Percutaneous coronary intervention in nonagenarians: pros and cons

Percutaneous coronary intervention is a mainstay in the management of symptomatic or high-risk coronary artery disease. The bulk of clinical evidence and experience underlying this fact relies, however, on relatively young patients. Indeed, few data of very limited quality are available which adequately define the risk-benefit and cost-benefit profile of coronary angioplasty and stenting in very old subjects, such as those of 90 years of age or older (i.e., nonagenarians). The aim of this review is to provide a concise, yet practical, synthesis of the available evidence on percutaneous coronary revascularization in the very elderly. The main arguments elaborated upon are to what extent we can extrapolate findings from studies including younger patients to nonagenarians, whether we should provide higher priority to prognosis or quality of life in such patients, and whether we can afford to allocate vast resources to care for such subjects in an era of financial constraints. Our review of 18 studies and 1082 patients suggest that percutaneous coronary intervention is feasible and associated with acceptable short- and long-term results in this population, which is nonetheless fraught with a high mortality risk irrespective of the revascularization procedure. Accordingly, the pros and cons of percutaneous coronary intervention should be carefully weighed when considering this treatment in nonagenarians.     

冠状动脉旁路移植术后再次急性冠状动脉综合征患者的冠状动脉造影分析

目的分析接受冠状动脉旁路移植术(CABG)后的患者再次发作急性冠状动脉综合征(ACS)的时间与相关血管的关系.方法从本院1997～2001年间因CABG术后再次发作ACS而入院的168例患者中,选出行再次冠状动脉造影的患者43例,男38例,女5例,平均年龄(57.9±10.2)岁,再次发作ACS时间在术后次日至11年间.分析术后再次发作ACS的时间与罪犯血管之间的关系.结果 (1)由原自身冠状动脉血管病变加重导致的ACS共19例,占44.2%,由移植血管病变导致的共24例,占55.8%,其中12例移植血管病变发生在术后半年内,占移植血管病例的50%,且大部为吻合口病变.(2)从发作时间上划分,在术后次日至半年内发作ACS的为14例,占所有分析病例的32.6%.其中12例为移植血管病变所致,占整组病例的27.9%.随时间的延长,引起ACS的相关血管既有移植血管,也有原自身冠状动脉血管远端病变加重的血管,但术后3年内发作的ACS大多数由移植血管病变引起,检出率为75%,特异度为63%(P<0.01),3年后发生的ACS主要为未移植血管的原自身冠状动脉或移植血管远端的原自身冠状动脉血管病变加重所致.(3)所分析的43例患者共置入静脉血管桥99支,病变37支,总病变率37.4%,动脉桥31支,病变9支,总病变率29.0%.两者间差异有显著性(P<0.01).(4)桥病变的发生与患者综合危险因素间无明确相关性.结论 CABG术后3年内发作的ACS,其相关移植血管病变检出率为75%,特异度为63%,尤其半年内发生ACS的患者,移植血管病变检出特异度达89%,而且大部分为吻合口病变.移植血管病变的发生率与综合危险因素之间无明确相关性,但静脉移植血管的闭塞率要高于动脉移植血管.     

Takotsubo syndrome-different presentations for a single disease: A case report and review of literature

We report three cases of Takotsubo syndrome(TS) with atypical myocardial involvement. All three cases were triggered by physical or mental stress, resulting in transient myocardial compromise. However, the clinical presentation, localization and extent of myocardial damage varied in each case, ranging from low-risk acute chest pain to cardiogenic shock with low ejection fraction and dynamic obstruction of the left ventricular outflow tract. These cases outline the range of possible presentations of this rare entity and illustrate atypical forms of TS.     

