胸痛患者冠状动脉造影术前心理状态研究

目的观察胸痛及冠心病患者的心理状态及其临床意义。方法横断面研究。采用整群抽样法,对在我院进行冠状动脉造影术（CAG）检查的99例胸痛患者术前使用汉密尔顿焦虑量表（HAMA）、汉密尔顿抑郁量表-17项（HAMD-17）进行心理状态评估,观察冠心病和非典型胸痛患者CAG术前焦虑抑郁等情绪改变;同时,结合CAG结果,比较CAG阳性与阴性患者在一般情况和心血管危险因素方面的差异。结果99例患者中术前有焦虑症状者44例,占44．4％;有抑郁症状者18例,占18．2％;既有焦虑又有抑郁者16例,占16．2％。CAG检查阳性者46例,阴性者53例,CAG阴性率53．5％。CAG阴性组焦虑症状较CAG阳性组更明显（HAMA平均分：14．1±7．2比11．1±6．7,P〈0．05）。CAG阴性组具有女性多,传统心血管病危险因素少,焦虑水平高等特点。结论冠心病和非典型胸痛的患者均具有较高的焦虑、抑郁症状发生率。     

Diurnal variation of soluble E- and P-selectin, and intercellular adhesion molecule-1 in patients with and without coronary artery disease

BACKGROUND: The more frequent onset of acute coronary syndromes (ACS) in the morning has been known for a long time. Diurnal changes of fibrinolysis such as lower activity of tissue plasminogen activator and higher activity of plasminogen activator inhibitor-1 (PAI-1) in the morning has been demonstrated previously and correspond with the manifestation of ACS. Less is known about the diurnal variation of soluble adhesion molecules as markers of endothelial or platelet activity in patients with coronary artery disease (CAD). PATIENTS AND METHODS: 80 patients with a history of myocardial infarction and/or chest pain with positive exercise testing admitted for elective coronary angiography were studied. 10 had normal findings on coronary angiography (control group), 70 patients had at least one or more stenoses >/=50% of the diameter of an epicardial vessel. None of the patients suffered from acute inflammation, connective or tumor disease. Blood samples were drawn at 7:00 a.m. and at 7:00 p.m. at rest and plasma concentration of soluble P-selectin (sP-selectin), E-selectin (sE-selectin), intercellular adhesion molecule-1 (sICAM-1) and acute-phase proteins were measured by ELISA. RESULTS: In both groups, no diurnal variation was found in sE-selectin and sICAM-1. sP-selectin levels were significantly higher in the evening (CAD group: 149.8 +/- 54.5 vs. 172.2 +/- 68.8 ng/ml, p < 0.001; control: 148.7 +/- 75.5 vs. 187.5 +/- 96.3 ng/ml, p = 0.001, Wilcoxon test). CONCLUSION: We have demonstrated diurnal variation of sP-selectin in patients with CAD. We conclude that high sP-selectin values in the evening represent the shed forms of the morning membrane-bound P-selectin.     

Predictors of circulating endothelial progenitor cell levels in patients without known coronary artery disease referred for multidetector computed tomography coronary angiography

IntroductionEndothelial progenitor cells (EPCs) have an important role in vascular repair. Levels in peripheral circulation are thought to be related to overall cardiovascular risk and may represent potential therapeutic targets. The aim of this work is to identify predictors of circulating EPC concentrations in patients without known coronary artery disease (CAD).MethodsThe study population consisted of 215 patients without known CAD referred for multidetector computed tomography (MDCT) coronary angiography (CTA) during a 6-month period. All patients underwent: 1) short anamnesis; 2) anthropometric measurements; 3) blood pressure and heart rate assessment; 4) blood tests; and 5) MDCT (including quantification of visceral fat, quantification of coronary artery calcification [CAC] and CTA).ResultsThe patients’ mean age was 58 ± 11 years (26–84) and 61% were male. Dyslipidemia (59%) and hypertension (57%) were the most prevalent risk factors. Twenty-seven percent met the ATP III criteria for metabolic syndrome. Mean Framingham risk score was 12 ± 9%. Sixty-seven percent had no significant CAD but 64% had some degree of coronary calcification. The mean CAC (Agatston) was 186 ± 433.Mean EPC concentration, expressed as a percentage of total white blood cells, was 0.05 ± 0.08% (0.0–0.58%). EPCs were inversely related to the presence of diabetes mellitus and smoking, and positively related to C-reactive protein. No significant correlations were found between EPCs and other risk factors, measurements of adiposity, atherosclerotic burden or severity of CAD.ConclusionIn patients without known CAD referred for MDCT, EPC levels in peripheral blood cannot be significantly estimated or predicted from knowledge of patient anamnesis, risk factors, visceral fat, CAC or CTA.     

