不同ST段改变的急性冠脉综合征的临床特征

目的探讨不同ST段改变的急性冠脉综合征(ACS)患者的临床特征。方法将380例急性冠脉综合征患者分为ST段抬高组及非ST段抬高组,后者包括不稳定心绞痛和非ST段抬高的心肌梗死(NSTE-M I),记录患者的临床特征及住院结果并进行相关分析。结果380例急性冠脉综合征患者,152例伴有ST段抬高,228例不伴有ST段抬高,其中伴有ST段抬高组相对年龄稍轻,吸烟率及血运重建率较高,而非ST段抬高组则年龄较大,高血压,糖尿病等合并症较多,且女性比例较高。结论ST段抬高的急性冠脉综合征患者吸烟率较高,单支病变及血运重建率亦较高,而非ST段抬高的急性冠脉综合征中高血压、糖尿病更多见,且女性偏多,年龄偏大。     

非ST段抬高急性冠脉综合征危险分层的现状与展望

急性冠脉综合征（Acs）是指冠状动脉血流突然受阻致急性心肌缺血的临床病症,现已成为影响人类身心健康的一个社会公共问题。根据发病时的心电图特征,临床上将ACS分为非ST段抬高和ST段抬高2种。由于非ST段抬高ACS（NSTE-ACS）冠脉存在严重狭窄,且心电图改变常常为一过性或短暂ST段压低,或T波倒置、低平,或“伪正常化”,导致临床上经常出现误诊或漏诊。而对NSTE-ACS患者进行风险评估,可以尽早筛查出高危患者。因此,本文主要对NSTE—ACS早期风险评估、出院前风险评估及现有危险分层做一综述,以便更好地了解患者所处的危险程度,指导临床策略。     

HEARTS3对提高急诊非ST段抬高胸痛危险分层作用的研究

目的 在HEART评分系统基础上,研究HEARTS3评分对提高急诊非ST段抬高胸痛患者危险分层和急性冠脉综合征(ACS)的预测应用价值.方法 回顾性分析2011年7月至2015年5月775例符合标准的急诊非ST段抬高胸痛患者,分别进行HEART和HEARTS3评分,并随访患者发病后30 d内ACS和心肌梗死(MI)发病情况,根据评分进行危险分层,分析不同分层患者发病后30 dACS与MI的发生情况与评分之间的关系,并比较两种评分对胸痛患者发病后30 d ACS的预测能力.使用SPSS 13.0软件进行统计分析计数资料以百分比(％)表示,两组计量资料之间的比较用成组t检验,两种评分不同评分段患者发生ACS比例比较用行x列表x2检验,每种评分方法对发生心血管事件ACS患者分辨度用ROC曲线下面积(AUROC),并用Z检验进行比较.结果 共有92例发病后30 d发生ACS,HEART和HEARTS3的对高危胸痛患者预测敏感性分别为64.79％、77.97％,特异性分别为97.57％、97.85％.HEART与HEARTS3危险评分ROC曲线下面积,MI(0.952 vs.0.813;P =0.028),30 dACS (0.913 vs.0.815;P=0.034),两者差异具有统计学意义.结论 HEART和HEARTS3都可以应用于急诊胸痛患者的危险分层和预后评估,但HEARTS3更可靠.     

B型利钠肽在非ST段抬高急性冠脉综合征早期危险分层的研究

【目的】探讨B型利钠肽(BNP)在非ST段抬高急性冠脉综合征早期危险分层的作用,以便发现高危患者。【方法】2007年1月至2007年7月就诊于中国医科大学附属盛京医院的非ST段抬高急性冠脉综合征患者62例,检测血浆BNP值,并行冠状动脉造影对冠脉病变进行评估,所有患者进行为期60d的随访。【结果】BNP升高组患者与多支血管病变和较差预后相关。【结论】BNP检测在急性冠脉综合征早期危险分层中起重要作用,BNP能提供较多的预后信息。     