血清和肽素水平在急性冠状动脉综合征患者危险分层及预后的价值

目的探讨急性冠状动脉综合征患者血清和肽素(copeptin)水平对冠状动脉病变严重程度及预后方面的预测价值。方法连续入选2010年9月至2011年5月同济大学附属东方医院因胸痛入院并确诊急性冠状动脉综合征的患者共112例,分别测定胸痛发作3 h内、6、12及24 h后血清和肽素、肌钙蛋白水平;入院后均行冠状动脉造影术,并随访1年观察其主要心血管不良事件(MACE)的发生率。结果单支、双支和三支病变患者的血清和肽素水平分别为(0.46±0.13)μg/L、(0.74±0.32)μg/L和(1.23±0.43)μg/L;冠状动脉Gensini积分<20、20≤积分<40、积分≥40组患者的血清和肽素水平分别为(0.43±0.17)μg/L、(0.59±0.18)μg/L和(1.08±0.42)μg/L,均显著高于正常对照组(0.37±0.62)μg/L,且两两比较差异均有统计学意义(均为P<0.05);血清和肽素水平与冠状动脉病变支数、Gensini积分均呈显著正相关(r=0.729,0.659;均为P<0.001)。所有患者随访约12个月[(12.6±1.1)个月],共21例患者发生MACE,MACE组患者的24 h和肽素水平较无MACE组明显升高[(0.82±0.34)μg/L比(0.39±0.13)μg/L,P<0.001]。结论血清和肽素水平可作为反映冠状动脉病变严重程度的一个参考指标;胸痛24 h后血清和肽素水平持续升高可提示预后不良。     

Delay in invasive risk stratification of women with acute coronary syndrome is associated with worse outcomes

Background Invasive risk stratification in patients with acute coronary syndromes (ACS) has been shown to improve outcomes. There is paucity of data on women undergoing invasive risk stratification. We investigated whether the time to coronary angiography affects survival of female patients admitted with ACS. Method Female patients admitted to the coronary intensive care unit with ACS between 1/1/97 and 12/31/00 and undergoing coronary angiography during same hospitalization were divided into three groups based on the time to angiography: same day, 1–2 days and >2 days. The baseline clinical features, angiography results and outcomes were compared between the angiography groups. Results Of the total 350 female patients who fulfilled the inclusion criteria, 63% underwent angiography within two days of presentation. Three year mortality rates in women undergoing angiography on the same day, 1–2 days and >2-days were 7%, 7% and 22% respectively (p = 0.001). Using multivariate analysis, angiography beyond 2 days was a significant predictor of mortality among women (OR 2.6, 95% CI 1.3–5.0, p = 0.006) after adjusting for confounding variables. Conclusion Later invasive risk stratification after 2 days of presentation in women with ACS is associated with worse survivial. Gender should not be a reason to defer early coronary angiography in these patients.     

Sex differences in treatment and prognosis of acute coronary syndrome with interventional management

Objective

Female sex has been associated with differences in diagnostic and management of acute coronary syndrome (ACS). Our aim was to analyze sex differences in ACS with interventional management in a tertiary care hospital.

青年和老年急性冠脉综合征患者危险因素及冠脉造影特点的对比研究

目的探讨青年和老年急性冠脉综合征（ACS）患者危险因素与冠脉造影特点。方法将临床确诊为ACS、年龄〈45岁的69例患者（青年组）与65岁以上的421例患者（老年组）进行病例对照研究,分析其危险因素、临床特征、冠脉造影病变程度、经皮冠状动脉介入治疗（PCI）效果,以及相关因素的不同特点。结果青年组与老年组比较,ACS危险因素中吸烟史、阳性家族史明显升高,而合并高血压、糖尿病则低于老年组。血脂谱分析显示,青年患者TG、LDL—C、ApoB显著高于老年组,HDL—C则相反。冠脉造影显示,青年组单支病变（73．9％）明显多于老年组（28．0％）,而双支病变（10．1％）、多支病变（15．9％）则显著少于老年组（27．1％、55．1％）;冠脉病变程度用改良的Genisi积分比较,青年组（7．68±5．31）显著低于老年组（16．61±7．82）。对多种危险因素进行相关性分析显示,LDL—C与改良的Genisi积分呈明显的正相关（r=0．287,P=0．041）。HDL—C（r=-0．581,P=-0．01）、ApoA—I（r=-0．357,P=-0．025）与改良的Genisi积分明显负相关。结论吸烟、早发冠心病家族史、代谢紊乱是青年ACS的主要危险因素;青年ACS患者冠脉病变程度显著低于老年组,介入治疗成功率也高。     