Prevalence of obstructive coronary artery disease in patients with and without prior stroke undergoing coronary angiography for suspected coronary artery disease

This study was conducted to investigate the prevalence and severity of obstructive coronary artery disease (CAD) in 64 men and 38 women (mean age 71+/-9 years) with previous stroke and in 102 age- and gender-matched patients with similar coronary risk factors without previous stroke who underwent coronary angiography for chest pain. Obstructive CAD was present in 100 of 102 patients (98%) with previous stroke and in 84 of 102 (82%) patients without previous stroke (p<0.001). Obstructive 3-vessel CAD was present in 56 of 102 patients (55%) with previous stroke and in 35 of 102 patients (34%) without previous stroke (p<0.005). The prevalence of 2-vessel CAD and of 1-vessel CAD was not significantly different between patients with and without previous stroke. In conclusion, patients with previous stroke have a significantly higher prevalence of obstructive CAD and of obstructive 3-vessel CAD than age- and gender-matched patients with similar coronary risk factors without previous stroke who undergo coronary angiography for chest pain.     

The prevalence of endothelial dysfunction in patients with and without coronary artery disease

Background:

Endothelial dysfunction (ED) is frequently present in patients presenting with acute or stable coronary artery disease (CAD), but it is also found in patients presenting with chest pain without angiographic coronary lesions.

Hypothesis:

We hypothesized that even in patients without CAD, the presence of cardiovascular (CV) risk factors will correlate with the presence of ED.

Methods:

Our study included a total of 341 consecutive patients referred for coronary angiography. We used pulse wave analysis with a finger plethysmograph (peripheral arterial tonometry) to determine endothelial function. Hyperemia ratio was calculated as the ratio of the postischemic hyperemia response relative to baseline measurement.

Results:

The hyperemia ratio was significantly higher in patients without CAD (2.02 ± 0.52) compared with patients with chronic CAD (1.81 ± 0.44, P = 0.001) or acute CAD (1.74 ± 0.49, P < 0.001). Prevalence of ED was 33%, 46%, and 58%, respectively. In multivariate analysis, the presence of CAD, diabetes, and cigarette smoking, and the total number of CV risk factors, were strong predictors of ED. In 67% of the patients without CAD but with ≥3 CV risk factors, ED was present.

Conclusions:

Prevalence of ED in patients with chest pain depends on the presence of CAD and CV risk factors. Patients without CAD but with ≥3 risk factors frequently presented with ED. Such patients may be at increased risk for future CV events and may profit from intensified therapy to control CV risk factors. The authors have no funding, financial relationships, or conflicts of interest to disclose. This study was supported by the Swiss Heart Foundation, Bern, Switzerland, and the Kamillo Eisner Foundation, Hergiswil, Switzerland. Stefan Toggweiler was supported by a grant from the Swiss National Foundation. None of the granting institutions had any influence on the study design, data collection, analysis, or interpretation.     

Unfavourable endothelial and inflammatory state in erectile dysfunction patients with or without coronary artery disease.

