平板运动试验Duke评分在冠心病中的应用价值

平板运动试验是临床最常用的无创检查手段之一.平板运动试验Duke评分结合了运动时间、ST段偏移和运动中出现的心绞痛症状等因素,可以预测有无冠心病及其严重程度,并且可以评估冠心病患者的预后.现主要概述Duke评分在冠心病诊断和评价预后方面的价值.     

运动试验中收缩压恢复比对女性患者诊断冠心病的价值

目的　探讨运动试验中收缩压恢复比在女性患者中诊断冠心病的价值。方法　 12 1例有胸痛症状的女性患者根据冠状动脉造影结果分为非冠心病组 ( 5 3例 )和冠心病组 ( 68例 ) ,均接受心电图平板运动试验 ,比较两组患者收缩压恢复比 (运动结束后 3min与运动高峰时收缩压比值 )的差异 ;并探讨该比值在女性患者中诊断冠心病的价值。结果　在冠心病组 ,运动试验中收缩压恢复比明显高于非冠心病组 ( 0 .99± 0 .11vs0 .83± 0 .10 ,P<0 .0 1) ;在女性患者中 ,单用 ST段下移≥ 0 .1m V诊断冠心病的敏感性、特异性和阳性预测值分别为 60 .3%、5 8.6%、65 .1% ;以运动中 ST段下移≥ 0 .1m V且运动后收缩压恢复比 >0 .90为标准 ,诊断冠心病的敏感性、特异性和阳性预测值分别为 5 2 .9%、88.7%、85 .7% ,与前者比较 ,敏感性无明显变化 ( P>0 .0 5 ) ,但特异性和阳性预测值明显提高 ( P分别 <0 .0 1和 <0 .0 5 )。结论　在女性患者 ,运动试验中收缩压恢复比是判断冠心病的有用指标 ,结合 ST段下移 ,可以提高运动试验诊断冠心病的特异性和阳性预测值     

关于冠心病患者社区/家庭心脏运动康复效果研究的进展

基于社区/家庭的心脏运动康复程序不仅能为冠心病患者提供结构化的运动训练方案、教育支持和心理咨询,同时也为患者提供二级预防策略.但目前我国基于社区/家庭的心脏运动康复开展较少,尤其是冠心病患者参与率较低.本文综述冠心病患者进行社区/家庭心脏运动康复的临床益处,以期为冠心病患者的治疗和康复提供新的思路.     

平板运动试验心率恢复及心率变异性与冠心病的相关分析

目的 评价平板运动试验后心率恢复、心率变异性与冠心病的关系及临床意义.方法 对310例拟诊为冠心病的患者行活动平板运动试验,并对照其冠状动脉造影结果,将患者分为冠心病组106例和非冠心病组204例.比较两组患者的心率恢复值、达标时间、静息心率及运动最大心率,分析心率恢复异常与冠心病.同时评估短期心率变异性.结果 冠心病组运动后心率恢复值低于非冠心病组,差异有统计学意义;冠心病组心率变异性与非冠心病组相比,差异有统计学意义.结论 冠心病组与非冠心病组相比,心率恢复异常及心率变异性差异均有统计学意义,两者综合评价冠心病的准确率更高.     

活动平板运动试验QT离散度对冠心病诊断的意义

目的:探讨活动平板运动试验的QT离散度对冠心病诊断的意义.方法:30例正常人和27例冠心病人进行活动平板运动试验,测定运动前和运动高峰的QT离散度(QTd)及校正QT离散度(QTcd).结果:正常人群运动前后QTd及QTcd无差别,而冠心病患者运动后QTd和QTcd较运动前明显增大.结论:运动后QT离散度增大是反映冠心病心肌缺血的重要指标,运动后QTd、QTcd增大结合ST段偏移可增加对冠心病诊断的敏感性.     

