体外心脏震波治疗难治性心绞痛新进展

传统的冠心病治疗方法为药物治疗联合冠状动脉介入治疗和(或)冠状动脉旁路移植术。但仍有部分患者经过严格上述治疗后心绞痛仍发作频繁或逐渐加重,严重影响了患者的生活质量或预后。因此,为这些患者寻找一种新的治疗方法至关重要。体外心脏震波治疗是近年来开展的一项新的治疗方法,已被用于缺血性心脏疾病的治疗。本文就体外心脏震波在难治性心绞痛治疗中的应用进行综述。     

体外心脏震波治疗老年冠心病患者的疗效和安全性分析

目的 探讨体外心脏震波系统(CSWT)治疗老年冠心病患者的有效性和安全性. 方法 11例顽固性心绞痛的老年冠心病患者.根据心肌核素显像和冠状动脉造影结果确定缺血心肌靶目标,行CSWT治疗.疗程为3个月,共治疗9次.疗效评价分别采用临床症状描述、加拿大心血管学会心绞痛(CCS)分级、6 min步行试验、纽约心功能心脏病学会心功能(NYHA)分级、西雅图心绞痛量表(SAQ)、硝酸甘油使用量、左心室舒张末期直径(LVEDD)和左心室射血分数(LVEF)等;心肌核素显像评价治疗前后心肌缺血改善情况;观察患者治疗过程中症状、心电监测、血压和氧饱和度变化、治疗后肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)、肌钙蛋白T、丙氨酸氨基转移酶(ALT)、肌酐、脑钠肽和超敏C反应蛋白(HsCRP)的变化评价其安全性. 结果 CCS分级、NYHA分级、6 min步行试验和硝酸甘油用量在治疗第4个月和1年与治疗前相比均有改善(P＜0.05).心绞痛稳定状态和疾病认识程度有明显改善,较治疗前差异均有统计学意义(P＜0.05).共治疗21个节段,治疗后静息状态心肌缺血的改善率为46.2％(6/13),其中有效率为38.5％ (5/13),明显有效率为7.8％(1/13);负荷状态心肌缺血的改善率为57.1％(12/21),其中有效率为47.6％(10/21),明显有效率为9.5％(2/21).与治疗前比较,CK、CK-MB、肌钙蛋白、ALT、肌酐、脑钠肽和HsCRP均无明显改变,心率、收缩压、舒张压和氧饱和度亦无明显变化. 结论 CSWT是一种安全、有效治疗老年冠心病患者的方法,并能保持疗效至少1年.     

体外心脏震波治疗冠心病中国专家共识(2022版)

冠心病是当今严重威胁人类健康的心血管疾病之一。《中国心血管健康与疾病报告2020》[1]的数据显示,中国心血管病患病率仍处于持续上升阶段,推算心血管疾病现患人数达3.3亿,其中冠心病1139万,成为威胁我国人民健康的主要疾病。随着治疗药物及再血管化技术的进展,冠心病患者的生存期明显延长,同时有更多患者步入疾病晚期。     

体外心脏震波治疗冠心病

冠心病,又称缺血性心脏病,是由于冠状动脉粥样硬化造成血管狭窄或阻塞,发生冠脉循环障碍,造成心肌缺血、缺氧或坏死的一种心脏病。冠心病的发病有9个独立危险因素：年龄、吸烟史、心绞痛病史、急性心梗家族史、高血压、低密度脂蛋白升高、高密度脂蛋白降低、高甘油三酯血症和糖尿病。随着我国经济发展和人民生活方式的改变,人口老龄化,人群血压、     

