钙化积分对冠状动脉介入治疗的稳定性冠心病患者的预测价值

目的探讨冠状动脉钙化积分（CCS）对稳定性冠心病患者经皮冠状动脉介入治疗（PCI）后近、远期预后的预测价值。方法 109例稳定性心绞痛患者在首次PCI治疗前均接受冠状动脉CT检查,计算CCS;对患者进行长期随访,记录有无死亡、非致死性心肌梗死、靶病变血运重建以及再发心绞痛入院等主要心脏事件（MACE）发生。结果 CCS与患者年龄呈正相关（r=0.42,P=0.000）,男性患者和糖尿病患者中CCS明显高于女性患者（590.8±764.5比352.8±336.3,t=2.25,P=0.026）和非糖尿病患者（693.3±912.4比413.0±464.1,t=2.11,P=0.037）。平均随访15个月（3～40个月）,Kaplan-Meier生存分析发现CCS≤300,CCS301～1000和CCS〉1000的患者累积无事件生存率差异有统计学意义（88.2%比81.6%比62.5%,Logrank7.49,P=0.024）。校正了年龄、性别、体重指数、糖尿病、高脂血症、多支病变、是否完全血运重建及PCI并发症后,多因素Cox回归分析显示CCS〉1000的患者发生MACE的风险较CCS≤300的患者增加3.44倍（HR=3.44,P=0.043）。结论 CCS是预测稳定性冠心病患者PCI治疗后发生主要心脏事件的独立危险因子,对慢性稳定性冠心病患者的预后评价具有重要意义。     

Prognostic value of coronary artery calcium score in patients with stable an-gina pectoris after percutaneous coronary intervention

Objectives To evaluate the prognostic value of the coronary artery calcium （CAC） score in patients with stable angina pectoris （SAP） who underwent percutaneous coronary intervention （PCI）. Methods A total of 334 consecutive patients with SAP who underwent first PCI following multi-slice computer tomography （MSCT） were enrolled from our institution between January 2007 and June 2012. The CAC score was calculated according to the standard Agatston calcium scoring algorithm. Complex PCI was defined as use of high pressure bal-loon, kissing balloon and/or rotablator. Procedure-related complications included dissection, occlusion, perforation, no/slow flow and emer-gency coronary artery bypass grafting. Main adverse cardiac events （MACE） were defined as a combined end point of death, non-fatal myo-cardial infarction, target lesion revascularization and rehospitalization for cardiac ischemic events. Results Patients with a CAC score〉300 （n=145） had significantly higher PCI complexity （13.1%vs. 5.8%, P=0.017） and rate of procedure-related complications （17.2%vs. 7.4%, P=0.005） than patients with a CAC score≤300 （n=189）. After a median follow-up of 22.5 months （4-72 months）, patients with a CAC score≤300 differ greatly than those patients with CAC score＆gt;300 in cumulative non-events survival rates （88.9 vs. 79.0%, Log rank 4.577, P=0.032）. After adjusted for other factors, the risk of MACE was significantly higher [hazard ratio （HR）：4.3, 95%confidence inter-val （95%CI）：2.4-8.2, P=0.038] in patients with a CAC score〉300 compared to patients with a lower CAC score. Conclusions The CAC score is an independent predictor for MACE in SAP patients who underwent PCI and indicates complexity of PCI and proce-dure-related complications.     

Relationship of C-reactive protein to adverse cardiovascular events in patients treated by percutaneous coronary intervention for stable angina pectoris

