替格瑞洛和氯吡咯雷抗血小板治疗急性冠脉综合征的临床疗效比较研究

目的探讨替格瑞洛和氯吡咯雷抗血小板治疗急性冠脉综合征的临床疗效,为急性冠脉综合征的临床治疗实践提供依据。方法选取我院心血管内科2015年12月～2017年2月期间临床收治的急性冠脉综合征患者288例为研究对象,采用随机数字表法将患者分成研究组和对照组,各144例。全部患者入院后均给予阿司匹林等常规基础治疗。同时,研究组患者给予替格瑞洛,首次剂量为180mg,以后剂量调整为90mg,2次/d;对照组患者给予氯吡格雷,首次剂量为300mg,以后剂量调整为75mg,1次/d。对两组患者的血小板聚集情况、心血管事件发生情况和不良反应发生情况进行观察和比较。结果 (1)研究组患者的血小板聚集率为(30.23±6.44)%,显著低于对照组的(40.77±7.32)%,组间比较差异有统计学意义(P<0.05);(2)研究组心血管事件发生率为7.64%,显著低于对照组的27.78%,组间比较差异有统计学意义(P<0.05);(3)研究组不良反应发生率与对照组水平基本相当,组间比较差异无统计学意义(P>0.05)。结论在临床治疗急性冠脉综合征的实践中,与氯吡咯雷相比,采用替格瑞洛抗血小板治疗的临床综合效果更好,安全性更高是临床治疗急性冠脉综合征的理想方案之一。     

Clopidogrel in acute coronary syndromes (unstable angina and non-Q-wave myocardial infarction)

Given the importance of thrombosis in acute coronary syndromes, antithrombotic therapy has become standard treatment for these conditions. This article reviews the mechanism of action and the major evidence supporting the clinical use of clopidogrel, a potent antiplatelet agent of the thienopyridines class, focusing on its role in the setting of acute coronary syndromes without persistent ST segment elevation (unstable angina and non-Q wave myocardial infarction). Some unanswered questions relating to this medication are also highlighted. Finally, current updates on clinical guidelines for the use of clopidogrel in acute coronary syndromes are discussed.     

Pharmacogenomics in acute coronary syndrome

Inheritance of cardiovascular diseases has been the subject of a large number of retrospective candidate gene studies and is now a topic of genome-wide, single-nucleotide-polymorphism investigations using chip-array techniques. The question as to whether or not genetic variants could also influence drug response is much less well investigated, although many factors involved in the etiology of coronary artery disease or acute coronary syndromes may also contribute to the clinical response to drug treatment. Moreover, inter-individual differences in the pharmacokinetics and pharmacodynamics were partly shown to affect the clinical outcome of long-term coronary artery disease treatment. However, except for the prevention of thrombosis by vitamin K antagonists, there is only weak evidence that the short-term treatment of acute coronary syndromes is dependent on any genetic trait. This review focuses on the role of polymorphic platelet aggregation, clotting factors, vascular function, and lipid metabolism and transport. The present picture is complex and many findings could not be reproduced or are often contradictory. In conclusion, statistically well-powered, prospective studies are required considering multiple genetic traits in order to estimate the impact of pharmacogenomics in acute coronary syndrome risk and individualized drug treatment. At present, no data are available that should influence a physicians decision on drug treatment in acute situations. However, for long-term treatment distinct genetic markers may be applied in the future.     

Th17细胞与急性冠状动脉综合征

辅助性T细胞（T help,Th）17是新近发现的T效应细胞亚群,主要分泌IL-17因子,在多种自身免疫性疾病、感染性疾病、炎症性疾病中发挥重要作用。急性冠状动脉综合征（acute coronary syndrome）的发病与动脉粥样硬化斑块的不稳定性密切相关。Th17细胞在调控慢性炎症、动脉粥样硬化、血栓形成中起重要作用,加速动脉粥样硬化的进程。并且Th17细胞可能在动脉粥样硬化斑块的不稳定性中起驱动作用。     

髓过氧化物酶——急性冠状动脉综合征的炎症标志物

炎症因子参与冠状动脉粥样硬化性疾病的发生和发展。已发现作为中性粒细胞活化标志物的髓过氧化物酶能参与冠状动脉粥样硬化的全过程,且能用于预测不稳定斑块和急性冠状动脉综合征预后等。     

急性冠脉综合征预防进展

预防动脉粥样硬化斑块破裂是预防急性冠脉综合征的最主要手段。动脉粥样硬化斑块破裂有其内在的和外在的因素。 3 羟基 3 甲基 戊二酰辅酶A(HMG CoA)还原酶抑制药、过氧化物酶体增殖激活受体α激动药、血管紧张肽转换酶 (ACE)抑制药、抗感染药物等是目前预防急性冠脉综合征的主要治疗方法。     

