women was aged between 55 and 70 years. They had been admitted to hospital with a diagnosis of acute coronary syndrome (ACS) between 6 and 14 months prior to participating in this study. MAIN OUTCOME MEASURES: Scores on Depression, Anxiety, and Stress Scale (DASS 21). RESULTS: Of the 117 posted questionnaires, 39 women with a mean age of 63 (S.D. 4.97) responded to the survey, representing a response rate of 33.3%. Most participants scored within normal levels of depression (66.7%), anxiety (60.5%), and stress (70.3%), however, mild to extremely severe levels of each construct (33.4%, 39.6%, and 29.7%, respectively) were found. CONCLUSIONS: The reporting of elevated levels of depression, anxiety and stress in a subset of women more than 6 months following an ACS event underscores the importance of ongoing screening for risk factors impacting on psychological well-being and the inclusion of this information in education and counseling strategies in both the inpatient and outpatient settings. Based on these pilot data, consideration of a screening system in the immediate post discharge period for women at risk and an education or support service are recommended.     

Primary prevention of coronary disease

In 1995, the latest year for which statistics are available, heart disease, cancer, and stroke continued to be the three leading causes of death in the United States. Notably, however, a wealth of experience has confirmed that hygienic interventions such as diet, exercise, weight loss, and smoking cessation can reduce the toll from heart disease while also reducing the morbidity and mortality associated with stroke and cancer. This chapter will describe the rationale for the primary prevention of coronary heart disease (CHD), review the basic concepts involved in cholesterol screening, and update the reader regarding key preventive measures, such as diet, exercise, and smoking cessation. Also highlighted will be recent clinical trial results suggesting the benefits of lipid-lowering drugs in "high-risk" individuals who have not experienced a coronary event. These findings represent an exciting advance that emphasizes the value of preventive efforts in curbing CHD.     

Oral anticoagulant use in addition to antiplatelet therapy for secondary prevention in acute coronary syndrome: current perspectives

Patients with acute coronary syndrome (ACS) are typically managed with long-term dual antiplatelet therapy of acetylsalicylic acid plus a P2Y₁₂ platelet receptor antagonist; however, although effective, the risk of another vascular event within 12 months remains at approximately 10%. Considerable efforts have been made to find improved therapeutic approaches to secondary prevention in ACS. The ATLAS ACS 2-TIMI 51 trial demonstrated that rivaroxaban (2.5 mg twice daily) significantly reduced recurrent vascular events, increased the risk of major bleeding but not the risk of fatal bleeding, and resulted in reduced rates of death from cardiovascular causes. These results formed the basis for approval in Europe of rivaroxaban (2.5 mg twice daily) in conjunction with standard antiplatelet therapy for the secondary prevention of ACS.     

Anti-integrins--new platelet function inhibitors for therapy and prevention of acute coronary syndrome

Acute occlusion of a large coronary artery by a platelet thrombus is a life-threatening event. Intravasal thrombus generation in most cases is caused by a disturbed interaction between platelets and the vessel wall, with accompanying platelet hyperreactivity, local adhesion to the vessel wall, activation and aggregate formation after binding of soluble fibrinogen to the activated GP IIb/IIIa-receptor. Conventional antiplatelet agents, such as aspirin or ticlopidine/clopidogrel, inhibit uncontrolled local agonist-induced signal transduction within the platelet by interfering with the thromboxane A2 and ADP pathway, respectively. This results in an activation of the platelet GP IIb/IIIa-receptor and, finally, in a reduced capacity of fibrinogen binding. Antiintegrins inhibit cell-cell and cell-matrix interactions. Antagonists of the platelet integrin alpha IIB/beta 3 (GP IIb/IIIa) (eg. Abciximab, Eptifibatide, Tirofiban) inhibit platelet adhesion and aggregation via their RGD (KGD) binding sequence, resulting in reduced fibrinogen binding. The significance of inhibition of other RGD-containing adhesion molecules (von Willebrand Factor, Vitronectin) with respect to the clinical efficacy of these compounds is stil under debate. GP IIb/IIIa-antagonists are the most effective inhibitors of platelet function and in high doses, may cause complete inhibition of platelet aggregation and maximum prolongation of bleeding time. The clinical efficacy of GP IIb/IIIa-antagonists for acute percutaneous coronary interventions and in the management of the acute coronary syndrome is established. Whether Abciximab and low-molecular weight intravenous compunds (Eptifibatide, Tirofiban, Lamifiban) are equipotent, remains to be demonstrated by controlled comparative studies. Orally active low-molecular-weight compounds (Sibrafiban, Xemilofiban and others) are currently undergoing clinical trials. Whether these substances are superior to oral aspirin and/or clopidogrel in long-term prevention of acute arterial vessel occlusions remains to be determined.     

Primary and secondary prevention using lipid-lowering therapies

The observation that coronary heart disease was greatest in those individuals with the highest cholesterol levels resulted in the development of interventions to lower cholesterol to improve coronary risk status. Some individuals will achieve target lipid levels with diet and lifestyle modification alone. Therefore, diet and lifestyle modification is the preferred initial treatment. For more aggressive management of those who do not respond to diet and lifestyle modification or who have documented coronary heart disease, lipid-lowering drugs, extensively tested in large, multicenter, randomized clinical trials are preferred. Initially, questions arose about adverse effects of lipid-lowering drugs, but continued use has demonstrated that these drugs are both safe and efficacious. The need remains, however, for clinicians to monitor each patient's response to lipid-lowering diets, lifestyle modification efforts, and drugs and evaluate whether beneficial effects outweigh the cost and potential for adverse effects.     

