非ST段抬高急性冠状动脉综合征治疗进展

非ST段抬高急性冠状动脉综合征(non-ST-segment elevation acute coronary syndromes,NSTEACS)已成患者急诊和入院的主要原因,其抗血小板、抗凝、调脂、介入治疗等方面研究对提高患者的生存率及生存质量有重要意义。近年来,关于新的治疗药物、治疗方法的选择、介入治疗的时机及特殊人群的处理等方面都有一些新的进展。     

Antiplatelet therapy in non-ST-segment elevation acute coronary syndromes

Acute coronary syndromes are a frequent cause of hospital admission for patients with coronary artery disease. The pathophysiology of acute coronary syndromes often involves plaque rupture or fissure with platelet aggregation. Recognition of the importance of platelet aggregation resulted in several large randomized trials testing 3 types of platelet antagonists, aspirin, glycoprotein IIb/IIIa inhibitors, and adenosine diphosphate inhibitors. A thorough understanding of the data, risks, and benefits of these therapies is important to optimize treatment of the patient with an acute coronary syndrome. Recognition that there is a great deal of interpatient variability in response to these antiplatelet therapies highlights the need for future research in this area.     

A simplified approach to the management of non-ST-segment elevation acute coronary syndromes

Context  While current practice guidelines provide an evidence-based approach to management of acute coronary syndromes (ACS), application of the evidence by individual physicians has been suboptimal. Objective  To assess and synthesize the evidence regarding optimal management of non–ST-segment elevation ACS (NSTE-ACS). Data Sources  Systematic searches of peer-reviewed publications were performed in MEDLINE and the Cochrane Database from January 1990 through November 2004, with consultation by content experts. Search terms included antiplatelet therapy, antithrombotic therapy, angiotensin-converting enzyme inhibition, angiotensin receptor blockade, -blockade, hypertension, hyperlipidemia, cigarette smoking, diet, diabetes mellitus, exercise, myocardial ischemia, and coronary artery disease. Study Selection and Data Extraction  Criteria for selection of studies included controlled study design, English language, and clinical pertinence. Data quality was based on the publishing journal and relevance to clinical management of NSTE-ACS. Data Synthesis  While outcomes of controlled studies support a comprehensive approach in the management of patients with NSTE-ACS, many physicians perceive existing guidelines as lengthy and complex. After risk stratification to identify those patients most likely to benefit from an early invasive vs early conservative strategy, a comprehensive management plan can be assembled through an "ABCDE" approach. The elements of this include "A" for antiplatelet therapy, anticoagulation, angiotensin-converting enzyme inhibition, and angiotensin receptor blockade; "B" for -blockade and blood pressure control; "C" for cholesterol treatment and cigarette smoking cessation; "D" for diabetes management and diet; and "E" for exercise. Conclusion  An "ABCDE" approach for the management of NSTE-ACS provides a practical and systematic means to implement evidence-based medicine into clinical practice.      

曲美他嗪联合生脉注射液治疗非ST段抬高性急性冠脉综合征的效果

目的探讨曲美他嗪联合生脉注射液在非ST段抬高性急性冠脉综合征（NSTEACS）中的应用。方法将选择的46例NSTEACS患者随机分为对照组与治疗组,在常规药物治疗的基础上,对照组加用曲美他嗪治疗,治疗组则在对照组治疗的基础上加用生脉注射液进行治疗。观察并比较两组患者治疗总有效率、治疗前后血浆高敏C-反应蛋白（hs-CRP）、一氧化氮（NO）以及内皮素（ET）水平变化。结果治疗组治疗总有效率为91.30%,显著高于对照组的82.61%,差异有统计学意义（P〈0.05）;治疗后两组患者血浆hs-CRP及ET水平均显著降低,NO水平显著升高（P〈0.05）,以治疗组变化更为显著（P〈0.05）。结论曲美他嗪联合生脉注射液治疗NSTEACS疗效肯定,可显著改善内皮功能并抑制炎症,疗效优于单用曲美他嗪。     