Low-grade inflammation as detected by increased C-reactive protein (CRP) levels predicts the risk of cardiovascular events. However, there is still controversy over the mid-term predictive value of CRP in patients referred for elective percutaneous coronary revascularization (PCI) for stable angina pectoris. The aim of this study was to assess the relationship between baseline CRP level and mid-term outcome of patients undergoing PCI. Two groups of patients with stable angina pectoris were prospectively studied. Group A consisted of 150 consecutive patients with a CRP level < or = 3 mg/L, and group B consisted of 150 consecutive patients with a CRP level > 3 mg/L undergoing PCI at our institution. Comparing both groups of patients, the analysis confirmed a significant difference between medians of the CRP levels (0.5 versus 8 mg/mL; P < 0.001). A higher level of CRP in group B was associated with a lower presence of male gender (P < 0.05) and history of myocardial infarction (P < 0.05). On the other hand, in group B there was higher occurrence of smoking (P < 0.001), hypertension (P < 0.05), hypertriglyceridemia (P < 0.001), and diabetes mellitus (P < 0.01). The incidence of myocardial infarction based on post-interventional release of TnI > 1.5 ng/mL reached 12% in group A and 14% in group B (P = 0.73). Analyses were repeated with adjustment for significant baseline variables, which did not change our findings. The incidence of adverse cardiovascular events during a six month follow-up was 13% in both groups (NS). Increased CRP serum prior to PCI was not associated with the risk and extent of procedure-related myocardial injury measured by TnI release and does not portend heightened cardiovascular risk at six months after percutaneous revascularization. On the other hand, a CRP level > 3 mg/L was associated with a higher occurrence of cardiovascular risk factors (smoking, hypertension, hypertriglyceridemia, and diabetes mellitus).     

Usefulness of intravenous enoxaparin for percutaneous coronary intervention in stable angina pectoris

This pilot study was designed to determine whether the low molecular weight heparin, enoxaparin, could be used for elective percutaneous coronary intervention (PCI) to provide antithrombotic effects without the full systemic anticoagulation that occurs with the use of unfractionated heparin. Sixty patients were randomized to receive intravenous enoxaparin (1 mg/kg bolus dose) or unfractionated heparin at the time of coronary intervention. Laboratory testing was performed at baseline, 5 minutes, and 4 hours after study drug to test if a single bolus dose of intravenous enoxaparin can consistently achieve therapeutic antithrombotic effect, thus eliminating the need for multiple doses of heparin and closely monitoring levels of anticoagulation during PCI. Thirty percent of patients who received unfractionated heparin required a second bolus of intravenous heparin to achieve the target-activated clotting time of 300 seconds before PCI. Enoxaparin showed antithrombotic properties comparable to that of unfractionated heparin as measured by anti-Xa levels, with less inhibition of thrombin (factor IIa) at the time points measured (p <0.0001). Angioplasty success rates, in-hospital ischemia, bleeding, and vascular complications were similar in both groups. Thus, intravenous enoxaparin has predictable and effective antithrombotic effects during elective PCI. Although the level of anticoagulation attained with enoxaparin is significantly lower than that after unfractionated heparin, no increase in ischemic complications were noted. The use of a single bolus of intravenous enoxaparin, without the need for measuring the activated clotting time or titrating heparin anticoagulation, has the potential for simplifying the performance and perhaps enhancing the safety of PCI.     

Comparison of patients undergoing enhanced external counterpulsation and percutaneous coronary intervention for stable angina pectoris

Enhanced external counterpulsation (EECP) has recently emerged as a treatment option for angina in selected patients suitable for revascularization with percutaneous coronary intervention (PCI). We compared baseline characteristics and 1-year outcome in 2 cohorts of PCI candidates presenting with stable symptoms: 323 patients treated with EECP in the International EECP Patient Registry (IEPR), and 448 NHLBI Dynamic Registry patients treated with elective PCI. Compared with patients receiving PCI, IEPR patients had a higher prevalence of many risk factors including prior PCI (53.0% vs 33.3%, p <0.001), prior coronary artery bypass grafting (42.1% vs 18.6%, p <0.001), prior myocardial infarction (56.4% vs 27.8%, p <0.001), history of congestive heart failure (16.8% vs 9.2%, p <0.01), and history of diabetes (37.9% vs 23.5%, p <0.001). Left ventricular ejection fraction was lower among IEPR patients (mean 50.3% vs 59.2%, p <0.001). At 1 year, survival was comparable in the 2 cohorts (98.7% IEPR vs 96.8% PCI, p = NS), as were rates of coronary artery bypass grafting during follow-up (4.5% IEPR vs 5.7% PCI, p = NS). At 1 year, 43.7% of IEPR patients reported no anginal symptoms compared with 73.4% of Dynamic Registry patients (p <0.001). Rates of severe symptoms (Canadian Cardiovascular Society class III, IV, or unstable) at 1 year were 15.5% among IEPR patients and 9.5% in the Dynamic Registry (p = 0.02). PCI candidates suitable for and treated with EECP had 1-year major event rates comparable to patients receiving elective PCI. Although PCI was associated with substantially lower rates of 1-year symptoms, EECP may be a safe treatment option for selected patients with obstructive coronary disease.     

