Treatment of Patients with Left Main Coronary Artery Disease

Considering lesion priority and its clinical consequences, coronary artery bypass grafting (CABG) has been a treatment of choice for revascularization in patients with significant left main coronary artery (LMCA) disease, However, with remarkable advancements in techniques of percutaneous coronary intervention (PCI), supporting devices, and adjunctive pharmacologic therapy, PCI with stenting has emerged to be a less invasive and feasible revascularization treatment for these patients. The cumulative evidence suggests that the safety outcomes such as mortality or composite of death, myocardial infarction, and stroke are similar among PCI and CABG, with the only difference being the rate of repeat revascularization. Based on these data, the current guideline of revascularization of LMCA disease has adopted an increasing off-label experience with stenting and clinical studies and been updated to partly approve PCI as a viable alternative (in level of class IIb) in selected patients. The choice of PCI or CABG for unprotected LMCA disease depends on several clinical and anatomic features, ensuring crucial patient selection to be a cornerstone for achieving favorable long-term outcomes. In patients with very complex anatomic features and concomitant diffuse multivessel disease, CABG is preferred so as to avoid procedural and future thrombotic risks and to provide more complete revascularization. By contrast, in patients with relatively simple LMCA disease, such as ostial/shaft LMCA disease, isolated LMCA disease (with or without one or two-vessel involvement), and LMCA disease with low SYNTAX score, PCI is an alternative, and in some cases a preferred, strategy to reduce surgical risks (eg, stroke and in-hospital events following major surgery). For the future, ongoing large clinical trials might also boost interventional cardiologists to select PCI with stenting as an alternative revascularization strategy for unprotected LMCA disease. This evidence will most likely change the current clinical practice and guidelines of optimal revascularization strategy for unprotected LMCA disease.     

老年人左冠状动脉主干病变的临床分析

目的:对比老年人和非老年人左冠状动脉主干(LM)狭窄的临床表现、冠状动脉造影、治疗及预后的特点。方法:回顾性分析121例经冠状动脉造影证实的左主干病变患者的临床资料,其中将年龄≥65岁者为老年组,其余为非老年组。结果:①老年患者左冠状动脉主干狭窄的发生率(5.1%),高于非老年患者(2.3%)。②老年患者危险因素中高血压、糖尿病比非老年组多见,而非老年组吸烟、肥胖、脂质异常者高于老年组。③老年患者急性心肌梗死发生率(28.6%)高于非老年组(17.7%),心力衰竭发病率高、程度重。④老年患者左冠脉主干狭窄以合并多支血管病变为主(90%),并且以合并三支病变者多见。左冠状动脉主干狭窄多位于左主干远端分叉处(79%)。⑤34例(48.6%)老年LM患者和28例(54.9%)非老年患者接受了冠状动脉旁路移植手术(CABG),术后大部分患者心绞痛消失,症状好转。手术死亡率为2.5%。结论:老年左冠状动脉主干狭窄发生率略高,多伴发糖尿病、高血压,合并有多支血管病变,病情更严重,提示预后更差。无病保护左主干的介入治疗正在兴起,目前CABG仍是最佳治疗手段。     

老年冠状动脉左主干病变患者临床特点及危险因素分析

【摘要】 目的 探讨老年冠状动脉左主干病变患者临床特点及可能的危险因素。方法 入院 我院2012年9月至2016年9月经冠状动脉造影诊断为冠心病的患者195例,根据患者冠脉病变是否累积左主干分为左主干病变组（实验组,n=52）和对照组（n=143）。比较两组患者基本临床资料、实验室指标及冠脉造影相关结果差异。结果 两组患者在基本临床资料、实验室的比较中仅糖尿病病史（40.4%vs.28.7%,P=0.041）、血尿酸（367.04±45.63vs.352.57±41.91,P=0.014）、超敏C反应蛋白（4.01±0.91vs.3.46±0.98,P=0.038）差异有统计学意义。Logitic回归分析表明糖尿病（P=0.048）、血尿酸（P=0.021）、hs-CRP（P=0.042）是老年左主干病变的危险因素。结论 老年冠状动脉左主干病变患者冠状动脉病变范围可能更广泛、病变程度可能更重,糖尿病病史、较高水平尿酸及hs-CRP是老年左主干病变的危险因素。     

