老年冠心病人再发心脏事件的临床危险因素

随访曾住院的２６５例老年冠心病人２～８．５年，观察增龄、男性、高血压、糖尿病、吸烟、血清总胆固醇（ＴＣ）与高密度脂蛋白胆固醇（ＨＤＬ－ｃ）比值≥４．５、复杂室性心律失常、无痛性心肌缺血和左室肥厚等临床危险因素对再发心脏事件（包括急性心肌梗塞和心源性猝死）的影响。由Ｋａｐｌａｎ－Ｍｅｉｅｒ生存曲线得到８年累积再发心脏事件率为２３．９％。单因素分析提示，除增龄外的每个危险因素都使再发心脏事件明显增加。Ｃｏｘ多因素分析提示，冠心病合并高血压、ＴＣ与ＨＤＬ－Ｃ比值≥４．５，无痛性心肌缺血和复杂室性心律失常是再发心脏事件的重要的独立预报因素。     

Adiponectin and risk of acute coronary syndromes: defining the obesity phenotype.

Obesity is a major risk factor for coronary heart disease (CHD),the leading cause of death worldwide.¹ Acute coronary syndromes(ACS), including unstable angina pectoris and myocardial infarction,usually result from acute coronary thrombosis as a product ofatherosclerotic CHD. There is no straightforward relationshipbetween plaque size and likelihood of plaque rupture, and angiographicstudies have shown that lesions preceding non-fatal acute eventsare usually not haemodynamically significant.² Further, themajority of ruptured plaques heals without clinical consequence.Understanding the pathophysiology that leads to CHD in generaland to ACS specifically and identifying the risk factors arecrucial steps for efforts to prevent these diseases. Obese individualshave an ~1.5–2.0-fold increased risk for CHD, and between15 and 20% of all cases of CHD can be attributed     

Meaning of Low‐Density Lipoprotein‐Apheresis for Hypercholesterolemic Patients at High Risk for Recurrence of Coronary Heart Disease

Abstract: The goal of cholesterol‐lowering therapy in hypercholesterolemic patients at high risk for recurrence of coronary heart disease (CHD) is the prevention of acute coronary syndrome by stabilization of coronary atheromatous plaque. We often encounter patients in whom it is difficult to maintain the serum cholesterol level at a desirable level with dietary therapy and drug treatment, despite the development and use of statins. For secondary prevention in patients who are at high risk for the recurrence of CHD and whose cholesterol level cannot be controlled by drugs alone, low‐density lipoprotein (LDL)‐apheresis therapy, which involves removal of LDL through extracorporeal circulation, is now available. Many reports concerning improvement of vascular endothelial function, improvement of myocardial ischemia, regression of coronary atherosclerotic lesions, stabilization of coronary plaque, and reduction in the incidence of cardiac events as a result of LDL‐apheresis treatment have been published in various countries. We believe that LDL‐apheresis should be performed on hypercholesterolemic patients with existing CHD for whom diet and maximum cholesterol‐lowering drug therapies have been ineffective or not tolerated and whose LDL cholesterol level is 160 mg/dL or higher.     

Inhibition of intestinal absorption of cholesterol by ezetimibe or bile acids by SC-435 alters lipoprotein metabolism and extends the lifespan of SR-BI/apoE double knockout mice

