不稳定型心绞痛的介入治疗体会

目的 观察不稳定型心绞痛经皮冠状动脉腔内成形术（PTCA）治疗的效果。方法 38例患者共50支血管进行了PTCA或PTCA＋支架治疗。结果 共植入支架48个,单纯PTCA2例均获成功。无一例发生严重并发症。结论 对内科保守治疗无效的不稳定型心绞痛患者,为避免AMI和猝死的发生,应及时采取介入治疗。本疗法安全,成功率高,并发症少。     

国产注射用比伐卢定对冠状动脉介入治疗患者凝血功能的影响

目的探讨国产注射用比伐卢定对经皮冠状动脉介入(PCI)治疗术患者凝血功能的影响。方法随机选择50例择期行PCI的患者,术中用肝素(对照组,25例)或国产注射用比伐卢定(比伐卢定组,25例)抗凝。分别于PCI术前、用药后5 min、术后即刻、停药后30 min、停药后2 h测活化凝血时间(ACT)。用药前、用药结束后6、24、72 h,静脉采血,检测活化凝血酶时间(APTT)、凝血酶原时间(PT)、凝血酶时间(TT)和纤维蛋白原(FIB)。结果用药后5 min及术后即刻比伐卢定组ACT显著高于对照组(均为P<0.001);PCI术前和停药后30 min两组患者ACT差异无统计学意义(P=0.362、P=0.732),停药后2 h比伐卢定组ACT显著低于对照组[(208.27±34.84)s比(241.48±41.34)s,P=0.01]。术后凝血功能4项与对照组比较差异无统计学意义(均为P>0.05),两组之间均无心血管临床事件发生(P=1.00),大出血事件两组之间差异也无统计学意义(P=1.00)。结论与常规肝素抗凝相比,国产注射用比伐卢定作为抗凝剂应用于PCI术中,起效更快,效果更强,而且半衰期更短,提示其有效性和安全性比肝素钠更佳。     

负荷量阿托伐他汀对不稳定型心绞痛患者冠状动脉介入治疗后近期心血管事件的影响

目的观察负荷量阿托伐他汀对不稳定型心绞痛(unstable angina,UA)患者经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗后近期心肌损伤、心肌灌注和心血管事件的影响。方法选取2009年11月至2011年10月在江门市五邑中医院行PCI治疗的UA患者56例,按电脑随机数字表法分为治疗组28例和对照组28例。治疗组在术前7 d给予负荷量阿托伐他汀40 mg/d,术后两组均给予阿托伐他汀10 mg/d治疗。分别于术前,术后24 h、3 d检测血清心肌型肌酸激酶同工酶(MB isoenzyme of creatine kinase,CK-MB)、血肌钙蛋白(troponin I,TnI)、一氧化氮(nitric oxide,NO)浓度;术前、术后即刻评估TMI心肌灌注分级(TMImyocardial perfusion,TMP)情况,并记录术后随访3个月的主要心血管事件。结果两组术后24 h血CK-MB、TnI浓度明显升高,术后3 d较前有所下降;治疗组血清CK-MB、TnI浓度均低于对照组,差异均有统计学意义(P=0.037,P=0.046);两组术后NO水平明显升高,以治疗组升高更为显著,差异有统计学意义(P=0.049);PCI治疗前、后治疗组TMP 0/1级的发生率低于同期对照组,差异均有统计学意义(P=0.017,P=0.019);术后随访3个月,治疗组心血管事件发生率10.7%低于对照组21.4%,治疗组整体发生主要心血管事件的病情程度轻于对照组,差异均有统计学意义(P<0.05)。结论 PCI治疗前给予负荷量阿托伐他汀能改善UA患者术后心肌血流灌注,减少心肌损伤,可能降低术后3个月内心血管事件发生率及减轻病情严重程度,从而改善患者的预后。     

