药物涂层材料对支架置入后血管内再狭窄的影响

目的：评价不同材质的血管内支架置入的安全性,分析不同血管内支架材料置入后抗凝血性、耐腐蚀性和生物相容性的变化。 方法：以计算机检索方法在检索中国期刊全文数据库中(CNKI：2002/2007)检索关于不同血管内支架材料置入后抗凝血性、耐腐蚀性和生物相容性的变化的自身前后对照实验,检索词为“血管内支架、药物涂层材料、再狭窄”。检索后对每项研究的资料结果进行提取、分析。 结果：共有19项实验2 731例血管内支架置入患者符合纳入标准,血管内支架置入后血管脉狭窄率均较术前降低,随访结果显示药物涂层支架较金属裸支架能明显减低再狭窄率,支架形态良好,无变形,支架处血流通畅,无血管内再狭窄发生。同时对比得出血管内支架置入后的炎症过程的激活对血管内皮的增生与再狭窄起着重要作用。 结论：血管内支架置入治疗动静脉狭窄的成功率高,具有很好的临床效果,特别是药物涂层支架能够显著降低血管内再狭窄的发生率,临床应用安全有效。但由于纳入试验少,证据的强度不足,其他有效性指标和安全性,有待更多证据加以评价。     

冠状动脉药物涂层支架与置入后的血管再狭窄

背景：近年来随着药物涂层支架研究的增多及临床应用不断扩大，使冠状动脉内支架置入后再狭窄率显著降低，且在预防再狭窄中较裸支架具有独特应用价值。 目的：阐述药物涂层支架的临床应用进展，并探讨支架的涂层材料、类型与置入后再狭窄的关系及与宿主的相容性。 方法：作者以“冠脉支架，金属支架，药物涂层支架，再狭窄”为检索词，在中国期刊全文数据库及Medline 数据库中，采用电子检索的方式进行文献检索。排除Meta分析及重复性研究，共检索到27篇文献。 结果与结论：药物涂层支架的确是介入心脏病学的一项重要突破，使介入心脏病学进入了一个新的时代，但其远期效果仍需进一步观察。各种药物涂层支架所含药物或含量不同，其作用机制不同，而且药物释放的速率也不同，所以药物涂层支架临床应用后的效用和安全性需要由严谨和大量的临床研究来证实。现今药物支架的载体材料经过长时间的人体腐蚀，材料本身会老化、脱落，在血管组织内形成小块，从而可能引起晚期的不良反应。如果采用生物可降解的材料作为药物载体材料，那么就有可能减少晚期不良反应的出现。因此，开发一种理想的支架系统，目前主要的研究方向是可降解的低致炎性聚合物材料以及高效的药物控释体系。     

冠状动脉支架置入后：糖化血红蛋白与再狭窄的关系

背景：众多基础和临床研究表明，多种因素参与了冠状动脉支架内再狭窄的形成，支架内再狭窄除与支架本身有关，吸烟、糖尿病和不稳定心绞痛等更是触发再狭窄的重要预测因素。糖化血红蛋白为糖尿病疗效评定的监测指标以及微血管病变的生化标志。 目的：分析冠状动脉支架置入后支架内再狭窄与糖化血红蛋白的关系。 方法：将36例成功接受支架置入治疗的冠状动脉粥样硬化性心脏病患者，根据糖化血红蛋白和空腹血糖水平分为3组：糖化血红蛋白与空腹血糖均正常组(n=11)、糖化血红蛋白正常而空腹血糖升高组(n=15)、糖化血红蛋白与空腹血糖均升高组(n=10)。支架置入后患者因胸痛再发或常规行冠脉造影随访，以原靶病变管腔直径狭窄≥ 50%为支架内再狭窄，对照分析糖化血红蛋白对冠状动脉再狭窄的影响。 结果与结论：36例患者中，7例发生冠状动脉内再狭窄，占19%，其中糖化血红蛋白与空腹血糖均正常组中有1例发生再狭窄，糖化血红蛋白正常而空腹血糖升高组中2例发生再狭窄，糖化血红蛋白与空腹血糖均升高组中有4例发生再狭窄。糖化血红蛋白与空腹血糖均升高组中冠状动脉内再狭窄比率明显高于其他两组(P < 0.05)。回归分析显示糖化血红蛋白升高是冠状动脉支架置入后再狭窄的重要因素之一，测定糖化血红蛋白可进一步评估冠脉支架置入后再狭窄的风险。 关键词：冠状动脉疾病；支架置入；支架内再狭窄；糖化血红蛋白；再狭窄 doi:10.3969/j.issn.1673-8225.2010.29.022     