52例冠心病患者经皮冠状动脉介入术后运动心电图分析

目的探讨运动心电图评价冠心病患者经皮冠状动脉介入(PCI)术后心脏功能的意义.方法52例冠心痛患者,其中心绞痛24例,心肌梗死28例,于PCI术后行运动试验检查,总结并分析其运动试验结果.结果冠心病患者PCI术后运动心电图阳性率为23.1%,较治疗前明显降低.于心肌梗死急性期进行的PCI效果最好.结论PCI术后运动试验阳性可能与不全血管重建、冠状动脉储备受损或恢复正常的左室功能有关.运动心电图对评价冠心病患者PCI术后运动耐量、心脏功能有意义.     

药物负荷试验心肌灌注显像

心肌灌注显像被公认为诊断冠心病的最可靠、常用的无创性方法[1-2],美国的年心肌灌注显像的病例数超过了800万例,多于心电图运动试验、负荷试验超声心动图和冠状动脉造影[3].运动试验是心肌灌注显像常用的负荷试验方法,运动试验心肌灌注显像诊断冠心病的灵敏度受患者运动量的影响.     

平板运动试验对青年男性冠心病患者的诊断价值

目的 探讨平板运动试验对不同性别青年冠心病患者诊断的价值.方法 选择本院2002年6月～2006年10月住院的有典型胸痛症状的男性及女性患者各100例,分别进行平板运动试验与冠脉造影对照分析.结果 平板运动试验对青年女性冠心病诊断的特异性为49.1%,准确性为69.O%;对青年男性冠心病诊断的特异性为82.8%,准确为性92.0%.结论 平板运动试验对青年男性冠心病有较高的诊断价值,对于早期发现冠心病有重要的临床意义.     

平板运动试验对冠脉钙化病变患者的诊断价值

目的 研究平板运动试验对钙化病变的男性冠心病患者的诊断价值.方法 选择经多层螺旋CT冠状动脉检查发现有钙化狭窄病变的男性冠心病疑似患者67例,行平板运动试验并择期行冠状动脉造影检查,对其结果进行对照分析.结果 平板运动试验比多层螺旋CT冠状动脉检查对钙化病变的男性冠心病疑似患者的诊断特异度（78％ vs.33％）及正确诊断指数（69％vs.31％）高,差异有统计学意义（p＜0.05）.结论 平板运动试验检查对钙化病变男性冠心病患者的诊断比多层螺旋CT冠状动脉检查更具优势.     

卧式踏车运动中冠心病患者血液动力学变化

本文应用阻抗法测定冠心病患者卧式踏车运动中血液动力学变化。根据心搏量、心输出量,心率的变化,将运动中心血管反应分为三期。冠心病患者运动负荷耐量主要在运动第二期和第三期较差,这是冠心病患者心搏量下降速度快,且对心搏量下降幅度耐受性较差所致。运动分期为冠心病患者康复确定安全有效运动量提供了依据。     

Global risk assessment for lipid therapy to prevent coronary heart disease

Randomized clinical trials have established that lipidlowering pharmacologic therapy can substantially reduce morbidity and mortality in patients with known coronary artery disease (CAD). Researchers are now working to define the role of lipid-lowering agents in the primary prevention of CAD to extend their benefit to patients at increased risk for future coronary events. The risk assessment models presently used for secondary prevention are not sufficient to identify high-risk, asymptomatic patients. Building on the accumulated data about the physiologic mechanisms and metabolic factors that contribute to CAD, novel serum markers and diagnostic tests are being critically studied to gauge their utility for the assessment of high-risk patients and occult vascular disease. New risk prediction models that combine traditional risk factors for CAD with the prudent use of new screening methods will allow clinicians to target proven risk reduction therapies at high-risk patients before they experience a cardiac event.     

The prevalence of cardiac risk factors in women 45 years of age or younger undergoing angiography for evaluation of undiagnosed chest pain