经皮冠状动脉介入治疗右冠状动脉起源异常的不稳定型心绞痛

目的分析右冠状动脉（fight coronary artery,RCA）起源异常的不稳定型心绞痛经皮冠状动脉介入（percutaneous coronary intervention．PCI）治疗的临床特点。方法回顾性分析2005年10月至2012年10月武汉市第五人民医院收治行PCI治疗的不稳定型心绞痛合并RCA起源异常5例患者的临床资料。结果共计623例不稳定型心绞痛患者中6例合并存在RCA起源异常,其中5例罪犯血管为RCA,发生率0．96％。5例患者中男3例,女2例．中位年龄57（32～75）岁;其中RCA起源于左冠状窦3例,起源于嵴上1例,起源于主动脉前壁1例;单支血管病变4例,两支血管病变1例;4例植入药物洗脱支架1枚,1例植入药物洗脱支架2枚;5例PCI治疗围术期无夹层、血栓、心肌梗死、心力衰竭、脑卒中、死亡等并发症发生;随访14．6（6-24）个月,无心绞痛、死亡、再次冠状动脉事件入院、再次血管化等主要心血管事件发生。结论PCI治疗为RCA起源异常的不稳定型心绞痛患者提供了一种安全有效的治疗方法。     

国产比伐卢定用于冠状动脉介入治疗术中抗凝的疗效和安全性评价

目的:评估国产比伐卢定应用于择期冠状动脉介入治疗术(PCI)中抗凝治疗的疗效及安全性.方法:采用随机、单盲、多中心临床试验设计,随机将接受择期PCI的患者分为比伐卢定组和肝素组,在PCI术中分别采用比伐卢定或普通肝素抗凝治疗,主要疗效评价指标为术中测定激活的全血凝固时间(ACT)、手术成功率(靶病变术后狭窄程度小于20%并24 h内无冠状动脉事件发生)及30天无心血管事件生存率,主要安全性评价指标为轻度及重度出血.结果:共有218例患者入选,实际入组完成试验207例,比伐卢定组(n=105)和肝素组(n=102).用药后5 min除肝素组2例需要追加剂量外,其余两组患者PCI术中均能维持ACT>225 s,两组差异无统计学意义(P>0.05);比伐卢定组和肝素组PCI手术成功率和30天无心脏事件生存率均分别为100%和98.04%(P>0.05),差异无统计学意义.比伐卢定组和肝素组24 h内轻度出血的发生率分别为0.95%和6.86%(P<0.05)、30天内轻度出血发生率分别为1.9%和8.8%(P<0.05),肝素组有1例发生严重消化道出血.结论:国产比伐卢定能安全有效地应用于择期PCI术中抗凝治疗,疗效不劣于肝素且出血副作用低于肝素.     

比伐卢定对急诊经皮冠状动脉介入治疗患者心肌灌注及近期疗效的影响

目的观察比伐卢定对直接经皮冠状动脉介入治疗(PCI)的急性ST段抬高型心肌梗死(STEMI)患者心肌灌注水平、近期治疗效果及安全性的影响。方法收集急诊PCI治疗的STEMI住院患者128例,将上述患者随机分为比伐卢定组(60例)和替罗非班加肝素组(68例)。比伐卢定组:球囊扩张罪犯血管病变后,静脉注射0.75 mg/kg比伐卢定,在3~5 min内推注完毕后再植入支架。术后以维持量1.75 mg·kg~(-1)·h~(-1)微量泵泵入4 h。替罗非班加肝素组:术前静脉内注射10μg/kg负荷剂量替罗非班,同时再注射普通肝素100 U/kg,然后以0.75μg·kg~(-1)·min~(-1)持续静脉滴注替罗非班36 h。观察两组PCI术中心肌梗死溶栓实验(TIMI)血流分级及心肌灌注评分(TMPG);并观察两组术后24 h、1个月内各种不良事件发生率。结果两组术后TIMI、TMPG及24 h、1个月内主要不良心血管事件发生率相比较,差异均无统计学意义(P0.05),比伐卢定组1个月内出血并发症发生率明显减少(P0.05)。结论急诊PCI术中,单独应用比伐卢定治疗效果在主要不良心血管事件发生率方面与替罗非班加肝素相似,但可显著减少术后1个月内的出血事件,并且TIMI评分中高危的STEMI患者获益更高。     