An analysis of patients receiving emergency CAG without PCI and the value of GRACE score in predicting PCI possibilities in NSTE-ACS patients

Background There are patients who underwent emergency coronary angiography (CAG) but did not receive percutaneous coronary intervention (PCI). The aim of this study was to analyze these reasons. Methods This is a single-center retrospective study. We recruited 201 consecutive patients who received emergency CAG but did not receive PCI. To investigate the value of the Global Registry of Acute Coronary Events (GRACE) score in predicting PCI possibilities in non-ST segment elevation acute coronary syndrome (NSTE-ACS) patients, we recruited 80 consecutive patients who presented with NSTE-ACS and received emergency CAG as well as emergency PCI. Results Among the 201 patients who received emergency CAG but did not receive PCI, 26% patients had final diagnosis other than coronary heart disease. In the patients with significant coronary artery stenosis, 23 patients (11.5%) were recommended to coronary artery bypass grafting (CABG), one patient (0.5%) refused PCI; 13 patients (6.5%) with significant thrombus burden were treated with glycoprotein IIb/IIIa receptor antagonist; 74 patients (36.8%) were treated with drug therapy because no severe stenosis (> 70%) was present in the crime vessel. Moreover, 80 of the 201 patients were presented with NSTE-ACS (excluding those patients with final diagnosis other than coronary heart disease, excluding those patients planned for CABG treatment), referred as non PCI NSTE-ACS. When comparing their GRACE scores with 80 consecutive patients presented with NSTE-ACS who received emergency CAG as well as emergency PCI (referred as PCI NSTE-ACS), we found that PCI NSTE-ACS patients had significantly higher GRACE scores compared with non PCI NSTE-ACS patients. We then used Receiver Operator Characteristic Curve (ROC) to test whether the GRACE score is good at evaluating the possibilities of PCI in NSTE-ACS patients. The area under the curve was 0.854 ± 0.030 (P < 0.001), indicating good predictive value. Furthermore, we analyzed results derived from ROC statistics, and found that a GRACE score of 125.5, as a cut-off, has high sensitivity and specificity in evaluating PCI possibilities in NSTE-ACS patients. Conclusions Our findings indicate that the GRACE score has predictive value in determining whether NSTE-ACS patients would receive PCI.     

aVR ST段抬高对急性冠状动脉综合征患者罪犯病变的预测价值

目的 探讨aVR ST段抬高对非ST段抬高性急性冠状动脉综合征患者罪犯病变的预测价值.方法 选择因非ST段抬高性急性冠状动脉综合征入院的患者213例,根据aVR ST段分为抬高组和不抬高组,分析心电图与冠状动脉造影结果及冠状动脉病变范围及狭窄程度（以Gensini积分表示）的关系.结果 抬高组Gensini积分（58.16±43.85）高于不抬高组（23.53±26.80）,差异有统计学意义（P＜0.05）.而ST段抬高的3个亚组（抬高＜0.10mV、0.10～0.15mV、＞0.15mV）Gensini积分差异均无统计学意义（均P ＞0.05）.aVR ST段抬高0.5mV以上对左主干病变的敏感度、特异度、阳性预测值、阴性预测值分别为77.8%、59.5%、34.0%、90.9%;对三支病变分别为82.1%、67.1%、53.4%、89.1%;对左主干合并三支病变分别为88.5%、57.2%、22.3%、97.3%.结论 aVR ST段抬高者病变较重,但抬高幅度并不能预测狭窄程度.aVR ST段抬高是急性冠状动脉综合征左主干和（或）三支病变较强的预测因子.     

