Should the patient with coronary artery disease use sildenafil?

Since the etiology of erectile dysfunction is frequently related to endothelial dysfunction, a problem in common with much vascular disease, erectile dysfunction disproportionately affects patients with cardiovascular disease. With the development of phosphodiesterase 5 inhibitors, the first of which was sildenafil (Viagra), an effective oral medication became available. The question of safety of these drugs, especially in patients with latent or overt coronary artery disease, is of concern. Sildenafil relaxes smooth muscle and therefore lowers systolic and diastolic blood pressure slightly. With organic nitrates, the drop in blood pressure is potentiated, at times dangerously, thereby making it contraindicated to take nitrates within 24 hours of using sildenafil. In double-blind, placebo-controlled trials, there was no difference between sildenafil subjects and control patients in the incidence of myocardial infarction, cardiovascular, and total deaths. Coronary disease patients with stable angina, controlled on medications, were included in the trials. Therefore, sildenafil, as a drug, is safe in such patients. With a patient with coronary artery disease suddenly engaging in the physical exercise associated with sexual intercourse, there is the danger of increased risk of precipitating myocardial infarction or death. The cardiovascular metabolic cost of sexual activity is reviewed and appears to be approximately at the level of 3-5 metabolic equivalents of exercise. Sexual activity occurs within 2 hours of the onset of an acute myocardial infarction in <1.0% of patients. Although sexual intercourse is estimated to increase the risk of myocardial infarction by a factor of 2x, there is still only a very small increase in risk, a risk acceptable to patients who feel their quality of life will be markedly improved by their ability to engage in sexual activity.     

Sex,erectile dysfunction,and the heart: a growing problem

BACKGROUND: Erectile dysfunction (ED) is defined as the inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance. ED may also be an early sign of cardiovascular disease. The main risk factors for coronary heart disease (high LDL, smoking, hypertension, diabetes) and ED are the same. ED after the diagnosis of coronary artery disease or myocardial infarction is also common. CARDIOVASCULAR EFFECTS AND RISK OF SEXUAL ACTIVITY: Cardiac and metabolic expenditures during sexual intercourse will vary depending on the type of sexual activity. When oxygen uptake was measured in men, an average metabolic expenditure during stimulation and orgasm of 2.5 metabolic equivalents (METs) was found for woman-on-top coitus, and of 3.3 METs for man-on-top coitus (range 2.0-5.4 METs). However, coital death is rare, encompassing only 0.6% of all sudden death cases. A retrospective case-crossover study has shown that although sexual activity can trigger the onset of myocardial infarction, the relative risk in the 2 h after sexual activity was low (2.5; 95% confidence interval [CI] 1.7-3.7). Sexual activity was a likely contributor to the onset of myocardial infarction only 0.9% of the time. Regular exercise appears to prevent triggering. It has to be cautioned that these reassuring data should not be extrapolated to patients taking sildenafil, if they perform at higher cardiac and metabolic expenditures during coitus. The hemodynamic changes associated with sexual activity may be far greater with an unfamiliar partner, in unfamiliar settings, and after excessive eating and drinking. The Princeton Consensus Table for estimation of cardiovascular risk during sexual intercourse gives a first orientation regarding the question which patients can perform sex safely and which subgroup needs further diagnosis and treatment. PHOSPHODIESTERASE-5 INHIBITORS FOR ED TREATMENT: The introduction of sildenafil has been a valuable contribution to the treatment of ED. Sildenafil acts as a selective inhibitor of cyclic guanosine monophosphate-(cGMP-)specific phosphodiesterase type 5 (PDE 5), resulting in smooth muscle relaxation, vasodilation, and enhanced penile erection. Reported cardiovascular side effects in healthy males are headache, flushing, and < 10% decreases in systolic and diastolic blood pressures. Significant hypotension can be found in patients who are concurrently taking nitrates. On the basis of the pharmacokinetic profile of sildenafil, the co-administration of a nitrate within the first 24 h is likely to produce a severe, potentially lifethreatening hypotensive response and is therefore contraindicated. The risk of precipitating a cardiotoxic, hypotensive, or hemorrhagic event secondary to combining sildenafil (a PDE 5 inhibitor) with specific PDE 3 inhibitors such as milrinone and enoximone or with nonspecific PDE inhibitors such as theophylline and pentoxifylline is unlikely. Sildenafil is predominantly metabolized by both the P450 2C9 pathway and the P450 3A4 pathway. Thus, potent inhibitors of the P450 3A4 pathway may increase the plasma concentrations of sildenafil, like cimetidine, erythromycin, digitoxin, and CSE inhibitors (simvastatin, atorvastatin, etc.). A creatinine clearance < 30 ml/min also increases plasma levels of sildenafil. SAFETY PROFILE OF SILDENAFIL: Sildenafil is safe in healthy subjects. In a postmarketing study on 6,527 males, no increase of cardiovascular events was found. However, in older males with coronary heart disease, the risk of sildenafil and the risk of physical exercise during sexual intercourse contribute both to fatal outcomes. Of 69 cases reported to the FDA, 46 patients might have had a cardiovascular event, and in twelve a possible interaction with nitrate use has been reported. Sildenafil is absolutely contraindicated in patients taking long-acting nitrates, those with severe aortic stenosis, and patients with hypertrophic obstructive cardiomyopathy (HOCM). No nitrates should be used within 24 h of sildenafil use. Caution is necessary in patients with a combination of antihypertensive medications, and in patients with cardiac insufficiency. A "pre-Viagra" treadmill test to assess for the presence of stress-induced ischemia can be helpful for both the patient and the physician. If the patient can achieve > or = 5 METs without demonstrating ischemia, the risk of ischemia during coitus is low. MANAGEMENT OF SEVERE ADVERSE EVENTS: If severe hypotension occurs, aggressive fluid resuscitation is the first step, followed by administration of vasoactive drugs and, if necessary, by intraaortic balloon counterpulsation. If unstable angina or myocardial infarctions occurs after the use of sildenafil, the patient is treated according to the guidelines, but without nitrates. CONCLUSION: Sexual activity is a cornerstone of quality of life. However, giving the incidence of "occult" cardiovascular disease in patients with ED and the indications and contraindications of PDE 5 inhibitors in patients with cardiovascular diseases, all patients with ED must be evaluated by a cardiovascular specialist.     

