不同血运重建策略对老年非ST段抬高型急性冠脉综合征合并多支血管病变患者预后的影响

目的比较一次与分次经皮冠状动脉介入(PCI)治疗完全血运重建对高龄非ST段抬高型急性冠脉综合征(NSTE-ACS)合并多支血管病变(MVD)患者预后的影响。方法回顾性分析陕西省第四人民医院心血管内科2016年6月至2017年1月住院治疗的高龄NSTE-ACS合并MVD患者110例,其中男性67例,女性43例,年龄(63.1±8.5)岁。根据完全血运重建策略不同分为一次PCI组(n=48)和分次PCI组(n=62),比较两组患者PCI治疗、住院期间主要并发症和院内主要不良心血管事件(MACEs)发生率。术后对患者随访6个月,比较两组心功能、心绞痛症状改善情况和MACEs发生率。采用SPSS 19.0统计软件对数据进行分析。组间比较采用t检验或x~2检验。结果患者术前左室射血分数(LVEF)和院内全球急性冠状动脉事件注册(GRACE)评分差异无统计学意义(P0.05)。分次PCI组单次造影剂用量明显低于一次PCI组[(180.0±60.0)vs(230.0±70.0)ml,P=0.04],院内MACEs和住院期间主要并发症较一次次PCI组显著降低[1.6%(1/62)vs 10.4%(5/48),P=0.04;4.8%(3/62)vs 18.8%(9/48),P=0.02]。随访6个月结果表明分次PCI组较一次PCI组MACEs发生率降低[4.9%(3/61》)vs 17.4%(8/46),P=0.03]。结论分次PCI完全血运重建安全有效,可能是高龄NSTE-ACS合并MVD患者优先选用的介入治疗策略。     

多支血管病变患者的血运重建策略

多支血管病变患者的治疗策略选择,应充分考虑各种因素。与单支血管病变患者相比,多支血管病变患者往往合并糖尿病、肾功能不全、既往心肌梗死史和左室射血分数减低。多支血管病变患者的冠状动脉常为钙化、慢性完全闭塞、弥漫和小血管病变,而导致操作过程复杂。血运重建策略的选择应综合考虑所有这些临床、解剖和操作因素。     

分次介入治疗策略在多支血管病变中的应用进展

多支血管病变(多支病变)的经皮冠状动脉介入治疗(PCI)极富挑战性,其复杂程度和手术风险远高于单支病变,血运重建策略的选择也存有争议.研究表明,与不完全性血运重建相比,完全性血运重建显著提高多支病变患者的预后,是介入治疗的首选策略[1].但对于完全性血运重建,是选择一次性PCI还是分次PCI则一直是争论的焦点.     

急性心肌梗死多支血管病变经皮冠脉介入治疗一次性完全血运重建的住院期间和长期预后

由于潜在增加并发症的危险性，目前指南并不主张在急性心肌梗死（AMI）早期对多支血管病变进行经皮冠脉介人治疗（PCI）一次性完全血运重建（多支血管PCI）。然而，随着介入治疗技术的快速进展及新型抗血小板药物的应用，多支血管PCI的安全性和长期预后有待重新验证。该研究对AMI（ST段抬高AMI和非ST段抬高AMI）早期进行多支血管PCI的预后进行了评价。     

经皮冠状动脉介入治疗急性冠脉综合征患者的临床疗效

目的回顾与总结经皮冠状动脉介入(PCI)治疗急性冠脉综合征(ACS)患者的临床疗效。方法选择2003年10月至2013年10月苏州市立医院北区心血管内科确诊的ACS患者543例。依据入院后手术日期分为急诊PCI组(n=236)和择期PCI组(n=307)。急诊PCI组中,老年组(≥60岁)124例,非老年组(42~59岁)112例;择期PCI组中,老年组(≥60岁)137例,非老年组(42~59岁)170例。收集患者的临床资料,包括穿刺成功率、手术成功率、手术总时间、术后并发症情况及出院后随访1年主要不良心血管事件发生情况等。结果急诊PCI组,老年组与非老年组性别比例、家族史比例、吸烟比例、心梗部位、罪犯血管、血脂、左室射血分数比较无统计学差异(P均0.05)。老年组较非老年组,糖尿病、高血压比例增加,总胆固醇降低,差异有统计学意义(P均0.05)。择期PCI组,老年组与非老年组性别比例、家族史比例、心梗部位、罪犯血管、血脂、左室射血分数比较,无统计学差异(P均0.05)。老年组较非老年组,糖尿病、高血压、吸烟比例增加,差异有统计学意义(P均0.05)。急诊PCI组以及择期PCI组,老年组与非老年组穿刺成功率、手术成功率、手术总时间、造影剂量、住院期间再次血运重建以及随访1年再次心梗、再次行血运重建术比较,无统计学差异(P均0.05)。急诊PCI组,老年组较非老年组,住院期间死亡比例增加,随访1年死亡、心力衰竭增加,差异有统计学意义(P均0.05)。结论 PCI治疗是ACS有效的治疗手段,但其对老年ACS患者远期预后的影响仍需进一步探讨。     

血流储备分数在多支血管病变患者冠状动脉介入治疗中应用的荟萃分析

冠状动脉粥样硬化引起的心肌缺血是冠心病患者不良临床结果的重要因素[1],临床上多支血管病变的冠心病患者存在心肌缺血常见,死亡率高,对于这类患者判断缺血相关血管及对其进行血管重建术,包括经皮冠状动脉介入治疗(PCI)和冠状动脉旁路移植术(CABG)治疗策略的选择非常重要[2].     