vWF升高预测非ST段抬高的急性冠脉综合征患者的不良预后

目的评价血管性血友病因子（von Willebrand factor,vWF）对判断非ST段抬高的急性冠脉综合征（NSTE-ACS）患者预后的意义。方法70例NSTE-ACS患者,检测基线时、入选12 h及48 h血浆vWF水平。研究的复合终点包括随机入选后30 d内的死亡、心肌梗死或复发心肌梗死以及复发心绞痛。比较发生终点事件与未发生终点事件的患者之间血浆vWF水平的区别。结果①在随访30 d时,22例（31.4%）发生了至少一个终点事件。在有终点事件的患者与无终点事件的患者间,48 h与基线vWF浓度的差值为100±34%比73±33%（P〈0.05）。②在有终点事件的患者与无终点事件的患者间,男性比率为55%比75%（P〈0.05）,多支血管病变比率为73%比50%（P〈0.05）。结论非ST段抬高的急性冠脉综合征发病早期48 h内vWF的浓度升高是30 d终点事件的独立预测因素。     

Advances in antiplatelet therapy for acute coronary syndromes

Admissions to emergency care centres with acute coronary syndromes remain one of the principal burdens on healthcare systems in the Western world. Early pharmacological treatment in these patients is crucial, lessening the impact on both morbidity and mortality, with the cornerstone of management being antiplatelet agents. While aspirin and clopidogrel have been the drugs of choice for nearly a decade, an array of newer, more potent antiplatelet agents are now available or in late stage development. Data are rapidly gathering suggesting these agents have superior anti-ischaemic properties, improving patient outcomes, but that for some agents increased vigilance and appropriate patient selection may be necessary to guard against bleeding complications. In this review, the authors aim to deliver an overview of the changing field of antiplatelet therapy and provide information about the relative risks and benefits of these newer agents, many of which will be entering widespread clinical use imminently.     

加强基层培训,不断提高对非ST段抬高型急性冠状动脉综合征的诊治水平

简要介绍《非ST段抬高型急性冠状动脉综合征基层诊疗指南(2019年)》制订的背景和涵盖内容。基层医疗机构医师应熟悉心肌损伤标志物肌钙蛋白(cTn)检测在非ST段抬高型急性冠状动脉综合征早期诊断中的重要性,重视其早期评估和危险分层,规范治疗策略,以改善长期预后。     

心脏生化标志物联合检测在非ST段抬高急性冠脉综合征预后评价中的意义

目的 初步探讨多种心脏生物标志物联合检测在非ST段抬高急性冠脉综合征(NSTEACS)预后评价中的意义.方法 纳入NSTEACS患者262例,按照是否发生心脏事件分为两组.检测所有研究对象的血清末端B型利钠钛原(NT-proBNP)、超敏C反应蛋白(hs-CRP)、肌酸肌酶同工酶(CK-MB)、肌钙蛋白I(cTnI)、过氧化物酶体增殖因子活化受体A(PPAR-A)、胎盘生长因子(PLGF)及人可溶性p-选择素(sP-selectin)及糖化血红蛋白水平.选择出其中对预后评价有影响的生物标志物,进一步建立能够对NSTEACS患者进行预后评价的数学模型.结果 通过对心脏事件组和非心脏事件组的临床基线特征和生化标志物比较发现,两组间左室后壁(LVD)、左室射血分数(LVEF)、NT-proBNP、hs-CRP、cTnI、CK-MB、PPAR-A、PLGF及sP-selectin差异具有统计学意义(P＜0.05),而糖化血红蛋白(HbA1c)则差异无统计学意义(P＞0.05);利用Logistic逐步回归方法分析发现其特异度和灵敏度分别为95.0％和78.4％,绘制ROC曲线,ROC曲线下面积为97.8.结论 上述生化标志物的联合检测结果对心脏预后的评估具有高度的特异性和准确性.     