合并糖尿病的冠心病患者冠状动脉粥样硬化与颈动脉粥样硬化的关系

目的探讨合并糖尿病的冠心病患者颈动脉粥样硬化与冠状动脉粥样硬化的关系.方法通过对73例合并2型糖尿病的冠心病患者行冠状动脉造影明确冠状动脉病变,同时行颈动脉超声检查,检测颈动脉内膜-中膜厚度.结果不同支数冠状动脉病变者之间比较,颈动脉内膜-中膜厚度、颈动脉斑块积分和斑块发生率差异有显著性(分别为P＜0.001、P＜0.005、P＜0.01).冠状动脉病变支数与颈动脉内膜-中膜厚度和颈动脉斑块积分有明显的相关性,其相关系数分别为0.71和0.68(P＜0.001).冠状动脉造影积分与颈动脉内膜-中膜厚度及颈动脉斑块积分相关系数分别为0.69和0.66(P＜0.001).结论合并糖尿病冠心病患者颈动脉粥样硬化与冠状动脉粥样硬化存在显著的正相相关性,这类患者通过了解颈动脉病变可间接反映冠状动脉粥样硬化病变.     

国产BuMA支架在无保护左主干病变中的应用研究

目的比较国产BuMA支架和进口XienceⅤ支架在无保护左主干病变应用的有效性和安全性。方法回顾性分析81例无保护左主干病变置入BuMA支架（36例）或Xience V支架（45例）的患者,随访1年,观察冠状动脉造影及血管内超声情况,比较死亡、心肌梗死、靶病变重建等主要心血管事件及支架内再狭窄发生率。结果两组患者主要心血管事件的发生率差异无统计学意义（5.6%vs 6.7%,P=1.00）。两组患者支架内再狭窄的发生率差异无统计学意义（5.6%vs 6.7%,P=1.00）。两组患者支架内径的晚期丢失及支架内面积的晚期丢失差异无统计学意义（P=0.614,P=0.833）。结论在血管内超声的指导下,国产BuMA支架在无保护左主干病变中的应用拥有与Xience V支架相似的安全性及近中期疗效。     

QRS时间对非ST段抬高型急性冠状动脉综合征患者左主干或三支病变的预测作用

目的测定非ST段抬高型急性冠脉综合症患者的心电图QRS时间,通过与冠状动脉造影对比,判断其对左主干／三支病变诊断的指导作用。方法对比106例非ST段抬高型急性冠脉综合症患者的体表心电图QRS时间,并与冠状动脉造影结果比较。结果QRS时间和左主干／三支病变具有相关性（OR=904,P〈0．01）,QRS时间／〉90ms预测左主干／三支病变的敏感性为88％,特异性为88％。结论QRS时间增宽可作为非ST段抬高型急性冠脉综合症患者左主干／三支病变的预测因子。     

Chronic Kidney Disease and Post–Percutaneous Coronary Intervention Mortality in Patients With Left Main and Equivalent Coronary Artery Disease

BackgroundPatients with chronic kidney disease are underrepresented in registries and in randomized trials of coronary artery disease management. To investigate effects of chronic kidney disease on outcomes of nonemergent percutaneous coronary intervention in patients with left main or left main–equivalent coronary artery disease, we analyzed data from the New York State Percutaneous Coronary Intervention Registry during the calendar year 2015, involving 2,956 elective percutaneous coronary intervention cases. Outcomes of percutaneous coronary intervention in patients with various degrees of chronic kidney disease and stable left main or left main–equivalent coronary artery disease were compared.MethodsOnly patients with left main or left main–equivalent coronary artery disease and elective percutaneous coronary intervention were included in the study cohort. Patients with acute coronary syndromes within 24 hours of the index percutaneous coronary intervention, patients reported to be in shock, and patients with prior coronary artery bypass surgery were excluded from the study cohort.ResultsIn this cohort, stage 4 or 5 chronic kidney disease, current congestive heart failure, and left main disease remained statistically significant predictors of post–percutaneous coronary intervention mortality.ConclusionOur findings in this large, statewide cohort indicate that advanced kidney disease is associated with markedly increased post–nonemergent percutaneous coronary intervention mortality.     