AIMS: Erectile dysfunction (ED) confers an independent cardiovascular risk. We investigated the role of low-grade inflammation and endothelial dysfunction in ED patients with or without coronary artery disease (CAD). METHODS AND RESULTS: We evaluated 141 men (age 58.8 years) for ED and CAD through a rigourous investigation (including coronary angiography to reveal occult CAD). Blood levels of inflammatory (hsCRP, IL-6, IL-1beta, and TNF-alpha) and endothelial-prothrombotic markers/mediators (vWF, tPA, PAI-1, and fibrinogen) were significantly increased in ED patients and correlated negatively with sexual performance. ED was associated with higher levels of these substances (except for IL-6) on top of CAD alone. For most substances, the unfavourable impact of ED alone was not significantly different than the impact of CAD alone. In multivariable models, these markers/mediators predicted independently ED presence. In our population, the negative predictive value of the combination of fibrinogen <225 mg/dL with IL-6 <1.24 pg/mL for excluding ED was 91.7% (95% CI: 61.5-99.8). CONCLUSION: ED is associated with increased inflammatory and endothelial-prothrombotic activation in men with or without CAD. ED confers an incremental unfavourable impact on the circulating levels of these markers/mediators when combined with CAD. These findings have implications for increased cardiovascular risk in ED patients.     

Association between P-selectin gene polymorphisms and soluble P-selectin levels and their relation to coronary artery disease

P-selectin is a cellular adhesion molecule that mediates the interaction of activated endothelial cells or platelets with leukocytes. Increased levels of soluble P-selectin have been reported in various cardiovascular disorders. We measured serum soluble P-selectin levels as well as 3 polymorphisms of the P-selectin gene (C-2123G, A-1969G, and Thr715Pro) in a large cohort of patients with documented coronary artery disease (n=869) and a healthy control group (n=334). The 3 P-selectin polymorphisms were strongly associated with P-selectin levels and altogether explained 7.3% and 18.6% of the P-selectin variability in patients and controls, respectively. Genotype distributions did not significantly differ between patients and controls. P-selectin levels were increased in patients younger than 55 years of age compared with controls (135.2 vs 114.3 ng/mL, P<0.01). On the contrary, patients older than 65 years of age had significantly lower P-selectin levels than did controls (121.5 vs 134.7 ng/mL, P<0.02). In intermediate age groups, P-selectin levels did not significantly differ between the 2 groups. In conclusion, this study revealed a strong association between P-selectin gene polymorphisms and serum P-selectin levels and a complex age-dependent relation between soluble P-selectin levels and coronary artery disease, which suggests that this molecule might have different roles in the atherothrombotic process.     

Soluble P-selectin levels in diabetes mellitus patients with coronary artery disease

Type 2 (non-insulin-dependent) diabetes is associated with a marked increase in the risk of coronary heart disease. Platelets play a significant role in coronary artery disease. Soluble P-selectin is an index of platelets activation. In this study, Soluble P-selectin levels were measured by ELISA in the peripheral blood of 55 diabetic patients with coronary artery disease [21 acute myocardial infarction (AMI), 20 with unstable angina (UA), 14 with stable angina (SA)], 20 patients with diabetes mellitus without coronary artery disease (DM without), and 10 healthy controls.Soluble P-selectin level was significantly higher in patients with AMI (M+/-SD; 239.3+/-13.0 ng/ml), than those with UA (141.5+/-15.2 ng/ml), SA (92.1+/-7.7 ng/ml), DM without (89.8+/-7.1 ng/ml), and healthy control (86.1+/-4.5 ng/ml) (P < 0.001). In patients with US, sP-selectin was found to be significantly elevated as compared to the SA, DM without and control group. sP-selectin was not significantly different in DM without as compared to healthy controls. The sP-selectin levels was correlated to the duration of diabetes mellitus(R=0.33, P=0.03 ). Moreover, sP-selectin level was significantly higher in AMI patients with recurrent anginal attack as compared to that in those with single attack Multivariate analysis revealed that sP-selectin level at presentation had high adverse influence on coronary artery insult compared to healthy LDL cholesterol level, and the degree of hypertension. IN CONCLUSION: Plasma levels of soluble P-selectin were increased in patients with AMI, and UA compared to patients with SA and normal controls. Measurement of soluble P-selectin may be helpful marker of impending coronary artery insult in diabetic patients.     

