冠心病患者经皮冠状动脉介入治疗术后再次血运重建的危险因素研究

目的探讨冠心病患者PCI术后再次血运重建的相关因素分析。方法回顾性分析278例冠心病患者介入治疗的临床资料,分为再次血运重建组(血运重建组)55例,无再次血运重建组(无血运重建组)223例,比较2组的病史、症状和冠状动脉造影等临床资料。对复发胸痛再次血运重建的患者进行危险因素分析。结果与无血运重建组比较,血运重建组第一次入院诊断为急性心肌梗死(50.9%vs 14.3%,P=0.030)、心功能≥Ⅱ级(34.5%vs9.0%,P=0.020)、室壁运动异常(72.7%vs 26.9%,P=0.035)、多支冠状动脉病变(89.1%vs 40.4%,P=0.010)等均显著增高,差异有统计学意义。多因素logistic回归显示,复发胸痛(OR:2.49,95%CI:1.16～5.00,P=0.020)、左心室舒张末内径(OR:1.12,95%CI:1.00～1.22,P=0.043)是血运重建治疗的独立预测因素,而冠状动脉单支病变(OR:0.25,95%CI:0.15～0.90,P=0.040)和双支病变(OR:0.22,95%CI:0.07～0.53,P=0.006)较冠状动脉3支病变再次血运重建治疗风险低。结论冠心病患者PCI术后1年的随访提示,复发胸痛、严重的冠状动脉病变和左心室舒张末容积增大是再次血运重建治疗的独立危险因素。     

冠状动脉介入治疗术后肥胖对非靶病变血运重建的影响

目的评价肥胖对接受药物洗脱支架（DES）置入的冠心病患者再次血运重建的影响,包括由再狭窄引起的靶病变血运重建（TLR）和动脉粥样硬化进展引起的非靶病变血运重建（非TLR）。方法我们回顾性分析了安贞医院自2004年1月至2006年12月接受DES的共4972例患者,根据体重指数（BMI）分为三组：正常组（BMI〈24.9kg/m2,1284例）;超重组（BMI25～29.9kg/m2,2475例）以及肥胖组（BMI〉30kg/m2,1213例）。中位随访时间为26个月。结果随访结果显示,肥胖患者与正常和超重患者的TLR差异无统计学意义（6.8%比5.4%比6.3%,P=0.186）。而肥胖组患者的非TLR较正常和超重组患者明显增加（8.6%比5.9%比5.7%,P=0.001）。多因素分析显示,肥胖与糖尿病、高脂血症一起,均是非TLR的独立预测因素（HR=1.45,95%CI=1.03～1.98,P=0.024）,而他汀治疗是非TLR的保护因素（HR=0.66,95%CI=0.52～0.84,P〈0.001）。进一步分析发现,肥胖在未服用他汀的患者人群中是非TLR的独立预测因素（HR1.54,95%CI1.03～2.30;P=0.038）,但在同时服用他汀的人群中,肥胖并不独立地增加非TLR的风险（HR1.28,95%CI0.81～2.04,P=0.265）。结论在接受DES的冠心病人群中,肥胖不增加TLR的风险,但可独立增加非TLR的风险。他汀治疗可能会部分缓解肥胖对非TLR的不良影响。本研究结果仍有待进一步研究的证实。     

冠状动脉药物洗脱支架术后再狭窄研究进展

虽然药物洗脱支架（DES）的临床应用大幅度降低了经皮冠状动脉介入治疗后支架内再狭窄和靶血管再次血运重建的发生率,但是由于越来越多的高危患者和复杂冠脉病变接受介入治疗,因此支架再狭窄的发生率仍高达5％～20％。DES再狭窄的发生机制尚未完全清楚,其处理策略和预防措施还需进一步完善。该文就近年来有关DES再狭窄的研究进展作一介绍。     