SR-BI/apoE double knockout (dKO) mice exhibit many features of human coronary heart disease (CHD), including hypercholesterolemia, occlusive coronary atherosclerosis, cardiac hypertrophy, myocardial infarctions, cardiac dysfunction and premature death. Ezetimibe is a FDA-approved, intestinal cholesterol absorption inhibitor that lowers plasma LDL cholesterol in humans and animals and inhibits aortic root atherosclerosis in apoE KO mice, but has not been proven to reduce CHD. Three-week-ezetimibe treatment of dKO mice (0.005% (w/w) in standard chow administered from weaning) resulted in a 35% decrease in cholesterol in IDL/LDL-size lipoproteins, but not in VLDL- and HDL-size lipoproteins. Ezetimibe treatment significantly reduced aortic root (57%) and coronary arterial (68%) atherosclerosis, cardiomegaly (24%) and cardiac fibrosis (57%), and prolonged the lives of the mice (27%). This represents the first demonstration of beneficial effects of ezetimibe treatment on CHD. The dKO mice were similarly treated with SC-435 (0.01% (w/w)), an apical sodium codependent bile acid transporter (ASBT) inhibitor, that blocks intestinal absorption of bile acids, lowers plasma cholesterol in animals, and reduces aortic root atherosclerosis in apoE KO mice. The effects of SC-435 treatment were similar to those of ezetimibe: 37% decrease in ILD/LDL-size lipoprotein cholesterol and 57% prolongation in median lifespan. Thus, inhibition of intestinal absorption of either cholesterol (ezetimibe) or bile acids (SC-435) significantly reduced plasma IDL/LDL-size lipoprotein cholesterol levels and improved survival of SR-BI/apoE dKO mice. The SR-BI/apoE dKO murine model of atherosclerotic occlusive, arterial CHD appears to provide a useful system to evaluate compounds that modulate cholesterol homeostasis and atherosclerosis.     

内皮祖细胞与动脉粥样硬化蚀损斑块合并血栓形成

动脉粥样硬化易损斑块是急性冠脉综合征和心脏缺血性猝死的重要病理基础。蚀损斑块是易损斑块的重要病理类型之一,其主要特点:斑块表面大面积内皮细胞脱落和血栓形成。目前有关蚀损斑块合并血栓形成机制的研究罕见。近年的研究认为,内皮祖细胞参与血管内皮损伤后的修复。因此,内皮祖细胞可能参与蚀损斑块合并血栓形成,或对其有治疗作用,此方面研究国内外未见,值得探讨。     

Hormone replacement therapy and risk of cardiovascular disease: implications of the results of the Women's Health Initiative

The higher rates of coronary heart disease (CHD), stroke, and venous thrombosis among women taking estrogen and progesterone (E+P) compared with placebo in the Women's Health Initiative clinical trial have important implications for women's health. Previous studies in both men and women have shown that estrogen therapy lowers low-density lipoprotein cholesterol and raises high-density lipoprotein cholesterol. The changes in these lipoproteins should be associated with at least a 30% decline in CHD risk. Estrogens increased very-low-density lipoprotein (VLDL) triglyceride levels and C-reactive protein. There is evidence that estrogens increase thrombin generation and fibrinolysis. The increase in VLDL triglycerides may enhance thrombotic risk as well as higher levels of atherogenic lipoproteins, such as dense low-density lipoprotein. Genetic variations in estrogen receptors and thrombosis or fibrinolysis may also be important in risks associated with E+P therapy. The increased risk of CHD and stroke with E+P therapy may be attributable to rise in VLDL triglycerides and thrombosis.     

无症状性冠状动脉内膜病变与冠心病危险因素关系的探讨

目的探讨无症状性冠状动脉内膜病变的发生频率及其与高血压、糖尿病和低密度脂蛋白胆固醇(LDL-C)的关系。方法应用冠状动脉血管内视镜技术对2003-06—2004-09日本医科大学附属千叶北总病院收治的120例陈旧性心肌梗死和稳定型心绞痛患者的非罪犯血管进行观察其有无黄色斑块、斑块破裂和(或)血栓形成等内膜病变,分别探讨它们与高血压、糖尿病和LDL-C的关系。结果120例患者(155支)非罪犯血管内,观察到内膜病变者80例(66·67%),其中合并高血压和高LDL-C血症者明显高于非内膜病变组(P<0·005),合并糖尿病者也高于非内膜病变组(P<0·05);观察到黄色斑块者30例(25·00%),其中合并高LDL-C血症者明显高于非内膜病变组(P<0·005);观察到斑块破裂和(或)伴有血栓形成等复杂斑块者50例(41·66%),其中合并高血压者明显高于非内膜病变组(P<0·005),合并高胆固醇血症者也高于非内膜病变组(P<0·01)。结论糖尿病、高血压及高LDL-C血症等是无症状性粥样斑块形成、不稳定甚至破裂的基础,所以,对糖尿病、高血压及血脂积极控制和治疗对ACS的预防是极其重要的。     