Tetrahydrobiopterin improves endothelial dysfunction in coronary microcirculation in patients without epicardial coronary artery disease

OBJECTIVES: We aimed to determine whether intracoronary supplementation with nitric oxide (NO) synthase co-factor tetrahydrobiopterin (BH4) improves NO-dependent coronary microvascular dilation in patients with coronary risk factors but no significant organic stenosis. BACKGROUND: Impaired coronary microvascular dilator reserve attributable to endothelial dysfunction plays an important role in the regulation of coronary blood flow (CBF). METHODS: Fifteen patients were measured for CBF (Doppler-wire and quantitative coronary angiography). Stimulated release of NO in the coronary microcirculation was evaluated by percent increase in CBF (%ACBF) at graded doses of intracoronary acetylcholine (1, 3, 10 and 30 microg/min). Measurements were repeated after intracoronary co-infusion of BH4 (4 mg/min) and acetylcholine. RESULTS: The patients were divided into two groups on the basis of CBF responses to acetylcholine: those with "diminished" (%deltaCBF <300%, n = 8) and "normal" (%deltaCBF >300%, n = 7) flow responses. Tetrahydrobiopterin significantly (p < 0.0001) improved acetylcholine-induced increases in CBF in patients with diminished flow responses, but exerted no effect in those with normal flow responses. Among the 15 studied patients, the magnitude of flow improvement by BH4 was inversely correlated with baseline flow responses (p < 0.02). Microvascular dilator response to direct NO donor (isosorbide dinitrate) was not affected by BH4. CONCLUSIONS: We demonstrated for the first time that intracoronary BH4 improved acetylcholine-induced microvascular dilator responses in patients with endothelial dysfunction in vivo. Thus, supplementation with BH4 may be a novel therapeutic means to increase NO availability for patients with coronary microvascular disease.     

他汀对未合并冠心病的高胆固醇血症患者血管内皮功能的影响

目的探讨辛伐他汀对未合并冠心病的高胆固醇血症患者血管内皮功能及动脉僵硬度的影响。方法 30例高胆固醇血症患者应用辛伐他汀20 mg/d治疗12周,治疗前后分别采集空腹静脉血,通过酶联免疫吸附实验检测血浆一氧化氮（NO）水平;应用动脉硬化测定仪测定肱踝脉搏波传导速度（PWV）,评价动脉硬化程度;应用彩色多普勒超声诊断仪测定肱动脉血流速度积分（VTI）,评价血管舒张功能。结果辛伐他汀治疗后患者总胆固醇（TC）、低密度脂蛋白胆固醇水平明显降低,PWV水平显著降低,血浆NO、肱动脉VTI值显著高于基线水平。结论辛伐他汀可改善无明确冠心病的高脂血症患者血管内皮功能及动脉硬化程度。     

冠心病患者肾动脉造影的临床意义

目的　探讨冠心病患者肾动脉狭窄发生率及危险因素,以了解冠状动脉造影患者同时行肾动脉造影的必要性。　方法　对169例接受冠状动脉造影患者同时行肾动脉造影,其中男性76例,女性93例,年龄60~81岁,平均(69±8)岁。本组患者临床表现高血压80例,糖尿病27 例,高脂血症36例,肾功能不全17例,低钾血症11例。　结果　169 例患者中,肾动脉狭窄33 例,发生率为19 5%。经过冠状动脉造影证实的70 例冠心病患者中肾动脉狭窄19 例,检出率为27 1%;冠状动脉造影正常的99例患者中肾动脉狭窄14例,检出率为14 1 %,冠心病患者中肾动脉狭窄发生率明显高于非冠心病组(P<0 05),且冠心病患者三支病变的肾动脉狭窄发生率明显高于单、双支病变(P<0 01)。　结论　冠心病患者中肾动脉狭窄发生率高,冠状动脉造影同时行肾动脉造影有助于提高肾动脉狭窄的临床检出率。     

Prevalence of left main coronary artery disease,of three- or four-vessel coronary artery disease,and of obstructive coronary artery disease in patients with and without peripheral arterial disease undergoing coronary angiography for suspected coronary artery disease