多支血管病变的功能性血运重建

<正>传统认为,冠状动脉多支血管病变的不完全血运重建(incomplete revascularization,IR)增加死亡、心肌梗死、心绞痛和再次血运重建的风险,解剖学上的完全血运重建(complete revascularization,CR)则能够改善长期的临床预后,从而成为心脏介入治疗追求的主要目标。然而,一项外科的注册研究发现,     

急性ST段抬高型心肌梗死多支病变患者血运重建策略

急性ST段抬高型心肌梗死（ST-segment elevation myocardial infarction,STEMI）是一种发病率逐年上升的心血管急重症之一,致残、致死率高。40%~65%的STEMI患者存在冠状动脉多支病变（multi-vessel disease,MVD）,与单支病变相比,并发MVD的STEMI患者心血管不良事件的发生率明显增加。目前,在不考虑外科干预的情况下,针对STEMI多支病变患者的治疗策略主要有3种:即仅对梗死相关血管（infarct-related artery,IRA）即罪犯血管（culprit vessel）行急诊经皮冠状动脉介入（Percutaneous Coronary Intervention,PCI）治疗（culprit-PCI）、同时对IRA及至少1支非梗死相关血管（non-infarct-related artery,non-IRA）行急诊PCI（MV-PCI）、对IRA行急诊PCI后择期对至少1支non-IRA行PCI（staged-PCI）。由于STEMI多支病变患者non-IRA病理生理状态相对特殊,因此,国内外对non-IRA的处理策略及处理时机存在争议。同时,随着临床新技术及新型口服药物不断发展,STEMI多支病变处理策略也不断完善。本文就STEMI多支病变患者血运重建策略研究进展进行综述。     

不同抗血小板治疗方案对急性冠脉综合征冠脉多支病变行PCI术治疗效果的随访观察

目的 探讨三种抗血小板治疗方案对急性冠脉综合征冠脉多支病变行PCI术治疗的有效性及安全性。方法 选取急性冠脉综合征多支病变且行PCI术患者215例为研究对象,并根据不同的治疗方案将患者分为氯吡格雷高剂量组(试验A组,n=38,术前顿服300 mg,术后每次150 mg,每日1次),替格瑞洛组(试验B组,n=78,术前顿服180 mg,术后每次90 mg,每日2次)和氯吡格雷普通剂量组(对照组,n=99,术前300 mg顿服,术后每次75 mg,每日1次)。术后均对患者随访12个月,比较三组患者基本临床资料、冠脉病变特征、药物使用情况、CYP2C19 基因多态性及12个月内主要不良心血管事件、不良反应发生。结果 三组患者基本临床资料、冠脉病变特征、药物使用情况比较未见统计学差异(P>0.05),具有可比性。试验组中CYP2C19基因型为中慢代谢型的患者的比例明显高于对照组,差异有统计学意义(P<0.05)。试验B组患者随访期间(12个月内)MACE发生率显著低于对照组(7.7%比25.3%),且低于试验A组(7.7%比21.1%),差异有统计学意义(P<0.05);呼吸困难发生率、出血事件及总不良反应发生率三组比较未见统计学差异(P>0.05)。结论 替格瑞洛较两种剂量氯吡格雷对急性冠脉综合征冠脉多支病变行PCI术患者具有良好的有效性及安全性。     

Multivessel percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction

Background

The optimal percutaneous interventional strategy for dealing with significant non-culprit lesions in patients with multivessel disease (MVD) with acute myocardial infarction (AMI) at presentation remains controversial.

Methods

A total of 820 patients treated with primary angioplasty for AMI between 1998 and 2002 were classified in groups of patients with single vessel disease (SVD) or MVD (≥70% stenosis of ≥2 coronary arteries). Patients with MVD were subdivided in 3 groups on the basis of the revascularization strategy: 1) patients undergoing percutaneous coronary intervention (PCI) of the infarct-related artery (IRA) only; 2) patients undergoing PCI of both the IRA and non-IRA(s) during the initial procedure; and 3) patients undergoing PCI of the IRA followed by staged, in-hospital PCI of the non-IRA(s). Procedural, 30-day, and 1-year outcomes are reported.

Results

At 1 year, compared with patients with SVD, patients with MVD had a higher incidence of re-infarction (5.9% vs 1.6%, P = .003), revascularization (18% vs 9.6%, P <.001), mortality (12% vs 3.2%, P <.001), and major adverse cardiac events (MACEs; 31% vs 13%, P <.001). In patients with MVD, compared with PCI restricted to the IRA only, multivessel PCI was associated with higher rates of re-infarction (13.0% vs 2.8%, P <.001), revascularization (25% vs 15%, P = .007), and MACEs (40% vs 28%, P = .006). Multivessel PCI was an independent predictor of MACEs at 1 year (odds ratio = 1.67, P = .01).

