2000年AHA冠脉支架循证试验的最新总结

本文介绍了冠状动脉支架临床循证试验的结果,对其疗效进行了评价,对其辅助疗法、适应证、禁忌证和今后的研究方向做了详尽讨论。     

冠状动脉内支架植入术治疗冠心病的初步体会

冠状动脉内支架植入术治疗冠心病的初步体会泰安市中心医院（２７１０００）王凤珍吴云李金龙杜波赵庆平我院采用冠状动脉内支架植入术治疗５例冠心病患者，现将结果报告如下。资料与方法：本组男３例，女２例；年龄４０～６８（平均５２．３±３．７）岁。４例为不稳定性...     

冠心病病人经皮冠状动脉支架植入后的心电图分析

目的观察静息状态下冠心病病人心电图ST-T的水平及冠状动脉支架植入术后心电图ST—T、QT间期离散度的变化。评价心电图ST-T、QT间期离散度的变化与冠状动脉狭窄程度的关系。方法依据冠状动脉造影结果将冠心病病人心电图有无持续性ST—T改变分为ST-T正常组与ST-T异常组，观察冠状动脉植入支架术后心电图ST-T的变化及QT间期离散度的变化。结果两组在冠状动脉支架植入后心电图ST-T无变化。QT间期离散度比较有统计学意义（P〈0．05）。结论静息状态下心电图持续性ST—T改变与冠状动脉狭窄无相关性，QT间期离散度与冠状动脉是否狭窄有关。     

冠状动脉长病变支架治疗进展

自从经皮冠状动脉腔内成形术 (PTCA)与支架术联合应用于冠心病治疗以来 ,冠心病的预后有了很大的改观 ,总体上术后 3～ 6个月的再狭窄率已从 30 %～ 5 0 %降至 1 5 %～ 2 0 %。但是对于冠状动脉长病变 (病变长度 >2 0mm)而言 ,仍有较高的术后再狭窄率及操作造成的心血管事件发生率(MACE) ,因此冠状动脉长病变已成为冠心病治疗过程中最为棘手的问题之一 ,本文对冠状动脉长病变支架治疗作一综述。1　冠状动脉长病变的一般特征冠状动脉长病变有以下特征 :①多见于糖尿病和老年患者 ;②常伴有血管成角、扭曲、钙化 ,增加手术操作的难度及并…     

冠状动脉支架术治疗冠心病78例

作为切除粥样硬化斑块的替代方法,血管内支架可保持有病变的冠状动脉节段处于伸展状态,可免除管壁发生急性或慢性回缩,支撑破裂的易碎粥样硬化组织,并尽可能减少血液与管壁内膜下的致血栓形成物质接触,改善冠状动脉的血流动力学.现在冠状动脉支架术已广泛应用于临床治疗,对治疗冠状动脉突然闭塞或经皮冠状动脉再通操作后血管造影结果不满意时具有良好的治疗效果[1].     

冠状动脉支架内再狭窄的相关因素分析

目的　探讨可能引起支架内再狭窄的临床及支架相关因素。方法　选择随访的冠状动脉造影资料较全的 137例支架术后患者。依冠状动脉造影结果将其分为支架内再狭窄组和非再狭窄组 ,然后对可能引起支架内再狭窄的临床和支架相关因素在两组中进行对比分析。结果　两组年龄、吸烟、饮酒等情况相似 ,高血压病及糖尿病的发生率差异无显著性。再狭窄组术前靶血管狭窄程度较非再狭窄组重 ,分别为 91%± 7%和 88%± 14% (P =0 0 33)。再狭窄组所选支架的平均直径较非再狭窄组的小 ,分别为 (3 19± 3 90 )mm和 (3 6 3± 0 30 )mm(P =0 0 0 5 ) ;支架长度却较非再狭窄组的长 ,分别为 (2 1 91± 8 98)mm和 (18 2 0± 6 0 7)mm(P =0 0 11)。再狭窄组的支架扩张总时间明显短于非再狭窄组 ,分别为 (2 2 74± 19 5 6 )s和 (2 9 12± 2 5 72 )s(P =0 0 2 6 )。两组的支架扩张次数和扩张压力差异无显著性。结论　本文资料提示年龄、吸烟、饮酒、高血压病、糖尿病、支架扩张次数及压力的大小等因素对支架内再狭窄无明显影响 ,但术前靶血管狭窄程度和支架长度与支架内再狭窄呈正相关 ,而支架直径和支架扩张总时间则呈负相关。     