左主干病变的介入治疗

冠状动脉旁路术曾是无保护左主干病变的标准治疗,随着经皮冠状动脉介入治疗技术的进步,介入治疗已成为左主干病变的一种有效治疗手段。进一步规范患者的选择,科学选择治疗策略及相关器械有助于提高左主干病变经皮冠状动脉介入治疗的有效性及安全性。如何加强患者的定期随访、抗血小板治疗反应性的监测是亟待解决的问题。     

冠状动脉左主干病变的心电图表现

冠状动脉左主干负责左心室大部分的心肌供血,左主干严重狭窄或闭塞易引起心脏突发事件.心电图作为一个方便、广泛使用的诊断方法,对于早期预测左主干病变并尽早采取治疗措施有重要意义.     

Impact of Nonobstructive Left Main Coronary Artery Atherosclerosis on Long-Term Mortality

BackgroundAlthough the presence of severe stenosis in the left main coronary artery (LMCA) is a well-established predictor of mortality, whether this extends to nonobstructive atherosclerosis in the LMCA is unknown.ObjectivesThe aim of this study was to evaluate the association between LMCA disease by intravascular ultrasound (IVUS) and long-term mortality.MethodsBetween 2005 and 2013, 3,239 patients with LMCA IVUS imaging without LMCA revascularization (either before angiography or scheduled based on index angiography or IVUS) were included. The primary and secondary endpoints were all-cause and cardiac mortality at a minimum of 5 years obtained from the National Death Index.ResultsThe IVUS-measured LMCA minimum lumen area (MLA) and plaque burden were 13.1 ± 5.0 mm² and 41.7% ± 15.6%, respectively. The median follow-up was 8.2 years. The Kaplan-Meier estimated 12-year all-cause and cardiac death rates were 37.5% and 17.0%, respectively. Greater plaque burden (unadjusted HR per 10%: 1.17; 95% CI: 1.12-1.22; P < 0.0001) and smaller IVUS MLA (unadjusted HR per 1 mm²: 0.98; 95% CI: 0.96-0.99; P = 0.0008) were associated with all-cause death. After adjusting for clinical, angiographic, and IVUS factors, plaque burden (adjusted HR per 10%: 1.12; 95% CI: 1.04-1.21; P = 0.003) but not MLA (adjusted HR per 1 mm²: 1.02; 95% CI: 0.99-1.04; P = 0.18) was associated with long-term all-cause death. These findings were also consistent for long-term cardiac mortality.ConclusionsIn the present large-scale study with a 12-year follow-up, increasing LMCA plaque burden was associated with long-term all-cause and cardiac mortality in patients not undergoing LMCA revascularization, even when the lumen area was preserved.     

药物洗脱支架治疗左主干病变的疗效评价

冠脉搭桥术曾经被认为是左主干病变治疗的“金标准”,近年来经皮冠脉介入治疗也在该领域取得一些进展,一系列临床试验证实药物洗脱支架治疗左主干病变安全可行,但在左主干远端分叉病变还存在再狭窄率高的问题。就目前而言,对于有选择的左主干病变,药物洗脱支架是一种充满生机的治疗方法。     

老年患者股动脉粥样硬化与冠心病关系的研究

目的　研究老年患者股动脉粥样硬化与冠心病的关系。方法　对 110例冠状动脉造影的老年患者作双侧股动脉超声检查 ,测量股动脉后壁内中膜厚度 (IMT) ,斑块厚度 ,及粥样斑块发生率 ,并与冠脉造影结果进行对比分析。结果　 (1)冠心病组IMT ,斑块积分及斑块发生率明显高于正常对照组 (P <0. 0 1)。 (2 )随冠脉病变支数增加 ,斑块积分及IMT增加 ,各组比较有显著性差异 (P <0. 0 1)。 (3)以IMT >0 .85mm和 (或 )出现粥样斑预测冠心病 ,特异性 75. 0 % ,敏感性 87 .1% ,阳性预测率 89. 3%。结论　老年患者股动脉粥样硬化严重程度与冠心病发生率成正比 ;通过股动脉超声检查可为冠心病的诊断提供依据。     