Associations among carotid plaque progression,cerebrovascular/cardiovascular diseases and LDL-C/non-HDL-C goal achievement in diabetic patients: A retrospective cohort study

BackgroundImpaired glycolipid metabolism can induce vascular injury and plaque formation. It is important to investigate the associations between carotid plaque progression and lipid-lowering goal achievement and cardiovascular disease.MethodsDiabetic patients who underwent at least 2 carotid ultrasound scans with intervals ≥0.5 years and were hospitalized in the Department of Endocrinology at Sun Yat-sen Memorial Hospital were included. Patients were divided into 3 groups based on carotid plaque progression: the persistent plaque absence, new-onset plaque and persistent plaque presence groups. The primary outcomes were CHD and stroke, while the secondary outcomes were low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) goal achievement.ResultsThere were 304 diabetic patients included, with a median follow-up period of 2.15 years. In multivariable logistic regression analysis, persistent plaque presence was positively associated with a 2.285-fold increase in coronary heart disease (CHD) prevalence, while new-onset plaque was associated with a 3.225-fold increase in stroke prevalence compared to persistent plaque absence in patients with follow-up periods ≥ 0.5 years. The association remained significant in patients with a follow-up period ≥ 1 year and ≥2 years. The velocity of average plaque length change was independently associated with increased ΔLDL-C (last – goal) (β = 0.073, P = 0.048).ConclusionCarotid plaque progression had long-term association with CHD and stroke starting from 0.5 years, while the velocity of average plaque length associated with increased ΔLDL-C (last – goal) might reflect patient response to statins. Repeated carotid plaque measurements might guide lipid-lowering therapies.     

Lipoprotein (A) in patients with coronary atherosclerosis]

The serum level of lipoprotein (a) (LP(a] was measured in 117 patients with coronary heart disease (CHD) angiographically documented, 22 patients with unaltered coronary arteries as evidenced by coronary angiography (Control Group 1), and 28 subjects without clinical CHD signs (Control Group 2). Total cholesterol, triglycerides, low and high density lipoprotein cholesterol, and apolipoproteins (apo) AI and B were measured in the patients and healthy subjects. They were found to be higher in CHD patients than in patients with unaltered arteries and healthy subjects. The level of LP(a) was significantly increased in patients with three-vessel disease as compared to the control groups and patients with single-vessel disease. There was no relation of LP(a) to total cholesterol, triglyceride, high density lipoprotein cholesterol, low and very low density lipoprotein cholesterol, apo-AI, apo-B, age, and sex. The findings supports the assumption that LP(a) is associated with coronary atherosclerosis.     

老年冠心病患者餐后高甘油三酯血症与颈动脉及股动脉粥样硬化的关系

探讨餐后血脂代谢异常与动脉粥样硬化的关系。47例冠心病患者及30例对照组禁食12－14h后，均接受低脂实验餐负荷试验。分别于空腹及餐后4h采血测定血清甘油三酯、总胆固醇、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇、载脂蛋白A及载脂蛋白B的浓度。利用二维彩色多普勒超声，检测两组颈动脉内膜中层厚度及颈动脉、股动脉斑块的发生状况。与对照组相比，冠心病组空腹血清总胆固醇、载脂蛋白B浓度显著增高，冠心病组餐后4h血清甘油三酯、低密度脂蛋白胆固醇浓度显著增高（P＜0．05），餐后血清高密度脂蛋白胆固醇浓度显著降低（P＜0．05）。冠心病组颈总动脉内膜中层厚度、颈内动脉内膜中层厚度、颈动脉及股动脉斑块指数均较对照组增高（P＜0．01）。餐后血清甘油三酯与空腹血清甘油三酯浓度呈正相关。颈动脉斑块指数与空腹总胆固醇呈正相关。提示餐后高甘油三酯血症可能与动脉粥样硬化有关。     