糖尿病合并冠心病患者药物洗脱支架术后应用氯吡格雷的疗效

目的评价糖尿病(DM)合并冠心病患者药物洗脱支架(DES)术后应用氯吡格雷不同剂量及疗程的安全性和有效性。方法 2008年1月至2010年2月连续选取共174例DM合并冠心病患者,按氯吡格雷服用情况随机分为A常规治疗组、B氯吡格雷双倍剂量组、C氯吡格雷双倍疗程组。A组和C组DES置入术前一次性给予氯吡格雷300 mg,术后75 mg/d,A组持续用药12个月,B组24个月;B组术前一次性给予氯吡格雷600 mg,术后150 mg/d,持续用药12个月,三组其他给药及治疗方案均一致。患者出院后每月随访1次,判断并记录终点事件。术后12个月进行冠状动脉造影复查,比较术后12个月的再狭窄发生率以及术后12个月和24个月的不良心脏事件发生率和血栓发生率。分别于术前24 h和术后48 h测定血小板聚集率,比较各组间血小板抑制率和氯吡格雷抵抗发生率。结果三组间临床基线特征和造影及介入特点均无统计学差异,双倍剂量的氯吡格雷可增加DM合并冠心病患者DES置入术后血小板抑制率(25.7 vs 21.5,P0.05)和病人对氯吡格雷的敏感性,降低CR现象的发生(15.5 vs 29.3,P0.01),降低双倍剂量12个月内的不良心脏事件(MACE)(1.7 vs 5.2,P0.01)、再狭窄发生率(3.4 vs 8.6,P0.01)和ST的发生率(1.7 vs 5.2,P0.01)。双倍剂量和双倍疗程的氯吡格雷均可降低DM合并冠心病患者DES置入术后24个月内的MACE(10.5 vs 16.4,P0.05;8.9 vs 16.4,P0.05)、死亡发生率(1.8%vs 5.5,P0.05;%0%vs 5.5%,P0.05)、ST发生率(3.5 vs 7.3,P0.05;1.8 vs 7.3,P0.01)。不论是双倍剂量还是双倍疗程,均未引起严重不良反应增加的风险(10.3 vs 8.6,P0.05;10.3 vs 8.6,P0.05)。结论对糖尿病合并冠心病患者进行DES介入治疗后长期大剂量应用氯吡格雷是安全有效的,可适当增加氯吡格雷的剂量和疗程,以达到更好的长期临床预后。     

2型糖尿病患者药物洗脱支架置入术后支架内再狭窄危险因素分析

目的:探讨冠心病合并2型糖尿病患者药物洗脱支架(DES)置入术后,支架内再狭窄相关危险因素分析。方法:将连续性入选的368例患者根据冠状动脉造影结果分为支架内再狭窄(ISR)组(n=74)及非支架内再狭窄(non-ISR)组(n=294)。应用Cox’s比例风险模型对两组进行统计学分析。结果:单因素分析ISR组较non-ISR组具有更高的VLDL-C、TG、UA、病变血管数目、多支病变、SYNTAX评分及既往冠状动脉介入术(PCI)病史,non-ISR组具有较高的饮酒史。COX比例风险模型分析糖尿病患者(DM),DES置入术后ISR的独立危险因素是VLDL(HR=1.85,95%CI=1.24~2.77,P=0.002)、UA(每增加50μmol/L,HR=1.19,95%CI=1.05~1.34,P=0.006)、SYNTAX评分(每增加5分,HR=1.34,95%CI=1.03~1.74,P=0.031)、既往PCI病史(HR=3.43,95%CI=1.57~7.80,P=0.003)。结论:研究提示VLDL-C、SYNTAX评分、血尿酸水平、既往PCI病史是DM患者ISR的独立危险因素。     

药物洗脱支架对糖尿病血运重建中期临床结果的影响

目的评价药物洗脱支架(DES)对糖尿病患者冠状动脉血运重建结果的影响。方法回顾置入DES糖尿病患者的临床、冠状动脉病变与血运重建资料,并进行临床随访。结果204例糖尿病患者接受经皮冠状动脉介入治疗(PCI)时置入了一个或以上的DES,共置入316枚支架,其中DES254枚。180例患者术后接受了平均为9.3±5(6~26)个月的临床随访(随访率88.2%)。主要不良心脏事件(包括死亡、再梗死和再次血运重建)发生率为3.9%(8/204)。18例患者平均于PCI术后6.7(5.5~10)个月接受造影复查(造影随访率8.8%),经DES处理的病变无1例出现再狭窄。结论糖尿病患者使用DES安全有效,能显著降低再狭窄率和靶病变再次血运重建率。     