Data from the present investigation showed that the prevalence of current cigarette smoking, current or ex-cigarette smoking, systemic hypertension, diabetes mellitus, and dyslipidemia was significantly higher in patients with peripheral arterial disease (PAD) than in patients without PAD. The present report also showed that compared with patients without PAD undergoing coronary angiography for suspected coronary artery disease (CAD), patients with PAD undergoing coronary angiography for suspected CAD had a higher prevalence of left main CAD (18% vs <1%), a higher prevalence of 3- or 4-vessel CAD (63% vs 11%), and a higher prevalence of obstructive CAD (98% vs 81%).     

冠心病患者血清可溶性E-选择素检测的意义

目的　探讨血清可溶性E 选择素在监测冠心病病情及与冠状动脉病变程度的关系。方法　 81例冠心病患者 ,按临床诊断分为 4组 :急性心肌梗死 (AMI) 17例、不稳定性心绞痛 (UAP) 2 4例、稳定性心绞痛 (SAP) 2 0例和对照组患者 2 0例。检测各组患者血清可溶性E 选择素的水平 ,并比较各组间的差异。对冠心病患者的冠状动脉损害行Gensini评分 ,并与其血清可溶性E 选择素水平进行直线相关分析。结果　 (1)AMI组、UAP组及SAP组的血清可溶性E 选择素水平比对照组高 ;(2 )AMI组、UAP组可溶性E 选择素水平和SAP组相比 ,其值增加明显 ;AMI组和UAP组结果相似 ;(3)急性冠脉综合征 (AMI组 +UAP组 )血清可溶性E 选择素水平与冠状动脉Gensini评分呈正相关。结论　血清可溶性 E选择素可能是冠状动脉粥样硬化的标志 ,参与了冠心病的发病过程 ,在急性冠脉综合征中 ,其值与冠状动脉病变程度密切相关。     

The effect of supplementation with omega-3 fatty acids on soluble markers of endothelial function in patients with coronary heart disease.

During progression of atherosclerosis the overlying endothelial cells alter their expression of some surface molecules. Circulating levels of such molecules may be quantified. We investigated the effect of omega-3 fatty acids (n-3 FA) on the levels of tissue plasminogen activator antigen, von Willebrand factor, and the soluble forms of thrombomodulin, P-selectin, E-selectin, and vascular cell adhesion molecule-1 in 54 patients with coronary heart disease. Twenty-three of the patients had taken 5.1 g/d n-3 FA for 6 months (group I) and 31 were given corn oil as placebo (group II). For another 4 weeks ("the study period") they all got 5.1 g/d of n-3 FA. Compliance was confirmed by demonstration of changes in relevant fatty acids in serum phospholipids. At baseline, significant differences between the groups were found with lower median values of von Willebrand factor (128% versus 147%) and soluble thrombomodulin (24.9 versus 32.5 ng/mL) and higher median values of soluble E-selectin (41.4 versus 35.5 ng/mL) and soluble vascular cell adhesion molecule-1 (573 versus 473 ng/mL) in group I. During the study period differences in changes between the groups were found; tissue plasminogen activator antigen and soluble thrombomodulin decreased (P for difference between the groups 0.001 and 0.015, respectively), whereas soluble E-selectin and soluble vascular cell adhesion molecule-1 increased (P for difference between the groups <0.01 for both) in group II relative to group I. Our results indicate that n-3 FA supplementation decreases hemostatic markers of atherosclerosis, whereas markers of inflammation may be increased. The latter may be the result of lipid peroxidation as a simultaneous decrease of vitamin E and increase in thiobarbituric acid-reactive substances were observed.     

Relation of depression to various markers of coagulation and fibrinolysis in patients with and without coronary artery disease.