氯吡格雷联合阿司匹林治疗非ST段抬高急性冠状动脉综合征的疗效

目的:运用氯吡格雷联合阿司匹林治疗非ST段抬高急性冠状动脉综合征,对比观察临床疗效。方法:收集我院诊治的非ST段抬高急性冠状动脉综合征患者100例,随机分为治疗组51例和对照组49例,对照组在常规治疗基础上加用标准剂量的阿司匹林,治疗组则在对照组基础上给予氯吡格雷治疗,连续治疗2个月,观察两组的临床疗效、统计心血管事件发生、检测凝血功能及血小板计数变化、记录药物的不良反应。结果:治疗组的临床疗效和心电图疗效均显著高于对照组(P<0.01),治疗组的心血管事件发生率也较对照组低(P<0.05)。但凝血功能及血小板计数两组间差异无统计学意义(P>0.05),两组均未见严重的不良反应。结论:氯吡格雷联合阿司匹林治疗非ST段抬高急性冠状动脉综合征疗效要优于单用阿司匹林,且安全性良好,二者联合可长期使用。     

急性非ST段抬高型与ST段抬高型心肌梗死冠脉病变特征比较

目的比较非ST段抬高型急性心肌梗死（NSTEAMI）与ST段抬高型急性心肌梗死（STEAMI）冠状动脉病变的特点。方法回顾NSTEAMI与STEAMI患者的临床及冠状动脉造影资料,分析二者的临床特点及冠状动脉病变血管的支数、狭窄程度及侧支循环情况。结果 NSTEAMI组的多支病变率为63.34%,其中大于75%的严重狭窄率为78.33%,侧支循环率为30.00%,三者均高于STEAMI组,而完全闭塞率为8.33%,低于STEAMI组。两组间高血压、糖尿病患病率差异无统计学意义。在病变血管的构成上组间无差异。结论 NSTEAMI的冠状动脉病变程度高于STEAMI,完全闭塞率低于后者,二者具有不同的冠状动脉病变特点。     

替罗非班在高危非ST段抬高急性冠脉综合征患者介入治疗中的应用研究

目的探讨高危非ST段抬高急性冠脉综合征患者介入治疗中替罗非班辅助治疗的临床应用价值。方法 176例高危非ST段抬高急性冠脉综合征患者随机均分为对照组和观察组。所有患者均行冠状动脉造影及经皮冠状动脉介入(PCI)治疗,观察组在上述治疗基础上加用替罗非班。比较两组患者介入治疗前后TIMI血流分级及心血管事件发生率。结果行PCI后观察组TIMI血流3级率明显高于对照组,TIMI血流2级率显著低于对照组,差异有统计学意义(P<0.05),观察组治疗后心血管事件发生率为2.27%,对照组为23.86%,两组比较差异有统计学意义(P<0.05)。结论高危非ST段抬高急性冠脉综合征介入治疗中应用替罗非班辅助治疗可有效提高患者临床疗效,降低心血管事件的发生率。     

低剂量替罗非班联合PCI治疗非ST段抬高型急性冠脉综合征的疗效观察

目的 探讨低剂量替罗非班联合经皮冠脉介入术(PCI)治疗非ST段抬高型急性冠脉综合征的临床疗效.方法 选取2018年8月至2019年8月于本院接受治疗的84例非ST段抬高型急性冠脉综合征患者作为研究对象,采用盲抽法分为观察组和对照组,每组42例.对照组采用PCI治疗,观察组在对照组基础上采用低剂量替罗非班治疗.比较两组TIMI心肌灌注、不良心血管事件(MACE)与出血发生率.结果 治疗后,观察组TIMI心肌灌注等级优于对照组,差异有统计学意义(P<0.05);治疗后,观察组MACE发生率低于对照组,差异有统计学意义(P<0.05);两组出血率比较差异无统计学意义.结论 在PCI治疗基础上加用低剂量替罗非班治疗非ST段抬高型急性冠脉综合征效果显著,可改善TIMI心肌灌注水平,降低MACE发生率,且不增加出血风险,值得临床推广应用.     