Prognostic implications of renal dysfunction in patients with stable angina pectoris

OBJECTIVE: Impaired renal function is emerging as an independent risk factor for cardiovascular (CV) disease. We analysed the prognostic implications of estimated renal function in patients with angina pectoris. DESIGN: Post hoc analysis of the Angina Prognosis Study In Stockholm (APSIS). The estimated creatinine clearance (eCrCl) was calculated according to the Cockcroft-Gault formula in 808 patients. Outcomes were compared for subgroups with CrCl > or =90, 60-89 and<60 mL min(-1). Setting. Hospital-based study with patients referred from primary care and hospital. SUBJECTS: A total of 809 patients (248 women) with clinically diagnosed stable angina pectoris. Intervention. Double-blind treatment with metoprolol or verapamil. RESULTS: One hundred and sixty-four patients (91 women) had an eCrCl below 60 mL min(-1). During a median follow-up of 40 months, 38 patients suffered CV death and 31 patients had a nonfatal myocardial infarction (MI). In a univariate analysis a lower eCrCl was related to a higher risk for CV death or MI amongst men (log rank P = 0.036). A multivariate Cox analysis showed an independent prognostic importance of eCrCl for CV death (P = 0.046) and for CV death or MI (P = 0.042) amongst all patients. When analysed as a continuous variable, a 1 mL min(-1) decrease in eCrCl was associated with a 1.6% (0.1-3.1) increase in the risk for CV death or MI, and a 2.1% (0-4.1) increase in the risk for CV death alone. CONCLUSION: Renal dysfunction was found to be common in patients with stable angina pectoris and estimated creatinine clearances carried significant independent prognostic information regarding CV death and nonfatal MI.     

Comparison of percutaneous interventions for unstable angina pectoris in patients with and without previous coronary artery bypass grafting

An increasing number of patients who have undergone previous coronary artery bypass grafting (CABG) are referred for percutaneous coronary revascularization. We identified patients who underwent percutaneous intervention for unstable angina from 1990 to 1998 at our institution and assigned them into 2 groups based on whether or not they had undergone previous CABG. There were 1,431 patients with and 4,629 patients without previous CABG. Previous CABG patients were older, had more atherosclerotic risk factors, more heart failure, lower ejection fraction, more multivessel disease, more multilesion treatment, more complex lesions, and less complete revascularization. Adjusting for baseline differences, previous CABG was associated with worse long-term mortality (RR 1.47, 95% confidence intervals [CI] 1.22 to 1.77, p < 0.001) and death, myocardial infarction, and/or revascularization (RR 1.16, 95% CI 1.04 to 1.30, p = 0.01); treatment of native lesions in patients with previous CABG versus treatment of vein graft lesions was associated with a reduction in this composite end point (RR 0.75, 95% CI 0.65 to 0.87, p < 0.001). Post-CABG patients treated between 1995 and 1998 had lower long-term mortality (RR 0.76, 95% CI 0.59 to 0.99, p = 0.04) and death, myocardial infarction, and/or revascularization (RR 0.76, 95% CI 0.66 to 0.88, p < 0.001) compared with those treated between 1990 and 1994. Thus, in patients with unstable angina referred for percutaneous revascularization, previous CABG is associated with reduced event-free survival, although the outcome of post-CABG patients treated from 1995 to 1998 is superior to that observed in patients treated from 1990 to 1994. In patients who underwent previous CABG, treatment of native lesions affords better long-term outcome than vein graft intervention.     