Antiplatelet therapy in the treatment of atherothrombotic disease: considering the evidence

Aspirin should be used to treat patients with acute myocardial infarction (MI) and continued indefinitely to reduce vascular death, nonfatal MI, and nonfatal stroke. Clopidogrel added to aspirin is beneficial in the treatment of patients with acute ST-elevation MI. Patients with unstable angina or non-ST-elevation MI should be treated with aspirin plus clopidogrel for at least 9 months to reduce the risk vascular death, nonfatal MI, and nonfatal stroke. Patients with prior MI should be treated indefinitely with aspirin and with clopidogrel if aspirin is contraindicated. Patients with ischemic stroke should be treated with either aspirin or clopidogrel indefinitely. Extended-release dipyridamole plus low-dose aspirin is more efficacious than low-dose aspirin but is associated with an insignificant increase in nonfatal MI and vascular death than low-dose aspirin. Clopidogrel is more effective than aspirin in reducing the risk of vascular death, nonfatal MI, and nonfatal stroke in patients with peripheral arterial disease.     

Sexual activity and the cardiovascular system in health and disease. Use of sildenafil in heart patients

Sexual intercourse involves mild to medium severe physical exertion of the cardiovascular system. The risk of sudden death associated with sexual activity is very low, and so is the risk of developing infarction. In patients with pre-existing ischaemic heart disease sexual activity is safe in case of controlled angina with tolerance of a medium-grade load on examination on a treadmill. After acute myocardial infarction with a non-complicated course sexual activity can be resumed in a familiar environment with a familiar partner after about 10 days. In stabilized anginous patients sildenafil administration is safe assuming that the patient does not take long-acting nitrates and does not need frequent administration of short-term acting nitrates. It is important to avoid nitrates also in the treatment of acute ischaemic conditions in these patients. At present we do not possess adequate information on the clinical importance of influencing sildenafil elimination by competition with other substances excreted by the same route.     

Prognostic value of B-Type natriuretic peptides in patients with stable coronary artery disease: the PEACE Trial.