Contemporary diagnosis and management of unstable angina

Unstable angina (UA) is one of the acute coronary syndromes, a group of conditions that also includes non-ST elevation myocardial infarction (MI) and ST elevation MI. The underlying pathogenic substrate of all these entities is the unstable coronary plaque with an overlying intracoronary thrombus. Initial management for the patient with suspected UA includes a resting electrocardiogram and oral administration of aspirin. ST-segment elevation indicates acute MI with the need for urgent reperfusion therapy. Patients without ST-segment elevation commonly have a mixture of UA and non-ST elevation MI; initial management is similar with assessment of near-term risk of MI or death as the next step. Features of UA indicating high risk include persistent ST-segment depression, persistent ischemic pain, elevated troponin level, or features of heart failure. Such patients undergo intensive medical therapy with heparin (unfractionated or low-molecular-weight), beta-blockade, and IIb/IIa antiplatelet agents, usually followed by coronary angiography and percutaneous intervention. The timing of intervention depends on the patient's response to therapy. Intermediate- or low-risk patients (including those presenting to the emergency department) can be managed with a chest pain unit strategy, and those with normal results on serial electrocardiograms, cardiac marker studies, and functional testing can be safely discharged home. Others are admitted for elective angiography, intensive medical therapy, or both. Assessment of coronary risk factors and their modification is an important component of long-term therapy for both high-risk and low-risk patients with UA, as well as those determined to have had non-ST elevation MI.     

Therapeutics of platelet glycoprotein IIb/IIIa receptor antagonism

The integrin glycoprotein IIb/IIIa receptor is the final common pathway to platelet aggregation. Administration of glycoprotein IIb/IIIa receptor antagonists reduces acute ischemic complications following plaque fissuring or rupture. Research on this subject was initially limited to patients undergoing percutaneous coronary intervention. Further studies evaluating the role of glycoprotein IIb/IIIa receptor antagonists in patients with non-ST segment elevation acute coronary syndrome have shown benefit of these drugs in reducing adverse cardiac events and death. Intravenous glycoprotein IIb/IIIa receptor inhibitors (abciximab, tirofiban, and eptifibatide) given in combination with traditional regimens are superior to placebo in management of non-ST elevation acute myocardial infarction. Oral glycoprotein IIb/IIIa receptor inhibitors (orbofiban, sibrafiban, and xemilofiban) are not effective in reducing ischemic events when used on a long-term basis after acute coronary syndrome. Pharmacokinetics, efficacy, and safety of glycoprotein IIb/IIIa receptor antagonists are elaborated.     

A potential pharmacogenomic strategy for anticoagulant treatment in non-ST elevation acute coronary syndromes: the role of interleukin-1 receptor antagonist genotype

OBJECTIVES: Our aim was to determine a pharmacogenomic approach to heparin use in non-ST elevation acute coronary syndromes, specifically the impact of interleukin (IL)-1 receptor antagonist polymorphisms upon von Willebrand factor (vWF) responses to unfractionated heparin (UFH) and low molecular weight heparin (LMWH). BACKGROUND: In acute coronary syndromes (ACS), identification of specific biological or genetic targets to direct pharmacological treatment remains a challenge. vWF has been shown to predict future cardiovascular risk and the response to anticoagulant treatments during non-ST elevation ACS. IL-1 receptor antagonist (IL-1RN) polymorphisms predict the change in vWF between 24 and 48 h (Delta vWF) during non-ST elevation ACS. METHODS: We genotyped at the IL-1 locus, 67 patients with non-ST elevation ACS who received either LMWH or UFH, and measured vWF levels at 24 and 48 h. RESULTS: LMWH was superior to UFH in reducing the rise in vWF between 24 and 48 h in the cohort as a whole. However, when patients were stratified by IL-1RN genotype, LMWH was superior to UFH in reducing Delta vWF only in allele *2 carriers (0.51 iU mL(-1) vs. 1.37, P < 0.01), but not in non-carriers (- 0.03 iU mL(-1) vs. 0.15, P = NS). CONCLUSION: IL-1RN genotype may be a useful marker to identify patients that benefit from LMWH in non-ST elevation ACS.     

