Minimally invasive coronary artery bypass grafting versus stenting for patients with proximal left anterior descending coronary artery disease

The purpose of this study was to compare the clinical outcomes of stenting and minimally invasive coronary artery bypass grafting (MIDCAB) in patients with proximal left anterior descending (LAD) coronary artery disease. The Patency, Outcome, Economics of Minimally invasive direct coronary bypass (POEM) study demonstrated that MIDCAB had similar safety and long-term efficacy for LAD revascularization compared with conventional coronary artery bypass grafting. Although LAD stenting is superior to conventional balloon angioplasty, whether it is comparable to MIDCAB is not known. We identified a matched population of 429 consecutive patients with 1-vessel disease who underwent elective proximal LAD stenting and compared their clinical outcomes with those of the 152 patients in the MIDCAB group of the POEM study. The in-hospital event rate was similar in both groups, except for a shorter length of hospital stay with LAD stenting compared with MIDCAB (2.68 vs 4.07 days, p <0.0001). At 6-month follow-up, the incidence of death and Q-wave myocardial infarction or that of cerebrovascular accident was not significantly different between these 2 groups. However, target vessel revascularization was significantly higher with LAD stenting than MIDCAB (13.3% vs 6.6%, p = 0.045). In the subgroup of patients without diabetes, all clinical events were similar in both groups, and the benefit of a shorter hospital stay associated with stenting was maintained. Compared with MIDCAB, LAD stenting is associated with higher repeat revascularization rates but offers the advantage of shorter hospitalization. For nondiabetics with proximal LAD disease, stenting may be the revascularization strategy of choice.     

老年冠心病患者冠状动脉病变特点

目的探讨老年冠心病患者冠状动脉的病变特点。方法临床诊断冠心病患者602例,其中老年女性207例(老年女性组),经冠状动脉造影确诊123例,中青年女性129例(中青年女性组),老年男性266例(老年男性组)。对比分析老年女性组与中青年女性组患者冠状动脉造影阳性率,老年女性组与老年男性组患者冠状动脉病变的不同特点。结果老年女性组不稳定性心绞痛和急性心肌梗死冠状动脉造影阳性率显著高于中青年女性组(77.3%vs57.7%,95.8%vs66.7%,P<0.01),两组患者稳定性心绞痛和陈旧性心肌梗死无统计学差异((78.2%vs76.5%,95.0%vs100.0%,P>0.05)。冠状动脉造影阳性的老年女性组与老年男性组患者不同临床类型的冠状动脉病变血管支数无统计学差异(P>0.05),老年女性组稳定性心绞痛和陈旧性心肌梗死冠状动脉Gensini积分均显著高于老年男性组[(54±7)分vs(46±5)分,(78±9)分vs(68±4)分,P<0.05],两组患者冠状动脉病变分布无统计学差异(P>0.05)。结论老年女性患者冠状动脉病变阳性率高于中青年女性,部分老年女性患者冠状动脉病变程度较老年男性患者重。     

Therapy of coronary vasoconstriction in patients with coronary artery disease

Patients with obstructive coronary artery disease and stable, exertional angina respond to the alpha adrenergic stimulus of the cold pressor test with an inappropriate increase in coronary vascular resistance. The clinical significance of this abnormal response and its possible role in the pathogenesis of ischemic heart disease are discussed. Comparison of the anti-anginal agents currently in use of undergoing investigation suggests that the calcium antagonists may be the most effective therapy for coronary vasoconstriction. Nifedipine, 10 mg buccally, successfully prevented the increase in coronary vascular resistance during the cold pressor test in 10 of 10 patients, whereas the response in placebo-treated patients was unaltered. This dose of nifedipine was without effect on systemic hemodynamics or myocardial oxygen consumption, suggesting a selective antivasoconstrictor effect on the coronary vasculature.     

Distribution of coronary atherosclerosis in patients with coronary artery disease

The distribution of coronary atherosclerosis has not been fully clarified. We measured coronary artery calcium score (CACS) in 624 consecutive patients for the right coronary artery (RCA), left main trunk (LMT), left anterior descending coronary artery (LAD), and left circumflex coronary artery (LCx), then calculated total CACS. Coronary artery calcium score was measured using the Agatston method. We divided these patients into four groups: CACS 1–100 (Group A, n = 267), CACS 101–400 (Group B, n = 160), CACS 401–1000 (Group C, n = 110), and CACS >1000 (Group D, n = 87). In Group A, B, and C, the CACS in LAD was significantly higher than in the other three arteries (P < 0.0001). In Group D, the CACS was not significantly different between LAD and RCA (P = 0.6930). In Groups A, B, and C, coronary artery calcium (CAC) was more frequently found in LAD compared with other arteries (P < 0.0001). However, in Group D the prevalence of CAC was not significantly different among the three arteries (P = 0.4435). Coronary artery calcium was found more frequently in LAD than in the other coronary arteries in patients with mild to high CAC, but not in those with very high CAC.     

