Echocardiography and coronary artery disease: Current and future applications

Echocardiographic techniques are becoming more widespread for evaluating patients with known or suspected coronary artery disease. Because it affords an excellent overall view of the heart, two-dimensional echocardiography, rather than M-mode echocardiography, is the imaging procedure of choice when dealing with coronary artery disease. This technique can be used to make the initial diagnosis of acute myocardial infarction, diagnose complications, and assess prognosis following myocardial infarction. Additionally by combining this test with stress testing, latent coronary artery disease can be detected. Recovery of wall motion can be assessed following interventions such as thrombolysis or balloon angioplasty. Investigational and future uses include tissue characterization, which may allow detection of ischemic but potentially viable myocardium, direct coronary visualization for detection of atherosclerotic involvement of the proximal coronary arteries and myocardial contrast echocardiography. The latter technique allows visualization of perfusion by way of injecting contrast material into the coronary circulation. This has been demonstrated to be an accurate means of determining myocardial infarction size in an animal model and is currently being used in a number of centers in patients at the time of cardiac catheterization. In summary two-dimensional echocardiography currently allows assessment of patients with myocardial infarction from the time of their presentation through their convalescent period with respect to diagnosis, prognosis and presence of complications. Exercise echocardiography can diagnose latent coronary artery disease. The newer investigational techniques show promise for furthering our ability to evaluate patients with coronary artery disease using echocardiography.     

Current use of beta-blockers in patients with coronary artery disease

Beta-blockers have long comprised a cornerstone in the symptomatic treatment of ischemic heart disease and in the secondary prevention of myocardial infarction and heart failure. The majority of studies underlying the evidence of a beneficial effect of beta-blockers on outcomes were conducted more than 25 years ago. In a contemporary era where treatment strategies and secondary prophylactic therapy have undergone several changes, the continued role of beta-blockers in ischemic heart disease has been questioned, especially in the absence of heart failure or a recent myocardial infarction. In summary, few randomized clinical trials are available on the effect of beta-blockers in the reperfusion era, especially on hard endpoints. Likewise, the results of numerous observational studies and meta-analysis are conflicting, emphasizing the need for additional large-scale randomized clinical trials to evaluate the role of beta-blocker therapy in current clinical practice.     

Diagnosing coronary artery disease in diabetic patients

Although several diagnostic modalities are available to the clinician interested in diagnosing coronary artery disease, very few have been validated in diabetic populations. This review discusses the non-invasive diagnosis of coronary disease in diabetic patients. Evidence regarding the prevalence and prognostic significance of silent ischemia is reviewed and the potential impact of silent ischemia on the diagnostic characteristics of the exercise treadmill test discussed. Other diagnostic tools are considered, and recommendations are made with respect to screening asymptomatic diabetic patients for coronary artery disease.     

冠心病非侵入性影像诊断技术的优缺点及研究进展

尽管冠脉造影可能低估较重的冠脉弥漫性病变,但冠状动脉的血管造影仍是诊断冠心病的“金标准”。冠脉造影不仅价格昂贵,而且因为是侵入性检查,可造成为数较少的严重的并发症。在要求安全性更高和花费更合理的情况下,非侵入性冠脉血管造影应运而生。     

Report: Association of coronary artery disease and valvular heart disease in chile

This study analyzes the prevalence of coronary artery disease (CAD) among patients with rheumatic valvular heart disease (VHD) in Chile. Coronary angiography was performed in all patients referred to cardiac catheterization with VHD who were over age 50 years and who had angina or ECG signs of ischemia. A total of 100 patients entered the study. Significant CAD (greater than 50% obstruction) was found in 14% of the cases: 7% in patients with mitral valve disease (MVD), 18% in aortic valve disease (AVD), and 21% in combined mitral and aortic valve disease (MAVD). Angina was present in 14% of the patients with MVD, 63% with AVD, and 53% with MAVD. Only 57% of patients with CAD had angina pectoris; 20% with angina had CAD. Hemodynamic parameters and left ventricular ejection fraction were not correlated with the presence or absence of CAD. We conclude that in patients with valvular heart disease, the incidence of CAD is lower in Chile than previously reported in the English literature. We confirmed the fact that angina is often not associated with CAD, and that CAD is often present in the absence of angina.     

Imaging in coronary artery disease. Cardiac magnetic resonance

Imaging in coronary artery disease should be regarded as a tool supporting patients’ management. Imaging helps physicians to diagnose patients more precisely and to treat them more effectively. There is a constant need to improve the decision-making process in patients with coronary artery disease. The growing number of cardiac magnetic resonance (CMR) centres, patients undergoing CMR studies and the plethora of evidence for the use of CMR both in patients with stable coronary artery disease, as well as acute coronary syndromes, justify reviewing its capabilities. Although research applications and technical developments are of particular value for progress being made in the field of imaging, clinical applications are the most crucial for patients and treating physicians, thus they will be discussed.     