冠状动脉支架置入后相关炎症因子的变化及其干预

背景：冠状动脉粥样硬化性心脏病支架置入治疗后的炎症反应以及其严重程度与再狭窄明显存在相关性,医学工作者试图从中寻找新思路预防支架置入后再狭窄,提高治疗质量。 目的：评价各种干预措施以及监测手段在冠状动脉置入术后炎症治疗中的应用价值和临床前景。 方法：电子检索EMbase(1980-01/2011-05),MEDLINE(1966-01/2011-05),中国生物医学文献数据库(CBM,1978/2011-05)和中国期刊全文数据库(CNKI),筛查相关文章的参考文献。中文检索词“冠状动脉支架,炎症因子,炎症,CRP,再狭窄”,英文检索词为“Coronary stent,inflammatory cytokines,inflammation,CRP,restenosis”。 结果与结论：临床试验结果显示支架置入后炎症反应明显加重,使用雷帕霉素药物洗脱支架,添加地塞米松、塞来昔布、瑞舒伐他汀等可更大程度上降低支架置入后炎症反应。动物试验发现使用雷帕霉素洗脱支架可减少支架置入段新生内膜的形成和缩小炎症面积。提示各种干预措施可降低支架置入后炎症反应从而降低远期再狭窄的发生,可进一步改良加以应用于临床观察其疗效。     

药物涂层支架防治冠脉血管内再狭窄的研究进展

目的：通过对目前研究和应用较为广泛的药物涂层支架进行讨论,进而探讨药物涂层支架对防治冠脉血管内再狭窄的作用。 方法：应用计算机检索PubMed (1993/2009)和中国期刊全文数据库(CNKI：1993/2009),按纳入和排除标准,对文献进行筛选和质量评价。从目前最常用的雷帕霉素涂层支架和紫杉醇涂层支架防治冠脉血管内再狭窄的临床应用,讨论药物涂层支架在防治冠脉血管内再狭窄中的应用进展与存在的问题。 结果：药物涂层支架可以很好地减少支架后血管内再狭窄的发生,但在临床应用中仍然存在着贴壁不良、支架断裂等其他问题。 结论：药物涂层支架防治冠脉血管内再狭窄的有效性和安全性均较良好。但是药物涂层支架存在的一系列问题有待于进一步研究解决。     

国产生物可降解聚合物支架与进口永久聚合物支架在冠状动脉血运重建中的对比

背景：雷帕霉素洗脱支架是冠状动脉支架置入后再狭窄的有效防治措施,是国产和进口支架材料会有什么区别吗？ 目的：比较新型国产EXCEL生物可降解聚合物雷帕霉素洗脱支架与进口Cypher永久聚合物雷帕霉素洗脱支架的疗效和安全性。 方法：回顾性分析259例冠状动脉心病患者临床资料,根据置入支架的不同分为两组进行比较观察：EXCEL支架组(n=130)：置入新型国产生物可降解聚合物雷帕霉素洗脱支架;Cypher支架组(n=129)：置入进口永久聚合物雷帕霉素洗脱支架。 结果与结论：256例患者完成随访,失访者3例,其中EXCEL支架组1例, Cypher支架组2例,失访率为1%。两组患者各有2例发生急性和亚急性血栓,Cypher支架组患者有3例发生晚期血栓。两组之间比较差异无显著性意义(P > 0.05)。随访期间未发生支架内再狭窄。置入后18个月无主要不良心脏事件生存率为98.8%,置入后亚急性血栓发生率1.56%。提示,EXCEL生物可降解聚合物雷帕霉素洗脱支架与Cypher永久聚合物雷帕霉素洗脱支架在冠状动脉血运重建方面的近期及远期各项指标差异无显著性意义,两者均是安全可靠的。     