PCI术后住院期间支架内急性亚急性血栓形成12例

<正>经皮冠状动脉介入术(PCI)是针对心脏冠状动脉狭窄的患者采取的一种治疗方式,现已成为有效治疗冠心病的重要手段之一〔1,2〕。支架内急性亚急性血栓是冠状动脉介入术后少见的并发症,严重危及患者的生命〔3〕。药物支架时代,术前、术后常规应用抗血小板聚集和抗凝药物治疗,仍未能完全杜绝支架内血栓(ST)的发生。ST的发生与多种因素相关,其危险因素包括抗血小板治疗、支架因素、介入操作因素、患者及病变因素等〔4〕。本文拟探讨ST的发生原因及防治策略。     

冠状动脉支架再狭窄预测因素的探讨

目的　为探讨冠状动脉支架再狭窄的预测因素。方法　收集我院行冠状动脉支架术并随访冠脉造影的病例 6 2例 ,按冠脉造影结果分为支架再狭窄组 33例 ,无再狭窄组 2 9例 ,并分别比较两组病人的临床特点、血管病变特征及术后即刻血管并发症。结果　再狭窄组病人合并有糖尿病史比例较无狭窄组明显增多 (30 3%∶6 9% ,P <0 0 5 ) ;再狭窄组前降支及开口病变比例均明显高于无狭窄组 (81 8%∶5 9 4% ,P <0 0 5 ;2 1 7%∶6 3% ,P <0 0 5 )。再狭窄组的长支架 (≥ 30mm)、单支血管多支架及小支架比例均明显高于无再狭窄组 (2 2 7%∶5 0 % ,P <0 0 1;40 5 %∶15 6 % ,P <0 0 5 ;2 7 2 %∶2 5 % ,P <0 0 5 ) ;再狭窄组病人的支架边端残余狭窄≥ 2 0 %的比例明显高于无再狭窄组(2 4 3%∶3 1% ,P <0 0 5 )。结论　冠状动脉支架术病人合并糖尿病史、前降支、开口病变、长支架、单支血管多支架、小支架及术后即刻支架残余狭窄可能是术后再狭窄的预测因素     

选择性直接冠状动脉支架置入术的临床应用

近年来 ,随着球囊预装支架通过狭窄病变性能的改进及支架置入技术的成熟 ,对冠状动脉病变有选择性的直接支架置入术已开始在临床应用〔1 ,2〕。本文旨在探讨直接冠状动脉支架置入术的可行性及其效果。1　对象与方法　　自 1 997年 5月～ 2 0 0 1年 3月对 1 7例冠心病患者采取了直接冠状动脉支架置入术 ,男 1 2例 ,女5例 ,年龄 42～ 62 ( 5 6.3± 5 .2 )岁 ,其中稳定型心绞痛 4例 ,不稳定型心绞痛 8例 ,近期急性心肌梗死 3例 ,陈旧性心肌梗死 2例 ;伴糖尿病者 2例 ,伴高血压者 5例。经冠状动脉造影确定病变血管为A型或B1 型者首选直接冠状动…     

冠状动脉内支架术对冠状动脉血流储备的远期影响

目的　采用经胸多普勒超声心动图冠状动脉 (冠脉 )血流显像技术观察冠脉支架置入术对冠脉血流储备 (CFR)的远期影响。方法　对 34例冠心病患者分别于支架术术前、术后 72h内及随访期 [( 6 .7± 1.5 )个月 ]记录病变血管远端静息舒张期血流峰速 (r Vd)、注射潘生丁及等长握力实验时最大舒张期血流峰速 (d Vd)及CFR。每例患者于随访期复查冠脉造影。结果　随访期造影无再狭窄 2 8例。据术后 72h内CFR分为CFR受损组 ( 10例 ,CFR≤ 2 .5 )及CFR未受损组( 18例 ,CFR >2 .5 )。术后近期CFR受损组r Vd较CFR未受损组明显增高 (P <0 .0 1) ;随访期时CFR受损组CFR升高至CFR未受损组水平 (P >0 .0 5 )。随访期出现再狭窄 6例 ,CFR均 <2 .0 ,降至术前水平。结论　 ( 1)成功的支架术后部分患者存在暂时性CFR降低 ,CFR的降低及其恢复与r Vd的一过性增高及恢复有关 ;( 2 )再狭窄患者冠脉血流储备于随访期显著降低 ,达到术前水平。经胸冠脉血流显像技术可作为冠脉介入治疗后一种简便、安全、无创的随访方法。     

