Management of Ischemic Heart Disease in Patients with Chronic Kidney Disease

Patients with chronic kidney disease (CKD) and ischemic heart disease (IHD) have strikingly high mortality rates. In the general population, there has been a reduction in the mortality and morbidity rates for IHD through the implementation of effective risk-factor-reduction programs and better interventions for patients with established IHD. No such trend has been observed in patients with end-stage kidney disease. This review article addresses the following topics: (i) epedemiology, pathogenesis, clinical CKD patients with IHD; (ii) diagnostic modalities for IHD and their limitation in CKD patients; (iii) medical treatment options and revascularization strategies for these high-risk patients; and (iv) optimal cardiovascular risk management. Generally, in CKD patients with IHD an aggressive approach to IHD is warranted, a low threshold for diagnostic testing should be employed, and awaiting a clinical trial targeting these patients they should be considered for all proven strategies to improve outcomes.     

A Metabolic Approach to the Management of Ischemic Heart Disease

Myocardial ischemia occurs when there is a supply and demand imbalance between the delivery of oxygenated blood to the myocardium and the needs of the myocardium to maintain normal cardiac function at any level of activity. The commonest cause of the imbalance is obstructive coronary artery disease. A pharmacologic hemodynamic approach to therapy principally focuses on reducing demand (slowing heart rate, lowering blood pressure, reducing contractility and increasing peripheral venous and arterial vasodilatation), with a variable effect on supply (coronary vasodilatation).This is a proven and highly effective approach indirectly improving myocardial metabolism. An alternative and complementary strategy avoids any effect on hemodynamics, but by direct action at the cellular level minimizes the ischemic disruption of cardiac metabolism. Trimetazidine inhibits the fatty acid oxidation enzyme long-chain 3-ketoacyl-coenzyme A thiolase (3-KAT), thereby decreasing fatty acid oxidation and increasing the combustion of glucose and lactate. This switch back from ischemia-induced fatty acid oxidation to glucose oxidation has been shown to be of significant clinical benefit, both subjectively and objectively, independent of or in combination with conventional hemodynamic agents.     

Gene Therapy for Ischemic Heart Disease

Gene therapy is evolving as an alternative mode to pharmacological intervention in the treatment of cardiovascular diseases. Experimental observations indicating that introduction of genes encoding for angiogenic peptide growth factors could result in improvement in perfusion to ischemic myocardium have led to the initiation of a number of preliminary clinical trials to evaluate this therapeutic modality. Sustained expression of the growth factor product from somatic cells transfected with the DNA for that protein has proven to be one of the major advantages of a gene therapy—based approach over administration of the recombinant protein. A number of gene therapy vectors have been developed, prominent among these being adenoviral vectors and naked plasmid DNA. Whereas plasmid DNA results in less efficient transfection, its tolerability profile may be superior to adenoviral vectors. Plasmid DNA is particularly suitable when the gene product to be produced is capable of being secreted by the cell which is producing it. Vascular endothelial growth factor (VEGF) is not only essential to the process of angiogenesis, but, because it can be secreted from intact cells, appears to be ideal for gene transfer therapy aimed at improving perfusion to ischemic myocardium. The DNA can be delivered to the myocardium by intra-arterial or intramuscular injection. At present, direct injection into the muscle either via a small thoracotomy incision or by use of a recently developed percutaneous catheter technique appears to be superior to arterial administration. Several clinical trials based on intramyocardial injection of VEGF DNA in patients with otherwise inoperable coronary artery disease and intractable angina pectoris have recently been completed. These phase I trials have documented the tolerability of gene transfer using plasmid DNA and show promise of being able to improve myocardial perfusion and reduce anginal symptoms in the majority of patients treated thus far. While the trials involving gene transfer via a thoracotomy did not allow for randomization to a placebo group, the recent advent of a percutaneous delivery modality has allowed for randomization which should enhance our ability to determine whether angiogenic gene therapy will prove to be as effective as initial results suggest. In the future, results from such randomized placebo-controlled trials, improvement in vectors utilized for gene transfer and innovative new delivery techniques will undoubtedly enhance the potential of this novel approach to myocardial revascularization.     