体外心脏震波治疗的心脏安全性研究

目的研究体外心脏震波治疗对正常大鼠心脏的安全性。方法 12只大鼠随机分为对照组(NC,6只)和震波治疗组(NC+SW,6只)。震波治疗后24 h收集标本。分别采用苏木素-伊红(HE)染色评估大鼠心肌组织病理形态学改变;TUNEL法检测心肌细胞凋亡率;Western blot法检测凋亡相关蛋白的表达。结果 HE染色显示震波治疗后心肌细胞无变性、坏死,心肌间质无炎症细胞浸润。治疗组与对照组心肌细胞凋亡率无明显变化(5.38%±0.81%比5.83%±0.44%,P=0.64)。治疗组与对照组Bcl-2、Bax蛋白表达无明显变化(Bcl-2:1.02±0.03比0.92±0.04,P=0.09;Bax:0.55±0.01比0.51±0.02,P=0.05);Caspase-3蛋白的剪切活化水平无升高(0.220±0.005比0.230±0.003,P=0.39);线粒体细胞色素C含量无降低(1.49±0.08比1.36±0.07,P=0.25);JNK、p38MAPK及Akt信号通路蛋白磷酸化水平无明显变化。治疗组与对照组血压无明显变化[收缩压:(120.6±2.0)mm Hg比(121.4±1.4)mm Hg,P=0.75;舒张压:(91.2±1.0)mm Hg比(89.4±1.5)mm Hg,P=0.35];心率无明显变化[(343.2±5.8)次/min比(334.3±6.6)次/min,P=0.34]。结论体外心脏震波治疗对正常大鼠是一项安全的方法。     

体外震波碎石引起的心脏起搏

心脏内外的心脏起搏在临床上得到了广泛的应用,但迄今尚未见到体外碎石震波引起心脏起搏的报道。现将笔者1989年1月从事体外震波碎石工作以来所见资料完整的50例总结如下。临床资料本组50例,男性35例,女性15例。胆道结石10例,肾结石20例,上输尿管结石16例(其中4例为肾结石经震波后下移所致),下输尿管结石8例(其中4例也为肾结石落到输尿管的结石),膀胱结石4例。     

体外心脏震波治疗冠心病的应用研究

目的 探讨体外心脏震波治疗冠心病的安全性、有效性和基本方法学要点.方法 纳入35例冠心病陈旧性心肌梗死及不稳定性心绞痛患者,其中25例应用瑞士Storz Medical公司生产的震波治疗仪,进行体外心脏震波治疗,10例作为阳性对照.治疗前经小剂量多巴酚丁胺负荷超声心动图和99Tcm-甲氧基异丁基异腈心肌灌注显像(MPI)识别存活心肌,定位缺血节段.治疗组分为2个亚组,A组(16例,29个节段)采用3个月完成9次治疗,第4个月随访;B组(9例,13个节段)采用1个月完成9次治疗,第2个月随访.治疗时经机载实时超声探头锁定缺血靶区,每个靶区实施-1～0～+1两两组合的9点治疗,每点发放200次脉冲,每次脉冲能量为0.09 mJ/mm2.整个过程行实时心电、血压、血氧饱和度监测.随访采用纽约心功能分级(NYHA)、加拿大心血管学会(CCS)心绞痛分级、西雅图心绞痛量表(SAQ)、6 min步行距离(6MWT)和硝酸甘油用量行临床评估,采用收缩期峰值应变率(PSSR)和MPI评价局部心肌收缩功能和血流灌注.结果 25例患者共42个缺血节段接受了9次震波治疗,血液动力学稳定,未出现心肌损伤、出血、栓塞等并发症;与治疗前比较,治疗后的NYHA、CCS心绞痛分级和硝酸甘油用量较少(P＜0.01),SAQ评分、6MWT较高(P＜0.05).治疗组治疗区域的静息态MPI评分和负荷态PSSR明显增高(P＜0.01).A组负荷态MPI评分治疗后高于治疗前(1.21±0.86比0.83±0.80,P＜0.01),缺血改善程度优于B组.对照组以上指标改变甚微.结论 初步研究表明,体外心脏震波治疗是一项无创、安全、有效的新型血管再生疗法,可以缓解患者心绞痛,提高运动耐量.     