冠心病与颈动脉斑块及丙二醛化低密度脂蛋白的相关性研究

目的研究冠心病患者冠心病与颈动脉内-中膜厚度(CCA-IMT)、斑块指数及丙二醛化低密度脂蛋白(MDA-LDL)的相关性。方法收集冠状动脉造影的冠心病患者82例,根据斑块形态,冠心病患者分为3组,即Ⅰ型病变(表面光滑)组(n=31),Ⅱ型病变(表面不规则)组(n=a2)及Ⅲ型病变(长段不规则)组(n=19),冠状动脉造影正常的25例为对照组纳入研究。采用高频超声探测各组双侧颈动脉 IMT 和软斑指数,硬斑指数及总斑块指数,以及测定血浆 MDA-LDL 含量。结果 (1)冠心病各组(包括Ⅰ型、Ⅱ型、Ⅲ型病变组)CCA-IMT、软斑 PI、硬斑PI、总斑 PI 与对照组相比明显增高(均P<0.01);冠心病Ⅱ型病变组软斑 PI、总斑 PI 与Ⅰ型、Ⅲ型病变组相比明显增高(P<0.01);Ⅱ型病变组血浆 MDA-LDL 含量与Ⅰ型、Ⅲ型病变组及照组相比明显增高(P<0.01)。(2)Ⅱ型病变组 MDA-LDL 含量与软斑 PI、总斑 PI 呈正相关(r=0.63,P<0.01;r=0.51,P<0.05)。结论通过颈动脉超声检测,颈动脉斑块(特别是软斑)的检出,结合血浆 MDA-LDL 含量,可以初步预测冠心病患者冠状动脉斑块的不稳定。     

Sudden coronary death in Glasgow: nature and frequency of acute coronary lesions

A detailed pathological study of the coronary arteries was carried out on 130 random white subjects (91 male and 39 female) who died suddenly in the Glasgow area. In 30 there was a clearly defined cause of death that was not due to ischaemic heart disease. In eight subjects the cause of death was in doubt. Ninety two of the 130 showed coronary stenosis resulting in a loss of more than 75% of coronary artery cross sectional area and/or acute coronary events with no other cause of death. Of these 92 subjects considered to have died suddenly of ischaemic heart disease, 64% showed plaque rupture and thrombosis which occurred at sites of previous high grades of stenosis. Twenty two subjects had intraluminal thrombosis unrelated to plaque fissuring. Thirty eight (41%) showed histological evidence of recent myocardial necrosis; acute coronary events occurred in 34 of these. There was no correlation between the duration of symptoms before death and the occurrence of acute coronary events. Acute coronary events, mainly in the form of plaque rupture, are a common finding in sudden coronary death when a careful study is made of the whole coronary arterial tree.     

Sudden coronary death in Glasgow: nature and frequency of acute coronary lesions.

A detailed pathological study of the coronary arteries was carried out on 130 random white subjects (91 male and 39 female) who died suddenly in the Glasgow area. In 30 there was a clearly defined cause of death that was not due to ischaemic heart disease. In eight subjects the cause of death was in doubt. Ninety two of the 130 showed coronary stenosis resulting in a loss of more than 75% of coronary artery cross sectional area and/or acute coronary events with no other cause of death. Of these 92 subjects considered to have died suddenly of ischaemic heart disease, 64% showed plaque rupture and thrombosis which occurred at sites of previous high grades of stenosis. Twenty two subjects had intraluminal thrombosis unrelated to plaque fissuring. Thirty eight (41%) showed histological evidence of recent myocardial necrosis; acute coronary events occurred in 34 of these. There was no correlation between the duration of symptoms before death and the occurrence of acute coronary events. Acute coronary events, mainly in the form of plaque rupture, are a common finding in sudden coronary death when a careful study is made of the whole coronary arterial tree.     

Plasma lipoprotein cholesterol in India in healthy persons and those with coronary heart disease

The plasma total cholesterol and lipoprotein cholesterol levels are presented for 186 healthy Indian subjects and 213 patients with coronary heart disease (CHD). Plasma lipid and lipoprotein concentrations vary with age. Higher total cholesterol and LDL cholesterol were noted in men compared with women. HDL cholesterol is highest in women in the age group 20-49 years. HDL cholesterol levels (negatively associated with CHD) are significantly higher in India compared with western countries. It is suggested that the high level of HDL cholesterol may be responsible for the relatively low incidence of CHD in India.     

