Rheumatic fever and rheumatic heart disease in Bangladesh: A review

Rheumatic fever (RF) and rheumatic heart disease (RHD) are the most-common cardiovascular disease in young people aged <25 years, globally. They are important contributors to cardiovascular morbidity and mortality in Bangladesh. Classical risk factors, i.e. poverty, overcrowding, ignorance, and insufficient health care services were responsible for the high incidence and prevalence of these diseases over the last century. In concert with the progresses in socioeconomic indicators, advances in health sectors, improved public awareness, and antibiotic prophylaxis, acute RF came into control. However, chronic RHD continues to be prevalent, and the actual disease burden may be much higher. RHD predominantly affects the young adults, seriously incapacitates them, follows a protracted course, gets complicated because of delayed diagnosis and is sometimes maltreated. The treatment is often palliative and expensive. Large-scale epidemiological and clinical researches are needed to formulate evidence-based national policy to tackle this important public health issue in future.     

Rheumatic Heart Disease and Pregnancy in Nigerian Women

Summary: The early onset of rheumatic fever and rapid progression to severe and incapacitating chronic valve disease, as in other developing tropical countries, has been repeatedly highlighted in Nigeria. Of interest is the fact that the peak frequency of age distribution is in the early child-bearing age. This study was undertaken to evaluate the clinical course of 44 pregnancies in 32 Nigerian women between 16 and 38 years of age (mean 27), with rheumatic heart disease. The patients received careful clinical assessment on follow-up at 1 to 4 week intervals depending on grade of symptoms and stage of gestation. All deliveries were conducted in the hospital and patients were clinically reassessed 6 months after delivery. The key to grading of symptoms was the New York Heart Association functional classification, coordinated with findings on detailed clinical examination. The majority of the cases were gravida 3 but closely followed by primigravidae. Mitral valve disease with dominant incompetence was the commonest valve lesion. Nevertheless, acute pulmonary edema (11 cases), the cause in 2 of the 3 maternal deaths, was the most frequent complication. Congestive heart failure occurred in 7 cases, and infective endocarditis in 4 cases. The only patient with mitral valve prosthesis was on warfarin prophylaxis and had 2 of the 3 stillbirths in the series. On clinical reassessment 6 months later, there was evidence of progression of functional state in 8, and interestingly, more maternal deaths occurred in less than a year. These findings are no doubt related to the presently limited medical facilities, inadequate socioeconomic and public health standards, and the need for health education in the country, and not excluding the seemingly rapid progression of rheumatic heart disease itself. In light of such circumstances, the relevant aspects of the accepted program of management in the more developed temperate countries would need to be meaningfully adjusted and suggestions have been made to this effect.     

Rheumatic heart disease in the developing world: prevalence,prevention, and control

Rheumatic heart disease (RHD) continues to be a common healthproblem in the developing world, causing morbidity and mortalityamong both children and adults. Although little longitudinaldata are available, evidence suggests that there has been littleif any decline in the occurrence of RHD over the past few decades.Recent reports from the developing world have documented rheumaticfever (RE) incidence rates as high as 206/100 000 and RHD prevalencerates as high as 18.6/1000. The high frequency of RHD in thedeveloping world necessitates aggressive prevention and controlmeasures. The major interventions for prevention and controlinclude: (1) reduction of exposure to group A streptococci,(2) primary prophylaxis to prevent initial episodes of RF, and(3) secondary prophylaxis to prevent recurrent episodes of RE.Because recurrent episodes of RE cause increasingly severe cardiaccomplications, secondary prophylaxis is the most crucial featureof an effective RHD programme. For some impoverished countries,secondary prophylaxis may be the only intervention that canrealistically be implemented. In addition to this intervention,however, financial and human resources must be committed, andall of these elements must be integrated into existing primaryhealth care systems. Because RHD continues to be a common healthproblem in the developing world, greater emphasis needs to beplaced on the simple and cost-effective prevention and controlmeasures that are currently available to combat this disablingdisease.     

Notch信号通路在风湿性心脏病炎症相关发病机制中的研究进展

风湿性心脏病是一种以长期、反复发作的风湿性心瓣膜炎导致慢性心瓣膜损害的疾病.炎症在风湿性心脏病的发生和发展中起到了重要作用.通过近年来的研究发现,Notch信号通路与高血压、先天性心脏病如二叶式主动脉瓣、心瓣膜钙化以及室间隔缺损等疾病的发生和发展相关.Notch信号通路与淋巴细胞发育和增殖及炎症过程有密切关系,考虑Notch信号通路在风湿性心脏病的发生和发展中起的重要作用.     