OBJECTIVES: The purpose of this study was to assess the association between B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) and the incidence of specific cardiovascular events in low-risk patients with stable coronary disease, the incremental prognostic information obtained from these two biomarkers compared with traditional risk factors, and their ability to identify patients who may benefit from angiotensin-converting enzyme (ACE) inhibition. BACKGROUND: The prognostic value of BNPs in low-risk patients with stable coronary artery disease remains unclear. METHODS: Baseline plasma BNP and NT-proBNP concentrations were measured in 3,761 patients with stable coronary artery disease and preserved left ventricular function participating in the PEACE (Prevention of Events With Angiotensin-Converting Enzyme Inhibition) study, a placebo-controlled trial of trandolapril. Multivariable Cox regression was used to assess the association between natriuretic peptide concentrations and the incidence of cardiovascular mortality, fatal or nonfatal myocardial infarction, heart failure, and stroke. RESULTS: The BNP and NT-proBNP levels were strongly related to the incidence of cardiovascular mortality, heart failure, and stroke but not to myocardial infarction. In multivariable models, BNP remained associated with increased risk of heart failure, whereas NT-proBNP remained associated with increased risk of cardiovascular mortality, heart failure, and stroke. By C-statistic calculations, BNP and NT-proBNP significantly improved the predictive accuracy of the best available model for incident heart failure, and NT-proBNP also improved the model for cardiovascular death. The magnitude of effect of ACE inhibition on the likelihood of experiencing cardiovascular end points was similar, regardless of either BNP or NT-proBNP baseline concentrations. CONCLUSIONS: In low-risk patients with stable coronary artery disease and preserved ventricular function, BNPs provide strong and incremental prognostic information to traditional risk factors.     

Statin use and survival outcomes in elderly patients with heart failure

BACKGROUND: Coronary artery disease is a leading cause of heart failure. Statins are efficacious drugs for the primary and secondary prevention of coronary heart disease, but their value in persons with heart failure remains unknown. METHODS: We performed a population-based retrospective cohort study involving the entire province of Ontario, Canada, restricting participants to those aged 66 to 85 years who were free of cancer and who survived at least 90 days following hospitalization for newly diagnosed heart failure. The primary study outcome was the risk of death from all causes, nonfatal acute myocardial infarction, or nonfatal stroke among persons newly dispensed statins (n = 1,146) relative to those who were not (n = 27,682). RESULTS: The mean age of all participants was 76.5 years, and half were women. During the 7-year study period, death, acute myocardial infarction, or stroke occurred in 217 statin recipients (13.6 per 100 person-years) vs 12,299 nonrecipients (21.8 per 100 person-years; adjusted hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.63-0.83). Most of the benefit from statins was related to a reduction in all-cause mortality (adjusted HR, 0.67; 95% CI, 0.57-0.78). No significant reduction was seen for subsequent myocardial infarction (adjusted HR, 0.81; 95% CI, 0.63-1.03) or stroke (adjusted HR, 0.81; 95% CI, 0.53-1.25). CONCLUSIONS: Statin use is associated with a lower risk of death among seniors newly diagnosed as having congestive heart failure. While statin use has been previously shown to be efficacious in patients with coronary heart disease and stroke, we could not control for all prognostic risk factors in the present study, including left ventricular ejection fraction and serum lipid levels. Better evidence can direct clinicians about which patients with heart failure might benefit from these drugs.     

Prognostic significance of programmed ventricular stimulation in patients surviving complicated acute myocardial infarction: a prospective study.

In survivors of complicated myocardial infarction, the inducibility of sustained ventricular tachycardia may help identify a subset that is at increased risk for subsequent sudden cardiac death or spontaneous sustained ventricular tachycardia. We performed prehospital discharge programmed ventricular stimulation in 86 survivors of acute myocardial infarction complicated by heart failure, angina pectoris, or nonsustained ventricular tachycardia. These patients also underwent cardiac catheterization with coronary angiography and 24-hour ambulatory ECG recording. Programmed ventricular stimulation induced sustained ventricular tachycardia in 19 patients (22%) and ventricular fibrillation in six (7%) and did not induce these arrhythmias in 61 patients (71%). During an average follow-up of 18 +/- 13 months, 11 patients had arrhythmic events (seven sudden death and four nonfatal spontaneous sustained ventricular tachycardia) and 10 patients had nonsudden cardiac death. The total cardiac mortality rate was 20%. Arrhythmic events occurred in 32% of the 19 patients with inducible sustained ventricular tachycardia compared with 7% of the remaining 67 patients (p less than 0.003). By multivariate analysis the occurrence of arrhythmic events was independently predicted by both inducible sustained ventricular tachycardia and Killip class III or IV heart failure. The risk of arrhythmic events was 4.4% in the absence of both variables versus 38.4% (p less than 0.001) when both variables were present. The total cardiac mortality rate was best predicted by low left ventricular ejection fraction (less than 30%). Thus programmed ventricular stimulation is useful in risk stratification of survivors of complicated acute myocardial infarction. The prognostic utility appears to be particularly high in patients with infarction complicated by Killip class III or IV heart failure.     