冠心病合并糖尿病患者经皮冠状动脉介入治疗中的支架选择和远期预后

正糖尿病是冠心病患者发生主要心脏不良事件(major adverse cardiac events,MACE)的独立危险因素。与非糖尿病患者比较,合并糖尿病的冠心病患者MACE发生率明显增加。冠状动脉造影显示,冠心病合并糖尿病患者具有较高的多支病变、弥漫性狭窄病变、小血管病变等发生率,较高的粥样硬化斑块负荷,血管发育偏细小,侧支循环发育较差,且存在较严重的微循环功能障碍。冠心病合并糖尿病患者在接     

糖尿病和糖尿病前期与冠状动脉血运重建

<正> 糖尿病患病率逐年呈增长趋势。据统计,目前我国糖尿病人群接近4000万,患病率上升至3.5%,较20年前增加5倍。预计到2025年我国将成为仅次于印度的第二大糖尿病患者国家。糖尿病前期包括空腹血糖调节受损和糖耐量异常,每年有7.0%～11.0%的糖尿病前期患者发展为糖尿     

药物洗脱支架术后血栓致急性冠状动脉综合征病因分析及处理评价

目的:分析药物洗脱支架术(DES)后支架内血栓形成导致急性冠状动脉综合征的影响因素。方法:分析38例DES术后形成支架内血栓形成患者的临床特点、冠状动脉病变特点、手术相关资料及患者发生急性冠状动脉综合征后的临床表现,处理措施和预后情况。结果:患者冠状动脉造影显示病变特点比较复杂,其中B2/C型病变占到了71%,分叉病变、慢性完全闭塞(CTO)病变、弥散长病变以及小血管病变也占到了相当大的比例,反映了真实的临床情况;38例患者中52.6%表现为急性ST段抬高心肌梗死,29%的患者表现为急性非ST段抬高心肌梗死;支架内血栓中急性、亚急性血栓形成占63%,晚期及迟发晚期血栓形成占37%;绝大多数患者成功接受了再次血运重建治疗,其中有31.6%的患者死亡;2例患者血小板聚集率≥50%,发生率为8.3%;4例接受冠脉内超声(IVUS)检查的患者结果显示:支架近端贴壁不良1例,支架远端残余夹层1例,支架内膜增生不完全1例,支架两端动脉瘤形成1例。结论:DES术后支架内血栓形成与患者的冠状动脉病变复杂程度、术后抗血小板治疗不充分、支架贴壁不良、夹层形成、内膜增生不完全以及动脉瘤的发生等因素相关,支架内血栓形成(ST)后多数表现为ST段抬高心肌梗死(STEMI),尽管大部分能成功再次血运重建治疗,但死亡率仍然较高(31.6%)。     

药物洗脱支架术后冠状动脉瘤样扩张一例

<正>1病例介绍患者,男,65岁。因活动后胸闷心悸2年,加重1周于2015-06-18入住上海市普陀区中心医院心内科。患者否认既往高血压、糖尿病、慢性肾脏病等慢性病史。门诊查心电图示窦性心律、室性早搏;心超提示心脏多节段收缩活动异常,左室射血分数(LVEF)0. 40。入院查体无明显异常。实验室检查:血常规、尿常规、粪便常规、肝肾功能、凝血功能、血糖、血脂、肌钙蛋白等化验指标均正常。入院诊断:冠状动脉     