Management and outcomes of acute coronary syndrome with minimal myocardial necrosis: analysis of a large prospective registry from a non-interventional centre

The aim of this study was to assess the clinical risk of minimal myonecrosis below the cut-off for acute myocardial infarction (MI) in comparison with other grades of acute coronary syndrome (ACS). One-thousand four hundred and sixty seven consecutive patients with ACS admitted between May 2001 and April 2002 were studied in a non-interventional centre. Patients were divided into unstable angina (UA) (cTnT < 0.01 microg/l), non-ST elevation ACS with minimal myonecrosis (0.01 or= 0.1 microg/L) and ST elevation myocardial infarction (STEMI). UA (n = 638) was associated with the fewest events at 6 months (2% cardiac death or MI). Patients with any myonecrosis (n = 829) had worse outcomes (6-month cardiac death or MI 18.3-23.3%). Compared with ACS patients with minimal myonecrosis, UA patients were at significantly lower risk (OR 0.21, 95% CI 0.12-0.45, p < 0.001), NSTEMI patients were at similar risk (OR 1.45, 95% CI 0.89-2.35, p = 0.13), and STEMI patients were at higher risk (OR 2.12 95% CI 1.26-3.85, p = 0.008) in adjusted analyses. Nearly 85% of cardiac deaths occurred within 6 months. The risk of adverse events was higher among patients managed by non-cardiologists (OR 1.66, 95% CI 1-2.75, p = 0.049). Patients with non-ST elevation ACS and minimal myonecrosis are a high-risk group more comparable with NSTEMI and clearly distinguishable from patients with UA.     

不同性别非ST段抬高急性冠状动脉综合征患者的临床特征

目的 探讨不同性别非ST段抬高急性冠状动脉综合征（ACS）患者的临床特征.方法回顾性分析首次发作不稳定型心绞痛（UA）或非ST段抬高心肌梗死（NSTEMI）患者临床资料,记录患者临床特点、治疗方法以及住院事件的发生率等情况.分析不同性别患者的临床与病变特征和住院临床结果.结果 869例患者,女性223例（25.7%）,与男性相比,女性患者有原发性高血压史较多（P＜0.001）,心肌梗死史较少（P=0.001）,吸烟史较少（P＜0.001）,糖尿病、卒中等病史差异无显著性;女性患者的年龄较大（P＜0.001）,入院时收缩压较高（P＜0.001）,空腹血糖较高（P＝0.001）,血清胆固醇较高（P＜0.001）,血肌酐较低（P＜0.001）,白细胞计数较低（P＝0.02）,左心室射血分数较高（P＜0.001）;男性和女性患者的多支血管病变比例差异无显著性;两组患者血运重建率相似,院内主要不良心脏事件的发生率差异无显著性.结论冠状动脉造影阳性非ST段抬高的ACS患者中,女性多见,心肌梗死和吸烟史较少,血糖、血脂较高,左心室收缩功能较好,不同性别患者的院内事件发生率差异无显著性.     

急性非ST段抬高心肌梗死患者临床特点分析

目的 分析急性非ST段抬高心肌梗死(NSTEMI)患者的临床特点.方法 对211例NSTEMI和急性ST段抬高心肌梗死(STEMI)116例患者行冠状动脉造影、超声心动图检查,采集病史和症状特征进行分析.结果 与STEMI患者相比,NSTEMI患者危险因素较多,梗死后心绞痛常见,重度冠状动脉病变和三支病变多见,对心功能影响相对较小.结论 NSTEMI患者冠状动脉病变严重,梗死后心肌缺血常见,应重视对其治疗.     

B型尿钠肽对无ST段抬高急性心肌梗死患者的诊断价值

目的:评价B型尿钠肽(BNP)对伴急性胸痛但心电图无ST段抬高的急性心肌梗死(AMI)患者的诊断价值。方法:对156例门诊及急诊急性胸痛或胸部不适患者进行前瞻性研究,测定BNP和肌钙蛋白I(cTnI),评价BNP对无ST段抬高的AMI患者的早期诊断价值。结果:156例患者中,不伴有心电图ST段抬高AMI患者,其入院时BNP水平显著高于不稳定型心绞痛和非急性冠状动脉综合征患者。BNP诊断无ST段抬高的AMI的敏感度为0.63,特异度为0.42。联合应用BNP及cTnI可显著提高对无ST段抬高AMI的诊断敏感度(0.99),阴性预测值可提高至0.98。经多元回归分析发现,对于诊断无ST段抬高AMI,BNP是一个显著的独立指标。结论:对于伴有急性胸痛但无ST段抬高的AMI患者,尤其是cTnI还未达到AMI诊断阈值时,BNP联合cTnI可能成为其有效的早期诊断指标之一。     