aVR导联ST段回落对非ST段抬高型急性冠脉综合征患者短期预后的评估价值

目的探讨aVR导联ST段抬高回落在非ST段抬高型急性冠脉综合征（NSTE-ACS）患者短期预后中的评估价值。方法纳入NSTE-ACS aVR导联抬高的患者45例;根据入院6h后aVR导联ST段是否回落分为ST段回落组（n=20）与非ST段回落组（n=25）;分析入选患者一般临床资料、心电图、冠状动脉造影结果,并对不良心脏事件的危险因素进行Logistic回归分析。结果 aVR导联ST段无回落组左主干＋三支血管病变率、30d内再发心肌梗死率、急诊PCI及冠脉旁路移植术比例均高于ST段回落组患者,具有统计学差异（P〈0.05）。Logistic回归分析显示,aVR导联ST段无回落是入院后30d内不良心脏事件（死亡、心肌梗死及行血运重建术）独立预测因子（OR=18.54,95%CI：3.57～96.1,P〈0.001）。结论 aVR导联ST段抬高无回落的NSTE-ACS患者其预后差于ST段抬高回落者,aVR导联ST段无回落是NSTE-ACS不良心血管事件的独立预测因子。     

急性冠脉综合征患者GRACE评分与冠脉病变的相互关系

目的 探讨急性冠脉综合征（ACS）患者全球急性冠状动脉事件注册（GRACE）评分与冠状动脉病变程度的关系,评价GRACE评分对冠状动脉病变预测的价值.方法 收集2008年5月至2010年10月住院的ACS患者共360例,对其进行GRACE评分.以评分差异分组,分为高危组、中危组和低危组,分析不同组别中患者冠状动脉病变的严重程度,以及与GRACE评分的关系.结果 随着GRACE评分分值的增加,ACS患者冠状动脉狭窄支数及狭窄程度呈增加的趋势.结论 GRACE评分对ACS患者冠状动脉病变支数、狭窄严重程度有一定的预测价值.     

Prevalence of normal coronary angiography in the acute phase of suspected ST-elevation myocardial infarction: experience from the PRAGUE studies

BACKGROUND: Acute ST-elevation myocardial infarction in patients with normal coronary arteries has previously been described, but coronary angiography in these patients was performed after the acute phase of the infarction. It is possible that these patients did not have normal angiograms during the acute phase (transient coronary thrombosis or spasm were usually suspected to be the cause). Information on the prevalence of truly normal coronary angiograms during the acute phase of a suspected ST-elevation myocardial infarction is lacking. PATIENTS AND METHODS: The Primary Angioplasty in patients transferred from General community hospitals to specialized PTCA Units with or without Emergency thrombolysis-1 (PRAGUE-1) and PRAGUE-2 studies enrolled 1150 patients with ST-elevation acute myocardial infarction, in whom 625 coronary angiograms were performed within 2 h of the initial electrocardiogram. A simultaneous registry included an additional 379 coronary angiograms performed during the ST-elevation phase of a suspected myocardial infarction. Thus, a total of 1004 angiograms were retrospectively analyzed. A normal coronary angiogram was defined as one with the absence of any visible angiographic signs of atherosclerosis, thrombosis or spontaneous spasm. RESULTS: Normal coronary angiograms were obtained for 26 patients (2.6%). Among these, the diagnosis at discharge was a small myocardial infarction in seven patients (0.7%), acute (peri)myocarditis in five patients, dilated cardiomyopathy in four patients, hypertension with left ventricular hypertrophy in three patients, pulmonary embolism in two patients and misinterpretation of the electrocardiogram (ie, no cardiac disease) in five patients. Seven patients with small infarctions underwent angiography within 30 min to 90 min of complete relief of the signs of acute ischemia, and thus, angiograms during pain were not taken. None of the 898 patients catheterized during ongoing symptoms of ischemia had a normal coronary angiogram. Spontaneous coronary spasm as the only cause (without underlying coronary atherosclerosis) for the evolving infarction was not seen among these 898 patients. Thus, the causes of the seven small infarcts in patients with normal angiograms remain uncertain. CONCLUSIONS: The observed prevalence of normal coronary angiography in patients presenting with acute chest pain and ST elevations was 2.6%. Most of these cases were misdiagnoses, not infarctions. A normal angiogram during a biochemically confirmed infarction is extremely rare (0.7%) and was not seen during the ongoing symptoms of ischemia.     

Determinants of use and outcomes of invasive coronary procedures in acute coronary syndromes: results from ENACT.