心衰患者心源性猝死的一级预防

心衰患者SCD平均发生率约40％。 本文综述SCD发生率、原因、高危病人的识别及药物治疗对SCD的影响。并且概述ICD在SCD一级预防中的重要性。     

他汀在女性心血管疾病一级预防中的作用

冠心病是发达国家男性和女性的首要死亡原因。低密度脂蛋白胆固醇（LDL-C）升高是重要、独立的心血管危险因素。他汀能够有效地降低LDL-C水平,能够减少心血管发病率和病死率,他汀是冠心病预防策略必不可少的组成部分。但女性患者在一级和二级预防中,他汀处方使用明显不足。一度认为对于女性心脏病的预防,尤其是未诊断为冠心病的女性,无证据证明使用他汀能获益。现回顾他汀在预防女性冠心病中的作用。累积的证据显示,在一些研究中,女性受试者代表性不足,后续统计分析有限。目前的指南对于血管性疾病建议无论男性和女性,血脂异常的处理策略相似。因此,他汀治疗对于男性和女性标准一致,目标也一致。     

风湿性心瓣膜病血栓前状态的研究

目的：对风湿性心瓣膜病血栓前状态进行研究；方法：观察了20例超声心动图发现云雾状回声对比（SEC）与20例血栓形成的风心病患者血管内皮，血小板活性、凝血与抗凝、纤溶系统各种分子标志物的变化；结果：VWF：Ag、GMP－140、血小板聚集活性、AT-Ⅲ：C、t－PA、PA.Ⅰ、D－Dimer均与对照组差异有显著性（P＜0．01），患者两组之间差异亦有显著性；结论：风心病患者在TEE发现SEC时即已出现高凝状态。     

稳心颗粒联合美托洛尔治疗风湿性心脏病换瓣术后频发性室性期前收缩

目的评价美托洛尔联合稳心颗粒治疗风湿性心脏病换瓣术后频发室性期前收缩的临床疗效及安全性。方法将风湿性心脏病换瓣术后频发室性期前收缩患者68例,随机分为两组。两组患者均常规口服美托洛尔,治疗组加服稳心颗粒,每次9g,每日3次,2周为1个疗程。观察两组患者临床症状、24h动态心电图、华法林用量、凝血酶原时间(PT)及国际化标准比值(INR)变化。结果治疗1个疗程后,两组症状及室性期前收缩明显减少。治疗组临床疗效总有效率91.18%,明显高于对照组79.41%(P<0.05),24h室性期前收缩减少总有效率88.23%,明显高于对照组82.35%(P<0.05),且未见严重不良反应。两组治疗前后华法林用量、PT及INR无明显差异(P>0.05)。结论稳心颗粒联合美托洛尔治疗风湿性心脏病术后室性频发早搏疗效明显,优于单用美托洛尔,且对华法林抗凝治疗无明显影响。     

High incidence of rheumatic fever and Rheumatic heart disease in the republics of Central Asia

The epidemiological situation involving rheumatic fever (RF) and rheumatic heart disease (RHD) not only remains unresolved but is also a cause of serious concern due to the rapid increase in the incidence of RF/RHD in many developing countries. After the collapse of the Soviet Union, the republics of Central Asia experienced an economic decline that directly affected the public health sector of this region. This is the main cause of the high prevalence of many infectious diseases in Central Asia, including streptococcal tonsillopharyngitis, which carries the risk of complications such as RF. The difficulty involved in early diagnosis of RF and the development of RHD among children and adolescents causes early mortality and sudden death, leading to economic damage in these countries due to the loss of the young working population. Among all the developing countries, Kyrgyzstan, which is located in the heart of Central Asia, has the highest prevalence of RF/RHD. The increase in the prevalence of RF in Central Asia can be attributed to factors such as the low standard of living and changes in the virulence of streptococci and their sensitivity to antibiotics.     