Use of antiplatelet drugs in secondary prevention in older persons with atherothrombotic disease

Unless there are contraindications to the use of aspirin, aspirin should be used in treating patients with acute myocardial infarction (MI) and continued indefinitely to reduce vascular death, nonfatal MI, and nonfatal stroke. Clopidogrel added to aspirin has been shown to be beneficial in the treatment of patients with acute ST-elevation MI. Patients with unstable angina or non-ST-elevation MI should be treated with aspirin plus clopidogrel for at least 9 months to reduce vascular death, nonfatal MI, and nonfatal stroke. Patients with prior MI should be treated indefinitely with aspirin and with clopidogrel if aspirin is contraindicated. Patients with ischemic stroke should be treated with either aspirin or clopidogrel indefinitely. Extended release dipyridamole plus low dose aspirin has been shown to be more efficacious than low dose aspirin in only one large study, and is associated with an insignificant increase in nonfatal MI and vascular death over low dose aspirin alone. Clopidogrel is significantly more effective than aspirin in reducing vascular death, nonfatal MI, and nonfatal stroke in patients with peripheral arterial disease.     

Randomized Comparison of Primary Coronary Angioplasty With Thrombolytic Therapy in Low Risk Patients With Acute Myocardial Infarction

Objectives. We sought to compare primary coronary angioplasty and thrombolysis as treatment for low risk patients with an acute myocardial infarction.Background. Primary coronary angioplasty is the most effective reperfusion therapy for patients with acute myocardial infarction; however, intravenous thrombolysis is easier to apply, more widely available and possibly more appropriate in low risk patients.Methods. We stratified 240 patients with acute myocardial infarction at admission according to risk. Low risk patients (n = 95) were randomized to primary angioplasty or thrombolytic therapy. The primary end point was death, nonfatal stroke or reinfarction during 6 months of follow-up. Left ventricular ejection fraction and medical charges were secondary end points. High risk patients (n = 145) were treated with primary angioplasty.Results. In low risk patients, the incidence of the primary clinical end point (4% vs. 20%, p < 0.02) was lower in the group with primary coronary angioplasty than in the group with thrombolysis, because of a higher rate of reinfarction in the latter group. Mortality and stroke rates were low in both treatment groups. There were no differences in left ventricular ejection fraction or total medical charges. High risk patients had a 14% incidence rate of the primary clinical end point.Conclusions. Simple clinical data can be used to risk-stratify patients during the initial admission for myocardial infarction. Even in low risk patients, primary coronary angioplasty results in a better clinical outcome at 6 months than does thrombolysis and does not increase total medical charges.(J Am Coll Cardiol 1997;29:908–12)© 1997 by the American College of Cardiology     

Nonfatal myocardial infarction in medically treated patients with coronary artery disease

The purpose of this study was to identify patient characteristics associated with nonfatal myocardial infarction as the first event after cardiac catheterization in medically treated patients with coronary artery disease. Multiple logistic risk analyste of 81 baseline characteristics in 354 patients who died or had nonfatal infarction identified 10 characteristics (5 clinical and 5 cardiac catheterization variables) as independently discriminating between the two events. Left ventricular function, specific coronary anatomy, previous myocardial infarction and age were the most important discriminators. Poor left ventricular function and left main coronary stenosis were associated with death. Subtotal left anterior descending and right coronary arterial stenosis, normal hemodynamics, absence of previous infarction and young age were associated with nonfatal infarction. Thus, in any subset of patients who have a uniform risk of ischemic events (nonfatal infarction or death), nonfatal infarction is most likely to occur in those who are young, have had no previous infarction, have subtotal left anterior descending and right coronary arterial stenosis and normal hemodynamics.     

Statin Rebound or Withdrawal Syndrome: Does It Exist?