阿托伐他汀对初诊不稳定型心绞痛患者介入治疗术后C-反应蛋白水平的影响及意义

目的探讨阿托伐他汀对初诊不稳定型心绞痛患者介入治疗术（PCI）后c-反应蛋白水平的影响及意义。方法30例初诊不稳定型心绞痛患者拟行PCI,随机分为阿托伐他汀组及对照组。阿托伐他汀组患者于术前3d开始服用阿托伐他汀40mg／d,介入术中使用低渗非离子型对比剂。术后全部患者立即接受水化治疗12h。入院时及术后第1天、第3天、第7天监测血清肌酐水平,入院时及术后第7天查c-反应蛋白水平。结果治疗组对比剂肾病发生率低于对照组（3％比13％,P〈0．05）。术后第1天、第3天、第7天血清肌酐水平（umol／L）均低于对照组（94．38±22．16、95．78±19．78、90．36±21．67比98．34±21．45、110．21±21．46、96．22±20．18,P〈0．05）。两组治疗前、后C-反应蛋白水平（mg／L）比较差异有统计学意义（13．68±0．45比10．28±0．23,13．45±0．34比12．14±0．33,P〈0．05）,治疗组较对照组改善更显著（P〈0．05）。结论初发不稳定型心绞痛接受PCI的患者在围手术期使用阿托伐他汀具有保护肾功能的作用。     

经皮冠状动脉介入治疗对不稳定型心绞痛患者血浆M30浓度的影响

目的探讨经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗对不稳定型心绞痛(unstable angina,UA)患者血浆M30浓度的影响。方法从2011年12月至2013年1月在广东省心血管病研究所心内二区住院并行PCI治疗的400例冠状动脉粥样硬化性心脏病(冠心病)患者血浆中,采用完全简单随机方法(随机数表法)抽取73例患者,其中稳定型心绞痛(stable angina,SA)9例、UA38例、心肌梗死(myocardial infarction,MI)26例。采用酶联免疫吸附法(ELISA)测定冠心病患者在PCI治疗前、治疗后第一天的血浆M30浓度。结果冠心病患者PCI治疗后血浆M30浓度比治疗前高,但差异无统计学意义(P>0.05)。亚组分型中,因UA组例数太少,不对其进行统计分析。MI组患者的术前血浆M30抗原浓度比UA组高,但差异无统计学意义(P>0.05)。UA组PCI治疗前、后血浆M30浓度比较,差异有统计学意义[129(109～497)U/L vs.149(83～542)U/L,P=0.037];PCI治疗后血浆M30抗原浓度明显高于PCI治疗前。MI组PCI治疗前、后血浆M30浓度比较,差异无统计学意义(P>0.05)。结论 UA患者血浆M30抗原浓度在PCI治疗后升高,说明PCI治疗会增加UA患者的心肌细胞凋亡。M30可作为细胞凋亡的监测指标并有助于观察UA患者PCI治疗后出现的心肌微损伤。     

国产比伐卢定在老年急性冠脉综合征患者介入术中治疗效果

目的 研究老年（年龄>65岁）急性冠脉综合征（ACS）患者在经皮冠脉介入（PCI）治疗术中使用国产比伐卢定的安全和有效性。方法 本研究通过回顾性分析我院35例PCI术中应用比伐卢定的老年ACS患者的临床资料,按1∶1匹配选取同期35例PCI治疗过程中常规应用普通肝素的老年ACS患者作为对照组,分析术后30 d内的主要不良心脑血管事件(major adverse cardiac and cerebrovascular events,MACCE)及出血并发症的发生情况。结果 两组临床资料对比,差异无统计学意义。术后30 d内MACCE发生率分别为4例（11%）和5例（14%）,差异无统计学意义;出血并发症发生率分别为1例（3%）和6例（17%）,比伐卢定组优于普通肝素组（P<0.05）。结论 老年ACS患者PCI术中使用比伐卢定与普通肝素相比,可减少术后30d内的出血事件发生率,且不增加MACCE的风险。     