BACKGROUND: It has been suggested that changes in blood coagulation and fibrinolysis might explain the observed association between depression and coronary artery disease (CAD). So far, only a few coagulation factors have been investigated in this regard, and the results were not consistent. DESIGN: The aim of our study was to analyse a broad range of coagulation and fibrinolytic factors, with emphasis on factors directly involved in clot formation and degradation or reflecting coagulation activation, in patients with CAD and controls without CAD, as assessed by coronary angiography, who also underwent a diagnostic procedure for depression. METHODS: We screened 306 patients with CAD and controls without CAD for depression using the Hospital Anxiety and Depression Scale and Allgemeine Depressions Skala-L questionnaires. In participants with positive screening result, diagnosis of major depression was confirmed or excluded by a structured interview. We analysed the following coagulation and fibrinolytic factors: fibrinogen, prothrombin fragment F1+2, factor XIII A-subunit, factor XIII B-subunit, tissue plasminogen activator, plasminogen activator inhibitor-1, thrombin-activable fibrinolysis inhibitor, and D-dimer. RESULTS: We did not observe significant associations between depression and CAD, nor between depression and cardiovascular risk factors. Coagulation and fibrinolytic factors showed no differences between patients with CAD and controls, but they were associated with several cardiovascular risk factors. Depression was not associated with coagulation and fibrinolytic factors. No associations were found either when both CAD and depression were taken into account. CONCLUSION: Our study gives no evidence that there is a significant relation among depression, CAD, and blood coagulation and fibrinolysis.     

Assessment of coronary artery disease using coronary computed tomography angiography and biochemical markers

Chronic inflammatory mechanisms in the arterial wall lead to atherosclerosis,and include endothelial cell damage,inflammation,apoptosis,lipoprotein deposition,calcification and fibrosis.Cardiac computed tomography angiography(CCTA)has been shown to be a promising tool for non-invasive assessment of theses specific compositional and structural changes in coronary arteries.This review focuses on the technical background of CCTA-based quantitative plaque characterization.Furthermore,we discuss the available evidence for CCTA-based plaque characterization and the potential role of CCTA for risk stratification of patients with coronary artery disease.     

Effect of cyclooxygenase-2 inhibition with rofecoxib on endothelial dysfunction and inflammatory markers in patients with coronary artery disease

OBJECTIVES: The aim of this study was to determine whether selective cyclooxygenase-2 (COX-2) inhibition with rofecoxib can modulate endothelial dysfunction and levels of circulating inflammatory markers in patients with established coronary artery disease (CAD). BACKGROUND: Expression of COX-2 is upregulated in atherosclerosis. Thus, it has been hypothesized that COX-2 may contribute to atherogenesis by producing eicosanoids, which mediate vascular inflammation and endothelial dysfunction. METHODS: In a randomized, double-blind, placebo-controlled, parallel-design trial, we studied the vascular effects of rofecoxib on brachial artery vasoreactivity and inflammatory markers in 60 patients with angiographically proven CAD who were taking concomitant low-dose aspirin. Patients were randomly assigned to receive either rofecoxib (25 mg/day; n = 30) or placebo (n = 30) for eight weeks. Brachial artery endothelium-dependent flow-mediated dilation (FMD), endothelium-independent nitroglycerin-mediated dilation (NMD), and inflammatory markers (i.e., high-sensitivity C-reactive protein [CRP], soluble intercellular adhesion molecule-1 [sICAM-1], and soluble interleukin-6 receptor [sIL-6r]) were measured at baseline and after eight-week follow-up. RESULTS: Baseline clinical characteristics were similar in the two groups. After eight weeks of treatment, FMD did not significantly change in either the rofecoxib or placebo group (4.0 +/- 3.0% to 4.0 +/- 3.8% vs. 2.7 +/- 2.7% to 3.1 +/- 2.7%, respectively; p = 0.6 by two-way analysis of variance). Similarly, NMD remained unchanged in both groups. Levels of CRP, sICAM-1, and sIL-6r were not significantly altered in either the rofecoxib or placebo group. CONCLUSIONS: The addition of selective COX-2 inhibition with rofecoxib did not appear to have any favorable or adverse effects on endothelial dysfunction or vascular inflammation in patients with CAD using concomitant low-dose aspirin.