体外心脏震波治疗冠心病新进展

体外心脏震波治疗(ESWT)用于缺血性心脏疾病治疗已经有10年历史,早期研究即观察到ESWT可以增加缺血心肌部位血管新生,促进各类生长因子上调,改善心肌功能。新近的一系列研究发现,ESWT不仅可通过促进血管新生而起治疗作用,在治疗缺血性心脏疾病时,亦可促进心肌干细胞潜能激活,抑制炎症、氧化应激、减少纤维化及细胞凋亡。大量研究证据还表明,ESWT可有效改善心脏功能及临床症状。ESWT治疗在基础研究和临床研究中,并没有发现会导致心肌损伤及其他严重并发症,可认为该项治疗是安全可靠的。     

体外心脏震波对大鼠心肌梗死后心肌凋亡的影响

目的研究体外心脏震波治疗(CSWT)对大鼠心肌梗死后(MI)心肌细胞凋亡及凋亡蛋白的影响。方法结扎大鼠左冠状动脉前降支建立大鼠急性心肌梗死模型,随机分为假手术(Sham)组(n=10)、MI组(n=10)及CSWT组(n=10)。CSWT治疗4 w后,取各组心肌样本进行TUNEL检测观察心肌细胞凋亡,Masson染色观察心肌纤维化,Western印迹检测Bax、Bcl-2和Caspase-3蛋白表达。结果与Sham组相比,MI和CSWT组心肌细胞凋亡指数及纤维化程度均增高,Bax和Caspase-3表达显著上调,Bcl-2表达明显下调(P0.05);而CSWT组较MI组,心肌细胞凋亡指数及纤维化程度均降低,Bax和Caspase-3表达下调,Bcl-2则表达上调(P0.05)。结论大鼠心肌梗死后心肌凋亡明显增加,体外心脏震波可抑制大鼠心肌梗死后细胞凋亡,减轻左心室纤维化。     

体外心脏震波治疗难治性冠心病的安全性研究

目的探讨体外心脏震波治疗难治性冠心病的安全性。方法应用瑞士STORZ MEDICAL公司生产的震波治疗仪(MODULITH SLC),对35例冠心病患者进行体外心脏震波治疗。治疗前经小剂量多巴酚丁胺负荷超声心动图(LDDSE)和~(99)m锝-甲氧基异丁基异腈(~(99)mTc-MIBI)心肌灌注显像(MPI)定位缺血节段,识别存活心肌。治疗时经机载实时超声探头锁定缺血靶心肌,联合心电监测,以"R"波触发,部分"R"波触发不良的患者使用"1"触发(每秒发放1次脉冲),每个靶区实施-1～0～+1两两组合9点治疗,每点发放200次脉冲,能量0.09mJ/mm~2。每个疗程9次治疗。结果所有患者每个疗程9次治疗,每次治疗和其他次治疗期间心率、血压和氧饱和度差异均无统计学意义(均为P>0.05),心律无改变,末见新发心律失常,无明显皮肤损伤,肝酶正常,无血栓栓塞、呼吸困难等不良反应。对部分心电图"R"波触发不良的患者使用"1"触发,同样未发现致心律失常现象。结论体外心脏震波治疗是一项无创、安全的疗法,无致心律失常或心肌损伤作用,对心率、心律、血压、氧饱和度、心肌酶、肝酶无影响,治疗无痛苦,患者耐受性好,是治疗难治性冠心病心肌缺血的一项新选择。     