Efficacy of coronary artery bypass grafting in elderly patients with coronary artery disease

A consecutive series of 121 patients 70 years of age and older who underwent aortocoronary artery saphenous vein bypass grafting without other cardiac procedures during a 5 year period was analyzed and follow-up status ascertained. This group was compared with a consecutive series of 2,850 patients under the age of 70 who underwent aortocoronary bypass during the same period. The patients aged 70 years or greater had a higher incidence of unstable angina pectoris, congestive heart fallure and cardlomegaly on roentgenography. They had more severe coronary obstruction with a 29 percent incidence rate of left main coronary disease versus a 15 percent incidence rate in the patients aged less than 70 years (P < 0.001). The hospital mortality rate for patients aged less than 70 years was 1.1 percent (31 of 2,850) and for those aged 70 years or greater was 1.6 percent (2 of 121). The 119 patients aged 70 years or greater who survived surgery had a significantly greater incidence of postoperative stroke (3 patients), supraventricular tachycardia (28 patients), transient postoperative psychosis (9 patients), heart block requiring permanent pacing (2 patients), intraaortic balloon pumping (5 patients) and pulmonary embolism (4 patients) than patients aged less than 70 years. Both groups had significant symptomatic improvement: More than 95 percent of the survivors in each group were angina-free or in improved condition at late follow-up. Survival at 36 months was 95 percent for the patients in both age groups. A subgroup of patients aged 75 years or greater had comparable symptomatic results and survival. Patients aged 70 years or greater need not be denied the benefits of coronary bypass surgery on the basis of advanced age alone, although these patients have complfcations of surgery more frequently. However, severe calcification of the ascending aorta is a relative contraindication to saphenous vein bypass surgery in this age group.     

Evaluation of patients with coronary artery disease

The evaluation of the patient suspected of coronary heart disease takes many forms, but always begins with consideration of the patient's potential susceptibility to the disease followed by exploration of the nature of the patient's specific complaint. The typicality of recurrent chest pain, the likelihood of a prior true myocardial infarction, and the presence of repetitive ventricular arrhythmias or congestive failure are all helpful clues. The physical examination holds many valuable findings. These are occasionally diagnostic, but only if the patient's initial complaint is chest pain. The most useful maneuver that the clinician can carry out is provoking an attack of symptoms under direct observation. He can then study the accompanying subjective, auscultatory, and electrocardiographic phenomena as well as the effectiveness of specific modalities of pain relief. Depending on the attitudes of the physician, the nature of complaints, and the age of the patient, evaluation extends usually to catheterization and angiography. These procedures provide a firm morphologic and functional diagnosis. They form the basis for a decision on the type and probable effectiveness of therapy, and, at the very least, they serve as an accurate indication of the patient's prognosis.     

Decreased carotid intima-media thickness in patients with coronary artery ectasia compared with patients with coronary artery disease

BACKGROUND: Although atherosclerosis is supposed to be responsible for more than 50% of coronary artery ectasia, the precise pathology of coronary artery ectasia is not clearly understood. A histopathological examination of ectatic segments has revealed mainly destruction of the media layer of the artery. In the present study, we assessed carotid intima-media thickness and common carotid artery diameter in patients with and without coronary artery ectasia. MATERIALS AND METHODS: Thirty-five consecutive patients with coronary artery ectasia and coronary artery disease and 35 age and sex-matched patients with coronary artery disease alone were included in the study. The common carotid artery was studied as the longitudinal plane within 10 mm from the bifurcation of the common carotid artery. The intima-media thickness was measured in the far wall at end-diastole from the B-mode screen to a point within the 10-mm segment proximal to the bifurcation by one investigator blinded to clinical data. RESULTS: No significant differences with respect to age, body mass index, hypertension, diabetes mellitus, hypercholesterolemia and smoking habits were observed between the two groups studied. Intima-media thickness of the common carotid artery of the patients with coronary artery ectasia was significantly lower than that of the patients with coronary artery disease alone (0.71 +/- 0.13 vs. 0.77 +/- 0.09 mm, respectively, P = 0.04). CONCLUSION: Decreased intima-media thickness of the carotid artery in patients with coronary artery ectasia and coronary artery disease may have pathogenic mechanisms different from coronary artery disease per se.     