Antiplatelet Management for Coronary Heart Disease: Advances and Challenges

Coronary heart disease (CHD) remains the leading cause of death in the USA. CHD accounts for 48 % of all cardiovascular mortality or approximately one of every seven deaths. Disruption of atherosclerotic plaques—usually by rupture or erosion—and superimposed thrombosis can result in acute coronary syndromes and sudden cardiac death. Silent plaque disruption may also occur and result in coronary plaque progression and ultimately the symptomatic manifestations of stable CHD. Antiplatelet agents remain the cornerstone therapy for acute thrombotic coronary syndromes and are essential for thromboprophylaxis against these events in patients with stable CHD. Antiplatelet drugs are also important adjunct therapies during percutaneous coronary intervention (PCI) as they mitigate equipment-associated thrombotic complications that are partially induced by iatrogenic plaque rupture by interventionalists during balloon angioplasty in the cardiac catheterization laboratory. Since the introduction of clopidogrel, there has been considerable development in this field with at least three novel P2Y₁₂ antagonists approved by the Food and Drug Administration (FDA) over the past decade. Rapidly accumulating evidence is helping to guide the optimal duration of treatment with dual antiplatelet therapy after stenting, especially with the newer drug-eluting stents. More data are also emerging on the hazards and long-term safety of these agents. It is therefore prudent for clinicians to remain current on treatment options and recent advances in this area. We herein review current and emerging antiplatelet therapies and summarize their characteristics and indications of use as well as challenges and areas of ongoing research.     

Frequency and distribution of thin-cap fibroatheroma and ruptured plaques in human coronary arteries: a pathologic study.

OBJECTIVES: Our purpose was to quantify the frequency and distribution of suspected vulnerable lesions, defined as thin-capped fibroatheroma (TCFA) and ruptured plaque, in human coronary artery autopsy specimens. BACKGROUND: Most acute coronary events and sudden death are believed to arise from rupture of a TCFA followed by thrombosis. Although there is general agreement that clinical events are usually caused by focal lesions, there is considerable debate over the relative importance of focal versus systemic factors in the pathogenesis of atherosclerosis. METHODS: We longitudinally sectioned coronary arteries from 50 whole hearts taken from patients (mean age 73 years, 64% men) dying of cardiovascular (n = 33), noncardiovascular (n = 13), and unknown (n = 4) causes. A total of 3,639 longitudinal segments of length 3 mm were sectioned from 148 arteries, accounting for 10.9 m of total tissue length. Specimens were classified on the basis of histology and computer-aided morphometry. RESULTS: Twenty-three TCFA and 19 ruptured plaques were found (mean +/- SD: 0.46 +/- 0.95 and 0.38 +/- 0.70 per heart, respectively), and these lesions accounted for only 1.6% and 1.2%, respectively, of the total length of the coronary tree examined in patients dying of cardiovascular causes. The majority of TCFA and ruptured plaque localized in the proximal third of the major coronary arteries, and in 92% of cases these lesions clustered within 2 or fewer nonoverlapping 20-mm segments. CONCLUSIONS: The suspected precursors of rupture-mediated thrombosis occur in a limited, focal distribution in the coronary arteries.     

Cardiovascular risk factors for stable angina pectoris versus unheralded myocardial infarction

Background

Ischemic heart disease can vary substantially in its clinical presentation. Some patients have acute myocardial infarction (MI) without any previous signs of myocardial ischemia, whereas other patients may have stable angina pectoris for years without periods of acute unstability. This study compared baseline risk factors between subjects in whom stable angina pectoris developed and subjects in whom unheralded fatal or nonfatal MI developed during the follow-up period.