冠状动脉支架材料类型与置入后的效果评价

目的：冠状动脉内支架有金属裸支架、药物涂层支架、生物降解支架以及新型支架如放射性血管支架、静脉覆盖支架和基因支架等多种。如何选择适宜的支架，以取得最佳的治疗效果，是目前医学界研究的热点。 目的：阐述冠状动脉支架的临床应用进展，并探讨冠状动脉支架置入后的治疗效果。 方法：作者以“冠状动脉内支架，金属裸支架，药物涂层支架，生物降解支架，心血管新型支架，凝血系统，炎症反应”为检索词，在中国期刊全文数据通信(CNKI：2002/2010)中，采用电子检索的方式进行文献检索。排除Meta分析及重复性研究，共检索到27篇文献，从冠状动脉支架的种类、研究进展及其生物相容性，冠状动脉支架置入后凝血系统的变化，以及冠状动脉支架置入后炎症反应等方面进行探讨。 结果：①不论是金属裸支架、药物涂层支架、生物可降解支架以及新型支架，其支架材料的改进更新均以改善生物相容性和生物力学性能为目标。②心血管支架的生物相容性是一个复杂的连锁过程，血液相容性和组织相容性是评定生物相容性的两项基本内容。③利用有限元分析心血管支架材料的力学特性可为未来支架的优化设计提供有益的帮助。 结论：现行的心血管支架尚未完全解决生物相容性问题，理想的心血管支架还有待进一步的深入开发与研究。 关键词：冠状动脉内支架；金属裸支架；药物涂层支架；生物降解支架；心血管新型支架；凝血系统；炎症反应 doi:10.3969/j.issn.1673-8225.2010.25.041     

冠状动脉内支架置入在老年冠状动脉粥样硬化性心脏病治疗中的应用价值

用冠状动脉内支架置入来重建血运,对一些药物治疗适应证和疗效均有限制、冠状动脉旁路移植风险高的老年冠状动脉粥样硬化性心脏病患者是一种较好的治疗方式。裸金属支架和药物涂层支架置入均具有预防支架内再狭窄的作用,近年来已广泛应用于各种类型冠状动脉粥样硬化性心脏病和不同程度冠状动脉病变,并明显减少了支架置入后再狭窄的发生率。文章针对老年冠状动脉粥样硬化性心脏病特点、冠状动脉内支架置入对老年冠状动脉粥样硬化性心脏病的疗效、安全性及生物相容性等方面进行探讨,证实冠状动脉内支架置入在治疗老年冠状动脉粥样硬化性心脏病上是可行的,也是安全的,并具有较好疗效。     

血管内超声与冠状动脉造影在冠状动脉支架置入中的应用比较

目的：冠状动脉支架置入已成为治疗冠状动脉狭窄性病变的主要方法,支架治疗策略的选择成为主要技术问题,文章对冠脉造影后的血管狭窄分析和血管内超声成像的血管分析应用效价进行探讨。 方法：根据文献报道对冠状动脉造影血管狭窄分析及血管内超声在冠脉支架置入前后的应用,结合南昌大学第二附属医院冠状动脉支架置入前后的血管造影及血管内超声的应用进行对比分析。 结果：冠状动脉造影对支架置入前后的影像学造影检查,只能观其血管外壁形态、血流变化。对管腔黏膜病变情况、内支架贴壁情况,支架是否完全对称性扩张,以及支架对病变段的覆盖情况,不能精确显示。血管内超声对靶血管的狭窄程度、血管内斑块及黏膜病变情况能够精确实时显示,可实时显示支架是否完全扩张,支架扩张是否均匀对称,支架对血管壁斑块的挤压支撑情况如何。 结论：血管内超声在冠脉支架置入前后的应用,较冠状动脉造影更能全面的评价血管内病变情况,对支架的选取策略及支架释放后的评价与指导,防止血管内再狭窄具有重要的意义。     

西罗莫司与紫杉醇洗脱支架置入后支架内血管再狭窄发生率的比较

经皮冠状动脉腔内成形治疗已成为冠状动脉粥样硬化性心脏病血管重建的重要手段，但其主要问题是会造成支架置入后发生再狭窄。药物洗脱支架的临床应用，使再狭窄发生率显著降低，西罗莫司洗脱支架和紫杉醇洗脱支架是目前世界市场上主流的2种药物洗脱支架，西罗莫司洗脱支架在预防血管内再狭窄、降低靶病变血运重建率方面表现优于紫杉醇洗脱支架。随着临床研究的不断深入，有关药物洗脱支架置入后再狭窄发生率的问题将逐渐得到满意的解答。     