Diagnostic and prognostic role of cardiac troponin I (cTnI) measured on the DPC Immulite

OBJECTIVE: To evaluate the diagnostic and prognostic role of the Immulite cTnI assay for the detection of acute coronary syndromes (ACS). POPULATION: 150 males and 63 females with a median age of 63 years, range 28 to 88, and an interquartile range of 18 years were admitted within 24 h of chest pain and non-ST segment elevation ACS were studied. The median onset of symptoms was 3 h (range 0-23). METHODS: Venous samples were taken on admission (t = 0) and at 24 h (t = 24). The serum samples were assayed for CK, CK-MB and cTnT on an Elecsys 1010 (Roche Diagnostics, Lewes, UK). The cTnT assay CV was 5.5% at 0.32 microg/l and 5.4% at 6.0 microg/l, and the detection limit was 0.01 microg/l with an upper limit of 25 microg/l. For cTnI using the Immulite (DPC, Gwynedd, Wales), the detection limit was 0.1 microg/l, and the upper limit was 180 microg/l. Final diagnostic categorization was performed by both WHO and European Society of Cardiology criteria using cTnT as the diagnostic cardiac biomarker. Patients were followed for the major adverse cardiac events (MACE), endpoints cardiac death, AMI or need for urgent revascularization. ROC curves were constructed using final diagnosis. Outcome prediction was assessed by ROC curves and Kaplan-Meier survival curves. RESULTS: Both methods had equivalent diagnostic efficiency using WHO criteria for AMI. When ESC criteria were used the AUC for admission and 24 h cTnT and cTnI values were 0.945 vs. 0.910, P = 0.20 and 0.998 vs. 0.937, P = 0.005, respectively. Both methods predicted outcome as either death or MI or MACE and were not significantly different. CONCLUSION: The Immulite cTnI assay can be used for diagnosis and risk stratification in patients admitted with non-ST segment elevation acute coronary syndromes.     

不同药物洗脱支架置入老年急性非ST段抬高型冠脉综合征后的炎症因子反应

背景：雷帕霉素及其衍生物依维莫司洗脱支架能改善急性冠脉综合征患者支架置入后的炎症反应,减少再狭窄的发生率。Firebird支架是目前中国使用最广泛的国产雷帕霉素药物洗脱支架,XIENCE.V支架是目前使用最多的雷帕霉素衍生物依维莫司洗脱支架。目的：比较国产雷帕霉素洗脱Firebird支架及进口XIENCE.V支架对老年非ST段抬高型急性冠脉综合征患者经皮冠状动脉介入后炎症因子高敏C-反应蛋白及白细胞介素6影响的差异。方法：选取2012年9月至2014年7月间老年非ST段抬高型急性冠脉综合征患者112例,其中不稳定心绞痛47例,非ST段抬高型心肌梗死65例。经药物治疗病情72 h后,行经皮冠状动脉介入治疗,其中Firebird支架组58例,XIENCE.V支架组54例。结果与结论：与置入前相比,两组高敏C-反应蛋白及白细胞介素6置入后24 h显著升高（P 〈0.01）,置入后1个月显著下降（P 〈0.05）。置入后24 h、1周、1个月,两组高敏C-反应蛋白及白细胞介素6差异无显著性意义。两组术中及置入后1个月均无心脏意外事件发生,两组安全性及组织相容性相似。结果证实,Firebird支架与XIENCE.V支架治疗均能抑制老年非ST段抬高型急性冠脉综合征患者支架置入后炎症反应,且临床疗效相似。     

