2018年美国《慢性乙型肝炎指导意见》介绍:慢性乙型肝炎筛查咨询和预防北大核心CSCD

2018-02-05美国Hepatology杂志发表了美国肝病研究学会（AASLD）于2017-12-04批准通过的《慢性乙型肝炎预防、诊断、和治疗更新:AASLD2018乙型肝炎指导意见》（以下简称指导意见）。指导意见旨在补充2016年AASLD的慢性乙型肝炎（CHB）治疗实践指南[1],并更新2009年以来的乙型肝炎病毒（HBV）指南[2-3]。     

老年冠心病患者介入前后生存质量的影响因素

中国现有老龄人口已超过1.6亿,且每年以近800万的速度增加,有关专家预测,到2050年将达到总人口的三分之一[1].目前缺乏冠脉介入治疗后对老年冠心病患者生活质量变化影响的系统评价体系[2].本文旨在全面评价冠脉介入治疗对冠心病患者生存质量的影响. 1资料与方法 1.1 纳入标准(1)冠心病心绞痛的诊断标准必须符合2011年英国国家卫生与临床优化研究所(NICE)制定的《稳定性心绞痛诊治指南》[3]和2007年中华医学会心血管病学分会制定的《慢性稳定性心绞痛诊断与治疗指南》[4]中的相关内容.(2)符合卫生部发布《慢性稳定性心绞痛介入治疗临床路径》(2009版)的纳入标准,并行经皮冠状动脉介入治疗.(3)排除心肌梗死、主动脉夹层、急性肺栓塞等疾病.     

慢性冠状动脉综合征的概念和要点及意义

2019年8月巴黎欧洲心脏病学会（ESC）年会上公布了慢性冠状动脉综合征（CCS）指南,该指南刷新了2013年发布的《稳定性冠状动脉疾病治疗指南》,提出了慢性冠状动脉综合征的概念。新指南的颁布抛弃了“稳定”这一概念,提出了冠心病全程管理的理念,强调了CTCA在非侵入诊断中的价值,提出了对高缺血风险患者长期双联抗栓的重要性,提升了NOAC以及新型调脂与降糖药物的地位。     

遵循指南,合理开展冠心病的介入治疗

<正>我国2012年PCI指南发表之后~[1],在临床上对冠心病的规范治疗起到了重要的引导作用。近年,国内外又发表了大量的循证证据。为此,中华医学会心血管病学分会介入心脏病学组、中国医师协会心血管内科医师分会血栓防治专业委员会、中华心血管病杂志编辑委员会邀请相关专家组成专家组,参考国外指南,结合最新的证据特别是国内的循证研究,编写了中国经皮冠状动脉介入治疗指南(2016)~[2]。指南回答了近年PCI治疗领域的热点和焦点问题,必将对中国冠心病介入治疗的合理开     

2014年美国肝病学会和欧洲肝病学会对慢性肝病时肝性脑病实践指南的建议要点

<正>为了提高肝性脑病(HE)的临床研究水平,从而提高对HE患者的管理水平,欧洲肝病学会(EASL)和美国肝病学会(AASLD)联合发布了2014年慢性肝病时HE的实践指南[1],主要面向内科医生需要,给出了对慢性肝病HE成人患者诊断、治疗和预防方面的建议。指南具有一定的灵活性,这一点与处理每一例患者都必须遵守的诊疗规范不同。该指南的推荐意见基于现有文献的支持证据,采用GRADE     

中美欧三大指南对酒精性肝病诊断的共识与差异

2010年Hepatology发表了美国肝病学会酒精性肝病(alcoholic liver disease,ALD)诊疗指南(简称美国指南)[1],并在中华肝脏病杂志给予介绍;同年中国肝病学会脂肪肝和酒精性肝病学组也发表了中国的ALD诊疗指南(简称中国指南)[2];2012年欧洲肝病学会在J Hepatol上发表了欧洲ALD诊疗指南(简称欧洲指南)[3],欧州指南在本期由曾民德教授给与详细介绍和述评.     