应用基因微阵列初步研究风湿性心脏病所致心力衰竭的基因表达谱

目的:应用基因微阵列研究分析风湿性心脏病所致心力衰竭(风心病心衰)患者以及正常成人的左心室心肌基因表达谱,筛选出风心病心衰相关靶基因.方法:采用6张人类全基因组微阵列HG U133 Plus 2.0 GeneChip,分别构建风心病心衰患者(实验组n=15)与正常对照组(n=9)的左心室乳头肌基因表达谱.运用GeneSpring软件筛选出两组间差异表达基因,作为风心病心衰相关靶基因,并进行生物信息学分析.采用实时荧光定量多聚酶链反应(Real-time PCR),对其中3个靶基因进行验证.结果:确定102个风心病心衰相关靶基因,并将它们归入7个风心病心衰相关基因群.实时荧光定量多聚酶链反应检测证实,风心病心衰患者左心室心肌内,基因NPPB与IGFBP2明显上调,ATF3明显下调,与基因微阵列实验结果非常吻合,说明基因微阵列实验结果可靠.结论:风心病心衰发生发展过程中存在众多基因表达的改变,全基因组表达谱的研究有助于认识该综合征的发病机制.对风心病心衰相关靶基因的深入研究,有助于揭示该综合征发病学上的遗传标志以及分子机制.     

Novel and Emerging Therapeutics for Primary Prevention of Cardiovascular Disease

Cardiovascular disease is responsible for 205 deaths per 100,000 persons annually and is the leading cause of death worldwide. The public health burden of cardiovascular disease is expected to continue to grow as the prevalence of many cardiovascular risk factors increases. Several novel classes of glucose-lowering, lipid-lowering, and weight-loss therapeutics have shown mortality benefits in outcomes trials. However, a large proportion of subjects in those trials had established cardiovascular disease, so, as a result, the role of these novel therapeutics in primary cardiovascular prevention is controversial. In this review, we highlight recent advances in the pharmacotherapeutic management of the cardiovascular risk factors of hyperglycemia, dyslipidemia, and obesity. We examine key subgroups within recent cardiovascular outcome trials, weigh the risks and benefits of several novel therapeutics, and provide practical insight into the use of these agents. Our article concludes with a look toward the future and provides the practitioner and scientist with an early view of emerging therapeutics that may play an important role in primary cardiovascular prevention.     

血脂康调整血脂对冠心病的二级预防研究

目的:研究血脂康调整血脂对冠心病的二级预防作用。方法:采用双盲、随机、安慰剂对照长期随访临床试验,研究时间从1997年至2003年,对97例血清总胆固醇(TC)水平在4．40～6．47 mmoL／L(170～250 mg/dl)之间、年龄18～75岁,有明确心肌梗死的冠心病患者分为血脂康组(49例),安慰剂组(48例),主要终点为冠心病事件(包括非致死性心肌梗死和冠心病死亡)。次要终点为总死亡。同时观察血脂变化。结果:冠心病事件和总死亡在血脂康组发生率分别为4．25％和6．12％,在安慰剂组发生率分别为18．75％与20．83％。两组冠心病事件和总死亡率分别比较,差异均有统计学意义,P<0．05。调脂治疗后,血脂康组TC、甘油三酯(TG)、低密度脂蛋白胆固醇分别降低19．04％、13．76％、25．52％;对照组TC、TG、低密度脂蛋白胆固醇分别降低3．21％、4．57％、1．21％;血脂康组高密度脂蛋白胆固醇升高4．35％,安慰剂组升高1．77％,两组间各指标比较均有统计学差异。在临床不良反应和实验室指标异常方面,血脂康组和安慰剂组间差异无统计学意义。结论:与安慰剂组比较,血脂康能显著降低冠心病心肌梗死患者的冠心病事件与总死亡的发生率。     

芦沙坦联合胺碘酮对风湿性心脏病心功能的改善作用研究

目的比较芦沙坦与胺碘酮联合应用与常规治疗对风湿性心脏病患者心功能方面的影响。方法选择2006年1月—2010年9月收治的86例风湿性心脏病患者,按照患者意愿,随机分为对照组（常规治疗,41例）和观察组（常规治疗＋芦沙坦＋胺碘酮,45例）;每个阶段各治疗8周,期间有2周的洗脱期,后观察各组对心脏功能的改善效果。结果观察组在3个月后随访观察,45例患者的心室率控制较为满意,有效率达到100%（45/45）,对照组的有效率为73.17%（30/41）,两组比较有显著性差异;观察组的心功能分级、血压以及心率值与对照组比较,差异有统计学意义,观察组治疗前后风湿性心脏病疗效比较差异显著。结论对于风湿性心脏病患者来说,在常规的治疗上采用芦沙坦联合胺碘酮来控制患者的心室率及改善心脏的功能具有显著性意义,值得临床上应用。     