急性冠脉综合征的抗凝治疗

急性冠脉综合征（acute coronary syndrome．ACS）是由于冠状动脉粥样斑块破裂或溃烂．进而诱发血栓形成引起冠脉血流完全中断或极度降低的病理生理改变所导致的综合衙．主要包括不稳定性心绞痛（UA）、急件非ST段抬岛心肌梗死{NSTEMI）和ST段抬高心肌梗死（STEMI）,     

Cytokine imbalance in acute coronary syndrome

The excessive mortality of coronary heart disease is attributed primarily to rupture and thrombotic transformation of the atherosclerotic plaque. Inflammation plays a critical role in plaque destabilization and vulnerability. Inflammation is not confined to the culprit segment but is convincingly widespread in the coronary and remote vascular beds. Systemic inflammatory, thrombotic and hemodynamic factors are relevant to the pathological and clinical outcome. In addition to their fundamental role in thrombosis, there is ample evidence that platelets contribute significantly to promoting plaque inflammation. A new paradigm of unbalanced cytokine-mediated inflammation is emerging, providing diagnostic and therapeutic opportunity for intervention. Amplifying intrinsic anti-inflammatory mechanisms constitutes attractive avenues for future investigation.     

Marijuana-induced recurrent acute coronary syndrome with normal coronary angiograms

We report a case of a man in his 40s presented to the emergency department twice, 1 month apart, with severe ischaemic sounding chest pain within 1 h of smoking marijuana on both occasions. He had elevated serial biomarkers and ischaemic electrocardiogram changes. His coronary angiograms on both episodes were entirely normal along with normal echocardiogram. This potentially suggests a coronary vasospasm as an underlying mechanism for these non-ST elevation myocardial infarctions. This should alert clinicians and the public alike to this potential risk of cannabis use.     

Emerging antiplatelet therapy for coronary artery disease and acute coronary syndrome

Antiplatelet therapy is used widely with proven benefit for the prevention of further ischemic cardiac complications in patients with known coronary artery disease (CAD) and a history of acute coronary syndrome (ACS). The limitations of conventional antiplatelet therapy with aspirin, clopidogrel, or prasugrel, as well as the fact that rates of recurrent ischemic events still remain high with use of these agents, underscore the need to investigate alternate agents that may further reduce event rates while limiting bleeding risk. The selection of antiplatelet therapy is further influenced by the following: ticagrelor was approved in July 2011 by the United States Food and Drug Administration (FDA), and clopidogrel is slated to become available as a generic productin 2012. We provide an overview of emerging agents for the treatment of CAD and ACS, including the reversible P2Y(12) antagonists ticagrelor, cangrelor, and elinogrel, and a new class of oral protease-activated receptor-1 (PAR-1) inhibitors, vorapaxar and atopaxar.The recently approved P2Y(12) antagonists prasugrel and ticagrelor demonstrate enhanced ability to prevent adverse cardiac outcomes. However, this comes at a cost of a potential increased risk of bleeding. New adverse effects have also emerged, including dyspnea for all of the reversible P2Y(12) antagonists (ticagrelor, cangrelor, and elinogrel) and ventricular pauses for ticagrelor. In addition, the newer P2Y(12) antagonists have a faster onset and offset. Two of these agents, cangrelor and elinogrel, are available as intravenous formulations, which may provide additional benefits in patients who undergo coronary artery bypass graft (CABG) surgery. Trials with the PAR-1 inhibitors have also shown trends toward reductions in cardiac events, but not without the possibility of increased bleeding. More than ever, as the arsenal of antiplatelet therapy expands, health care providers need to understand the pharmacologic and pharmacodynamic differences between conventional and emerging antiplatelet therapies for patients with ACS and CAD. Health care providers must also carefully assess patient-specific factors such as risk of thrombosis, concomitant disease states, age, drug adherence, and aspirin dose, and plan for those patients who will be undergoing CABG when selecting antiplatelet therapy in order to optimally balance bleeding and thrombosis risk.     