解读首个《IgG4相关性疾病管理和治疗的国际共识指南》

<正>2015年3月,ArthritisRheumatology杂志发表了《IgG4相关性疾病管理和治疗的国际共识指南》[1],以下简称指南。该指南是迄今为止国际上关于IgG44相关性疾病(IgG44-related disease,IgG44-RD)诊治和管理的首个指导性意见,对指导IgG44-RD的临床实践有重要意义。指南制定背景     

科学认识、重视防治、勇于探索——评析国内外慢性阻塞性肺疾病诊断和治疗新指南

慢性阻塞性肺疾病(COPD)是一种常见病、多发病,目前居全球死亡原因的第4位,WHO公布,至2020年COPD将位居疾病经济负担的第5位。近年COPD的临床和基础研究成果不断涌现,对其认识也日渐深入。国内外医学界发表了一系列关于COPD诊断和治疗的新指南,包括2006年慢性阻     

室上性快速心律失常治疗指南

经中华医学会心血管病学分会和中国生物医学工程学会心脏起搏与电生理分会及其相关杂志共同合作,组织国内有关专家,编写室上性快速心律失常治疗指南,目的是为了使我国对此类心律失常的诊断和处理有合理而正确的共识.编写组参考美国心脏病学院(ACC)、美国心脏学会(AHA)及欧洲心脏病学会(ESC) 于2003年发表的室上性心律失常治疗指南[1],并将国外发表的循证医学资料与我国成功的经验加以综合.本指南叙述了各类型室上性快速心律失常的主要机制、诊断要点、临床特征、急性发作时的处理、预防复发的药物及非药物治疗、可能的并发症及预后等,力求做到科学、准确及实用;可作为临床医生在处理或治疗绝大多数室上性快速心律失常的一个重要的参考依据.当然,会有特殊的个别病例需要结合具体情况再论.本指南不包括心房颤动(简称房颤)这一最常见的快速室上性心律失常.因为在2001年已制定和发表了"抗心律失常药物治疗建议" [2],2002年又制定和发表了"关于心房颤动患者治疗的建议"[3],其中有关房颤的诊断和治疗原则、药物的应用方法和剂量至今仍有实用价值,并与国际上的原则接轨,可以与本指南组成认识和处理室上性快速心律失常的整体文件.     

2010年美国肝病学会酒精性肝病指南解读

2010年1月《Hepatology》发表了酒精性肝病(alcoholic liverdisease,ALD)诊疗指南[1],该指南由美国肝病学会和美国胃肠病学会制订,对ALD的流行病学和自然史、危险因素、诊断和治疗等方面均进行了详细而客观的介绍,并作出了     

肠黏膜屏障与炎症性肠病

炎症性肠病（Innammatory bowel disease，IBD）是一组病因不明的慢性肠道炎症性疾病，主要包含两个独立的疾病，溃疡性结肠炎（Ulcerative colitis，UC）和克罗恩病（Crohn’s disease，CD）。近年研究发现，肠黏膜屏障功能异常在IBD发病机制中发挥重要作用。更好地了解正常及疾病状态下肠黏膜屏障的结构和功能可以为IBD的治疗提供新的思路。     

Clinical Significance of Heart Chronotropic Incompetence in Patients With Coronary Heart Disease

Objectives To investigate the relationship between the chronotropic incompetence and angiographic severity of coronary artery disease, and the clinical value of inappropriate chronotropic responses in exercise. Methods Coronary angiography was performed in 130 patients suspected or diagnosed as coronary heart disease （ CHD）, and angiographic severity of coronary artery disease was quantitated by Duke score and Gensini score. The patients were divided into 4 groups ： non-CHD group （39 cases）, CHD group with only one coronary artery involved （ CHD1, 30 cases）, CHD group with two coronary arteries involved （ CHD2, 31 cases） and CHD group with three coronary arteries involved （CHD3 group, 30 cases ）. A month before coronary angiography, symptom-limited bicycle ergometor exercise had been accomplished, the chronotropic response had been measured and expressed as ratio of heart rate reserve （HRR） and the maximal age-predicted heart rate achieved （rHR）. Results Analysis of variance showed that rHR and HRR were much significantly lower （all P 〈0. 01 ） in CHD2 group （rHR 0. 793 ±0. 078, HRR 0. 626±0. 110） and CHD3 group （ rHR 0. 775 ± 0. 065, HRR 0. 586 ± 0. 125 ） than that in non-CHD group （ rHR 0. 888 ± 0. 062, HRR 0. 798 ±0. 105）and CHD1 group（rHR 0. 857 ±0. 084, HRR 0. 735 ±0. 146）. rHR was similar both between non-CHD group and CHD1 group（ P 〉 0. 05 ） and between CHD2 group and CHD3 group （ P 〉 0. 05 ）. HRR has no difference between CHD2 group and CHD3 group （ P 〉 0. 05 ）, but was significantly different between non-CHD group and CHD1 group （P 〈0. 05 ）. There was a significantly negative correlation between rHR, HRR and Duke score （r = -0. 554, - 0. 578, respectively, all P 〈0. 01 ）, Gensini score （ r = -0. 453, -0. 467 ,respectively, all P 〈0. 01 ）. CHD proportion reached 75% in patients who had positive rHR （ or HRR） and non-ST depression. Diagnostic value [ sensitivity 0. 868 （P 〈0. 01 ）, 0. 846（P 〈0. 01 ?     