老年冠心病患者药物洗脱支架置入术后临床结局分析

目的探讨经皮冠状动脉介入治疗范围、复杂性和血小板反应性对药物洗脱支架置入术后老年冠心病患者临床结局的影响。方法选择2014年1月～2017年1月彭州市人民医院心内科收治的行药物洗脱支架置入术的老年冠心病患者150例,术后给予三联抗血小板治疗18个月,随访2年,根据2年内是否发生不良心血管事件分为预后不良组43例和预后良好组107例。观察2组临床特征、经皮冠状动脉介入治疗范围、复杂性、血小板反应性和心功能指标。采用多因素logistics回归分析药物洗脱支架置入术后老年冠心病患者发生不良心血管事件的危险因素。结果与预后良好组比较,预后不良组病变支数、支架数量、支架总长度、Gensini评分和血小板聚集率明显增加(P0.01)。与预后良好组比较,预后不良组平均室壁应力、左心室舒张末期容积明显增加[(974.75±94.65)mg vs (921.92±89.86)mg,P=0.002;(158.88±14.43)ml vs (151.73±13.87)ml,P=0.005]。多因素logistics回归分析显示,血小板聚集率、病变支数、支架数量、支架总长度、Gensini评分和左心室舒张末期容积是药物洗脱支架置入术后老年冠心病患者发生不良心血管事件的危险因素(P0.05)。结论冠状动脉病变复杂、治疗范围广、血小板抵抗和心功能下降是药物洗脱支架置入术后老年冠心病患者发生不良心血管事件的危险因素。     

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。     

老年慢性肾功能不全患者冠状动脉内药物洗脱支架术远期疗效

目的观察>65岁慢性肾功能不全患者行冠状动脉内药物洗脱支架术的远期疗效。方法将585例年龄> 65岁行冠状动脉介入治疗(PCI)的患者,根据肌酐清除率分为慢性肾功能不全组(355例)和对照组(230例),前者又分药物脱支架组和普通金属支架组,记录各例患者住院期一般资料、冠状动脉造影和PCI情况及随访期所有原因死亡、中风和主要心脏不良事件。比较药物洗脱支架和普通金属支架对慢性肾功能不全组患者的临床疗效。结果与对照组比较,慢性肾功能不全组患者年龄增大,体重减轻,女性、吸烟和不稳定性心绞痛较多。平均随访17个月,慢性肾功能不全组较对照组所有原因病死率(8．17％和3．48％,P<0．05)和心源性病死率(6．48％和2．17％, P<0．05)显著增高,但主要心脏不良事件(13．80％和10．86％,P>0．05)及靶血管再次血运重建率(5．63％和6．08％,P>0．05)无显著差异。慢性肾功能不全组中,药物洗脱支架组(224例)较普通金属支架组(131例)主要心脏不良事件发生率(8．92％和19．84％,P<0．05)和靶血管再次血运重建率(3．12％和9．92％,P<0．05)显著减少,但心源性死亡(4．91％和8．39％,P>0．05)和所有原因死亡(6．25％和11．45％,P>0．05)发生率无显著性差异。结论年慢性肾功能不全患者行PCI术后死亡率增加;与普通金属支架比较,药物洗脱支架可以显著降低靶血管再次血运重建和主要心脏不良事件发生率,但对心源性死亡和所有原因死亡无明显影响。     

Possible predictors of target lesion revascularization after drug-eluting stent implantation

BACKGROUND. A small number of patients still need target lesion revascularization (TLR) after drug-eluting stent (DES) implantation. It is important for the management of coronary artery disease to assess the predictors of TLR after DES implantation. METHODS AND RESULTS. Two hundred ninety-seven patients (325 lesions) were treated with Cypher sirolimus-eluting and/or TAXUS paclitaxel-eluting stent implantation at four centers in Japan and Brazil. Among these centers, 20 patients (24 lesions) needed clinically driven TLR. The clinical and angiographic characteristics of TLR patients were compared to those of non-TLR patients. Hemodialysis, prior myocardial infarction (MI) and prior coronary artery bypass grafting (CABG) were more frequent in TLR patients than in non-TLR patients. An ostial stenosis was more frequent in the TLR group than in the non-TLR group (41.7% vs 19.9%, p=0.012). In addition, post-procedure in-stent percentage diameter stenosis (%DS) was higher in TLR patients (21.9% vs 13.3%, p = 0.002). Stepwise logistic regression analysis indicated that all of these variables were independent predictors of TLR after DES implantation. CONCLUSIONS: Hemodialysis, prior MI, prior CABG, ostial lesion location and high in-stent %DS may be independent predictors of TLR after DES implantation.     