Studies in vascular cells in culture and in laboratory animals revealed that statin discontinuation triggers a rebound deterioration of vascular function. Retrospective studies of patients admitted with an acute coronary syndrome revealed that stopping statins during the first days of admission was associated with worse outcomes. In a prospective, randomized controlled trial in patients with a hemispheric ischemic stroke, stopping statins for 3 days was associated with a 4.7-fold increase in the risk of death or dependency, greater neurological deterioration, and a larger infarct volume. Discontinuing statins during the post-operative period following major vascular surgery was associated with a higher incidence of myocardial ischemia, nonfatal myocardial infarction, and cardiovascular death. However, no increase in adverse outcomes was observed in patients with stable chronic coronary artery disease following statin treatment discontinuation. Despite some study limitations, the bulk of the evidence suggests that under conditions of severe acute vascular stress, removal of statins must be contraindicated.     

Prognostication of the course of stable ischemic heart disease by exercise stress echocardiography

We analyzed data from 549 patients (450 with high and 99 -- low pretest probability of ischemic events). Duration of observation was 12-42 (mean 20.1+/-11.6) months. End points were death, nonfatal myocardial infarction, and revascularization. Cox proportional hazards model was used for assessment of relationship between clinical-instrumental data and events. One year risk of cardiac death and nonfatal myocardial infarction was 3 and 15%, event free survival -- 95 and 66% for patients with negative and positive result of stress echocardiography, respectively. Besides local contractility disturbances total test duration less than 6 min was significantly related to prognosis of main events while left ventricular hypertrophy, amount of METs, development of angina during stress test, and hypertensive disease were predictors of combined end point (death, nonfatal myocardial infarction, or revascularization). Thus results of exercise stress echocardiography had high prognostic power in patients with ischemic heart disease.     

急性心肌梗死并心源性休克的院内死亡危险因素分析

目的 分析影响急性心肌梗死（AMI）合并心源性休克（CS）院内死亡的危险因素.方法 选择2008年6月至2012年12月间223例急性心肌梗死合并心源性休克的住院患者,记录患者的相关临床资料,根据住院期间是否死亡分为两组：死亡组和存活组,应用Logistic回归分析评估AMI合并CS患者院内死亡的危险因素.结果 223例AMI合并心源性休克患者中107例死亡,116例存活.与生存组相比,死亡组中年龄≥70岁、糖尿病、陈旧性心梗史、慢性肾功能不全、前壁心肌梗死、未置入IABP、室间隔穿孔、消化道出血比例及入院时心率、左室射血分数、肾小球滤过率差异有统计学意义（P＜0.05）.Logistic多元回归分析发现,年龄≥70岁、糖尿病、前壁心肌梗死、心率快、左室射血分数低、室间隔穿孔、消化道出血为AMI合并CS院内死亡的独立危险因素.结论 对于急性心肌梗死合并心源性休克的患者,年龄≥70岁、糖尿病、前壁心肌梗死、心率快、左室射血分数低、室间隔穿孔、消化道出血为院内死亡的独立危险因素.     

Usefulness of right ventricular fractional area change to predict death, heart failure, and stroke following myocardial infarction (from the VALIANT ECHO Study)

Severe right ventricular dysfunction independent of left ventricular ejection fraction increased the risk of heart failure (HF) and death after myocardial infarction (MI). The association between right ventricular function and other clinical outcomes after MI was less clear. Two-dimensional echocardiograms were obtained in 605 patients with left ventricular dysfunction and/or clinical/radiologic evidence of HF from the VALIANT echocardiographic substudy (mean 5.0 +/- 2.5 days after MI). Clinical outcomes included all-cause mortality, cardiovascular (CV) death, sudden death, HF, and stroke. Baseline right ventricular function was measured in 522 patients using right ventricular fractional area change (RVFAC) and was related to clinical outcomes. Mean RVFAC was 41.9 +/- 4.3% (range 19.2% to 53.1%). The incidence of clinical events increased with decreasing RVFAC. After adjusting for 11 covariates, including age, ejection fraction, and Killip's classification, decreased RVFAC was independently associated with increased risk of all-cause mortality (hazard ratio [HR] 1.61, 95% confidence interval [CI] 1.31 to 1.98), CV death (HR 1.62, 95% CI 1.30 to 2.01), sudden death (HR 1.79, 95% CI 1.26 to 2.54), HF (HR 1.48, 95% CI 1.17 to 1.86), and stroke (HR 2.95, 95% CI 1.76 to 4.95), but not recurrent MI. Each 5% decrease in baseline RVFAC was associated with a 1.53 (95% CI 1.24 to 1.88) increased risk of fatal and nonfatal CV outcomes. In conclusion, decreased right ventricular systolic function is a major risk factor for death, sudden death, HF, and stroke after MI.     