心血管支架材料生物力学及生物相容性特征

目的：分析心血管支架材料的特点和植入后生物力学与生物相容性的研究现状。 方法：检索Pubmed数据库和中国期刊全文数据库文献，然后对资料进行初审，选取包括心血管、冠状动脉、支架材料、生物相容性的文献开始查找原文，并查看文献后的引文文献。纳入标准：文章所述的内容为心血管支架材料及其生物相容性的研究；以近5年且发表在较权威的杂志者优先。排除标准：重复的研究或Meta分析类文章。 结果：①心血管支架中不论是金属裸支架、药物涂层支架和生物可降解支架，其支架材料的改进更新均以改善生物相容性和生物力学性能为目标。②心血管支架的生物相容性是一个复杂的连锁过程，血液相容性和组织相容性是评定生物相容性的两项基本内容。③利用有限元分析心血管支架材料的力学特性可为未来支架的优化设计提供有益的帮助。 结论：现行的心血管支架尚未完全解决生物相容性问题，理想的心血管支架还有待进一步的深入开发与研究。     

Association between ADAMTS13 polymorphisms and risk of cardiovascular events in chronic coronary disease

Introduction

Association between ADAMTS13 levels and cardiovascular events has been described recently. However, no genetic study of ADAMTS13 in coronary patients has been described.

Materials and Methods

Based on related populations frequencies and functional studies, we tested three ADAMTS13 polymorphisms: C1342G (Q448E), C1852G (P618A) and C2699T (A900V) in a group of 560 patients enrolled in the Medical, Angioplasty, or Surgery Study II (MASS II), a randomized trial comparing treatments for patients with coronary artery disease (CAD) and preserved left ventricular function. The incidence of the 5-year end-points of death and death from cardiac causes, myocardial infarction, refractory angina requiring revascularization and cerebrovascular accident was determined for each polymorphim's allele, genotype and haplotype. Risk was assessed with the use of logistic regression and Cox proportional-hazards model and multivariable adjustment was employed for possible confounders.

Results

Clinical characteristics and received treatment of each genotype group were similar at baseline. In an adjusted model for cardiovascular risk variables, we were able to observe a significant association between ADAMTS13 900V variant and an increased risk of death (OR: 1,92 CI: 1,14-3,23, p = 0,015) or death from cardiac cause (OR:2,67, CI: 1,59-4,49, p = 0,0009). No association between events and ADAMTS13 Q448E or P618A was observed.

Conclusions

This first report studying the association between ADAMTS13 genotypes and cardiovascular events provides evidence for the association between ADAMTS13 900V variant and an increased risk of death in a population with multi-vessel CAD.     

Fatigue, depressive symptoms, and hopelessness as predictors of adverse clinical events following percutaneous coronary intervention with paclitaxel-eluting stents

OBJECTIVE: We investigated the relative effects of fatigue, depressive symptoms, and hopelessness on prognosis at 2-year follow-up in percutaneous coronary intervention (PCI) patients. METHODS: Consecutively admitted PCI patients (n=534) treated with paclitaxel-eluting stent as the default strategy completed the Maastricht Questionnaire (MQ) at baseline. Apart from an overall vital exhaustion score, the MQ also assesses fatigue (seven items; Cronbach's alpha=.87) and depressive symptoms (seven items; Cronbach's alpha=.83), with hopelessness (one item) comprised in the depressive symptom items. Patients were followed up for adverse clinical events (mortality and nonfatal myocardial infarction) at 2 years. RESULTS: At 2-year follow-up, there were 31 clinical events. In univariable analyses, overall vital exhaustion and depressive symptoms, but not fatigue, were associated with adverse prognosis; in multivariable analysis, depressive symptoms [hazard ratio (HR)=2.69; 95% confidence interval (95% CI)=1.31-5.55] remained the only predictor of clinical outcome. Among the depressive symptoms, hopelessness (HR=3.44; 95% CI=1.65-7.19) was the most cardiotoxic symptom. The incidence of clinical events was higher in the high-hopelessness patients (11% vs. 3%; P=.001) than in the low-hopelessness patients. Hopelessness (HR=3.36; 95% CI=1.58-7.14; P=.002) remained an independent predictor of clinical outcome at 2 years in adjusted analysis. CONCLUSION: Symptoms of depression, but not fatigue, predicted adverse clinical events. Hopelessness was the most cardiotoxic symptom, associated with a more than three-fold risk of clinical events 2 years post-PCI. Screening for hopelessness may lead to the identification of high-risk patients.     