BACKGROUND: Relatively little is known about the prevalence of cardiac risk factors, the use of noninvasive testing and the medical management of younger women (younger than 45 years of age) undergoing evaluation for chest pain. OBJECTIVES: To determine the rate of angiographically critical coronary artery disease (CAD) in women under the age of 45 years who were sent for first-time evaluation of chest pain requiring cardiac catheterization, and to determine the prevalence of cardiac risk factors, the role of noninvasive testing and the quality of medical management in these patients. PATIENTS AND METHODS: A retrospective chart review was performed on all female patients aged 45 years or younger from February 1997 to December 2000 (n=187) without prior known CAD referred for diagnostic cardiac catheterization. Chart information was studied, including catheterization results, cardiac risk factors, noninvasive testing done before catheterization (within six months) and medications at discharge. RESULTS: Angiographically critical CAD was found in 55 of 187 patients (29%), of whom 52% had single-vessel disease. One hundred twenty-one patients (65%) had completely normal coronary arteries. The most prominent cardiac risk factor for all study patients was a family history of premature CAD (67%), followed by smoking (55%) and dyslipidemia (55%). When compared with people without CAD, women with CAD had a higher prevalence of dyslipidemia (72% versus 47%, P=0.002), diabetes (29% versus 9%, P<0.001) and smoking (67% versus 50%, P=0.03). Noninvasive testing including exercise stress testing (calculated sensitivity of 44% and a specificity of 73%), and stress sestamibi scintigraphy (sensitivity of 67%, specificity of 30%) were both found to be poor predictors of those with CAD. Of all patients diagnosed as having critical CAD (n=55), 40% were discharged on an angiotensin-converting enzyme inhibitor, 73% on acetylsalicylic acid and 69% on a beta-blocker. CONCLUSIONS: The present study implies that younger women with CAD may have a higher prevalence of dyslipidemia, diabetes and smoking. The high percentage of women with minimally diseased or normal coronary arteries emphasizes the importance of confirmatory testing and poor use of noninvasive testing. The medical management of young women diagnosed with CAD is seemingly suboptimal, which may have important implications in later years of life.     

Recent Developments in Sex-Related Differences in Presentation,Prognosis, and Management of Coronary Artery Disease

Coronary artery disease (CAD) is the most prevalent type of heart disease among women and men. Sex-related differences in the presentation, prognosis, and management of patients with CAD has been increasingly studied. Compared with men, women are more likely to present with multiple comorbidities, have a higher prevalence of psychological risk factors, and present with atypical symptoms. These factors, along with delays in seeking medical attention, might contribute to sex-related treatment differences in women with stable angina and acute coronary syndrome. This review article highlights recent evidence examining sex-related differences in stable CAD patients with obstructive CAD, nonobstructive CAD, as well as myocardial infarction.     

Undertreatment of dyslipidemia in peripheral arterial disease and other high-risk populations: an opportunity for cardiovascular disease reduction

Atherosclerosis is a form of arterial disease that manifests in the coronary circulation as coronary artery disease (CAD), in the carotid arteries as cerebrovascular disease, and in the aorta and lower extremity arteries as peripheral arterial disease (PAD). The systemic nature of the disease is reflected in the fact that individuals with PAD or carotid artery disease are more likely to have CAD than those without. Since individuals with PAD are at markedly increased risk of cardiovascular ischemic events, early identification of this population and more aggressive medical interventions could substantially improve both morbidity and survival. The incidence of PAD in the general population is high, and currently affects 8-10 million Americans. The risk of developing PAD is predicted by both age and common atherosclerosis risk factors (e.g., smoking and diabetes). Efficient office-based PAD detection depends on the application of objective techniques to establish this diagnosis. Objective noninvasive tests, such as measurement of the ankle-brachial index (ABI), are known to be more sensitive than traditional clinical assessments. Since the major threat to patients with PAD is from secondary cardiovascular ischemic events, a primary therapeutic goal is to modify atherosclerotic risk factors. While national recommendations mandate aggressive lowering of serum low-density lipoprotein cholesterol (LDL-C) levels as a primary treatment goal in all patients with overt atherosclerosis, as 'coronary heart disease risk equivalent' syndromes, individuals with PAD are less intensively treated than those with CAD. Statins are the most effective of current treatments in lowering LDL-C, and have proven efficacy in secondary prevention among patients with established CAD. The use of statin medications in high-risk groups such as PAD patients could prove particularly beneficial in reducing cardiovascular morbidity and mortality and therefore merits prospective clinical investigation.     