Efficacy of nifedipine therapy for refractory angina pectoris

Nifedipine is a calcium-channel blocking agent that has been effective for patients with angina pectoris when used as single-agent therapy and as part of a combination regimen with conventional antianginal therapy. However, the efficacy of nifedipine in patients with angina refractory to maximum tolerated conventional therapy has not been extensively studied. We present experience using nifedipine in the treatment of three distinct subsets of patients with refractory angina pectoris. One hundred twenty-seven patients with Prinzmetal's variant angina and documented coronary vasospasm were treated with nifedipine after experiencing an inadequate response to conventional therapy. Nifedipine, 40 to 160 mg daily, reduced the mean weekly rate of angina attacks from 16 to 2 (p < 0.001). In 63% of the patients complete control of angina attacks was achieved, and in 87% the frequency of angina was reduced by at least 50%. Nifedipine therapy was well tolerated, and the beneficial response persisted for the 9 months of follow-up. Nifedipine therapy was added to a second group of 11 consecutive patients with refractory episodes of recurrent rest ischemia following acute myocardial infarction. Prior to infarction all the patients had a history of exertional angina only; yet following the infarction, episodes of recurrent ischemia occurred at rest in spite of maximal medical management with beta blockers and/or nitrate preparations. With maximum tolerated conventional therapy the heart rate was lowered to a mean of 65 beats/min and the blood pressure to a mean of $\text{109}\text{70}\text{mm Hg}$. The episodes of rest ischemia were prevented in all but one patient by the addition of nifedipine (mean daily dose 60 mg, range 40 to 120 mg) without causing a change in heart rate or blood pressure. Two patients continued to have myocardial ischemia with minimal exertion, although resting pains were abolished, and they underwent coronary bypass surgery for rellef of exertional pain. Only one patient continued to have episodes of ischemia at rest, and bypass surgery was necessary for pain relief. The other eight patients have been managed medically for a mean of 5.4 months and have remained pain free on combined regimens of nifedipine, beta blockers, and/or nitrate preparations. The third group of patients treated with nifedipine is composed of 239 patients with severe classic exertional angina pectoris without a suspicion of superimposed coronary vasospasm. The anginal episodes in these patients were refractory to maximum tolerated conventional therapy; however, the addition of nifedipine (mean daily dose 60 mg, range 40 to 120 mg) reduced the mean weekly angina attack rate from 20.8 to 6.4 (p < 0.00001). Although only 11% of patients had complete prevention of angina during nifedipine therapy, a total of 70% experienced a reduction in angina frequency of at least 50%. We conclude that the addition of nifedipine therapy may provide further benefit for patients with angina pectoris refractory to maximum tolerated conventional therapy. Randomized, placebo-controlled studies are necessary to confirm the efficacy of nifedipine therapy in patients with refractory angina and to clarify the mechanism of the beneficial response.     

External counterpulsation therapy improves endothelial function in patients with refractory angina pectoris

OBJECTIVES: The goal of this study was to investigate the influence of short-term external counterpulsation (ECP) therapy on flow-mediated dilation (FMD) in patients with coronary artery disease (CAD). BACKGROUND: In patients with CAD, the vascular endothelium is usually impaired and modification or reversal of endothelial dysfunction may significantly enhance treatment. Although ECP therapy reduces angina and improves exercise tolerance in patients with CAD, its short-term effects on FMD in patients with refractory angina pectoris have not yet been described. METHODS: We prospectively assessed endothelial function in 20 consecutive CAD patients (15 males), mean age 68 +/- 11 years, with refractory angina pectoris (Canadian Cardiovascular Society [CCS] angina class III to IV), unsuitable for coronary revascularization, before and after ECP, and compared them with 20 age- and gender-matched controls. Endothelium-dependent brachial artery FMD and endothelium-independent nitroglycerin (NTG)-mediated vasodilation were assessed before and after ECP therapy, using high-resolution ultrasound. RESULTS: External counterpulsation therapy resulted in significant improvement in post-intervention FMD (8.2 +/- 2.1%, p = 0.01), compared with controls (3.1 +/- 2.2%, p = 0.78). There was no significant effect of treatment on NTG-induced vasodilation between ECP and controls (10.7 +/- 2.8% vs. 10.2 +/- 2.4%, p = 0.85). External counterpulsation significantly improved anginal symptoms assessed by reduction in mean sublingual daily nitrate consumption, compared with controls (4.2 +/- 2.7 nitrate tablets vs. 0.4 +/- 0.5 nitrate tablets, p <0.001 and 4.5 +/- 2.3 nitrate tablets vs. 4.4 +/- 2.6 nitrate tablets, p = 0.87, respectively) and in mean CCS angina class compared with controls (3.5 +/- 0.5 vs. 1.9 +/- 0.3, p <0.0001 and 3.3 +/- 0.6 vs. 3.5 +/- 0.5, p = 0.89, respectively). CONCLUSIONS: External counterpulsation significantly improved vascular endothelial function in CAD patients with refractory angina pectoris, thereby suggesting that improved anginal symptoms may be the result of such a mechanism.     