积极发挥医院药事管理在单病种管理中的作用

随着现代医学模式的转变，医院功能发生变化，医院药事管理也从对“物”的管理，转变为以对患者合理用药为中心的药事管理，向着多功能、标准化、制度化方面发展。保证和提高民众用药的安全性、有效性、经济性和适当性，也即保证和提高合理用药水平已成为医院药事管理的根本目标和任务。单病种管理是建立在疾病分级的基础上，对单一病种从确诊人院、治疗至治愈出院而进行的管理。     

Pharmacologic Rationale for Trimetazidine in the Treatment of Ischemic Heart Disease

Although systemic hypertension is a common clinical disorder, hypertensive emergencies are unusual in clinical practice. Situations that qualify as hypertensive emergencies include accelerated or malignant hypertension, hypertensive encephalopathy, acute left ventricular failure, acute aortic dissection, pheochromocytoma crisis, interaction between tyramine-containing foods or drugs and monoamine oxidase inhibitors, eclampsia, drug-induced hypertension and possibly intracranial hemorrhage. It is important to recognize these conditions since immediate lowering of systemic blood pressure is indicated. The diagnosis of hypertensive emergencies depends on the clinical manifestations rather than on the absolute level of the blood pressure. Depending on the target organ that is affected, the manifestations of hypertensive emergencies can be quite expressive, yet variable. Thus, the physician has to make the clinical diagnosis urgently in order to render appropriate therapy. Several parenteral drugs can quickly and effectively lower the blood pressure in hypertensive emergencies. Intravenous fenoldopam, a selective dopamine (DA₁) receptor agonist, offers the advantage of improving renal blood flow and causing natriuresis. Intravenous nicardipine may be beneficial in reserving tissue perfusion in patients with ischemic disorders. Whereas trimethaphan camsilate is the drug of choice for managing acute aortic dissection, hydralazine remains the drug of choice for the treatment of eclampsia. The α-adrenoceptor, phentolamine, is useful in patients with pheochromocytoma crisis. Enalaprilat is the only ACE inhibitor available for parenteral use and may be particularly useful in treating hypertensive emergencies in patients with heart failure. However, ACE inhibitors may cause a precipitous fall in blood pressure in patients who are hypovolemic. Although useful as adjunctive therapy in hypertensive crises, diuretics should be used with caution in these patients because prior volume depletion may be present in some conditions such as malignant hypertension. The treating physician should be familiar with the pharmacological and clinical actions of drugs which are indicated for and useful in the treatment of hypertensive emergencies. Once the patient’s situation has stabilized, the patient may be switched to an oral medication and the physician should discuss long term follow up plans. With appropriate clinical diagnosis, hypertensive emergencies can be successfully treated and the complications can be prevented with timely intervention.     

缺血性心脏病的基因治疗与血管新生

对于冠状动脉弥漫性狭窄、复发性难治性心绞痛、耐受能力差、合并多种危险因素等不适合用传统治疗方法重建血运的冠心病患者而言,基因治疗是一种促进血管新生的极具吸引力的治疗模式,将成为今后缺血性心脏病治疗上的主要进展。     

A Critical Review of the Use of Carvedilol in Ischemic Heart Disease

β-Adrenergic receptor antagonists (β-blockers) have been recognized for their cardioprotective properties, prompting use of these pharmacologic agents to become more mainstream in acute myocardial infarction (AMI) and congestive heart failure (CHF). Despite their popularity as a class, the ability to protect the myocardium varies significantly between different agents. Carvedilol is a non-selective β-blocker with α₁-adrenergic receptor antagonism properties. It is unique among β-blockers because in addition to improving exercise tolerance and its anti-ischemic properties secondary to a reduction in heart rate and myocardial contractility, carvedilol exerts other beneficial effects including: antioxidant effects; reduction in neutrophil infiltration; apoptosis inhibition; reduction of vascular smooth muscle migration; and improvement of myocardial remodeling post-AMI. These properties, documented in animal models and subsequent clinical trials, are consistent with established evidence demonstrating decreased morbidity and mortality in patients with CHF and post-AMI. This article reviews the role of carvedilol compared with other β-blockers in the treatment of CHF and post-AMI management.     