非ST段抬高型急性冠状动脉综合征基层诊疗指南(2019年)

一、概述(一)定义非ST段抬高型急性冠状动脉综合征(non-ST-segment elevation acute coronary syndrome,NSTE-ACS)根据心肌损伤生物标志物[主要为心脏肌钙蛋白(cardiac troponin,cTn)]测定结果分为非ST段抬高型心肌梗死(non-ST-segment elevation myocardial infarction,NSTEMI)和不稳定性心绞痛(unstable angina,UA),后者包括静息型心绞痛、初发型心绞痛、恶化型心绞痛和变异型心绞痛。UA与NSTEMI的发病机制和临床表现相似,但严重程度不同。     

Utilization of early invasive management strategies for high-risk patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative

Context  The American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of non–ST-segment elevation acute coronary syndromes (NSTE ACS) recommend early invasive management for high-risk patients, given the benefits with this approach demonstrated in randomized clinical trials. Objectives  To determine the use and predictors of early invasive management strategies (cardiac catheterization <48 hours following presentation) in high-risk patients with NSTE ACS and to examine the association of early invasive management with mortality. Design, Setting, and Patients  The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Quality Improvement Initiative evaluated care patterns and outcomes for 17 926 high-risk NSTE ACS patients (positive cardiac markers and/or ischemic electrocardiographic changes) based on ACC/AHA guidelines recommendations at 248 US hospitals with catheterization and revascularization facilities between March 2000 and September 2002. Main Outcome Measures  Use of early invasive management within 48 hours of presentation, predictors of early invasive management, and in-hospital mortality. Results  Of the 17 926 patients analyzed, 8037 (44.8%) underwent early cardiac catheterization less than 48 hours following presentation. Predictors of early invasive management included cardiology care, younger age, lack of prior or current congestive heart failure, lack of renal insufficiency, ischemic electrocardiographic changes, positive cardiac markers, white race, and male sex. Patients treated with early invasive management were more likely to be treated with medications and interventions recommended by the ACC/AHA guidelines and had a lower risk of in-hospital mortality after adjusting for differences in clinical characteristics and after comparing propensity-matched pairs (2.5% vs 3.7%, P<.001). Conclusions  An early invasive management strategy is not utilized in the majority of high-risk patients with NSTE ACS. This strategy appears to be reserved for patients without significant comorbidities and those cared for by cardiologists and is associated with a lower risk of in-hospital mortality.      

生长分化因子15与非ST抬高的急性冠脉综合征患者冠状动脉病变相关性研究

目的 探讨GDF-15血浆水平与非ST抬高的急性冠脉综合征患者冠状动脉血管狭窄程度(单支血管病变、多支血管病变)的关系.方法 入选经冠状动脉造影检查确诊为冠心病非ST抬高的急性冠脉综合征患者112例,以冠状动脉正常101例作为对照,对所有入组患者进行血清GDF-15检测.比较冠心病非ST抬高的急性冠脉综合征和对照患者的血浆GDF-15水平,同时在非ST抬高的急性冠脉综合征组中将不同亚组患者的血浆GDF-15水平进一步比较,明确血浆GDF-15水平与冠心病非ST抬高的急性冠脉综合征及其冠脉动脉血管病变严重程度的关系.结果 非ST抬高的急性冠脉综合征患者血浆GDF-15水平明显高于正常对照组.冠心病非ST抬高的急性冠脉综合征多支血管病变组血清GDF-15水平明显高于单支血管病变组(P＜0.01).结论 血浆GDF-15水平是冠心病非ST抬高的急性冠脉综合征新的生物标志物,且其水平与冠状动脉病变程度有关.     