AIMS: To explore the variations in the use of invasive coronary procedures after acute coronary syndromes. METHODS AND RESULTS: In the ENACT registry, use of invasive procedures was analyzed as a function of hospital type, country and patient characteristics among 2768 patients with acute coronary syndromes (731 with ST-segment elevation myocardial infarction (STEMI) within 12h of symptom onset, and 2037 with other acute coronary syndromes). Percutaneous coronary intervention (PCI) was more likely to be performed in teaching than in community hospitals, and in hospitals with, rather than without, catheterization facilities. There were marked country-to-country variations in the use of PCI during the index hospital stay, ranging from 8 to 67% after STEMI (p<0.001) and from 9 to 44% after other acute coronary syndromes (p<0.001). The main independent predictors of the performance of PCI were the country rate of use of PCI and the hospital availability of PCI. For patients with other acute coronary syndromes, the risk of adverse events, assessed by the simplified TIMI-risk score, was not associated with PCI. Logistic regression analysis showed that lack of PCI was an independent predictor of in-hospital mortality (odds ratio (OR): 3.75, p<0.029) after other acute coronary syndromes, but not after STEMI. CONCLUSIONS: The use of PCI after acute coronary syndromes appears related more to local practice and hospital characteristics than to patients' characteristics or risk.     

急性冠脉综合征与脂蛋白相关磷脂酶A2的相关性

目的 探讨急性冠脉综合征患者血清脂蛋白相关磷脂酶A2（Lp-PLA2）的水平及其对预后的临床价值.方法 入选急性冠脉综合征（ACS）患者112例,分为不稳定型心绞痛（UA）组、急性心肌梗死（AMI）组和非ST段抬高型心肌梗死（NSTEMI）组,其中UA组根据危险度分层分为低危、中危和高危组;对照组78例.所有患者均行冠状动脉造影检查,采用Gensini积分方法对各支冠状动脉病变程度进行评定,用ELISA方法测定各组Lp-PLA2水平,进行对比分析.结果 ACS各组患者血清Lp-PLA2水平均显著高于对照组（P＜0.01）;AMI组Lp-PLA2水平显著高于UA组（P＜0.01）;高危、中危组Lp-PLA2水平均高于低危组（P＜0.01,P＜0.05）,且三组相对应的冠脉评分也随着危险度的升高而增加（P＜0.01）.结论 Lp-PLA2水平可作为预测ACS病情严重程度及预后的重要生化指标之一.     

Efficacy and safety of individually tailored antiplatelet therapy in patients with acute coronary syndrome after coronary stenting: a single center, randomized, feasibility study

Background Low responsiveness to clopidogrel (LRC) is associated with increased risk of ischemic events. This study was aimed to explore the feasibility of tailored antiplatelet therapy according to the responsiveness to clopidogrel. Methods A total of 305 clopidogrel naive patients with acute coronary syndromes (ACS) undergoing coronary stenting were randomly assigned to receive standard (n = 151) or tailored (n = 154) antiplatelet therapy. The ADP-induced platelet aggregation tests by light transmission aggregometry were performed to identify LRC patients assigned to the tailored group. The standard antiplatelet regimen was dual antiplatelet therapy with aspirin and clopidogrel. The tailored antiplatelet therapy was standard regimen for non-LRC patients and an additional 6-month cilostazol treatment for LRC patients. The primary efficacy outcome was the composite of cardiovascular death, myocardial infarction or stroke at one year. Results LCR was present in 26.6% (41/154) of patients in the tailored group. The percentage platelet aggregation for LCR patients was significantly decreased at three days after adjunctive cilostazol treatment (77.5% ± 12.1% vs. 64.5% ± 12.1%, P < 0.001). At one year follow-up, a non-significant 37% relative risk reduction of primary events were observed in the tailored group as compared to the standard group (5.8% vs. 9.3%, P = 0.257). There were no differences in the rates of stent thrombosis and hemorrhagic events between the two groups. Conclusions Tailored antiplatelet therapy for ACS patients after coronary stenting according to responsiveness to clopidogrel is feasible. However, its efficacy and safety need further confirmation by clinical trials with larger sample sizes.