治疗缺血性心脏病新药：曲美他嗪

缺血性心脏病的传统治疗以对症处理为主 ,即增加心肌的供氧 ,降低耗氧。随着对心肌缺血代谢过程的研究和认识 ,提出了通过干预心肌能量产生的代谢环节 ,完善线粒体能量代谢而治疗缺血性心脏病的新概念。1　心肌能量代谢的特点正常心肌的能量 (ＡＴＰ)供给 6 0 %～ 70 %来自游离脂肪酸 (ＦＦＡ) β 氧化 ,2 0 %～ 2 5 %为葡萄糖氧化 ,5 %～ 10 %为糖酵解 (无氧代谢 )。ＦＦＡ氧化产生等量ＡＴＰ的耗氧量比葡萄糖氧化的耗氧量高 ,而且高水平ＦＦＡ氧化可明显抑制葡萄糖氧化的速率。心肌缺血时能量代谢的变化 :①交感神经兴奋 ,儿茶酚胺水平升…     

脑干梗塞患者心电图缺血样改变与预后分析

目的 观察急性脑干梗塞患者心电图改变及其与出血部位的关系.方法 112例脑干梗塞患者入院后24h内常规描记12导联ECG,并对其与临床关系进行分析.结果 112例中71例出现心电图缺血样改变,异常率为63.39%.ECG中有心电图缺血样改变者死亡66例(92.95%),无此改变者死亡3例(7.32%).两组比较预后有统计学意义(P＜0.01).结论 脑源性心脏缺血样改变与脑干梗塞有直接关系,且与预后密切相关.心脏缺血样改变可作为急脑干梗塞判定预后的主要指标之一.     

心脏瓣膜病合并冠心病的外科治疗体会

目的介绍心脏瓣膜手术同期行冠状动脉旁路移植术的治疗体会。方法 2003年5月至2013年12月,心脏瓣膜手术同期行冠状动脉旁路移植术29例,患者男性13例,女性16例。年龄35⁷0岁。共搭桥54根。二尖瓣成形术8例;主动脉瓣机械瓣置换术3例;二尖瓣机械瓣置换术10例;主动脉瓣置换及二尖瓣成形术4例;双瓣膜置换术4例。结果术后早期死亡5例,病死率17.24%,其中左室破裂2例,多器官功能衰竭2例,室颤1例。随访370岁。共搭桥54根。二尖瓣成形术8例;主动脉瓣机械瓣置换术3例;二尖瓣机械瓣置换术10例;主动脉瓣置换及二尖瓣成形术4例;双瓣膜置换术4例。结果术后早期死亡5例,病死率17.24%,其中左室破裂2例,多器官功能衰竭2例,室颤1例。随访3²4个月,心功能改善,无严重心绞痛发作。结论风湿性瓣膜病患者,有冠心病高危因素者,应常规行冠状动脉造影检查。缺血性二尖瓣关闭不全者如瓣膜成形效果差时,应选择保留瓣下结构的瓣膜置换术。     

冠心病患者降脂药物的应用评价

目的:评价各类降脂药物在冠心病治疗中的研究进展及临床应用情况.方法:查阅近期国外相关文献进行综述、评价.结果与结论:降脂药物主要分为他汀类、苯氧芳酸类、烟酸类及胆酸螯合剂等.降脂治疗在冠心病的治疗中占有重要地位,及早合理地应用降脂药物,可以使冠心病患者获得长期的受益.     