Effects of cilostazol on late lumen loss and repeat revascularization after Palmaz-Schatz coronary stent implantation

BACKGROUND: Cilostazol is an antiplatelet agent that increases the intracellular concentration of cyclic adenosine monophosphate by inhibiting phosphodiesterase III; it has been shown to reduce neointimal hyperplasia in animal balloon injury models. METHODS: One hundred thirty patients who underwent elective stenting (Palmaz-Schatz stent) were randomly assigned to cilostazol treatment 200 mg/d (n = 65) or to ticlopidine treatment 200 mg/d (n = 65). Angiographic follow-up was performed at 6 months, and clinical follow-up was continued up to 1 year. RESULTS: One sudden death and one myocardial infarction resulting from subacute occlusion were observed in the ticlopidine group. Drug adverse effects were observed in 3 patients in the cilostazol group, as opposed to 6 patients in the ticlopidine group. In the intention-to-treat analysis, 56 patients (61 lesions) in the cilostazol group and 58 patients (58 lesions) in the ticlopidine group were assessed with quantitative coronary angiography. Late loss in the cilostazol group was smaller (0.58+/-0.52 mm vs. 1.09+/-0.65 mm, P<.0001) than in the ticlopidine group. The restenosis rate was lower in the cilostazol group than in the ticlopidine group (16% vs. 33%, P = .044). The target vessel revascularization rate at 1 year was 23% in the cilostazol group and 42% in the ticlopidine group (P =.03). CONCLUSIONS: The results of this study suggest that cilostazol may be a safe medication that is effective in preventing restenosis after stent implantation.     

Risk of noncardiac surgery after coronary drug-eluting stent implantation

We examined the records of 38 patients who underwent 41 major and 18 minor noncardiac surgeries after successful drug-eluting stent (DES) implantation (57% sirolimus-eluting stents and 43% paclitaxel-eluting stents) at the Dallas Veterans Affairs Medical Center from April 2003 to January 2006. The mean patient age was 62 +/- 9 years, and all patients were men. A total of 41 major noncardiac surgeries (34% abdominal, 22% vascular, 17% genitourinary, and 27% other) were performed in 28 patients a median of 260 days after DES implantation. Also, 18 minor noncardiac surgeries (44% skin surgery, 44% injections, and 12% other) were performed in 10 patients a median of 297 days after DES implantation. No major adverse cardiac events or death occurred during or after the 41 major (0%, 95% confidence interval 0% to 9%) and 18 minor noncardiac (0%, 95% confidence interval 0% to 19%) surgeries. In conclusion, although our data were limited by the small sample size, they suggest a low risk of major cardiac complications in patients undergoing noncardiac surgery after coronary DES implantation.     

Clinical presentation and predictors of target vessel revascularization after drug-eluting stent implantation

BackgroundDrug eluting stent (DES) failure including restenosis and stent thrombosis, or disease progression may result in target vessel revascularization (TVR) but the relative contribution of these mechanisms in the DES era is not well described. We sought to examine the predictors and presentations of patients with clinically driven TVR after DES.MethodsPatients with all lesions treated with a DES in the Dynamic Registry from 2004 to 2006 were analyzed. Included were 2691 patients with 3401 lesions. Patients with and without incident clinically driven TVR at 2 years were compared according to baseline clinical, procedural, and angiographic characteristics and independent predictors of TVR and target lesion revascularization (TLR) were determined by multivariate analysis.ResultsBy 2-years, TVR occurred in 7.2% of patients and TLR in 3.8%, with 71.6% and 82.5% of repeat revascularization events occurring in the first year, respectively. The indication for first TVR was myocardial infarction in 18.6% (n = 34), unstable angina in 42.6% (n = 78), stable coronary disease in 25.7% (n = 47) and other/unknown in 13.1% (n = 24). Disease progression was responsible for 47% of TVR. Among patients with TLR, restenosis was the mechanism in 86.6% and stent thrombosis in 13.4%. Independent predictors of TVR included younger age, diabetes, attempted graft lesion, lesion length > 30 mm and prior lesion intervention. Independent predictors of TVR and TLR were similar.ConclusionThe incidence of clinically driven TVR is low in patients treated with DES and nearly half is attributable to disease progression, which along with the low rate of in-stent restenosis explains why the mode of presentation is often an acute coronary syndrome.