Pharmacoeconomics of anticoagulants in acute coronary syndrome and percutaneous coronary intervention

Economic evaluation plays an important role during almost all stages of pharmaceutical design and use. This paper reviews the recent pharmacoeconomic literature on the use of anticoagulants for acute coronary syndromes (ACS) and percutaneous coronary intervention (PCI). Both ACS and PCI are common reasons for hospitalization and contribute significantly to costs of care. ACS and PCI practice standards are still evolving. For ACS enoxaparin does appear to be more cost-effective around the globe than unfractionated heparin (UFH) when clopidrogel and glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors are not used. With the high prevalence of clopidrogel and GP IIb/IIIa use, the question may be moot. Since the cost of UFH therapy, including the cost of anticoagulant monitoring, is less expensive than enoxaparin therapy, UFH is probably the more cost-effective strategy. For PCI, as ischemic complications were reduced during the mid'90's, bleeding complications have become the most common problem and a major cost driver. Other complications that can drive costs include the occurrence of MI and revascularization procedures (repeat PCI or CABG). Results suggest that bivalirudin plus a provisional GP IIb/IIIa inhibitor is the most cost-effective strategy for patients undergoing elective PCI. There is no clear evidence regarding its use in urgent PCI. ACS and PCI practice standards are still evolving. It would be useful to embed economic studies within new clinical trials. Full economic analysis of groups at high risk for bleeding while undergoing PCI is needed.     

同型半胱氨酸与急性冠脉综合征相关性

目的 探讨同型半胱氨酸(Hcy)与急性冠脉综合征(AcS)相关性及冠脉介入治疗前后血清Hcy的变化.方法 采用透射免疫比浊法,分别检测89例ACS组和28例冠状动脉正常组的Hcy水平,以及70例行冠脉支架植入术后的Hcy水平.结果 ACS组的Hcy水平显著高于冠状动脉正常组(t=18.35、22.17,均P＜0.01).不同冠脉病变支数Hcy水平差异均有统计学意义(t=10.87、2.34、2.31,均P＜0.01).冠脉介入治疗前后Hcy差异无统计学意义(P＞0.05).结论 Hcy与ACS关系密切,检测其水平的变化,可反应ACS的发展进程及预后,为临床预防和治疗ACS提供可靠的依据.     

Emerging antithrombotic drugs for acute coronary syndrome

Introduction: Acute coronary syndrome (ACS) encompasses acute myocardial infarction (MI) and unstable angina. Activation of platelets and coagulation cascade plays a central role in the development of ACS. Over the past decade, there have been substantial improvements in the strategies for secondary prevention of ACS, including the development of more potent oral antiplatelet agents such as prasugrel and ticagrelor. However, therapies with even better efficacy and safety profiles and more rapid onset and offset of action would be desirable.

Areas covered: This review discusses the advantages and disadvantages of the currently available antithrombotic agents and describes the findings from recent clinical trials of three novel agents; cangrelor (an intravenous P2Y12 receptor antagonist), vorapaxar (protease-activated receptor-1 inhibitor) and rivaroxaban (an oral factor Xa inhibitor).

Expert opinion: Cangrelor appears more promising than clopidogrel when a very rapid onset and reversal of antiplatelet effect is needed. Vorapaxar in addition to standard oral antiplatelet therapy was effective in patients with prior MI, but was not safe in patients with a prior stroke. Low dose rivaroxaban decreased cardiovascular events and mortality in patients post-ACS compared to placebo, although bleeding was increased.     

Factor Xa inactivation in acute coronary syndrome

The increasing incidence of patients who develop acute coronary syndrome (ACS) stresses the importance of effective initial treatment to reduce morbidity and mortality. The recommended initial therapeutic regimen for patients with ACS includes both anticoagulants and antiplatelet agents to prevent excessive coronary thrombosis, stroke, and further coronary events. Most commonly, unfractionated heparin (UFH) is used for initial antithrombotic treatment of ACS, despite limited published evidence regarding effectiveness and safety (bleeding complications). Therefore, this treatment regimen is primarily based upon expert opinion rather than evidence-based medicine. Studies addressing the dilemma of effectiveness and increased risk of bleeding when using UFH and low molecular weight heparin (LMWH) in patients with ACS showed superior clinical outcome in patients treated with LMWH. Nevertheless, the concurrent increased risk of bleeding while using anticoagulants is a severe problem and negatively impacts upon clinical outcome. Furthermore, non-hemorrhagic side effects of heparin such as heparin-induced thrombocytopenia (HIT), and skin reactions at the site of subcutaneous injection are reduced but not abolished by replacing UFH with LMWH. The limitations of UFH and LWMH as outlined above provided the impetus for the development of a pentasaccharide, called fondaparinux, which inhibits factor Xa selectively. Fondaparinux has been shown to be as effective as enoxaparin in the prevention of thrombosis in patients undergoing orthopedic surgery and showed similar results compared to enoxaparin or UFH in patients with deep-vein-thrombosis or pulmonary embolism. Recently, a large clinical study addressed the dilemma of the effectiveness and adverse effects of anticoagulation in ACS by comparing fondaparinux and LMWH such as enoxaparin in patients with unstable angina or non ST-segment elevation myocardial infarction (NSTEMI).     