最大限度内科治疗对难治性不稳定心绞痛的作用

目的探讨最大限度内科治疗对难治性不稳定心绞痛的作用。方法回顾性分析了我院老年及老年前期不稳定心绞痛患者８８例，将这些患者分成药物难治组和药物治疗稳定组。结果经用４～５种药物最大限度内科治疗，８１例胸痛缓解，７例（８．０％）最后被证实为难治性不稳定心绞痛。难治性不稳定心绞痛组胸痛时多伴有前壁心电图变化，ＳＴ段压低６例，需用肝素６例、β阻滞剂６例，均显著多于药物治疗稳定组，院内发生急性心肌梗死２例。院内死亡１例以及进行经皮冠状动脉腔内成形术（ＰＴＣＡ）治疗者３例，也均显著高于药物治疗稳定组。结论应用最大限度内科治疗有利于降低难治性不稳定心绞痛的发生率。     

Cardiac shock wave therapy reduces angina and improves myocardial function in patients with refractory coronary artery disease

Background:

Safe and effective therapeutic management of refractory coronary artery disease (CAD) in heart patients is critical to enhance cardiovascular function and improve quality of life. Current therapies for refractory CAD are inadequate in ameliorating angina and promoting revascularization of ischemic myocardium.

Hypothesis:

Cardiac shock wave therapy (CSWT) is a safe and effective noninvasive intervention in the management of patients with refractory CAD.

Methods:

The study enrolled 9 male patients age 50 to 70 years (5.11 ± 5.46 years) with a diagnosis of CAD and stent implantation (3.00 ± 2.24 stents). CSWT was carried out for 3 months at 3 intervals during the first week of each month (first, third, and fifth day), for a total of 9 therapies per patient. Dobutamine stress echocardiography and radionuclide angiography identified the myocardial ischemic segments. The effects of CSWT on myocardial perfusion and systolic function were examined. Other outcome measures included myocardial injury enzyme markers, angina scale, nitroglycerin dosage, and cardiopulmonary fitness assessments.

Results:

Improved myocardial blood flow and regional systolic function (stress peak systolic strain rate ? 1.10 to ? 1.60 s^?1, P = 0.002) were detected in patients following CSWT. Reductions in creatine kinase (87.89 ± 36.69 to 86.22 ± 35.96 IU/L, P = 0.046), creatine kinase MB (10.89 ± 5.73 to 10.11 ± 5.93 IU/L, P = 0.008), aspartate transaminase (interquartile range [IQR], 28.00 to 27.00 IU/L, P = 0.034) were also found. Angina (Canadian Cardiovascular Society scale IQR 3.0 to 2.0, P = 0.035) and nitroglycerin dose reduction (IQR 3.0 to 1.0 times/wk, P = 0.038) were reported.

Conclusions:

This study is a preliminary assessment of CSWT in patients with refractory CAD. We report that CSWT is a noninvasive, effective, and safe intervention in the treatment of refractory CAD. Copyright © 2010 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.