冠状动脉左主干病变的治疗策略

冠状动脉(冠脉)左主干病变首选冠脉搭桥手术(CABG),尽可能选择不停跳CABG。急诊CABG风险较高,手术适应证①严重的左主干病变(>75%),尤其"无保护"左主干病变;②左主干病变>50%,并(或)有3支病变,出现严重的危及生命的室性心律失常;③左主干病变伴有急性冠脉综合征。     

Revascularization strategies for patients with stable coronary artery disease

Patients with coronary artery disease who have prognostically significant lesions or symptoms despite optimum medical therapy require mechanical revascularization with coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI) or both. In this review, we will evaluate the evidence‐based use of the two revascularization approaches in treating patients with coronary artery disease. CABG has been the predominant mode of revascularization for more than half a century and is the preferred strategy for patients with multivessel disease, especially those with diabetes mellitus, left ventricular systolic dysfunction or complex lesions. There have been significant technical and technological advances in PCI over recent years, and this is now the preferred revascularization modality in patients with single‐vessel or low‐risk multivessel disease. Percutaneous coronary intervention can also be considered to treat complex multivessel disease in patients with increased risk of adverse surgical outcomes including frail patients and those with chronic obstructive pulmonary disease. Improvements in both CABG (including total arterial revascularization, off‐pump CABG and ‘no‐touch’ graft harvesting) and PCI (including newer‐generation stents, adjunctive pharmacotherapy and intracoronary imaging) mean that they will continue to challenge each other in the future. A ‘heart team’ approach is strongly recommended to select an evidence‐based, yet individualized, revascularization strategy for all patients with complex coronary artery disease. Finally, optimal medical therapy is important for all patients with coronary artery disease, regardless of the mode of revascularization.     

青年冠心病患者冠状动脉病变特点及相关危险因素分析

目的探讨冠状动脉粥样硬化性心脏病(冠心病)的临床特点在青年与老年患者间的差异。方法回顾性分析48例青年冠心病患者与156例老年冠心病患者的临床资料,着重分析比较两组的危险因素及冠状动脉造影结果。结果青年组冠心病患者女性比例占6.25%(3/48),明显低于老年组的33.33%(52/156),差异有统计学意义(P0.01)。青年组体质量指数明显高于老年组,差异有统计学意义[(27.03±2.73)kg/m2vs.(25.16±3.05)kg/m2,P0.01]。青年组大量吸烟的比例也远高于老年组,差异有统计学意义[75.00%(36/48)vs.36.54%(57/156),P0.01]。老年组合并原发性高血压、糖尿病的发生率高于青年组,差异有统计学意义[51.28%(80/156)vs.16.67%(8/48),P0.01;30.77%(48/156)vs.6.25%(3/48),P0.01]。青年组血浆总胆固醇,低密度脂蛋白胆固醇及三酰甘油浓度与老年组比较,差异无统计学意义(P0.05)。青年组高密度脂蛋白胆固醇浓度低于老年组,差异有统计学意义[(0.85±1.80)mmol/Lvs.(1.08±0.23)mmol/L,P0.01]。青年组血浆尿酸浓度高于老年组,差异有统计学意义[(349.10±67.02)mmol/lvs.(323.77±73.82)mmol/L,P0.01]。青年组冠状动脉病变以单支病变为主,且左前降支病变发生率最高。结论男性、肥胖、大量吸烟为青年冠心病主要发病危险因素,低高密度脂蛋白胆固醇浓度和高尿酸浓度也可能为青年冠心病的危险因素;青年冠状动脉病变轻,以单支病变为主。     

多排螺旋CT冠状动脉成像的现状与展望

自1998年多排螺旋CT问世，2004年CT冠状动脉成像应用于临床，从最初的4排到现今的64排，CT冠状动脉成像迅速发展。除了设备厂商的大力推动、技术进步，以及软件、硬件的明显改善，最重要的是临床医师的认可与患者的需求推动了CT冠状动脉成像在临床的广泛应用，CT冠状动脉成像已经改变了确诊或疑似冠心病患者的就诊模式。     

The association of homocysteine and coronary artery disease

Hyperhomocysteinemia has been associated with increased risk of atherosclerosis and myocardial infarction by a number of prospective case-control studies. A variety of genetic mutations, nutritional deficiencies, disease states, and drugs can elevate homocysteine concentrations. Treatment with folic acid with or without B-complex vitamins effectively lowers homocysteine levels. Whether therapy corresponds with decreased risk of coronary events is unknown, but may be promising. This article reviews the biochemistry of homocysteine metabolism, pathogeneisis, and etiology of hyperhomocysteinemia, along with its association with coronary artery disease, screening, and treatment.     