Clopidogrel resistance: implications for coronary stenting

Clopidogrel, in combination wih aspirin, is currently the drug of choice to prevent thrombosis after coronary stent implantation. Currently, clopidogrel is administered to the vast majority of patients without any assessment of platelet inhibition. Response variability and resistance, however, definitely occur to clopidogrel treatment. Preliminary data support the hypothesis that patients with reactive or clopidogrel nonresponsive platelets are at risk for thrombotic events. However, the magnitude of the clinical effect remains unknown and relationship between nonresponsiveness and risk of clinical events is under-investigated. Several important questions that must be answered are: A) What is the relation of clopidogrel resistance and high platelet reactivity to the occurrence of stent thrombosis, recurrent myocardial infarction, stroke and death?; B) Is there a threshold of platelet reactivity that correlates with the onset of thrombotic risk?; and C) What is the cost of administering clopidogrel to non-responsive patients? Finally, our understanding of the clinical relevance of drug resistance and high platelet reactivity should be facilitated by the use of validated point-of-service devices. The mechanisms of the response variability to clopidogrel remain incompletely defined. The contribution of intra- and extracellular pathways are under investigation.     

急性冠脉综合征的危险因素分析

目的 探讨急性冠脉综合征的危险因素.方法 本院2012年1月～2014年6月所有确诊ACS入院的233例患者纳入观察组,156例稳定型心绞痛患者纳入对照组,分析并比较两组的H-FABP水平、cTnⅠ水平、传统预测指标等.结果 两组的H-FABP水平、cTnⅠ水平、心功能Killip分级比较差异有统计学意义(P＜0.05).H-FABP和心功能Killip分级是ACS近期独立危险因素,OR分别为5.987和2.956.结论 H-FABP针对ACS短期内心血管危险预测有重要的临床意义,是诊断患者病情并分析与预后判断的理想指标,值得临床推广.     

急性冠脉综合症患者冠状动脉侧支的临床意义

目的:探讨急性冠脉综合症患者侧支循环的临床意义。方法:通过分析251例急性冠脉综合症患者的选择性冠状动脉造影及临床资料,比较有、无侧支组间预后相关指标:血清高敏感C-反应蛋白(hs-CRP)、脑钠肽(BNP)、肌钙蛋白I(cTnI)及左室射血分数(LVEF)差异。结果:有侧支组38例,无侧支组213例。两组间hs-CRP及BNP无差异(hs-CRP,5.00±3.67vs5.66±3.83 mg.dl-1;BNP,828.8±757.6vs829.6±784.6 fmol.ml-1,P>0.05);cTnI值无侧支组较有侧支组显著升高(0.91±1.13vs0.29±0.23 ng.ml-1,P<0.01),而LVEF无侧支组较有侧支组显著降低(0.43±0.11vs0.48±0.11,P<0.01)。结论:冠脉侧支形成有助于减少急性冠脉综合症患者的心肌损伤,保护心功能。     

急性冠状动脉综合征之治疗进展

急性冠状动脉综合征(acutecoronarysyndrome,ACS)根据心电图ST段是否抬高而分为ST段抬高的ACS和ST段不抬高的ACS,前者多演变成ST段抬高的急性心肌梗死(ST-segmentelevationmyocardialinfarction,STEMI),而后者包括不稳定型心绞痛(UAP)和ST段不抬高心肌梗死(non-ST-segmenteleva-tionmyocardialinfarction,NSTEMI)。ACS患者的治疗在大型综合医院或心脏中心,其药物治疗、经皮冠状动脉介入干预(PCI)与外科冠状动脉旁路移植术(CABG)的比例约各占三分之一。近年来,随着一些新型药物、器械和新技术的应用以及有关大规模临床试…     

胎盘生长因子与急性冠脉综合征关系探讨

目的 探讨胎盘生长因子与急性冠脉综合征(ACS)的相关性.方法 临床上70例急性胸痛患者,肌钙蛋白阳性患者36例患者作为观察组,对照组34例肌钙蛋白阴性,所有患者入院即行血检验PLGF,住院过程中行冠脉造影检查,Gemini积分评估冠脉病变情况.结果 胎盘生长因子与肌钙蛋白在ACS中显著增高,与对照组比较有显著性差异(P<0.01),胎盘生长因子与肌钙蛋白呈正相关(r=1.2,P<0.01),胎盘生长因子与冠脉病变严重程度呈正相关(r=1,P<0.01).结论 胎盘生长因子在预测急性冠脉综合征有一定作用,较高血胎盘生长因子预示冠脉病变处于不稳定性.