比伐卢定与替罗非班合用肝素在急诊经皮冠状动脉介入治疗中的疗效

目的对比分析比伐卢定与替罗非班加肝素在急诊经皮冠状动脉介入治疗(PCI)中的疗效。方法选取该院2010年9月至2013年12月行PCI患者82例,采用随机数字表分为实验组和对照组,各41例,实验组在急诊PCI术前及术中给予比伐卢定;对照组在急诊PCI术前及术中给予滴注替罗非班和普通肝素,分别检测和比较两组患者的血流情况、ST段回降百分比、N末端脑钠肽前体(NT-proBNP)及术后出血情况。结果实验组血流情况在0、1、2、3级的患者人数分别为1、4、4、32例,ST段无回降者2例、部分回降4例、完全回降者35例,NT-proBNP平均差值为(727.59±87.29)pg/ml,2例(4.9%)患者出现消化道出血;对照组血流情况在0、1、2、3级的患者人数分别为3、2、3、33例,ST段无回降者3例、部分回降者5例、完全回降者33例,NT-proBNP平均差值为(724.46±82.16)pg/ml,11例(26.8%)患者出现出血症状;两组患者的血流情况、ST段回降情况及NT-proBNP平均差值均无统计学差异(均P>0.05),两组术后出血情况存在统计学差异(P<0.05)。结论比伐卢定与替罗非班加肝素在急诊经PCI治疗中的疗效相当,但比伐卢定治疗可减少术后出血情况的发生率。     

The impact of unfractionated heparin or bivalirudin on patients with stable coronary artery disease undergoing percutaneous coronary intervention

Objectives

To compare bleeding and clinical events of patients with stable angina or silent ischemia undergoing percutaneous coronary intervention (PCI) treated with unfractionated heparin (UFH) or bivalirudin.

Background

Few direct comparisons between UFH monotherapy versus bivalirudin exist for patients with stable ischemic heart disease undergoing PCI.

Methods

A prospective, investigator‐initiated, single‐center, single‐blinded, randomized trial of UFH versus bivalirudin was conducted. The primary endpoint was all bleeding (major and minor) from index‐hospitalization to 30 days post discharge. Secondary endpoints included major adverse cerebral and cardiovascular events (MACCE) and net adverse clinical events (NACE).

Results

Two‐hundred‐sixty patients were randomized for treatment with either UFH (n = 123) (47%) or bivalirudin (n = 137) (53%) There were no significant differences in baseline clinical and angiographic characteristics between the two groups. Primary endpoint was similar in both groups (10.9% with bivalirudin vs 7.3% with UFH [P = 0.31]). Major bleeding rates were 5.8% and 2.4%, respectively (P = 0.17). There was a higher MACCE (3.5% vs 0%, P = 0.03) and NACE (8.8% vs 2.4%, P = 0.03) rate with bivalirudin compared to UFH, respectively. Bivalirudin had increased odds of NACE (OR = 3.65, 95% CI: 1.00‐13.3.6). Death and stent thrombosis rates were low and similar in both groups. Radial access was associated with fewer bleeding events compared to femoral access but not statistically significant (P = 0.29).

Conclusions

Among patients with stable angina or silent ischemia, there was no difference between UFH and bivalirudin in bleeding rates up to 30‐days post‐PCI. MACCE and NACE were higher among the bivalirudin group. Radial access was associated with a numerically lower rate of bleeding compared with femoral access.     

不稳定性心绞痛患者经皮冠状动脉介入治疗后支架内再狭窄影响因素分析

目的探讨不稳定性心绞痛(UAP)患者PCI术后支架内再狭窄的术前影响因素。方法选择成功置入雷帕霉素药物涂层支架的UAP患者157例,根据冠状动脉造影结果分为再狭窄组16例和无狭窄组141例,回顾性分析2组性别、年龄、术前收缩压、糖尿病、TC、吸烟、体重指数、体力活动、高敏C反应蛋白(hs-CRP)水平和汉密尔顿抑郁量表(HAMD)评分,COX回归模型对有差异的因素进行分析。结果与无狭窄组比较,再狭窄组患者hs-CRP和HAMD评分明显升高(P0.01);伴有抑郁症状患者hs CRP明显高于无抑郁症患者(P=0.002)。校正UAP患者术前收缩压、吸烟、糖尿病、体重指数影响后,术前hs-CRP(OR=9.205,95% CI:2.986～28.378)、TC(OR=3.762,95% CI:1.348～10.497)、HAMD评分(OR=1.376,95% CI:1.098～1.724)与术后支架内再狭窄相关。结论 PCI术前hs-CRP、TC水平和抑郁症状是UAP患者术后支架内再狭窄的独立危险因素。     

Percutaneous transluminal coronary angioplasty for unstable angina: Predictors of outcome in a multicenter study