Diagnostic value of 123I-phenylpentadecanoic acid (IPPA) metabolic and thallium 201 perfusion imaging in stable coronary artery disease

The diagnostic value of ¹²³I-phenylpentadecanoic acid (IPPA)metabolic cardiac imaging was studied in a group (n=29) of patientswith angiographically confirmed CAD using single photon emissioncomputed tomography (SPECT). A symptom-limited exercise testwas first done with IPPA, and 2 days later with thallium. Medicationswere not withheld during testing. Fourteen healthy control subjectsparticipated in parallel IPPA and 15 in thallium tests. Data acquisition and output were comparable in the two imagingmodalities. By testing various relatively simple criteria forabnormality we found that the semiquantitative interpretationwas more accurate than the visual readings. The best compromiseof accuracy with the scored criteria consisted of a sensitivityof 86% and a specificity of 86%, obtained with IPPA polar tomograms(mild exercise defect) and a sensitivity of 86% and a specificityof 80% obtained with thallium (regionally decreased washout).With visual interpretation alone, a sensitivity of 83% and aspecificity of 71% was detected with IPPA (mild exercise defect)and 72% and 73%, respectively, with thallium (partial reversibility).The sensitivity of the exercise ECG alone was 62%. The results of this study imply that IPPA imaging could be arational, uncomplicated clinical method for non-invasive diagnosisof CAD. The diagnostic ability of IPPA is at least as good asthat of thallium, and it is possible to use them in succession.     

Anomalous origin of the right coronary artery from the left anterior descending: Angiographic diagnosis in a patient with coronary artery disease

The coronary angiographic findings of an individual whose right coronary artery originates from the proximal left anterior descending coronary artery are described.     

Peripheral atherosclerosis evaluation through ultrasound: A promising diagnostic tool for coronary artery disease

Effective treatment, but also proper diagnosis of cardiovascular diseases, remains a major challenge in everyday practice. A quick, safe, and economically acceptable non-invasive procedure should play a leading role in cardiovascular risk assessment before invasive diagnostics is performed. The staging of subclinical atherosclerosis may help in further clinical decisions. Safe, widely available, and relatively inexpensive, ultrasonography is a promising examination that should find wider application in clinical practice. The latest ESC guidelines emphasize the usefulness of carotid ultrasound in the diagnosis of coronary artery disease (CAD) and subclinical assessment of atherosclerosis, which help to determine the level of cardiovascular risk. Ultrasound examination of peripheral arteries, especially superficial vessels such as the femoral arteries, is quite easy, quick, and accurate. Other vascular beds, such as iliac and renal, are more demanding to examine, but can also provide valuable information. This review summarizes important studies comparing the severity of atherosclerosis in ultrasound-visible vascular beds in patients with established CAD. We especially emphasize the benefits of the combined assessment of atherosclerosis features, which were characterized by high sensitivity and specificity in the diagnosis of CAD and other serious cardiovascular diseases.     

Imaging of coronary atherosclerosis using computed tomography: Current status and future directions

Computed tomography (CT) imaging of the coronary arteries, using either electron beam tomography (EBT) or multidetector row CT (MDCT), offers two possibilities to assess coronary atherosclerosis. Without injection of contrast agent, coronary calcifications can be detected and quantified. Their presence and extent correlates to the presence and amount of coronary atherosclerotic plaque. Prospective studies have demonstrated a high predictive value concerning the occurrence of coronary artery disease events and overall mortality. An emerging consensus seems to indicate that calcium imaging may be clinically useful in patients at intermediate risk for coronary artery disease events as determined based on traditional risk factors. In addition, recent studies have shown that after injection of contrast agent and using high-resolution scan protocols, the visualization of noncalcified plaque is also possible with CT techniques. However, data on the accuracy of plaque detection, quantification of plaque volume, and characterization of plaque (eg, lipid-rich vs fibrous) is currently limited, and the prognostic significance of noncalcifed coronary atherosclerotic plaque detection is unclear.     

Echocardiography and coronary artery disease

Echocardiography is playing an increasingly important role in the management of patients with coronary artery disease. With the addition of new digital technology and new technological advances, such as multiplane transesophageal echocardiography and intravascular ultrasound, there is every expectation that this use of cardiac ultrasound will grow even more rapidly in the near future.     

冠心病患者肾动脉狭窄及其相关因素分析

目的　探讨接受冠状动脉造影及冠心病患者合并肾动脉狭窄的发生率及其危险因素。方法　对连续 15 7例接受冠状动脉造影的患者进行腹主动脉数字减影血管造影检查。结果　 15 7例患者中 ,肾动脉狭窄发生率为 14 0 % ;经冠状动脉造影证实的 81例冠心病患者中 ,肾动脉狭窄的发生率为 2 5 9% ;冠状动脉造影完全正常的 62例患者中 ,无 1例有肾动脉狭窄。多元Logistic回归分析表明 ,冠心病、糖尿病及血肌酐 >10 0 μmol/L是存在肾动脉狭窄的独立预测因素。 结论　对冠心病合并高血压、糖尿病、特别是血肌酐 >10 0 μmol/L的患者 ,冠状动脉造影时应常规进行腹主动脉造影检查 ,以尽早发现肾动脉狭窄。     

Management strategies in unstable coronary artery disease--current problems and future directions. The UCAD Council.

Unstable coronary artery disease continues to pose a major challenge to clinicians. The advent of new therapies, such as percutaneous transluminal coronary angioplasty, low-molecular-weight heparins, and glycoprotein IIb/IIIa inhibitors, provides new management options for this indication but also raises new questions with regard to optimal management. Prospective randomized trials with well-defined, long-term outcome measures and a means of identifying which patients will derive most benefit from each treatment, together with a means of rapid and clear dissemination of study results and implications, are required in order to advance the management of unstable coronary artery disease.