Conclusions

These data suggest that in patients with MVD, PCI should be directed at the IRA only, with decisions about PCI of non-culprit lesions guided by objective evidence of residual ischemia at late follow-up. Further studies are needed to confirm these findings.     

Optimal revascularization strategies for multivessel coronary artery disease

PURPOSE OF REVIEW: The aim of this article is to review the current status of optimal revascularization strategies in patients presenting with multivessel coronary artery disease. RECENT FINDINGS: Coronary artery bypass surgery is the gold standard for patients with multivessel disease. Recent developments in the interventional field, like drug-eluting stents, which significantly reduced restenosis and the need for repeat revascularizations, have cut back one of the largest limitations of percutaneous coronary intervention. SUMMARY: There is currently little evidence to believe that in a general population, opting for either coronary artery bypass surgery or percutaneous coronary intervention would imply a better long-term survival. Coronary artery bypass surgery is still associated with higher rates of complete revascularization and a higher durability than percutaneous coronary intervention, resulting in lower rates of repeat revascularization. The current evidence, however, is based on sub-optimal inconclusive data from single center or multicenter registries. Until the results of several dedicated ongoing randomized trials are presented, the choice for a revascularization strategy should be made not only on the basis of feasibility but also by taking into account each patient's co-morbidities and risk factors. Careful monitoring of glycemic control and lipid concentrations and an optimal pharmacological treatment are at least as important in achieving an optimal outcome.     

Prevalence and impact of metabolic syndrome in patients with multivessel coronary artery disease and acute coronary syndrome

Background and aimsMetabolic syndrome (MetS) is associated with increased incidence of diabetes and cardiovascular diseases in patients initially free from these diseases. However, its prognostic value in patients with established coronary artery diseases remains controversial. Therefore, we aimed to illustrate the prevalence and investigate the impact of MetS in patients with multivessel coronary artery disease (MVD) and acute coronary syndrome (ACS).Methods and resultsThis was a large registry of consecutive patients with ACS referred to primary percutaneous coronary intervention (PCI) and those with MVD were eligible for this analysis. MetS was defined based on modified Adult Treatment Panel III definition. The primary outcome was major adverse cardiovascular events (MACE), a composite of all-cause death, myocardial infarction and stroke. A total of 2532 patients were included in the current analysis and 993 (39.2%) of them had MetS. The prevalence of MetS increased from 2010 to 2016 (p _{for trend} = 0.005). In patients over 60 years old, the prevalence of MetS decreased with aging (p _{for trend} = 0.002). Female subjects had a higher prevalence than their male counterparts (61.5% verse 32.9% and p < 0.001). Over a median follow-up of 2.3 years, MetS was not significantly associated with MACE (adjusted 95% CI from 0.92 to 1.54).ConclusionMetS was frequently observed in patients with MVD and ACS. Patients with MetS were more likely to be young and female. However, it was not an independent predictor for MACE after primary PCI in those patients.     

稳心颗粒联合倍他乐克治疗冠心病心律失常疗效观察

目的探讨稳心颗粒联合倍他乐克治疗冠心病心律失常的临床效果。方法将2008-06～2011-06收治的冠心病心律失常患者160例,随机分为观察组和对照组各80例。观察组使用稳心颗粒联合倍他乐克治疗,对照组使用心律平治疗,观察两组患者药物治疗效果并进行比较分析。结果观察组的疗效和总有效率均优于对照组(P0.01)。结论稳心颗粒联合倍他乐克治疗冠心病心律失常疗效显著、副作用小、并发症少,但是临床用药应该考虑到患者的心功能和有无其他合并症等实际情况,注意用药个体化及避免滥用。     

应用小剂量肝素治疗急性呼吸窘迫综合症的临床疗效

目的探讨应用小剂量肝素治疗急性呼吸窘迫综合症(ARDS)患者的临床疗效。方法将我院重症医学科(ICU)住院治疗的明确诊断为ARDS的患者66人,随机分为试验组(34例)和对照组(32例),对照组给予常规治疗,试验组在常规治疗的基础上加用小剂量肝素(5～10 U/kg/h)持续泵入,测定两组间患者治疗前、治疗后第1天、第3天、第5天、第7天氧合指数(PaO2/FiO2)、呼吸频率(R)、血小板计数(PLT)、部分凝血酶原时间(APTT)、纤维蛋白原(FIB)、组织因子途径抑制物(TF-PI)。观察两组患者平均机械通气时间、平均ICU住院时间及28天病死率。结果与对照组相比,治疗后3、5、7天实验组PaO2/FiO2明显升高,R、TFPI含量明显下降,PLT、APTT、FIB含量无明显变化;对照组平均机械通气时间、ICU住院时间均显著低于对照组,28 d病死率较对照组有所降低。结论小剂量肝素治疗急性呼吸窘迫综合征疗效显著,临床应用安全。