冠状动脉扩张的发病机制及防治研究进展

<正>冠状动脉扩张(coronary artery ectasia,CAE)为心外膜冠状动脉的局限性或弥漫性扩张,管径扩大超过临近正常段或大于正常值上限的1.5².0倍。大约20%2.0倍。大约20%³0%的CAE患者被认为是先天性的[1]。目前关于CAE的发病机制仍不明确,有关其病因、临床意义和预后也知之甚少。随着近年来无创影像学检查技术的不断发展,以及经皮冠状动脉介入治疗和抗凝剂、硝酸酯和钙通道阻滞剂等药物的应用,将有     

The Treatment of Ostial Coronary Arteriopathy Secondary to Thoracic Irradiation With Off-pump Coronary Artery Bypass Grafting： A Case Report and Review of Literatures

Objectives We report a case in which a patient who suffered from angina secondary to mediastinal irradiation and have been treated by off-pump coronary artery bypass （OPCAB） in our hospital since 3 years ago. A 34-year-old man presented with angina for 8 years after receiving radiation therapy for Hodgkin＇s lymphoma. We retrospectively reviewed all the cases of OPCAB in our hospital and followed-up data for up to 3 years post-operatively. Mediastinal irradiation is probably the cause of significant ostial stenosis of left main coronary and right coronary artery. OPCAB grafting was performed on this patient 3 years ago. His angina disappeared after operation, and he recovered well during follow-up. Conclusions Patients with malignancies who have received mediastinal irradiation should be carefully followed up and routinely screened for the premature development of coronary artery disease. OPCAB may be an appropriate treatment for coronary artery disease caused by mediastinal irradiation.     

Changes of prethrombotic state molecular markers after percutaneous coronary intervention in patients with coronary artery disease with hypertension

Background The changes of pre-thrombotic state molecular markers(PSMMs) were investigated in patients with coronary artery disease(CAD) complicated by hypertension(HBP) after percutaneous coronary in-tervention(PCI), and their significances were evaluated. Methods Totally 70 patients with CAD were divided two groups: group A including 32 patients with CAD, and group B 38 patients with CAD complicated by HBP.All the patients received PCI. The levels of PSMMs were measured before PCI and 20 minutes, 24 hours, and7 days after PCI respectively. The patients were followed up for cardiac events after PCI for 6 months. Results(1) Compared with the data before PCI, the changes in von Willrand Factor(vWF), coagulation fators Ⅷ antigen(Ⅷ:Ag), antithrombin Ⅲ(ATⅢ), granular membrane protein-140( GMP-140), factor Ⅱ activity( F.Ⅱa),fibrinogen(Fbg), plasminogen(Plg), tissue plasminogen activator(t-PA), plasminogenemia activator inhibitor(PAI), and D-dimer were significant at 20 minutes after PCI(P 0.05 or P 0.01), and the changes in vWF,protein C(PC), Fbg, Plg, PAI, D-dimer were significant at 24 hours after PCI in group A(P 0.05 or P 0.01).(2) Compared with the data before PCI, the changes in vWF, Ⅷ:Ag, ATⅢ, GMP1-40, PC, F.Ⅱa, Fbg,PAI, and D-dimer at 20 minutes, 24 hours, and 7 days after PCI were significant in group B(P 0.05 or P 0.01). Conclusions There are significant changes of PSMMs in patients with CAD after PCI, especially in those with CAD complicated by HBP.     