曲美他嗪治疗缺血性心脏病心力衰竭

目的　观察曲美他嗪治疗缺血性心脏病心力衰竭患者的临床疗效。 方法　 选择缺血性心脏病、心力衰竭患者 2 70例 ,随机分为两组 :对照组 130例 ,TMZ组 (14 0例 )。 结果　TMZ组心功能改善的临床显效率 (70 % )和总有效率 (95 % )均较对照组 (2 5 4 % )和 (6 2 9% )显著提高 (P <0 .0 1) ,且无明显不良反应。结论　 用TMZ辅助治疗缺血性心脏病心力衰竭是一种安全有效的方法     

三药联合治疗风湿性心脏瓣膜病合并慢性心力衰竭的临床价值

目的观察三药联合治疗风湿性心脏瓣膜病(RVD)合并慢性心力衰竭(CHF)的临床价值分析。方法研究选取2017年2月至2018年4月我科室收治的RVD合并CHF患者143例作为观察对象,按照治疗方案差异将其分为对照组70例、观察组73例,入院后均给予相关基础治疗,对照组仅接受基础药物治疗,观察组给予倍他乐克+缬沙坦胶囊+螺内酯三联用药治疗,比较两组患者临床疗效。结果观察组治疗后LVEF、总有效率高于对照组,HR、DBP、LVESD、LVEDD均低于对照组(P <0.05);且两组治疗期间均未出现严重药不良反应。结论对RVD合并CHF患者实施基础治疗同时,采用倍他乐克+缬沙坦胶囊+螺内酯三联用药治疗效果显著,可有效改善患者心功能。     

L-carnitine Combined with Qumei Trimetazidine in Patients with Ischemic Heart Disease Patients

目的 观察左卡尼汀联合曲美他嗪改善心力衰竭患者的心功能以及心肌保护作用.方法 将缺血性心肌病患者随机分为治疗组(117例)和对照组(117例).两组患者均给予常规冠心病二级预防及抗心力衰竭治疗.治疗组加用左卡尼汀3.0g加入5%葡萄糖溶液(糖尿病患者为木糖醇溶液)100mL静脉滴注,1次/d,疗程2周,同时应用曲美他嗪20mg/次,3次/d.比较两组治疗前和疗程结束时的心功能(LVEDD、LVESD、LVEF)和心脏标志物CKMB、TNI、H-FAB以及BNP水平.结果 治疗组患者心功能改善显著,CK-MB、TnI、H-FABP以及BNP水平显著降低.结论 联合应用左卡尼汀和曲美他嗪能有效改善缺血性心肌病的心功能,并减少心肌损伤.     

农村居民缺血性心脏病发病的季节性特征分析

目的 回顾分析开封地区农村居民缺血性心脏病发病规律和特征,探索年龄、性别因素与其季节性发病的相关性,摸清缺血性心脏病发病的动态变化趋势.方法 逐年追踪开封市2008年至2010年参加新型农村合作医疗的农村居民的住院就诊情况,对其中患缺血性心脏病住院治疗病例的临床资料进行总结分析.结果 缺血性心脏病大都好发于4、5月,其他月份比较平稳.性别和年龄组的发病率好发月份没有明显区别,好发于4、5月.结论 开封地区缺血性心脏病发病率呈季节性是自然地理、社会地理以及医学地理环境因素综合影响所致.其中气候气象、自然地理环境、饮食因素等对缺血性心脏病的季节性高发也具有一定的影响.     