Prognostic value of exercise echocardiography in patients with classic angina pectoris

The role of stress echocardiography in the prognostic evaluation of patients with angina pectoris is not well defined. This study included 437 patients (241 men and 196 women) with angina pectoris and a pretest probability of coronary artery disease (CAD) of > or = 0.7 who were referred for exercise echocardiography. No patient had a history of acute myocardial infarction or coronary revascularization. Mean age was 65 +/- 10 years. During a median follow-up of 2.7 years, hard cardiac events (cardiac death or nonfatal myocardial infarction) occurred in 19 patients and 53 patients underwent coronary revascularization. Event-free survival rates in patients with normal versus abnormal stress echocardiograms were 98% versus 83% at 1 year, 96% versus 75% at 3 years, and 87% versus 69% at 5 years, respectively. In a multivariate analysis of clinical, exercise stress, and echocardiographic parameters, independent predictors of hard cardiac events were Q waves on the electrocardiogram (chi-square 8.7, p = 0.003) and the presence of wall motion abnormalities during exercise in multivessel distribution (chi-square 5.3, p = 0.02). In an incremental model of clinical, exercise, and echocardiographic variables for the prediction of all cardiac events, the addition of echocardiographic data increased the chi-square of the model from 62 to 78 (p = 0.0003). Exercise echocardiography provides useful information in the risk stratification of patients with suspected CAD and a high pretest probability of CAD. Patients with normal exercise echocardiograms have a low event rate and therefore can be exempted from invasive procedures during the 3 years after a normal exercise echocardiogram.     

C反应蛋白水平对不稳定性心绞痛的预后价值

目的：评价C反应蛋白(CRP)对不稳定性心绞痛(UAP)患预后的价值。方法：测定105例UAP患的血清CRP含量，并观察其终点事件的发生。结果：CRP＞3．6mg/L的UAP患其急性心肌梗死、心脏事件发生率明显高于CRP＜3．6mg/L的UAP患(P＜0．01)。结论：血CRP水平升高是不稳定性心绞痛预后的预测因子。     

不稳定型心绞痛患者PCI术后并发抑郁临床分析

目的:探讨抑郁症对不稳定型心绞痛(UAP)患者经皮冠状动脉介入治疗(PCI)后心血管事件的影响。方法:260例UAP患者行PCI术后填写汉密尔顿抑郁量表,按评分分为两组:非抑郁组、抑郁组,随访半年后心血管事件发生率。结果:UAP患者PCI术后并发抑郁发生率为30%,抑郁组心血管事件(UAP,非致死性心肌梗塞,室性心动过速,心源性猝死)发生率显著高于非抑郁组(P均0.05),左室射血分数[(50.38±10.12)%∶(58.13±12.28)%],6min步行距离[(213±5.60)m∶(280±10.32)m]显著低于非抑郁组(P均0.05)。结论:抑郁影响PCI术后患者的预后,临床上应重视患者的心理问题,并进行有针对性的心理干预。     

Outcome of percutaneous coronary intervention in unstable angina pectoris versus stable angina pectoris in two different time periods

Percutaneous coronary intervention (PCI) for unstable angina pectoris (UAP) has traditionally been associated with a higher risk of ischemic complications than that for stable angina pectoris (SAP). However, PCI procedures have evolved, so this study was designed to determine whether PCI for UAP is still associated with less favorable outcomes. In-hospital and 1-year outcomes in Dynamic Registry patients who presented for PCI with UAP (n = 2,994) or SAP (n = 1,457) between 1997 and 2002 were compared. One-year results were also compared with consecutive patients who underwent angioplasty (n = 2,431) from the 1985 to 1986 Percutaneous Transluminal Coronary Angioplasty Registry. Although Dynamic Registry patients with UAP were older and more likely to smoke (p < 0.05), have diabetes mellitus (p = 0.03), or a previous myocardial infarction (p < 0.001), procedural success was higher than in patients with SAP. By 1 year, there was greater risk of death (4.4% vs 2.6%, p < 0.01), death/myocardial infarction (9.9% vs 6.6%, p < 0.001), and death, myocardial infarction, and coronary artery bypass grafting (15.1% vs 11.6%, p < 0.01) in patients with UAP. In patients with UAP, there was no significant difference in adjusted 1-year death and death/myocardial infarction rates when comparing the waves of the Dynamic Registry with those of the Percutaneous Transluminal Coronary Angioplasty Registry, although death/myocardial infarction rates among Dynamic Registry patients were lower. However, in patients with SAP, the adjusted rate for death/myocardial infarction was lower in wave 3, and for death, myocardial infarction, and revascularization, there was a significant decrease in event rates with each successive recruitment period (p < 0.05 for all comparisons). In conclusion, in contradistinction to patients with SAP, death and death/myocardial infarction rates in patients who have undergone PCI for UAP have not significantly decreased over the past 16 years and patients with UAP remain at a greater risk of ischemic events at 1 year compared with patients with SAP.     

