伊伐布雷定治疗稳定性心绞痛的研究进展

心率增快是心血管疾病的重要危险因素,也是导致心绞痛发作的重要原因。伊伐布雷定是一种I(f)电流通道抑制剂,能有效减慢稳定性心绞痛患者心率,进而减低心肌耗氧量、改善临床症状、减少心绞痛发作次数。但目前关于伊伐布雷定能否改善稳定性心绞痛患者远期预后及提高患者生活质量等方面的研究仍存在争议。本文从伊伐布雷定作用机制、相关临床证据及不良反应等方面进行综述,以探讨伊伐布雷定治疗稳定性心绞痛的可行性。     

Stable Angina Pectoris

The stable coronary artery disease (SCAD) population is a heterogeneous group of patients both for clinical presentations and for different underlying mechanisms. The recent European Society of Cardiology guidelines extensively review SCAD from its definition to patients’ diagnostic and therapeutic management. In this review, we deal with five topics that, in our opinion, represent the most intriguing, novel and/or clinically relevant aspects of this complex coronary condition. Firstly, we deal with a peculiar SCAD population: patients with angina and ‘normal’ coronary arteries. Secondly, we reinforce the clinical importance of a diagnostic approach based on the pretest probability of disease. Thirdly, we review and critically discuss the novel pharmacological therapies for SCAD patients. Finally, we analyse the results of the most recent clinical trials comparing revascularization versus optimal medical therapy in SCAD patients and review the currently recommended use of intracoronary functional evaluation of stenosis.     

The Sensitivity of the Symptom Angina Pectoris as a Marker of Transient Myocardial Ischaemia in Chronic Stable Angina Pectoris

ABSTRACT Therapeutic decisions in patients with angina pectoris are traditionally based on the history reported by the patient, since objective evidence of myocardial ischaemia during daily life is often not available. In this study, ambulatory ST segment monitoring was performed in 60 patients with a history of chronic stable angina pectoris, positive exercise test and/or positive coronary angiography, and a correlation was made between the episodes of chest pain and ST segment change. The patients were grouped according to the results of exercise testing and coronary arteriography, and one group was studied with and without antianginal medication. Overall, 195 episodes of angina were noted, only 94 of which (48%) were accompanied by ST segment depression. Pain and ST segment changes were best correlated in patients with a positive exercise test, positive angiography and who were not receiving antianginal medication. In 101 episodes of chest pain, ST segment change could not be identified; in 18 (18%) there was sinus tachycardia, in 12 (12%) ventricular premature beats, and in 71 (70%) sinus rhythm solely. Thus, anginal pain appears not to be the reliable indicator of transient myocardial ischaemia as was previously thought, a finding which supports the use of objective methods in identifying episodes of transient myocardial ischaemia in daily life.     

核黄素对心绞痛治疗作用的临床研究

目的观察核黄素对心绞痛的临床疗效。方法７８例劳力性心绞痛患者随机分成Ｂ组（ｎ＝２８，核黄素７５ｍｇ·ｄ－１，ｐｏ）、Ｉ组（ｎ＝２２，硝酸异山梨（醇）酯１５ｍｇ·ｄ－１，ｐｏ）和Ｃ组（ｎ＝２８，安慰剂，ｐｏ），各组均连续服药４Ｗ。用药前后检测静息心电图（ＥＫＧ）、血小板聚集性（ＰＡＧ）和血清丙二醛（ＭＤＡ）含量，并于用药前、用药第２Ｗ、用药第４Ｗ末记录心绞痛症状。结果核黄素对ＥＫＧ和心绞痛症状的疗效与硝酸异山梨（醇）酯相比无明显差异，但显著高于Ｃ组（Ｐ＜０．０１，Ｐ＜０．０１）。结论核黄素能有效治疗心绞痛，其机制可能与抑制血小板聚集和抗脂质过氧化作用有关     

Role of Endothelial Dysfunction and Insulin Resistance in Angina Pectoris and Normal Coronary Angiogram