Methods

In 1970 to 1973, all 50-year-old men in Uppsala, Sweden, were invited to participate in a health survey aimed at identifying risk factors for cardiovascular disease. The present study is a nested case-control study of subjects who were free of coronary heart disease (CHD) at baseline and who then underwent revascularization (percutaneous transluminal coronary angioplasty or coronary artery bypass grafting) because of angina pectoris without preceding MI (n = 70) or in whom fatal or nonfatal MI developed without prior known CHD (n = 372) during the period until 1998.

Results

In multivariate Cox proportional hazard models, low-density lipoprotein and high-density lipoprotein levels (protective) were significant independent risk factors for stable angina pectoris demanding revascularization, whereas smoking, diastolic blood pressure, serum proinsulin levels, and serum lipid levels were significant independent predictors of subsequent unheralded MI. When comparing hazard ratios (HR), significantly higher HR for diastolic blood pressure (1.40 vs 1.00, for 1 SD increase) and serum proinsulin (1.82 vs1.20, for 1 SD increase) were found in the group in which unheralded MI developed than in the group with stable angina pectoris.

Conclusions

Serum lipid levels were important risk factors for the development of both stable and acute coronary heart disease. In addition, proinsulin levels and blood pressure were independent predictors of unheralded MI only, which suggests that these factors are involved in thrombosis, plaque rupture, or both.     

老年冠心病合并代谢综合征患者的冠状动脉病变特点

目的探讨老年冠心病合并代谢综合征患者的冠状动脉病变特点。方法检测54例老年冠心病合并代谢综合征患者与108例老年冠心病不合并代谢综合征患者的腰围、空腹血糖、血脂、血压及冠状动脉造影。结果合并代谢综合征组冠状动脉血管多支病变、弥漫性病变及闭塞性病变较不合并代谢综合征组多(P>0.05),且主要累及左主干和左回旋支(P>0.05);合并代谢综合征组左心室功能减退高于不合并代谢综合征组(P>0.05)。结论合并代谢综合征患者在多重心血管危险因素聚集下,冠状动脉呈多支病变且病变严重,积极干预心血管危险因素,对防止冠心病的发生、发展,改善预后有重要的意义。     

Acute changes in serum lipids and lipoprotein subclasses in triathletes as assessed by proton nuclear magnetic resonance spectroscopy.

Exercise is associated with changes in lipids that may protect against coronary heart disease (CHD). In this study of 28 triathletes, we analyzed acute changes in serum lipid and lipoprotein concentrations after completion of the 1995 World Championship Hawaii Ironman Triathlon. With standard laboratory assays, we demonstrate significant decreases in total cholesterol, VLDL cholesterol, ApoB100, and Lp(a). Total HDL cholesterol increased significantly immediately after the race. With a novel proton NMR spectroscopy assay, we demonstrate that smaller diameter LDL particles, corresponding to small, dense LDL, declined by 62%. Moreover, larger HDL subclasses, whose levels are inversely associated with CHD, increased significantly by 11%. Smaller HDL subclasses, which have been directly associated with CHD in some studies, acutely decreased by 16%. Therefore, exercise not only acutely induces changes in lipoprotein concentrations among the standard species in a manner that favorably affects CHD risk, but also induces favorable changes in specific lipoprotein subclass size distribution that also may alter CHD risk independently of the total lipoprotein serum concentration.     

冠心病患者血清γ-谷氨酰转移酶水平变化及临床意义

目的 研究冠心病患者血清γ-谷氨酰转移酶（GGT）与冠心病严重程度及主要危险因素的关系。方法 对笔者医院888例冠心病患者行冠状动脉造影、超声检查,并检测血清GGT、丙氨酸氨基转移酶（ALT）、天冬氨酸氨基转移酶（AST）、总胆固醇(TC)、三酰甘油(TG)、高密度脂蛋白(HDL-C)和低密度脂蛋白(LDL-C)水平。结果 与GGT正常组相比,GGT升高组ALT、AST增加,TG上升,HDL-C下降,LVEF下降,Gensini评分升高。且GGT与ALT、AST、TC、TG、LDL-C和Gensini评分呈正相关,与LVEF和HDL-C呈负相关。结论 冠心病患者血清GGT水平与冠心病严重程度及冠心病的主要危险因素有关。