Carotid Artery Disease and Stenting: Insights From Recent Clinical Trials

Cerebrovascular disease remains a leading cause of morbidity, mortality, and health care expenditure in the United States. Approximately 80% of strokes are ischemic in origin, with 20% to 25% due to atherosclerotic disease of the carotid artery. It is well established that untreated, symptomatic carotid stenosis confers a 25% risk of stroke within 2 years, and that asymptomatic carotid stenosis > 60% is associated with an 11% stroke risk at 5 years. Over the past six decades, surgical revascularization with carotid endarterectomy, when performed by experienced surgeons, has been demonstrated to be effective in reducing stroke risk in patients with severe stenosis. During the same time, medical therapy has improved considerably, and endovascular therapy with carotid angioplasty and stenting has emerged as an important alternative strategy that may play a significant role in reducing the risk of stroke in patients with carotid disease. In this review, we examine the current evidence regarding optimal medical therapy, endarterectomy, and stenting for the management of patients with carotid stenosis. Armed with these data, we may tailor our approach to optimize care based on patient- and lesion-specific considerations.     

Clinical Trials Update AHA Congress 2010

The clinical trials described in this article were presented at the Late Breaking Trials and the Clinical Science: Clinical Reports sessions of the American Heart Association Congress held in November 2010 in Chicago. The sessions and topics chosen for this article reflect the scope of interest of Cardiovascular Drugs and Therapy. The presentations should be considered preliminary, as further analyses may be done, which could alter the final publication of the results of these studies. PROTECT (ProBNP Outpatient Tailored Chronic Heart Failure Therapy) was designed to test the hypothesis that adjustment of intensity of chronic heart failure (HF) therapy on the basis of NT-proBNP plasma level monitoring would improve outcomes. The results provided some support of this concept, but needs further evaluation in larger, blinded trials. REVEAL (Reduction of Infarct Expansion and Ventricular Remodeling with erythropoietin after large myocardial infarctions) evaluated in the clinical setting of ischemia-reperfusion following STEMI that erythropoietin could salvage ischemic myocardium. The results did not show a reduction in infarct size, but, in contrast, an increase in adverse event rates in the erythropoietin group. GRAVITAS (Gauging Responsiveness with a VerifyNow assay-Impact on Thrombosis and Safety trial) investigated the effect of a standard vs. high maintenance clopidogrel dose in patients with stable myocardial ischemia or NSTEMI and drug–eluting stent insertion. Patients with high PRU values as determined by VerfyNow assay were randomized to 75 mg or 150 mg clopidogrel daily. The study did not show a significant difference in primary event rate between both groups. The Cholesterol Treatment Trialists’ Collaboration Studies group evaluated the concept proposed in the JUPITER study that HDL levels on statin treatment may not provide useful prognostic information. The CTTC in a large sample size of statin-treated patients observed, on the contrary, a significantly increased risk of CV events, even in patients with low LDL cholesterol levels. DEFINE (Determining the Efficacy and Tolerability of CETP inhibition with Anacetrapib) evaluated possible safety aspects with the CETP inhibitor anacetrapib (increase in blood pressure). The study did not show adverse safety aspects, but significantly reduced LDL cholesterol and increased HDL cholesterol levels. ASSERT, a phase 2 dose–ranging study, investigated whether RVX-208 would increase Apo-A1 production. Apo-A1 may induce cholesterol efflux from macrophages and facilitate atherosclerosis regression. The study did not meet its primary endpoint, but significant prominent effects on lipids were found. ASCEND-HF was a large trial of nesiritide in >7000 patients with acute heart failure. The study did not show convincing symptom benefit, but on the other hand did not show harmful effects of nesiritide. EMPHASIS-HF evaluated the long term effects of eplerenone in patients with mild (NYHA class II) heart failure and systolic dysfunction. The study was prematurely ended because of highly significant beneficial effects. CUPID (Calcium Up-regulation by Percutaneous administration of gene therapy In cardiac Disease) is the first human study with gene transfer of SERCA2a (AVV1/SERCA2a: Mydicar). In a small placebo-controlled dose-ranging study in advanced heart failure patients a multiple endpoint analysis provided positive effects of the highest dose on symptomatic, functional and structural efficacy endpoints without adverse effects.     