经皮冠状动脉介入治疗不稳定型心绞痛和非ST段抬高心肌梗死的临床研究

目的比较不稳定型心绞痛和非ST段抬高心肌梗死患者应用经皮冠状动脉介入治疗和药物治疗的疗效.方法选择我院心内科病房住院的不稳定型心绞痛和非ST段抬高心肌梗死患者共536例,分为药物保守治疗组和经皮冠状动脉介入治疗组.介入治疗组在药物治疗基础上于入院1～10 d行冠状动脉造影,据结果施行介入治疗术.随访患者1～24个月的心绞痛复发率、再次入院率和再次介入治疗率或血管搭桥术(次要终点),以及心源性死亡和(或)急性心肌梗死发生率(主要终点).结果 260例病人施行介入治疗,276例病人接受药物治疗.在1～24(1,6,12,24)个月随访中,介入治疗组的心源性死亡和(或)急性心肌梗死发生率明显低于药物治疗组(分别为1.2%:4.7%,1.2%:5.8%,1.9%:5.4%,1.5%:6.9%,P均<0.01);心绞痛复发率介入治疗组明显低于药物治疗组(6.1%:20.3%,10%:35.5%,11.9%:40.6%,13.5%:44.6%,P均<0.001);再入院率介入治疗组明显低于药物治疗组(5%:18.5%,8.1%:32.6%,10.4%:37.3%,10%:42.1%,P均<0.001);再次接受介入治疗或血管搭桥术的病人在介入治疗组亦明显低于药物治疗组(1.5%:5.8%,2.3%:8.0%,3.1%:6.5%,3.5%:8.3%,P均<0.01).结论经皮冠状动脉介入治疗能显著改善不稳定型心绞痛和非ST段抬高心肌梗死患者的预后,优于传统的药物治疗,可作为大多数患者的首选治疗方法.     

国产氯吡格雷治疗非ST段抬高型急性冠脉综合征临床疗效观察

目的观察国产氯吡格雷（泰嘉）治疗非ST段抬高型急性冠脉综合征（NSTEACS）的有效性及安全性。方法选择符合条件的80例患者,分为对照组和治疗组,对照组采用进口氯吡格雷（波立维）＋常规药物治疗,治疗组采用国产氯吡格雷（泰嘉）＋常规药物治疗,观察治疗期间胸痛和心电图变化情况及药物安全性。结果胸痛在两组治疗后均较治疗前明显缓解,心电图ST段两组在治疗后较治疗前明显改善。但两组之间的疗效及主要副作用差异无统计学意义。结论国产氯吡格雷治疗非ST段抬高型急性冠脉综合征疗效和进口氯吡格雷相当,副作用少,安全性高。     

非ST段抬高急性冠脉综合征合并H型高血压患者的预后分析

目的 探讨非ST段抬高急性冠脉综合征合并H型高血压患者的临床预后.方法 选取2014年11月至2015年12月安徽省淮北市中医院收治的非ST段抬高急性冠脉综合征合并原发性高血压患者123例,根据患者同型半胱氨酸(Hcy)水平将患者分成H型高血压组(Hcy≥10μmmol/L)55例及对照组(Hcy<10μmmol/L)68例.比较两组患者入院后2 h内B型脑钠肽和全球急性冠脉注册事件评分危险分层.结果 H型高血压组患者入院后2 h内血浆B型脑钠肽水平[(1489.52±448.37)ng/L]较对照组[(950.45±310.62)ng/L]高,差异有统计学意义(t=7.858,P<0.001);H型高血压组患者全球急性冠脉注册事件评分危险度高的比例较对照组高,危险度中的比例较对照组低,差异均有统计学意义(χ2=6.897、4.125,P=0.009、0.042).结论 非ST段抬高急性冠脉综合征合并H型高血压患者临床预后较差.