Background: Angiographic and clinical studies have demonstrated that coronary artery plaque rupture with thrombus formation, spasm, or both are frequently responsible for the syndrome of unstable angina. Percutaneous transluminal coronary angioplasty (PTCA) is commonly used in the treatment of patients with coronary artery disease and unstable angina. A number of studies have shown, however, that intracoronary thrombus increases the risk of abrupt vessel closure. The purpose of this study was to define preprocedural variables predictive of the outcome of PTCA performed on patients with unstable angina in a prospective multicenter study using a core angiographic laboratory.Methods and Results: A total of 386 patients with unstable angina underwent coronary angioplasty of 487 lesions treated with balloon PTCA at 9 medical centers. Multivessel or left main coronary artery disease was present in 55% and recent myocardial infarction in 22%. Clinical success was achieved in 317 of 386 patients (82.1%), as defined by <50% residual stenosis at every target lesion evaluated in the core angiographic laboratory and no major complication during hospitalization. Major complications (death, Q-wave or non-Q-wave myocardial infarction, or emergency coronary artery bypass surgery) occurred in 36 patients (9.3%), and abrupt vessel closure occurred in 50 (13.0%). Logistic regression analysis identified preprocedural variables that were predictive of outcome of angioplasty. Strong predictors of any complication (major complication or abrupt vessel closure) included age [odds ratio (OR)=1.04; 95% confidence interval [CI] 1.02, 1.07]) for each additional year of age; p < 0.001), number of diseased vessels (OR=1.58; 95% CI=1.16, 2.15 per additional vessel; p=0.012), the number of lesions treated at angioplasty (OR =1.72; 95% CI=1.11, 2.66; p=0.014), and angiographic evidence of filling defect preceding angioplasty (OR=3.30; 95% CI=1.11, 9.75; p < 0.001).Conclusions: The outcome of PTCA performed for unstable angina is influenced by a combination of clinical, angiographic, and procedural variables. This study suggests that PTCA performed on lesions associated with filling defects or on more than one lesion at the time of the procedure carries an increased risk of complication. The outcome of PTCA for unstable angina may be improved by identifying new strategies for the treatment of lesions associated with filling defects and by using more accurate methods to identify and treat the culprit lesion responsible for unstable angina.     

替格瑞洛对不稳定型心绞痛患者经皮冠状动脉介入术围手术期血小板反应性及短期预后的影响

目的探讨替格瑞洛对不稳定型心绞痛患者经皮冠状动脉介入术(PCI)围手术期血小板反应性及短期预后的影响。方法入选不稳定型心绞痛患者424例,随机分为2组:(1)替格瑞洛组(n=212):给予替格瑞洛治疗(负荷剂量180 mg,维持剂量90 mg,每天2次,口服);(2)氯吡格雷组(n=212):给予氯吡格雷治疗(负荷剂量300 mg,维持剂量75 mg,每天1次,口服)。2组均成功接受PCI术,支架均选择国产Firebird雷帕霉素药物洗脱支架。观察2组患者PCI术围手术期血小板反应性及心肌损伤标志物心肌肌钙蛋白I(cTnI)及PCI术后90天不良事件发生情况。结果 2组患者PCI术后cTnI水平比较差异无统计学意义(P0.05)。替格瑞洛组患者花生四烯酸及二磷酸腺苷诱导的血小板聚集率均低于氯吡格雷组(P0.05);替格瑞洛组患者二磷酸腺苷诱导的血小板高反应性比例低于氯吡格雷组(P0.05)。替格瑞洛组PCI术后90天内患者再发心肌缺血发生率低于氯吡格雷组(5.19%比16.04%,P0.05)。出血事件两组比较差异无统计学意义(P0.05)。结论替格瑞洛并不降低PCI术后心肌损伤的发生,但较氯吡格雷能发挥更强的抗血小板作用,减少术后再发心肌缺血事件发生率,并不增加出血风险。     

Visualized plaque debris as a cause of distal embolization after percutaneous coronary intervention in patient with unstable angina.

Procedural complications of percutaneous transluminal coronary angioplasty for unstable angina are higher than for stable angina. We report a case in which coronary angioscopy proved the dislodgment of a large plaque fragment after Cutting Balloon angioplasty and confirmed our suspicion that plaque fragmentation can cause distal embolization.