     

顽固性心绞痛的治疗

心绞痛是指冠状动脉供血不足 ,心肌因暂时性缺血缺氧而引起的短暂发作性胸骨上中段之后压榨性或窒息性疼痛 ,也可以波及大部分心前区 ,可向左肩、左上肢放射 ,部分病例向颈部、下颌放射。偶伴有濒死的恐惧感 ,发作时患者常不敢活动 ,可伴出汗 ,重者可脸色苍白。典型者一般历时 1～ 5分钟 ,不超过 15分钟 ,经休息或舌下含服硝酸甘油后缓解。发作时多无阳性体征 ,偶有血压升高或降低、心律失常等。据统计 ,90 %以上心绞痛患者至少有 1支冠状动脉主支管腔显著狭窄 (达横切面的 75%以上 ) ,有 5%～ 10 %病人无明显狭窄 ,可能与冠状痉挛、冠脉小…     

Treatment of refractory angina pectoris

Refractory angina pectoris is defined as Canadian Cardiovascular Society class III or IV angina, where there is marked limitation of ordinary physical activity or inability to perform ordinary physical activity without discomfort, with an objective evidence of myocardial ischemia and persistence of symptoms despite optimal medical therapy, life style modification treatments, and revascularization therapies. The patients with refractory angina pectoris may have diffuse coronary artery disease, multiple distal coronary stenoses, and or small coronary arteries. In addition, a substantial portion of these patients cannot achieve complete revascularization and continue to experience residual anginal symptoms that may impair quality of their life and increase morbidity. This represents an end-stage coronary artery disease characterized by a severe myocardial insufficiency usually with impaired left ventricular function. As the life expectancy is increasing, patients with angina pectoris refractory to conventional antianginal therapeutics are a challenging problem. We review the nonconventional therapies to treat the refractory angina pectoris, including pharmacotherapy, therapeutic angiogenesis, transcutaneus electrical nerve and spinal cord stimulation, enhanced external counterpulsation, surgical transmyocardial laser revascularization, percutaneous transmyocardial laser revascularization, percutaneous in situ coronary venous arterializations, and percutaneous in situ coronary artery bypass. These therapies are not supported by a large body of data and have only a complementary role; therefore, the aggressive traditional and proven treatment of angina pectoris should be continued along with these therapies, used on an individual basis.     

Predictors of treatment benefits after enhanced external counterpulsation in patients with refractory angina pectoris

BackgroundEnhanced external counterpulsation (EECP) is a noninvasive treatment that can decrease limiting symptoms in patients with refractory angina pectoris (RAP). Identifying responders to EECP is important as EECP is not widely available and relatively time intensive.HypothesisThe effect of EECP treatment on physical capacity in patients with RAP can be predicted from baseline patient characteristics and clinical factors.MethodsThis explorative study includes all patients from a cardiology clinic who had finished one EECP treatment and a 6 min walk test pre and post EECP. Clinical data, including Canadian Cardiovascular Society (CCS) classification and left ventricular ejection fraction (LVEF), were assessed before treatment. If patients increased their 6 min walking distance (6MWD) by 10% post EECP, they were considered responders.ResultsOf the 119 patients (men = 97, 40–91 years), 49 (41.2%) were responders. Multinomial regression analysis showed that functional status (i.e., CCS class ≥3) (OR 3.10, 95% CI 1.12–8.57), LVEF <50% (OR 2.82, 95% CI 1.02–7.80), and prior performed revascularization (i.e., ≤ 1 type of intervention) (OR 2.77, 95% CI 1.06–7.20) were predictors of response to EECP (p < .05, Accuracy 63.6%). Traditional risk factors (e.g., gender, smoking, and comorbidities) did not predict response.ConclusionsEECP treatment should be considered preferentially for patients that have a greater functional impairment, evidence of systolic left ventricular dysfunction, and exposure to fewer types of revascularization, either PCI or CABG. Improvement in 6MWD post EECP could imply improvement in physical capacity, which is a likely contributor to improved well‐being among patients with RAP.