Non-Invasive Imaging for Subclinical Coronary Atherosclerosis in Patients with Peripheral Artery Disease

Patients with peripheral artery disease are at high risk of coronary artery disease. An increasing number of studies show that a large proportion of patients with peripheral artery disease have significant coronary atherosclerosis, even in the absence of symptoms. Although the reported prevalence of subclinical coronary artery disease varies widely in patients with peripheral artery disease, it could include more than half of patients. No consensus exists to date on either the rationale for screening patients with peripheral artery disease for coronary atherosclerosis or the optimal algorithm and method for screening. An increasing number of imaging modalities are emerging that allow improved in vivo non-invasive characterization of atherosclerotic plaques. These novel imaging methods may lead to early detection of high-risk vulnerable plaques, enabling clinicians to improve risk stratification of patients with peripheral artery disease, and thus paving the way for individualized therapy.     

无保护左主干病变的药物洗脱支架与冠脉搭桥治疗

无保护左主干病变一直是冠脉搭桥治疗的传统领地。随着经皮冠状动脉介入治疗的迅速发展,尤其是药物洗脱支架广泛应用以来,学者们正在用大量的试验证明应用药物洗脱支架治疗无保护左主干病变的安全性、可行性,比较与冠脉搭桥治疗孰优孰劣。随着技术的发展和器械的更新,药物洗脱支架介入治疗的适应证势必进一步拓宽,但是就目前而言,无保护左主干的介入治疗由于其自身不足,不能完全替代冠脉搭桥治疗。     

左心室功能下降冠心病患者的血运重建治疗

冠心病是充血性心力衰竭的最常见病因。无瓣膜性病变的冠心病患者中,心力衰竭最常见由左心室收缩功能下降（左心室射血分数下降）导致,伴有左心室射血分数下降的冠心病患者预后不良。目前认为血运重建可以改善左心室射血分数下降的冠心病患者的预后,同时左心室射血分数下降患者血运重建风险高。现对左心室功能障碍的冠心病患者的血运重建治疗作一综述。     

Comparison of Coronary Artery Bypass Grafting and Drug-Eluting Stents in Patients with Left Main Coronary Artery Disease and Chronic Kidney Disease: A Systematic Review and Meta-Analysis

BackgroundTreatment of left main coronary artery disease (LMCAD) in patients with chronic kidney disease (CKD) with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) remains controversial. Therefore, we performed a meta-analysis to evaluate the optimal choice of therapy when treating LMCAD in patients with CKD.MethodWe performed an electronic database search of Pubmed, Embase, and Cochrane Library for all studies that compared PCI with CABG when treating LMCAD in the setting of CKD. Major adverse cardiac and cerebrovascular events (MACCE) were the primary outcome. Secondary outcomes included myocardial infarction (MI), cerebrovascular events, all-cause mortality, and repeat revascularization.ResultsOur analysis included 5 studies (2 randomized controlled trial and 3 retrospective) representing a total of 1212 patients. Mean follow up was 3.4 ± 1.3 years. Our study demonstrated a significant reduction in MACCE for patients treated with CABG compared with PCI (odd ratio [OR] 0.72; 95% confidence interval [CI] 0.55–0.95, P = 0.02, I² = 0%). We also found a significant reduction in both MI (OR 0.55; 95% CI 0.34–0.87; P = 0.01; I² = 0%) and repeat revascularization (OR 0.22; 95% CI 0.10–0.51; P < 0.001, I² = 63%) in the CABG group. However, CABG was associated with increased risks of cerebrovascular disease events compared with PCI (OR 2.04; 95% CI 1.02–4.08; P = 0.04, I² = 0%).ConclusionIn patients with CKD requiring LMCAD intervention, CABG is associated with a lower risk of MACCE, MI, and repeat revascularization, however it was associated with an increased risk of cerebrovascular accidents when compared to patients who received PCI therapy. Further RCTs with sufficient power are required to confirm these findings.