Prognosis of patients with Q wave myocardial infarction of inferior or anterior localization

The aim of the study was to determine clinical and demographic features that are significant for prognosis after the first-ever myocardial infarction (MI). Kaunas men and women aged 25 - 64 years, admitted to Kaunas hospitals due to their first-ever MI during 1983 - 1992 and with the first coded electrocardiogram (ECG) were enrolled into the study. The Kaunas ischemic heart disease (IHD) register was the source of data, ECGs were coded using the Minnesota Code, and deaths were identified via prospective death s register. Factors significantly increasing the risk of death from IHD during the first year after first-ever inferior MI were age (p=0.01), atrial flutter or fibrillation (p=0.02). In patients with Q wave in anterior site the risk of death from IHD was increased not only by age, but also by acute heart failure - 3.74-fold (p=0.01), history of previous stroke - 3.82 (p=0.046), and history of diabetes - 2.53 (p=0.04).     

Can the mode of death be predicted in patients with angiographically documented coronary artery disease?

To determine whether sudden versus non-sudden cardiac death could be predicted in high risk patients, 1157 medical patients were followed for an average of 46 months after a diagnostic coronary angiogram and 18 clinical, hemodynamic, and angiographic variables known to be associated with a high risk of mortality were analyzed. The total group of 141 deaths was classified into 3 subgroups: (1) 82 sudden deaths (less than 1 hour after onset of symptoms); (2) 46 deaths due to acute myocardial infarction with or without heart failure, and (3) 13 deaths unrelated to cardiac symptoms. In a subset of 64 patients, the duration of electrical systole (QTc) was calculated before angiography and before death. A comparison was made of QTc measurements at entry with QTc values of subjects with normal coronary arteries and normal left ventricular function. Deaths from cardiac causes could often be predicted from older age, male sex, history of myocardial infarction, unstable angina, congestive heart failure, abnormal cardiothoracic ratio, multivessel disease, abnormal left ventricular contraction, and abnormal ejection fraction. However, these variables did not discriminate between sudden and nonsudden cardiac deaths and both modes of death were characterized by depressed left ventricular function and multivessel coronary disease. During follow-up the incidence of acute myocardial infarction was not different in patients with cardiac and noncardiac deaths and in long-term survivors. However, patients dying from cardiac causes had a higher incidence of heart failure. Patients dying suddenly did not present new infarctions during follow-up whereas patients dying from acute myocardial infarction had a 13% incidence of prior infarction and a higher incidence of heart failure. In addition, QTc at entry was longer in nonsurvivors than in normal subjects (p less than 0.0001) and patients experiencing sudden death exhibited the highest incidence of QTc prolongation (greater than or equal to 440 ms) during follow-up (p less than 0.05). We conclude that: (1) although the severity of coronary disease and left ventricular dysfunction are closely related to cardiac mortality, they do not discriminate between sudden and nonsudden cardiac deaths; (2) patients experiencing sudden death are characterized by a low incidence of new myocardial infarction or congestive heart failure and prolongation of the QTc interval during follow-up.     

心血管病人性功能障碍的康复

性功能障碍的治疗过去属于泌尿科的范畴。因此性功能障碍的治疗出现突破，心血管病人伴性功能障碍更常见，心血管医师治疗勃起功能障碍的处方已处于非泌尿科医师的领先地位。研究说明尽管性生活可使心肌梗死患发生再梗或心性死亡的危险有所增加，但增加的绝对危险性（机率）很小，是每小时10／100万（0．00001％）；并无证据证明西地那非有引起心肌梗死或缺血性心脏病的危险。心脏康复医师应掌握心血管病人性功能障碍及其治疗的知识和技术，开展这项工作，改善患的生活质量。     

Predictors of nonfetal reinfarction in survivors of myocardial infarction after thrombolysis: Results of the gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) data base