Risk factors for coronary atherosclerosis in the elderly

To determine the importance of traditional risk factors for coronary artery disease (CAD) in the elderly, the authors studied 64 consecutive patients with angiographically normal or near-normal coronary arteries and 64 patients with CAD. All patients were greater than or equal to sixty years old. The risk factors studied were male sex, hypertension, diabetes mellitus, hypercholesterolemia, cigarette smoking, sedentary life-style, and family history. The prevalence of these risk factors in the two groups of patients was compared. The results suggest that in persons greater than or equal to 60 years old, male sex and cigarette smoking continue to remain risk factors for CAD. Since most of the patients with diabetes and hypertension were on medical management for their condition, the authors' findings also suggest that diabetes mellitus, even under treatment, remains an important risk factor for CAD in the elderly but controlled hypertension does not. Other traditional risk factors (hypercholesterolemia, sedentary life-style, and family history) do not discriminate individuals with moderate to severe CAD from those with normal or near-normal coronary arteries in persons greater than or equal to sixty years old.     

Depression, hostility, and social isolation in patients with coronary artery disease

Opinion statement Psychosocial risk factors such as depression, hostility, and social isolation are substantially more prevalent in patients with coronary artery disease (CAD) than is widely recognized. It has been demonstrated that patients with CAD who have these risk factors, individually or together, may have a substantially increased risk for recurrent ischemic events, as well as cardiac death, when compared with unaffected CAD patients. Numerous adverse physiologic changes that appear to occur as a consequence of these psychosocial risk factors have been identified, including increased platelet aggregation, hyperadrenergic states, elevated cortisol levels, abnormal endothelial function, and an increased propensity towards malignant ventricular arrhythmias. Each of these may explain the increased risk of recurrent coronary events (including death) among afflicted patients. Under-recognition, and hence under-treatment, remains a principal obstacle for improvements in the care of patients with CAD who have psychosocial risk factors. The diagnosis of psychosocial risk factors depends on systematic patient evaluation by experienced clinicians trained in the recognition of these disorders. All clinicians must be aware of the potential importance of these factors, their sometimes subtle presenting characteristics, and the available treatment options. The universal use of comprehensive cardiovascular rehabilitation offers the ideal conduit for such evaluation and management. Nonpharmacologic therapies for psychosocial risk factors include psychotherapy, stress-reduction techniques, and exercise therapy. Studies suggest that the reduction of social isolation among depressed patients with CAD may result in a reduced mortality rate in comparison with those without improvements in isolation. Pharmacologic therapies are mainly for the management of depression, and largely center on the use of selective serotonin reuptake inhibitors (SSRIs). Several SSRIs (paroxetine and sertraline) recently have been shown to be safe and effective for the treatment of depression in patients with ischemic heart disease. Whether use of antidepressants attenuate the increased cardiac risk from depression in the setting CAD remains to be proven; however, their use improves the quality of life in properly selected patients.     

Variant Angina—Correlation of Clinical, Electrocardiographic and Angiographic Features: Results of Medical and Surgical Management

Summary Angiographic coronary artery disease (CAD) was correlated with clinical features, electrocardiographic (ECG) findings and the results of medical management or aortocoronary bypass in 42 patients with angina at rest associated with transient ST segment elevation (variant angina).
Patients were divided into three sub-sets based on the coronary arteriographic findings. On the basis of > 75% luminal diameter narrowing, 28 patients had multiple vessel, ten had single vessel and four had minimal (< 50% narrowing) CAD. The angiographic sub-sets did not differ significantly in age, sex, coronary risk factors, time from onset of rest pain to coronary angiography, or in the presence of arrhythmias during ischaemic episodes. Patients with multiple vessel CAD more commonly had prior coronary events (P < 0·01), an abnormal baseline ECG (P < 0·05) or both (P < 0·001). These features did not distinguish patients with single vessel from those with minimal CAD. ST elevation in the inferior leads during episodes of myocardial ischaemia was more common (P < 0·005) in patients with minimal CAD.
Twenty-four patients with multiple vessel and six with single vessel CAD underwent aortocoronary by-pass surgery and relief of variant angina was achieved in all 25 long-term survivors during an average follow-up period of 36 months. Twelve patients (four of each subset) were treated medically. Among those with multiple vessel CAD, the small medically treated numbers precluded valid comparison of medical and surgical results. Patients with single vessel CAD followed for an average period of 17 months compared unfavourably with the operated group. Calcium antagonists or nitrates controlled variant angina in patients with minimal CAD followed for an average of 27 months.     