The impact of diabetes or elevated fasting blood glucose on cardiovascular prognosis in patients with stable angina pectoris.

AIMS: To examine the influences of diabetes and elevated fasting blood glucose on cardiovascular prognosis in patients with stable angina pectoris. METHODS: In a prospective study of 809 patients with stable angina pectoris randomized to receive metoprolol or verapamil, a subgroup of 69 diabetic patients was compared with non-diabetic patients with respect to the risk of cardiovascular (CV) death, non-fatal myocardial infarction (MI) and revascularization. We also analysed a subgroup of 67 patients with fasting blood glucose > or = 6.1 mmol/l, defined according to the most recent revised guidelines for the diagnosis of diabetes mellitus. Fasting blood glucose was measured in venous whole blood at baseline. RESULTS: The diabetic patients had a greater risk-factor burden, with a higher prevalence of hypertension, more likely to be male, a tendency towards a higher prevalence of previous MI, and higher triglyceride and lower high-density lipoprotein (HDL)-cholesterol levels. In multivariate analyses, diabetes was an independent risk factor for CV events with a relative risk of 2.64 (CI 1.39-5.00; P < 0.001) for CV death/MI, and 1.79 (CI 1.02-3.15; P < 0.01) for revascularization. Blood glucose > or = 6.1 mmol/l without a diagnosis of diabetes mellitus was found in 67 patients, and predicted CV death/MI [relative risk 2.76 (CI 1.97-3.84)] in both univariate and multivariate analyses. The prognosis of diabetic or hyperglycaemic patients did not differ significantly with metoprolol compared with verapamil treatment. CONCLUSIONS: Diabetes mellitus is an independent risk factor for CV death/MI and for revascularization in patients with stable angina pectoris. Elevated fasting blood glucose was seen in 9% of patients without known diabetes and was an equally strong and independent risk factor for CV death/MI as diagnosed and treated diabetes.     

Preconditioning effect during coronary angioplasty in patients with stable angina pectoris

OBJECTIVE: To determine whether collateral recruitment is involved in the preconditioning effect on the electrocardiogram, chest symptoms, and lactate metabolism during coronary angioplasty in patients with stable angina pectoris. METHODS AND PATIENTS: Sixteen patients with stable angina pectoris underwent three consecutive 2-min balloon inflations 5-min apart. The greatest ST elevation (deltaSTmax), the sum of ST elevations in all leads (sum(ST)), and QT dispersion (QTd) were measured at the end of each balloon inflation. Chest pain score was evaluated on a scale ranging from no pain (0) to the most severe pain (10). Lactate extraction ratio (LER) was determined by simultaneous blood sampling from the aorta and the coronary sinus. Collateral flow index (CFI) was derived from simultaneous measurements of mean aortic pressure and coronary wedge pressure obtained from a pressure guidewire during balloon inflation. RESULTS: Significant decreases were noted in deltaSTmax (3.3+/-2.1 vs. 3.0+/-1.9 vs. 2.6+/-1.8 mm, p<0.01), sum(ST) (9.7+/-7.2 vs. 8.5+/-6.1 vs. 6.9+/-5.3 mm, p<0.01), QTd (55.3+/-13.8 vs. 46.9+/-9.0 vs. 42.5+/-10.0 ms, p<0.01), and chest pain score (4.3+/-3.1 vs. 2.8+/-2.6 vs. 1.4+/-1.5, p<0.01) during the three sequential balloon inflations. LER significantly increased (-55.5+/-47.8 vs. -36.7+/-34.3 vs. -19.6+/-26.2%, p<0.01), indicating decreased lactate production. No significant difference was observed in CFI (0.16+/-0.10 vs. 0.15+/-0.10 vs. 0.15+/-0.10). CONCLUSION: Repeated balloon inflations during coronary angioplasty elicited a preconditioning effect on ST-segment shift, QT dispersion, chest pain, and lactate production that does not involve collateral recruitment.     