Tailored antithrombotic therapy for acute coronary syndromes

Acute coronary syndromes usually result from thrombotic occlusion of a coronary artery at the site of atherosclerotic plaque disruption. The mainstay of treatment is the use of antiplatelet and antithrombotic therapy to maintain patency of the artery. In patients with non-ST segment elevation acute coronary syndromes, antithrombotic therapy followed by coronary revascularization (when feasible in patients with high-risk features) is the optimal management strategy. In the patient with ST elevation acute coronary syndromes who receives a fibrinolytic agent antithrombotic agents, are also important to prevent reocclusion. Bleeding complications of antithrombotic therapy are associated with a substantial increase in adverse short- and long-term outcomes. Hence, the selection of the most appropriate antithrombotic agent aims to minimize both ischemic and hemorrhagic complications. Factors that are associated with increased bleeding risk and need to be considered when selecting an antithrombotic agent include decreased renal function, short time to invasive procedure (<24 h), and the overall bleeding risk. For patients who will undergo later cardiac catheterization and are not at high bleeding risk, either enoxaparin or fondaparinux are acceptable choices. For patients who are likely to undergo early catheterization or have an increased bleeding risk, either fondaparinux or unfractionated heparin are the optimal choice. Patients with severe impairment of renal function should receive unfractionated heparin.     

Tailored antithrombotic therapy for acute coronary syndromes

Acute coronary syndromes usually result from thrombotic occlusion of a coronary artery at the site of atherosclerotic plaque disruption. The mainstay of treatment is the use of antiplatelet and antithrombotic therapy to maintain patency of the artery. In patients with non-ST segment elevation acute coronary syndromes, antithrombotic therapy followed by coronary revascularization (when feasible in patients with high-risk features) is the optimal management strategy. In the patient with ST elevation acute coronary syndromes who receives a fibrinolytic agent antithrombotic agents, are also important to prevent reocclusion. Bleeding complications of antithrombotic therapy are associated with a substantial increase in adverse short- and long-term outcomes. Hence, the selection of the most appropriate antithrombotic agent aims to minimize both ischemic and hemorrhagic complications. Factors that are associated with increased bleeding risk and need to be considered when selecting an antithrombotic agent include decreased renal function, short time to invasive procedure (<24 h), and the overall bleeding risk. For patients who will undergo later cardiac catheterization and are not at high bleeding risk, either enoxaparin or fondaparinux are acceptable choices. For patients who are likely to undergo early catheterization or have an increased bleeding risk, either fondaparinux or unfractionated heparin are the optimal choice. Patients with severe impairment of renal function should receive unfractionated heparin     

Pathophysiology, prognostic significance and clinical utility of B-type natriuretic peptide in acute coronary syndromes

The natriuretic hormones are a family of vasoactive peptides that can be measured circulating in the blood. Because they serve as markers of hemodynamic stress, the major focus of the use of natriuretic peptide levels [predominantly B-type natriuretic peptide (BNP) and N-terminal (NT)-pro-BNP] has been as an aid to the clinical diagnosis and management of congestive heart failure (CHF). Recently, however, the measurement of natriuretic peptides in the acute coronary syndromes (ACS) has been shown to provide information complementary to traditional biomarkers (of necrosis) such as cardiac troponins and creatine kinase (CK). Studies in several types of acute coronary syndromes [ST-segment elevation myocardial infarction (STEMI), non-ST elevation MI (NSTEMI) and unstable angina (UA)] have shown that elevated levels of natriuretic peptides are independently associated with adverse outcomes, particularly mortality. Additional information is obtained from the use natriuretic peptides in combination with other markers of risk including biomarkers of necrosis and inflammation. This review will summarize the scientific rationale and clinical evidence supporting measurement of natriuretic peptides for risk stratification in acute coronary syndromes. Future research is needed to identify therapies of particular benefit for patients with ACS and natriuretic peptide elevation.     

A prospective cohort study of prognostic power of N-terminal probrain natriuretic peptide in patients with non-ST segment elevation acute coronary syndromes