Association between platelet P2Y12 haplotype and risk of cardiovascular events in chronic coronary disease

INTRODUCTION: A positive association was recently described between P2Y12 platelet receptor H1 and H2 haplotypes and peripheral artery disease. We tested the described P2Y12 receptor haplotypes in a group of patients with coronary artery disease. STUDY DESIGN AND METHODS: The P2Y12 platelet receptor H1 and H2 haplotypes was tested in a group of 540 patients enrolled in the Medical, Angioplasty, or Surgery Study II (MASS II), a randomized trial comparing treatments for patients with coronary artery disease (CAD) and preserved left ventricular function. After a 3-year follow-up period, the incidence of the composite end point of cardiac death, myocardial infarction, and refractory angina requiring revascularization was determined in the H1/H1, H1/H2 and H2/H2 haplotype groups. We used Student's t-test and the chi-square test to analyze the differences among groups and Kaplan-Meier method to calculate survival curves. Risk was assessed with the use of a Cox proportional-hazards model. RESULTS: The frequency of haplotypes among studied patients were 410 (75.9%) H1/H1, 119 (22.0%) H1/H2 and 11 (2.1%) H2/H2. The baseline clinical characteristics, mean clinical follow-up time and received treatment of each genotype group were similar. We did not disclose any association between haplotype groups regarding the incidence of any of the studied cardiovascular end-points. CONCLUSION: This is the first report studying the association of P2Y12 platelet receptor H1 and H2 haplotype and cardiovascular events. Our findings do not provide evidence for a strong association between H1/H1 and H1/H2 haplotypes and a increased risk of cardiovascular events in a population with CAD. Future works should address the role of the H2/H2 haplotype as a genetic marker for cardiovascular events.     

不同种类冠状动脉支架生物相容性与置入后血管再狭窄

目前，冠状动脉支架已广泛应用于临床，它可明显改善经皮腔内冠状动脉成形术引起的急性闭塞并发症以及血管再狭窄。但支架置入同样面临再狭窄的问题，尤其是复杂病变更易形成再狭窄。研究证实，血栓、炎症和平滑肌增生是支架再狭窄的3个重要阶段，其中血管内膜增生是再狭窄的最主要机制。文章通过检索文献总结了金属支架、药物洗脱支架的生物相容性及置入后再狭窄，分析了支架置入对侧支循环功能及炎性反应的影响，并探讨了生物可降解支架的应用。     

Multiple electrode aggregometry and vasodilator stimulated phosphoprotein-phosphorylation assay in clinical routine for prediction of postprocedural major adverse cardiovascular events

Reduced antiplatelet effect of clopidogrel assessed with multiple electrode aggregometry (MEA) and vasodilator stimulated phosphoprotein-phosphorylation (VASP-P) assay has been proven to predict major adverse cardiovascular events (MACE) after coronary stenting. So far no consecutive registry has evaluated the usefulness of different adenosine diphosphate-based platelet function tests to predict outcome in unselected patients. Hence, our objective was to determine the feasibility of MEA and VASP-P for clinical routine and whether low-response to clopidogrel as determined by MEA and/or the VASP-P assays predicts MACE in a "real-life" population undergoing coronary stenting. Three-hundred consecutive patients were included in this prospective registry. Blood was sampled 6-24 hours after stenting to measure MEA and VASP-P. The use of glycoprotein-IIb/IIIa-blockers limited MEA to 196 measurements. Concerning the VASP-P assay, 300 measurements were achieved. Receiver Operating Characteristics (ROC)-curves of sensitivity and specificity estimates for MACE were plotted for VASP-P assay. The area under the ROC-curve was 0.683 (p=0.014) for the platelet reactivity index (PRI) calculated from median fluorescence intensities (FI) with an optimal cut-off at 60.2% PRI. Patients above 60.2% had a significantly increased risk for MACE at six months follow-up (p=0.007). Estimating the cut-offs for the PRI from mean FI (52%) or from geometric mean FI (56.6%) led to clinically relevant differences. VASP-P assay is feasible for clinical routine to measure clopidogrel effects and to predict post-procedural MACE in unselected patients. With regard to differing cut-offs, exact standardisation of the VASP-P assay is mandatory. The use of GP-IIb/IIIa-blockers prevents MEA testing and limits its usability in unselected patients.