Abstract Angina pectoris and a normal coronary angiogram or cardiac syndrome X is a heterogeneous syndrome that probably encompasses different pathophysiological entities. Patients affected by cardiac syndrome X are often women presenting with severe, invalidating chest pain. However, there is a significant discrepancy among the severity of symptoms, the lack of hemodynamic evidence of myocardial ischemia and the relatively benign long-term prognosis. The vascular endothelium has numerous important functions, including the regulation of vascular tone, blood flow and permeability, secreting both vasorelaxing and vasoconstricting factors. It has been found that both endothelium and non-endothelium-mediated coronary blood flow are impaired in patients with cardiac syndrome X. Interestingly, it has been shown that impaired nitric oxide-dependent vasodilation could increase coronary microvessel tone and produce spasm. It has also been reported that circulating endothelin-1 levels are elevated with a direct relationship between endothelin-1 levels and impaired coronary flow reserve in these patients. In addition, patients with high endothelin-1 levels showed a time onset of chest pain during exercise significantly lower compared to patients with low endothelin-1 concentrations. Moreover, the nitric oxide/endothelin-1 ratio was found decreased in patients with cardiac syndrome X and endothelin-1 levels were also positively correlated with fasting asymmetric dimethylarginine levels. All in all, these data suggest a role of endothelial dysfunction as a cause of regional myocardial and peripheral blood flow abnormalities. Further studies are necessary to characterize the prevailing mechanisms determining alterations in nitric oxide/endothelin-1 pathway in these patients, in order to find new therapies able to improve both quality of life and prognosis.     

Role of Endothelial Dysfunction and Insulin Resistance in Angina Pectoris and Normal Coronary Angiogram

Angina pectoris and a normal coronary angiogram or cardiac syndrome X is a heterogeneous syndrome that probably encompasses different pathophysiological entities. Patients affected by cardiac syndrome X are often women presenting with severe, invalidating chest pain. However, there is a significant discrepancy among the severity of symptoms, the lack of hemodynamic evidence of myocardial ischemia and the relatively benign long-term prognosis. The vascular endothelium has numerous important functions, including the regulation of vascular tone, blood flow and permeability, secreting both vasorelaxing and vasoconstricting factors. It has been found that both endothelium and non-endothelium-mediated coronary blood flow are impaired in patients with cardiac syndrome X. Interestingly, it has been shown that impaired nitric oxide-dependent vasodilation could increase coronary microvessel tone and produce spasm. It has also been reported that circulating endothelin-1 levels are elevated with a direct relationship between endothelin-1 levels and impaired coronary flow reserve in these patients. In addition, patients with high endothelin-1 levels showed a time onset of chest pain during exercise significantly lower compared to patients with low endothelin-1 concentrations. Moreover, the nitric oxide/endothelin-1 ratio was found decreased in patients with cardiac syndrome X and endothelin-1 levels were also positively correlated with fasting asymmetric dimethylarginine levels. All in all, these data suggest a role of endothelial dysfunction as a cause of regional myocardial and peripheral blood flow abnormalities. Further studies are necessary to characterize the prevailing mechanisms determining alterations in nitric oxide/endothelin-1 pathway in these patients, in order to find new therapies able to improve both quality of life and prognosis.     

阿托伐他汀治疗冠心病心绞痛临床疗效研究

目的探讨阿托伐他汀治疗冠心病心绞痛的临床疗效。方法选取2010年1月—2012年1月我院心内科收治的冠心病心绞痛患者120例,采用随机数字表法将其分为对照组和观察组,各60例。对照组采用单硝酸异山梨酯片治疗,观察组采用阿托伐他汀钙治疗。观察两组临床疗效、不良反应发生率、平均症状缓解时间、心血管疾病发生率。结果观察组总有效率为95.0%(57/60),高于对照组的80.0%(48/60)(P0.05);观察组不良反应发生率和心血管疾病发生率均低于对照组(P0.05),平均症状缓解时间短于对照组(P0.05)。结论阿托伐他汀治疗冠心病心绞痛具有临床疗效显著、不良反应发生率低、症状缓解时间短、心血管疾病发生率低等特点。     

Coronary Arterial Spasm in Classic Angina Pectoris

A 47-year-old black male who presented with classical angina pectoris and positive exercise test developed spasm of the right coronary artery in the vicinity of an atherosclerotic lesion resulting in transient total occlusion of the vessel. It seemed unlikely that spasm was catheter induced in this case, and the vessel relaxed promptly following nitroglycerin administration. The occurrence of severe spasm in proximity to atherosclerotic narrowing of coronary artery may contribute to stable and unstable angina, myocardial infarction, and sudden death in patients with these conditions coexisting. The awareness of such a phenomenon is necessary to avoid serious errors in the interpretation of coronary angiograms.     