Prospective comparison of clinical and echocardiographic diagnosis of rheumatic carditis: long term follow up of patients with subclinical disease

OBJECTIVE—To determine the frequency of occurrence and long term evolution of subclinical carditis in patients with acute rheumatic fever.
DESIGN—Valvar incompetence was detected by clinical examination and Doppler echocardiographic imaging during the acute and quiescent phases of rheumatic fever. Patients were followed prospectively and submitted to repeat examinations at one and five years after the acute attack. Persistence of acute mitral and aortic lesions detected solely by echocardiography (subclinical disease) was compared with that of disease detected by clinical examination as well (thereby fulfilling the latest 1992 Jones criteria for rheumatic carditis).
SETTING—Three general hospitals with a university affiliation in Chile.
PATIENTS—35 consecutive patients fulfilling the revised Jones criteria for rheumatic fever. Clinical and echocardiographic examination was repeated in 32 patients after one year and in 17 after five years. Ten patients had subclinical carditis on admission, six of whom were followed for five years.
MAIN OUTCOME MEASURES—Auscultatory and echocardiographic evidence of mitral or aortic regurgitation during the acute attack or at follow up.
RESULTS—Mitral or aortic regurgitation was detected by Doppler echocardiographic imaging in 25/35 rheumatic fever patients as opposed to 5/35 by clinical examination (p = 0.03). Doppler echocardiography revealed acute valvar lesions in 10 of 20 rheumatic fever patients who had no auscultatory evidence of rheumatic carditis (subclinical carditis). Three of these subclinical lesions and three of the clinical or auscultatory lesions detected on admission were still present after five years of follow up, emphasising that subclinical lesions are not necessarily transient.
CONCLUSIONS—Doppler echocardiographic imaging improves the detection of rheumatic carditis. Subclinical valve lesions, detected only by Doppler imaging, can persist. Echocardiographic findings should be accepted as a major criterion for the diagnosis of rheumatic fever.


Keywords: rheumatic heart disease; rheumatic fever; echocardiography; carditis     

风湿性心脏病慢性心房颤动迷宫和二尖瓣手术围术期的血液动力学监测

采用Ｓｗａｎ－Ｇａｎｚ漂浮导管，对１４例同时行迷宫和二尖瓣手术的风湿性心脏病慢性心房颤动（简称房颤）患者在术前和术后２４ｈ、４８ｈ及１个月进行血液动力学监测。结果：①术后２４ｈ、４８ｈ、１个月的心输出量（ＣＯ）、心脏指数（ＣＩ）、每搏指数（ＳＩ）、体循环阻力指数（ＳＶＲＩ）、左室每搏作功指数（ＬＶＳＷＩ）和右室每搏作功指数（ＲＶＳＷＩ）与术前比较差异有显著性（Ｐ＜０．０５～０．０００１）。②心率（ＨＲ）、平均动脉压（ＭＡＰ）、平均肺动脉压（ＭＰＡＰ）、肺动脉毛楔压（ＰＡＷＰ）、中心静脉压（ＣＶＰ）、左心作功指数（ＬＣＷＩ）、肺循环阻力指数（ＰＶＲＩ）、右心作功指数（ＲＣＷＩ）等，术后与术前以及不同时间之间比较均无统计学意义，Ｐ＞０．０５。③ＭＰＡＰ、ＰＡＷＰ、ＣＯ、ＣＩ、ＳＩ、ＳＶＲＩ、ＬＶＳＷＩ的异常发生率术后１个月与术前比较有显著性差异，Ｐ＜０．０５、＜０．０１或＜０．０００１。迷宫术后ＣＯ较术前明显提高，左房压力恢复正常，肺血管压力降低。以上表明风湿性心脏病慢性房颤迷宫和二尖瓣术后ＣＯ、左心功能均有明显改善，无围术期死亡和严重并发症，提示血液动力学监测对及时了解泵功能状态、指导治疗和评价手术疗效是非常?     

干细胞治疗缺血性心脏病的主要问题

干细胞治疗是缺血性心脏病治疗的一种新的治疗策略,是心血管疾病治疗研究的前沿。国内外大量研究显示出细胞移植能够修复受损心肌,减少梗死面积,改善心脏功能。但目前细胞治疗仍处于早期阶段,各种问题尚待解决,如种子细胞类型的选择、细胞分化、梗死区细胞存活、最佳移植途径、安全性等问题还需深入探讨。为此,现总结前期干细胞治疗基础及临床研究结果,就目前存在的问题进行阐述。