Summary Background Braintype natriuretic peptide (BNP) or N-terminal segment of the prohormone (NT-proBNP) measured within the first few days after symptom onset offer prognostic information in patients with non- ST elevation acute coronary syndromes (ACS). Methods and Results This prospective cohort study included 493 patients with non-ST segment elevation ACS who underwent percutaneous coronary intervention in the Deutsches Herzzentrum and Klinikum rechts der Isar in Munich, Germany. NT-proBNP was measured on admission. Patients were divided into four groups according to quartiles of NT-proBNP. The primary end point of the study was mortality. Patients were followed for a median of 4.0 years [interquartile range 3.6 to 4.9 years]. During this time period, there were 65 deaths: 4 deaths in the 1st quartile, 9 deaths in the 2nd quartile, 16 deaths in the 3rd quartile and 36 deaths in the 4th quartile (Kaplan-Meier estimates of mortality: 3.4, 7.8, 16.0 and 33.9%; odds ratio [OR] 10.2, 95% confidence interval [CI] 4.5 to 23.5; P< 0.001 for 4th vs 1st quartile). Patients in the upper quartile of NT-proBNP had a more adverse cardiovascular risk profile than patients in lower quartiles of NT-proBNP. After adjustment in the Cox proportional hazards model, the NT-proBNP remained an independent correlate of mortality (adjusted hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.04 to 1.45, P = 0.014 for 4th vs 1st quartiles) but weaker than age (adjusted HR 2.11, 95% CI 1.53 to 2.90; P < 0.001 for a 10-year increase in age) or left ventricular ejection fraction (adjusted HR 1.35, 95% CI 1.09 to 1.68; P = 0.007 for a 10% decrease). Conclusion N-terminal probrain natriuretic peptide is a marker of weak-to-moderate strength in predicting the long-term prognosis in patients with non-ST segment elevation acute coronary syndromes after percutaneous coronary intervention. From the Klinik für Herz- und Kreislauferkrankungen und Institut für Laboratoriumsmedizin, Deutsches Herzzentrum München and 1. Medizinische Klinik Klinikum rechts der Isar, Technische Universit?t München, Munich, Germany     

急性冠脉综合征的抗血小板治疗

急性冠状动脉综合征(ACS)是严重威胁人类健康的一类急性心血管事件,包括不稳定性心绞痛、非S-T段抬高型和S-T段抬高型心肌梗死,以及以上各病症导致的猝死。血小板的激活在ACS的发生中起着重要作用,抗血小板治疗在ACS防治中的重要地位也越来越受到人们的广泛关注。通过对血小板致病的机制及抗血小板治疗的探讨,进一步明确抗血小板治疗的重要性。     

网织血小板和血小板参数在急性冠脉综合征中的变化及意义

目的:探讨急性冠脉综合征(ACS)患者网织血小板(RP)和血小板参数的变化及意义。方法:随机选取ST段抬高心肌梗死(STEMI)27例为STEMI组,非ST段抬高心肌梗死(NSTEMI)25例为NSTEMI组,不稳定心绞痛(UA)31例为UA组,健康体检者30例为对照组进行检测。用CD61-PE单抗标记血小板,噻唑橙(TO)为染料,应用富含血小板血浆(PRP)法检测RP;用COULTERJT型全自动血液分析仪测定血小板参数[血小板计数(PLT)和血小板平均体积(MPV)]。结果:STEMI、NSTEMI、UA组3组RP%均显著性高于对照组(P<0.05);STEMI、NSTEMI组的RP%显著高于UA组(P<0.05);STEMI、NSTEMI组的MPV均显著高于对照组(P<0.05)。结论:RP可能成为评估ASC患者血小板活性的新指标,它和MPV的检测可能对ACS有着一定的临床意义。     

Fondaparinux in the treatment of acute coronary syndromes: evidence from OASIS 5 and 6

Anticoagulant therapy is widely used for the management of acute coronary syndromes. In order to optimize patient outcomes, anticoagulants should ideally combine high antithrombotic efficacy with a low risk of bleeding. Intravenous unfractionated heparin has been in clinical use for more than 50 years and reduces the risk of recurrent ischemic events in patients with acute coronary syndromes but at the cost of increased bleeding. Enoxaparin, compared with intravenous unfractionated heparin, further reduces the risk of ischemic events but also increases bleeding. Neither of these approaches has been shown to reduce mortality. The synthetic parenteral Factor Xa inhibitor, fondaparinux, is highly effective for the prevention and treatment of venous thromboembolic disease in medical and surgical patients. The Organization for the Assessment of Strategies for Ischemic Syndromes (OASIS) 5 and 6 trials evaluated the efficacy and safety of fondaparinux in more than 32,000 patients with non-ST elevation acute coronary syndromes or ST elevation myocardial infarction. This clinical trial report discusses the findings of these two pivotal trials.