Increased lipoprotein （a） level is independently associated with the severity of coronary artery disease

Background Increased serum level of lipoprotein(a)(Lp(a)) is associated with atherosclerosis. Whether increased Lp(a) level is independently associated with the severity of coronary artery disease(CAD) is unclear. Methods Subjects were enrolled and received coronary angiography to assess the number of stenosed coronary artery. The subjects with CAD were divided into non-significant( 50% stenosis), single and multivessel stenosis(≥ 50 % stenosis) groups. Parameters of interest at baseline were collected. Statistical analyses were performed to evaluate the relationship between Lp(a) level and CAD severity. Results Totally 745 populations were enrolled and diagnosed as CAD(n = 605) or without CAD(n = 140) on the basis of angiography examination. As compared to the subjects without CAD, serum levels of Lp(a) and CRP, and the percentages of subjects with smoking or diabetes were significantly higher in subjects with CAD. In contrast,serum levels of HDL-C and Apo-A were significantly lower in subjects with CAD as compared to subjects without CAD. In comparison of subjects with non-significant stenosis(serum Lp(a) level, 170.0 ± 19.7 mg /d L), serum Lp(a) level was significantly higher in subjects with single(245.5 ± 22.3 mg / d L) or multiple vessel stenoses(265.8 ± 14.0 mg / d L). With multivariate regression analyses, after adjusted for age, gender,smoking, family history and hypertension, there was still significant association between serum Lp(a) level and the number of coronary artery stenosis. After additional adjustment for diabetes, Hb A1 c, total cholesterol,LDL-C, Apo-A, uric acid and CRP, Lp(a) remained strongly associated with CAD severity. Conclusion Serum Lp(a) level was significantly associated with the severity of coronary artery stenosis, which may add the value on cardiovascular risk evaluation.     

膜转运蛋白三磷酸腺苷结合盒转运体A1的表达调控与信号传导

<正>动脉硬化性心血管疾病(atherosclerotic cardiovascular disease,CVD)是最常见的死亡原因。高密度脂蛋白(High density lipoprotein,HDL)主要通过转运动脉巨噬细胞多余的胆固醇到肝脏代谢来预防CVD。这个途径的第1步称为胆固醇逆转运,由整合膜蛋白——三磷酸腺苷结合盒转运体A1(ATP-binding cassette transporter A1,ABCA1)介导。ABCA1转运细胞的胆固醇和磷脂到乏脂载脂蛋白     

心血管疾病合并无症状高尿酸血症诊治建议(第二版)

高尿酸血症（Hyperuricemia,HUA）常与传统的代谢性心血管危险因素伴发,长期以来被认为是代谢异常的一种标记。近30年来,多项大规模观察性研究,共有约40余万例以上的观察对象,采用多因素回归和COX风险回归分析,一致证实HUA是心血管疾病发病和预后的危险因素。目前尚没有大规模临床研究证实,降低血尿酸与心血管风险下降有关,但鉴于高尿酸与血管、心脏、肾脏不良预后密切相关,HUA的防治受到关注。     

心血管风险评估:新指南、新工具

<正>心血管疾病的发生、发展是多种危险因素共同作用的结果,自20世纪末以来,各种心血管疾病防治指南均强调了整体风险评估在心血管疾病一级预防中的重要性。目前全球已有多个心血管风险评估工具,如Framingham、ATP-Ⅲ、EURO-SCORE、Reynolds、QRISK、WHO/ISH和ICVD等;其中,最著名的当属根据Framingham心脏研究发展而来的Framingham10年风险评分。     

先天性肝纤维化如何诊断＊--附1例报告并文献复习

目的：通过1例可疑先天性肝纤维化（CHF）患者临床和肝组织病理学特点总结,来分析该病的诊断要领。方法1例男性57岁有长期脂肪肝病史患者,肝活检资料经两家医院病理学检查,给出不同的诊断,通过复习文献,分析不能确诊的原因。结果因反复乏力纳差4个月于2012年3月24日入院。2007年体检发现脂肪肝,肝功能正常。巩膜无黄染,未见蜘蛛痣及肝掌。心肺听诊无异常,肝脾肋下未触及,移动性浊音阴性。双下肢无浮肿。ALT 30.5 U/L,AST 23.8 U/L,TBIL 17.2μmol/L;PT 12.2s,INR 0.89。HBV、HCV、HIV标记物阴性。胃镜示胃体胃窦粘膜糜烂,食管静脉中上段显露伴下段轻度曲张。上腹部MRI检查示肝硬化,门脉高压,食管下段静脉曲张;肝脏多发性小囊肿,肾脏多发性小囊肿。肝脏活检见肝组织结构尚清晰,小叶部分肝细胞疏松水肿,散在少量点灶状坏死,部分肝细胞脂肪变性（以大泡型为主,约占20％）,汇管区少量淋巴细胞浸润,部分汇管区纤维组织增生,向小叶内延伸,纤维间隔呈渐成趋势。结论综合评判,该患者应诊断为非酒精性脂肪性肝病（G3 S3）,先天性肝纤维化诊断无依据。