Acetylsalicylic acid (ASA) use among Polish adults with diabetes mellitus

People with diabetes mellitus have higher risk of cardiovascular morbidity and mortality from thrombo-vascular complications than non-diabetics and it is recommended that they should use acetylsalicylic acid (ASA) as anitiplatelet agent regularly. The aim of this study was to examine current physician counseling about ASA therapy and the use of ASA by Polish patients with diabetes. The study involved 464 randomly selected Caucasian diabetic individuals, mainly with type 2 (>98%), who were asked to complete a questionnaire consisting of 16 questions while visiting out-patient medical centres for periodical examination or during hospitalization. We collected data on the prevalence of cardiovascular disease (CVD), frequency of risk factors among diabetic patients and on ASA physician counseling, and on the rate of regular ASA users among the patients. The most self-reported conditions were angina pectoris or prior myocardial infarction (63,6%). Current cigarette smoking was declared by 7,1% of the patients, elevated serum cholesterol levels by 58%, and hypertension by 62,9%. Majority of the patients were overweight, and family history of coronary artery disease (CAD) was reported by 30,2% of the patients. ASA was taken by 67,2% of all the patients and 72,1% of them had taken ASA regularly. The highest percentage (>80%) of regular ASA users was found among diabetic patients with CAD. A minority of the patients who reported stroke (43,9%) or claudication (15,8%) were taking ASA regularly. Number of the patients (32,8%) with CVD risk factor(s) but without diagnosed CVD did not use ASA at all. The majority of the patients (78%) were counseled by their physicians why they should use ASA regularly. In conclusion: the number of regular users of ASA among diabetic patients in Poland with CVD others than CAD or among patients with at least two CAD risk factors is still unsatisfactory. Therefore, while it seems that there is a remarkable growing of ASA therapy world-wide more effort is needed to make this practice a standard of multifactorial, intensive diabetes treatment. Our results also suggest the need for more aggressive education of both doctors and patients.     

Coronary Revascularization in Patients With Advanced Chronic Kidney Disease

Patients with chronic kidney disease (CKD) have an increased risk of obstructive coronary artery disease (CAD), whereas patients with end stage renal disease who are receiving hemodialysis represent a population at particularly high risk of developing cardiac ischemic events. Patients with CKD and acute coronary syndromes should be treated the same way as acute coronary syndromes patients without kidney dysfunction. The benefit of revascularization in patients with advanced kidney failure and CAD is unknown. Observational studies suggest that revascularization might confer a survival benefit compared with medical therapy alone. Little evidence from randomized trials exists regarding the effectiveness of revascularization of patients with CAD with either coronary artery bypass grafting or percutaneous coronary intervention vs medical therapy alone in patients with CKD. The risk of contrast-induced nephropathy is a major concern when percutaneous coronary intervention is performed in patients with CKD. Strict rehydration protocols and techniques to minimize contrast use are paramount to reduce this risk. Finally, in CKD patients who are awaiting kidney transplantation, a noninvasive or invasive CAD screening approach according to the cardiovascular risk profile should be used. Revascularization should be performed in candidates with critical lesions.     

Diagnostic and prognostic testing to evaluate coronary artery disease in patients with diabetes mellitus

Coronary artery disease (CAD) continues to be the most common cause of morbidity and mortality in patients with diabetes mellitus (DM). In recent years, the strategies for treatment of CAD in DM have undergone much evolution. Currently, all patients with DM, regardless of symptoms or diagnosed CAD, are treated aggressively for CAD risk factor reduction. In this clinical climate, the ability to specifically identify patients with disease that will benefit from more aggressive and invasive therapies remains a challenge. In this article we review the current literature on diagnostic and prognostic utility of conventional non-invasive modalities for assessment of CAD in patients with DM, as well as on novel and emerging methods for CAD risk stratification.