Primary and secondary prevention in dyslipidemia in the elderly

Cardiovascular disease (CVD) is the leading cause of mortality and a major cause of disability in advanced age. The relationship between coronary heart disease (CHD) and dyslipoproteinaemia is well known. The fact, however, that atherosclerosis is a systemic disease leads also to the consideration that patients suffering from cerebrovascular and peripheral arterial disease should benefit similarly from lipid lowering therapy as do patients with CHD. There is already growing evidence that the incidence of stroke may be markedly decreased by statin therapy. Though overall, the clinical significance of hypercholesterolaemia seems to decrease with increasing age, patients at age 65 to 75 tend to benefit even more than younger patients when elevated LDL-cholesterol is treated effectively. It should be noticed that prevention or postponement of cardiovascular events may also prevent premature functional limitations and disability in old age. Hence, it is suggested to screen elderly people with CVD for dyslipoproteinaemia and to treat elevated cholesterol levels by means of life style changes, nutritional therapy, and drug therapy. Treatment regimes should be considered depending upon complete risk stratification and geriatric assessment. Chronological age alone cannot be an argument to withhold a proven effective therapy from a growing segment of the population at risk.     

Primary and secondary prevention of colorectal cancer.

Colorectal cancer is the third leading cause of cancer deaths in the United States. Because of the nature and the progression of the disease, it is highly preventable and suitable for screening. Yet the American Cancer Society estimates included over 100,000 cases of new occurrence of colorectal cancer and over 50,000 deaths in the year 2002. The continued high colorectal cancer mortality rate is due to the under utilization of screening tests.This review will explore the barriers to low screening test use. Implications for healthcare professionals on how to increase the general populations' awareness of colorectal cancer and ways to increase adherence to screening by integrating theories of the Health Belief Model will be discussed. The current research and literature about primary prevention focused on modifiable risk factors and chemoprevention will be examined. Secondary prevention, however, will be the key to help reduce the mortality and morbidity of colorectal cancer. The current screening guidelines will be reviewed as well. It is possible to increase screening rate by modifying and influencing patients' perceived cancer risk, and by educating and training healthcare providers.     

Statins and secondary prevention of coronary heart disease

A mini-review (Griffiths, 2002) of double-blind randomized controlled trials (RCTs) was undertaken to assess the long-term effect of lipid lowering treatments (statins versus placebo) in secondary prevention of myocardial infarction (MI). The population sample was adult patients with a history of MI, documented coronary heart disease or coronary artery disease. The Cochrane Library and the database Medline were searched and three RCTs appeared to possess all of the stipulated inclusion and exclusion criteria. The trials all compared statins against a placebo; one trial was of simvastatin--the Scandinavian Simvastatin Survival Study (1994)--and the other two were of pravastatin--the Cholesterol and Recurrent Events Trial (CARE) (Sacks et al, 1996) and Long Term Intervention with Pravastatin Ischaemic Disease (LIPID) (Anon, 1998). The trials demonstrated that statins had a clear and consistent effect in significantly reducing the risk of MI. Overall an approximate decline of 30% in MI was produced from the three trials.     

Cardioembolic stroke. Primary and secondary prevention.

Modern prospective trials have recently shown that warfarin prescribed to produce less anticoagulant effect than was customary in the past reduces cardioembolic stroke by up to 80% in patients with nonvalvular atrial fibrillation. These results represent a major advance in stroke prevention. The effectiveness of antithrombotic treatment in other settings in which there is risk of cardioembolism is less well established but likely to be substantial.     

Primary and secondary prevention of heart failure with statins

Statins are effective in the prevention of coronary heart disease (CHD), a leading cause of heart failure (HF). Secondary analyses from 11 randomized clinical trials of patients with high-risk acute or stable coronary heart disease, but without HF, suggest that statins may prevent new-onset HF or HF-related hospitalization. In persons with established HF, several cohort studies found an approximate 35% relative risk reduction in all-cause mortality. While ongoing randomized clinical trials will help to determine the efficacy of statins in persons with established HF, it is reasonable to consider this class of medications in patients with a history of cardiovascular disease, dyslipidemia or diabetes mellitus, and who have either developed, or who remain at risk of, HF.     

Primary and secondary prevention of heart failure with statins

Statins are effective in the prevention of coronary heart disease (CHD), a leading cause of heart failure (HF). Secondary analyses from 11 randomized clinical trials of patients with high-risk acute or stable coronary heart disease, but without HF, suggest that statins may prevent new-onset HF or HF-related hospitalization. In persons with established HF, several cohort studies found an approximate 35% relative risk reduction in all-cause mortality. While ongoing randomized clinical trials will help to determine the efficacy of statins in persons with established HF, it is reasonable to consider this class of medications in patients with a history of cardiovascular disease, dyslipidemia or diabetes mellitus, and who have either developed, or who remain at risk of, HF.