Impact of Coronary Artery Tortuosity on Outcomes Following Stenting: A Pooled Analysis From 6 Trials

ObjectivesThe authors sought to determine whether coronary artery tortuosity negatively affects clinical outcomes after stent implantation.BackgroundCoronary artery tortuosity is a common angiographic finding and has been associated with increased rates of early and late major adverse events after balloon angioplasty.MethodsIndividual patient data from 6 prospective, randomized stent trials were pooled. Outcomes at 30 days and 5 years following percutaneous coronary intervention of a single coronary lesion were analyzed according to the presence or absence of moderate/severe vessel tortuosity, as determined by an angiographic core laboratory. The primary endpoint was target vessel failure (TVF) (composite of cardiac death, target vessel–related myocardial infarction [TV-MI], or ischemia-driven target vessel revascularization [ID-TVR]).ResultsA total of 6,951 patients were included, 729 of whom (10.5%) underwent percutaneous coronary intervention in vessels with moderate/severe tortuosity. At 30 days, TVF was more frequent in patients with versus without moderate/severe tortuosity (3.8% vs. 2.4%; hazard ratio [HR]: 1.64; 95% confidence interval [CI]: 1.09 to 2.46; p = 0.02), a difference driven by a higher rate of TV-MI. At 5 years, TVF remained increased in patients with moderate/severe tortuosity (p = 0.003), driven by higher rates of TV-MI (p = 0.003) and ID-TVR (p = 0.01). Definite stent thrombosis was also greater in patients with versus without moderate/severe tortuosity (1.9% vs. 1.0%; HR: 1.86; 95% CI: 1.02 to 3.39; p = 0.04). After adjustment for baseline covariates, moderate/severe vessel tortuosity was independently associated with TV-MI and ID-TVR at 5 years (p = 0.04 for both).ConclusionsStent implantation in vessels with moderate/severe coronary artery tortuosity is associated with increased rates of TVF due to greater rates of TV-MI and ID-TVR.     

Diabetes Mellitus and Acute Coronary Syndrome: Lessons From Randomized Clinical Trials

Diabetes mellitus is a major independent risk factor for acute coronary syndrome (ACS). In addition, diabetic patients with ACS suffer from increased mortality compared to their nondiabetic peers. Driven by multiple pathophysiological disturbances, such patients are predisposed to a proinflammatory, prothrombotic state, which may lead to plaque rupture. To counteract this more complex biology, several therapies and strategies have emerged, with some having unique preferential benefits in this population. Antiplatelet agents such as aspirin and clopidogrel have long been standard of care. Dose adjustment of these therapies remains the subject of continued research. Along with medical therapy, ACS diabetic patients preferentially benefit from primary percutaneous intervention compared to fibrinolysis. However, with advances in reperfusion techniques, the optimal strategy has yet to be determined. With these differences in ACS treatment responses, diabetic individuals may not just be a high-risk group, but may actually constitute a fundamentally different population, requiring dedicated clinical trials and individualized treatment regimens.     

Multivariate Analysis of Clinical Factors in Restenosis after Coronary Stenting

Ojbective To find the independent predictors for restenosis after coronary stenting. Methods Quantitative angiography was performed on 60 cases (67 successfully dilated lesions) after angio-plasty over 6-months follow-up, and both univariate and multivariate logistic regression analysis were done to i-dentify the correlations of restenosis with clinical factors. Results The total restenosis rate was 31. 3% (21 of 67 lesions), and according to univariate analysis the patients who underwent coronary stenting≥ 3. 5mm had a lower rate of restenosis ( P < 0. 01). Collateral circulation to the obstruction site, high maximal inflation pressure, smoking and the less minimal lumen diameter after PTCA made the rate of restenosis higherower ( P < 0. 05) . Multivariate logistic regression analysis showed that coronary stenting ≥3. 5mm had a low rate of restenosis, but high maximal inflation pressure and smoking made the restenosis rate higher. Conclusion Coronary stent size, maximal inflation pressure and. smokin