Usefulness of intravenous enoxaparin for percutaneous coronary intervention in stable angina pectoris

This pilot study was designed to determine whether the low molecular weight heparin, enoxaparin, could be used for elective percutaneous coronary intervention (PCI) to provide antithrombotic effects without the full systemic anticoagulation that occurs with the use of unfractionated heparin. Sixty patients were randomized to receive intravenous enoxaparin (1 mg/kg bolus dose) or unfractionated heparin at the time of coronary intervention. Laboratory testing was performed at baseline, 5 minutes, and 4 hours after study drug to test if a single bolus dose of intravenous enoxaparin can consistently achieve therapeutic antithrombotic effect, thus eliminating the need for multiple doses of heparin and closely monitoring levels of anticoagulation during PCI. Thirty percent of patients who received unfractionated heparin required a second bolus of intravenous heparin to achieve the target-activated clotting time of 300 seconds before PCI. Enoxaparin showed antithrombotic properties comparable to that of unfractionated heparin as measured by anti-Xa levels, with less inhibition of thrombin (factor IIa) at the time points measured (p <0.0001). Angioplasty success rates, in-hospital ischemia, bleeding, and vascular complications were similar in both groups. Thus, intravenous enoxaparin has predictable and effective antithrombotic effects during elective PCI. Although the level of anticoagulation attained with enoxaparin is significantly lower than that after unfractionated heparin, no increase in ischemic complications were noted. The use of a single bolus of intravenous enoxaparin, without the need for measuring the activated clotting time or titrating heparin anticoagulation, has the potential for simplifying the performance and perhaps enhancing the safety of PCI.     

Prognostic value of troponin I after elective percutaneous coronary interventions

BACKGROUND: A mild and asymptomatic increase in the troponin level following elective percutaneous coronary interventions (PCI) has been widely reported, however, the prognostic role of this finding has not yet been well established.Aim. To assess prognostic value of troponin I level increase following elective PCI. METHODS: The study group consisted of 90 consecutive patients who underwent elective PCI in our institution. Troponin I level (normal values <0.1 ug/L) was assessed at baseline and 12 as well as 24 hours after the procedure. In addition, CK-MB level was measured 12 and 24 hours following PCI. Left ventricular (LV) systolic performance was assessed echocardiographically at baseline and after 12 months. The incidence of major adverse coronary events (MACE) during one-year follow-up was also evaluated. RESULTS: An increase in troponin I level >0.1 ug/L was observed in 66 (73%) patients; of whom, 8 patients had a marked (>1.0 ug/L) increase of troponin I, with a concomitant significant elevation of the CK-MB level. Patients with a positive troponin test developed systolic LV abnormalities more often than patients with a normal troponin I level following PCI (p<0.001). There were 10 MACE in the troponin-positive group and 2 in the troponin-negative patients (NS). Seven MACE occurred in patients with marked increase in troponin I level (>1.0 ug/L) which was significantly more often than in the troponin-negative patients (p<0.001). CONCLUSIONS: A mild increase in troponin I level following elective PCI was frequent and did not predict poor outcome, however, was associated with the development of LV systolic impairment. A marked (>1.0 ug/L) increase in troponin I level identified patients at risk of MACE. An increase in troponin I level was similar following various types of PCI.     

Repeat percutaneous coronary angioplasty; clinical and angiographic follow-up in patients with stable or unstable angina pectoris

This study analyses the immediate outcome and the risk of recurrentrestenosis in patients who, at the time of repeat coronary angioplastyfor a first restenosis, had unstable (n = 50), 19%) or stable(n = 218, 81%) angina. Successful angioplasty was accomplishedin 250 (93%) patients, 222 (89%) of whom hadfollow-up angiography.Mean time from initial to repeat angioplasty was shorter (P= 0.0002) and angiographic evidence of thrombus was commoner(P = 0.0001) in the unstable group. Major complications (coronaryartery bypass grafting or myocardial infarction) were morefrequent(P <0.01) in the unstable group (6% vs 0.5%); no procedure-relateddeaths occurred. The angiographic rate of restenosis was significantlyhigher in the unstable group (61% vs 43%, P <0.05). Despitethis high rate of recurrent restenosis, most of the patientsin both groups were either asymptomatic or had atypical chestpain at follow-up. Repeat coronary angioplasty, in patients with unstable angina,has a high primary success rate but a higher risk of acute complicationsthan in patients with stable angina. The angiographic rate ofrestenosis was significantly higher in unstable than in stablepatients, however, the clinical status of most patients wasimproved at follow-up.