冠心病患者者的高凝状态

目的:探讨冠心病凝血功能变化的临床意义。方法:选择冠心病人79例,对照组61例,测定血浆纤维蛋白原、D-二聚体含量,并进行比较。结果:冠心病组血浆纤维蛋白原、D-二聚体含量均高于对照组(P<0.05～<0.01),且冠脉病变支数越多,纤维蛋白原含量越高。结论:冠心病患者存在高凝状态,其机制可能与血栓形成有关。     

Arterial hypertension in patients with coronary artery disease

Arterial hypertension is the most important risk factor for coronary artery disease (CAD). There is a high coincidence of both diseases, whereby both impair coronary microcirculatory function synergistically, which can be measured functionally by decreased coronary flow reserve. This dysfunction leads to permanent damage to the left ventricular myocardium. Lifestyle changes play a central role in the primary and secondary prevention of CAD. Additionally, there are well-established options for antihypertensive drug therapy, which should be combined with aspirin and statins. Pharmacological treatment should follow distinctive blood pressure goals in relation to the severity of CAD. Particular attention is paid in this context to the relation between diastolic blood pressure values and cardiovascular endpoints, which displays a j-shaped curve with the lowest risk at levels between 70 and 90?mmHg.     

Intracoronary temperature in patients with coronary artery disease

OBJECTIVES: Measurements of changes in plaque temperature may predict plaque rupture. The present study investigated variations in temperature within the atherosclerotic coronary artery using a pressure guide wire with thermal sensor (dual sensor guide wire). METHODS AND RESULTS: Seventy-seven patients (78 lesions), who had no significant lesion at the orifice of the culprit coronary artery, were studied. The patients had acute myocardial infarction (22 patients), unstable angina pectoris (20 patients), and stable angina pectoris (35 patients). The thermal sensor was calibrated at the orifice of the coronary artery, and then inserted into the culprit coronary artery. deltaT was defined as the difference between the intracoronary temperature at the position of the pressure gradient and at the orifice. deltaT was higher in patients with acute myocardial infarction and unstable angina pectoris than in patients with stable angina pectoris (0.09 +/- 0.07 and 0.07 +/- 0.07 vs 0.03 +/- 0.04 degrees C, p < 0.001, p = 0.02, respectively). There was no significant difference in deltaT between patients with acute myocardial infarction and unstable angina pectoris (p = 0.48). Patients with acute myocardial infarction and unstable angina pectoris showed a significant relationship between deltaT and C-reactive protein (r = 0.59, p = 0.0004). CONCLUSIONS: The variations in intracoronary temperature of the culprit coronary arteries in patients with acute coronary syndrome were higher than those in patients with stable angina pectoris. These variations may be related to inflammation of vulnerable plaque.     

Hemorheological study in patients with coronary artery disease

Hemorheological parameters (viscosity of whole blood, plasma viscosity, hematocrit, velocity of red blood cells) were studied in 30 patients with coronary artery disease (15 patients with acute myocardial infarction, 15 patients with chronic angina), 14 subjects at high risk for ischemic heart disease and 14 normal volunteers matched for sex and age. Viscosity of whole blood was high in all coronary disease patients and in high-risk subjects as compared with controls. Velocity of red blood cells was significantly decreased in these patients. On the other hand, plasma viscosity and fibrinogen values were in the normal range in both groups and hematocrit was only slightly elevated in patients with angina. Furthermore, there were no changes in rheological parameters during the period of observation (1 week). We can suppose that the hyperviscosity is due, above all, to the decreased red blood cell deformability both in coronary disease patients but also in high-risk subjects. It is probable that red blood cell damage is present before the acute ischemic event, and that is a preexisting cause and not a consequence of it.     

冠心病炎性标志物检测的意义

目的 :探讨不同类型冠心病患者可溶性E 选择素 (SES)、C 反应蛋白 (CRP)的变化及其临床意义。方法 :将 81例患者按临床诊断分为 4组 :急性心肌梗死 (AMI)组 17例 ,不稳定型心绞痛 (UAP)组 2 4例 ,稳定型心绞痛 (SAP)组 2 0例和对照组 2 0例。分别检测各组患者SES及CRP水平 ,对冠心病患者的冠状动脉损害行Gensini评分 ,并比较各组间的差异。结果 :①AMI组、UAP组及SAP组的SES、CRP水平高于对照组 ;②AMI组、UA组SES及CRP水平与SAP组相比 ,其值明显增加 ;AMI组和UAP组SES水平相近 ,AMI组CRP高于UA组 ;③冠状动脉多支病变组SES、CRP的含量高于单支病变组。随着冠状动脉病变Gensini评分的增加 ,SES、CRP升高越明显。结论 :SES、CRP是冠心病病情监测和评价粥样斑块不稳定性的非侵入性指标 ;它们的升高程度与冠状动脉病变程度有良好的相关性     

Comparison of C-reactive protein levels in patients with coronary artery ectasia versus patients with obstructive coronary artery disease

This study evaluated plasma C-reactive protein (CRP) levels, a specific marker of inflammation, in 32 patients with isolated coronary artery ectasia (CAE) and compared the results with those of 32 patients with obstructive coronary artery disease without coronary artery ectasia and 30 subjects with angiographically normal coronary arteries. CRP levels were found to be significantly higher in patients with isolated CAE (p <0.001), suggesting that more severe inflammation may be involved in the pathogenesis of CAE.     

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。