Systematic Review of the Efficacy and Safety of Perhexiline in the Treatment of Ischemic Heart Disease

Perhexiline was introduced about 30 years ago and rapidly gained a reputation for efficacy in the management of angina pectoris. However, hepatic and neurological adverse effects associated with perhexiline administration led to a marked decline in its use. The drug was originally classified as a coronary vasodilator, and later as a calcium channel antagonist, but recent data suggests that it acts as a cardiac metabolic agent, through inhibition of the enzyme, carnitine palmitoyltransferase-1 (CPT-1). Given the drugs’s unique anti-ischemic action and favorable hemodynamic profile, together with an improved understanding of the mechanisms underlying the adverse effects of the drug and the clear clinical need for additional therapies in refractory patients, perhexiline is currently being re-appraised as a potentially useful agent in the management of severe myocardial ischemia. Perhexiline is being considered for registration or re-registration in a number of countries and is being evaluated in a large-scale clinical trial in elderly patients with aortic stenosis and myocardial ischemia. This systematic review examines the evidence from available published literature in relation to the efficacy and tolerability of perhexiline in the treatment of cardiac disease. While there is a lack of well designed controlled trials using objective end-points to determine efficacy (almost all trials used a crossover design, included small numbers of patients and had limited statistical analysis of results), there is consistency in the data available that perhexiline is considerably more effective than placebo when used as monotherapy. Furthermore, it affords additional symptom relief in those already receiving maximal conventional anti-anginal therapy. However, there is a paucity of trials demonstrating the efficacy of low dosages of perhexiline (100 to 200 mg/day) in patients with refractory angina pectoris. Available evidence also suggests that the incidence of adverse events can be minimised, and the efficacy maintained, by keeping plasma perhexiline concentrations within a therapeutic range (150 to 600 μg/L).     

低分子量肝素对缺血性心脏病凝血机制的影响

目的 :研究低分子量肝素对缺血性心脏病患者高凝状态的影响。方法 :观察75例缺血性心脏病患者应用低分子量肝素后 ,凝血和抗凝血机制的变化。结果 :抗凝血酶Ⅲ活性在用药前为 (0 871±0 065)IU ,用药后10h为 (1 113±1 013)IU (t=3 22 ,P<0 05) ,有显著性差异 ;组织型纤溶酶原激活酶活性在用药前、后则分别为 (1 50±0 22)、(2 31±1 02)IU (t=8 45 ,P<0 01) ,有极显著性差异。结论 :低分子量肝素不但可改善缺血性心脏病患者高凝状态 ,且没有出血倾向。     

化痰药物在慢性阻塞性肺疾病中的作用及评价

化痰药能够清除粘液,减少细菌定植,减少急性加重和住院次数,改善生活质量,充分显示了其潜在的应用前景。     

Beyond Heart Failure and Ischemic Heart Disease: A Scoping Review of Novel Uses of Ivabradine in Adults

Ivabradine lowers heart rate by inhibiting the hyperpolarization-activated current in pacemaker cells, and its use for the treatment of heart failure (HF) and ischemic heart disease (IHD) is well described. Ivabradine may be an attractive treatment option for other conditions for which a reduction in heart rate is desirable but less is known about its role in these settings. The primary objective was to perform a scoping review summarizing the literature evaluating novel uses for ivabradine other than HF and IHD in adults. PubMed and EMBASE were searched for articles for all dates through September 2019. Search strategies combined terms generic, commercial/trade, and international names for ivabradine. Manual search of references was also performed to identify additional articles. Studies were included if they were published in English, evaluated the efficacy of ivabradine for indications other than HF or IHD in patients aged 18 years or older, and the primary outcome included clinically relevant end points. Articles were screened first by title and abstract followed by full-text screening of the remaining articles. After removal of duplicates, 1807 records were screened for inclusion and 84 studies were included in this scoping review. Novel uses of ivabradine were reported for various tachyarrhythmias, valvular heart disease, premedication for coronary computed tomography angiography, perioperative risk reduction, sepsis with and without multi-organ dysfunction syndrome, cor pulmonale, reactive airway disease, and erectile dysfunction. This scoping review identified several potential novel uses for ivabradine in adults. This review may help to identify existing gaps where further research is needed to elucidate the role of ivabradine for indications beyond HF and IHD.