Intravenous Nitroglycerine in Refractory Unstable Angina Pectoris

Abstract: Sixteen patients with severe coronary artery disease and unstable angina, refractory to standard therapy with nitrates, beta-blockers or calcium antagonists, were given intravenous nitroglycerine (500 μg/ml) in an open trial. The infusion was started at 0–17 ml/min. The final infusion rate ranged from 0 17 ml/min to 2 04 ml/min, depending on the symptomatic and haemodynamic response of the individual patient. At the slow infusion rates, the actual dose was probably only 15% of the delivered dose because of the adsorption of nitroglycerine to PVC tubing.
There was significant pain relief in all patients. In six patients, pain relief was complete; in ten patients, occasional episodes occurred during the nitroglycerine infusion but they were less frequent and less severe and few were associated with ST segment changes. Systolic blood pressure fell by a mean of 100 mmHg at the commencement of therapy but there was no significant change in heart rate. Apart from mild headaches, no other adverse effects were observed. The mean treatment time was 3-2 days (range 1–8 days). Eight patients were discharged on oral and/or cutaneous nitrate therapy and eight patients had coronary artery surgery.
Intravenous nitroglycerine is useful for controlling symptoms in patients with unstable angina refractory to conventional therapy and may be particularly valuable for settling these patients before coronary arteriography and during preparation for coronary surgery.     

尼可地尔对顽固性心绞痛患者心绞痛发作及心电图ST-T段的影响

目的探讨尼可地尔对顽固性心绞痛患者心绞痛发作及心电图ST-T段的影响。方法选取孝感市中心医院2012年4月—2015年4月收治的顽固性心绞痛患者80例,根据治疗方法不同分为研究组和对照组,各40例。两组患者均给予基础治疗,研究组患者给予尼可地尔治疗,对照组患者给予安慰剂治疗,两组患者均以4周为1个疗程。比较两组患者临床疗效和心电图ST-T段改善情况,治疗前后心绞痛发作频率和持续时间,治疗期间观察两组患者不良反应发生情况。结果两组患者临床疗效和心电图ST-T段改善情况比较,差异无统计学意义(u值分别为1.883和0.727,P值分别为0.060和0.467)。治疗前两组患者心绞痛发作频率和持续时间比较,差异无统计学意义(P0.05);治疗后研究组患者心绞痛发作频率低于对照组,持续时间短于对照组(P0.05)。治疗期间研究组不良反应发生率为30.0%,对照组为25.0%,差异无统计学意义(P0.05)。结论尼可地尔能有效减少顽固性心绞痛患者心绞痛发作频率,缩短心绞痛持续时间,且安全性较高,但其改善心电图ST-T段效果不明显。     

氯吡格雷治疗不稳定型心绞痛的疗效观察

目的 探讨氯吡格雷治疗不稳定型心绞痛的临床效果.方法 选择不稳定型心绞痛患者100例,随机分为观察组与对照组各50例,对照组给予常规治疗,观察组在常规治疗的基础上加用氯吡格雷治疗,观察两组的临床疗效.结果 观察组的总有效率明显高于对照组,两组比较,差异有统计学意义 (χ2=10.25,P＜0.05);观察组治疗后各指标与对照组比较,差异有统计学意义(P＜0.05).两组不良反应情况比较,差异无统计学意义(P＞0.05).结论 氯吡格雷治疗不稳定型心绞痛疗效满意,值得临床推广应用.     

初发型及稳定型心绞痛和急性心梗患者冠脉病变的变化

本文分析了初发型心绞痛（NAP）、无并发症的稳定型心绞痛（SAP）患者和以急性心肌梗塞（AMI）为冠心病首发症状患者的冠脉病变的严重性和范围，以探讨急性冠脉综合症与血管病变的关系。结果表明：无并发症的SAP组冠脉病变明显重于AMI与NAP组，无论是病变血管数、狭窄数、闭塞数还是病变范围，前者均重于后两组。SAP组81．3％为2支和3支血管病变，而AMI和NAP组大多数为单支血管病变（两组分别为88．2％和60．0％），各组冠心病危险因素相似。结论：急性冠脉综合症患者的冠脉病变的严重性无法预测能否发生急性冠脉综合症。     

东菱精纯克栓酶治疗不稳定型心绞痛疗效观察

东菱精纯克栓酶 (Ｂａｔｒｏｘｏｂｉｎ ,ＤＦ 52 1)是一种新型强力单成分溶栓剂 ,近年来国内开始用于治疗急性缺血性脑血管病[1,2 ] 。而用于治疗不稳定型心绞痛 (ＵＡ)尚少有报道。我们于 1995年开始将ＤＦ 52 1试用于治疗ＵＡ ,对其疗效及安全性进行评价。资料和方法一般资料　所有病例均符合 1979年ＷＨＯ冠心病ＵＡ诊断标准 ,均无溶栓禁忌证。入选患者 90例经住院确诊后随机单盲分为 3组 ,详见表 1。 3组性别、年龄、病程、梗塞史及分型均无显著差异 (Ｐ均>0 .0 5) ,具有可比性。表 1　临床一般资料Ａ组Ｂ组Ｃ组例数 30 2 832男 :女 (…