Objectives. This study was designed to reassess the prediction of recurrent nonfatal myocardial infarction in patients recovering from acute myocardial infarction after thrombolysis.Background. Recurrent nonfatal myocardial infarction is a strong and independent predictor of subsequent mortality. Current knowledge of risk factors for nonfatal reinfarction is still largely based on data gathered before the advent of thrombolysis. Thus, this prospective study was planned to identify harbingers of nonfatal reinfarction in the postinfarction patients of the multicenter Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) trial.Methods. Predictors of nonfatal reinfarction at 6 months were analyzed by multivariate technique (Cox model) in 8,907 GISSI-2 survivors of myocardial infarction with clinical follow-up, relying on a set of prespecified variables reflecting residual ischemia, left ventricular failure or dysfunction, complex ventricular arrhythmias, comorbidity as well as demographic and historical factors.Results. The postdischarge to 6-month incidence rate of nonfetal reinfarction was 2.5%. Independent predictors of nonfatal reinfarction were cardiac ineligibility for exercise test (relative risk 2.97, 95% confidence interval [CI] 1.98 to 4.45), previous myocardial infarction (relative risk 1.70, 95% CI 1.22 to 2.36) and angina at follow-up (relative risk 1.50, 95% CI 1.10 to 2.04). On further multivariate analysis, performed in 6,580 patients with both echocardiographic and electrocardiographic monitoring data available, a history of angina emerged as an additional risk predictor (relative risk 1.58, 95% CI 1.10 to 2.25).Conclusions. The 6-month incidence of nonfatal reinfarction is rather low in survivors of myocardial infarction after thrombolysis. Cardiac ineligibility for exercise testing and a history of coronary artery disease are risk predictors. Recurrent nonfatal infarction is not predictable by qualitative variables reflecting residual ischemia, except by postdischarge angina. Prediction of nonfatal reinfarction appears less accurate than prediction of mortality, as almost 50% of reinfarctions occur in patients without any of the identified risk factors.     

完全血运重建对DES治疗三支病变患者疗效的评估

目的: 探讨是否完全血运重建对接受药物洗脱支架（DES）治疗的冠心病三支病变患者临床疗效的分析。评价SYNTAX评分对三支病变患者治疗策略的指导意义。方法: 分析行DES植入治疗的118例三支病变患者,进行SYNTAX评分。根据是否完全血运重建分为两组。对两组患者术后3年的死亡、再次心绞痛复发、非致命性心肌梗死、非致死性脑卒中和再次血运重建事件进行随访,并综合SYNTAX评分进行分析。结果: 两组间各种心脑血管不良事件（MACCE）无统计学差异,但再次心绞痛复发、再次血运重建两类事件在非完全血运重建组有增高趋势,至非完全血运重建组总体MACCE发生率高于完全血运重建组,具有统计学差异（37% vs. 12%,P<0.05）。非完全血运重建组较完全血运重建组总体MACCE发生率在SYNTAX评分高计分、中低计分患者中均表现出增高趋势,且高计分患者更明显,但差异均未达到显著水平。结论: 接受DES植入治疗的三支病变患者完全血运重建效果好于非完全血运重建,SYNTAX高计分患者更明显。     

C-reactive protein and coronary events following percutaneous coronary angioplasty

PURPOSE: We investigated the associations between baseline C-reactive protein levels in patients undergoing percutaneous coronary angioplasty and death, nonfatal myocardial infarction, and repeat revascularization during 14 months of follow-up. METHODS: In a single-center, prospective, cohort study, plasma levels of C-reactive protein were measured in 1458 consecutive patients undergoing elective or urgent coronary angioplasty. Patients were followed at 12 to 14 months for the occurrence of death, nonfatal myocardial infarction, and repeat revascularization. RESULTS: The incidence of death or myocardial infarction was 6.1% (44/716) in patients with an increased C-reactive protein level (>3 mg/L) and 1.5% (11/742) in patients with a normal level (relative risk [RR] = 4.4; 95% confidence interval [CI]: 2.2 to 8.5; P <0.0001). In a multivariate logistic regression model, an increased C-reactive protein level was an independent predictor of death or nonfatal myocardial infarction (RR = 3.6; 95% CI: 1.8 to 7.2; P =0.0001). The incidence of repeat revascularization was similar in patients with or without an increased C-reactive protein level (23% [168/716] vs. 22% [163/742], P = 0.54). Statin therapy at the time of the procedure was associated with a lower mean (+/- SD) C-reactive protein level (5.8 +/- 9.7 mg/L vs. 7.2 +/- 12.1 mg/L, P =0.02), but was not associated with the risk of death, nonfatal myocardial infarction, and repeat revascularization during follow-up. CONCLUSION: An increased C-reactive protein level is an independent prognostic indicator for the occurrence of death or nonfatal myocardial infarction following coronary angioplasty, but is not associated with the need for repeat revascularization.