Prevalence and 1-year prognosis of transient heart failure following coronary revascularization

The occurrence of heart failure during the whole pre-discharge course of coronary revascularization, as far as its influence on subsequent prognosis, is poorly understood. The present study examined the effect of transient heart failure (THF) developing in the acute and rehabilitative phase on survival after coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI). Patients in the Italian survey on cardiac rehabilitation and secondary prevention after cardiac revascularization (ICAROS) were analyzed for THF, the latter being defined either as signs and symptoms consistent with decompensation or cardiogenic shock. ICAROS was a prospective, multicenter registry of 1,262 consecutive patients discharged from 62 cardiac rehabilitation (CR) facilities, providing data on risk factors, lifestyle habits, drug treatments, and major cardiovascular events (MACE) during a 1-year follow-up. Records were linked to the official website of the Italian Association of Cardiovascular Prevention and Rehabilitation (GICR-IACPR). The overall prevalence of pre-discharge THF was 7.6 %, with 69.8 % of cases in acute wards, 22.9 % during CR, and 7.3 % in both settings. THF affected more frequently patients with chronic cardiac condition (42.7 vs. 30.6 %; p < 0.05), age ≥75 years (33.3 vs. 23.1 %; p < 0.005), COPD (19.8 vs. 12.3 %; p < 0.05), and chronic kidney disease (17.7 vs. 7 %; p < 0.001). After discharge, THF patients showed good maintenance rates of RAAS modulators (90.6 %) and beta-blockers (83.3 %), while statin therapy significantly decreased from 81.3 to 64.6 % (p < 0.05). The pursuit of secondary prevention targets, as far as self-reported drug adherence, was not different among groups. Patients with THF had increased 1-year mortality (8.3 vs. 1.6 %, p < 0.001). Moreover, THF independently predicted adverse outcome with OR for recurrent events (mainly further episodes of decompensation) of 2.4 (CI 1.4–4.3). Patients who experienced THF after coronary revascularization had increased post-discharge mortality and cardiovascular events. Hemodynamic instability, rather than recurrent myocardial ischemia, seems to be linked with worse prognosis.     

择期完全血管开通与不完全血管开通急性心肌梗死非梗死相关血管的预后比较

目的:比较择期完全开通和不完全开通急性心肌梗死(AMI)患者非梗死相关血管的临床预后。方法:收集2007-01-2008-12在我院所有直接行冠状动脉介入治疗(PCI)的AMI患者154例,对非梗死相关血管择期完全血管开通与不完全血管开通进行临床预后分析。结果:所有病例随访1年以上,完全血管开通组心绞痛发生率显著低于不完全血管开通组(4∶20,P=0.009),其余临床事件,2组差异均无统计学意义。结论:AMI患者完全血管开通较不完全开通能有效改善患者生活质量,但对患者主要心脏不良事件无显著差异。     

Fascicular conduction disturbances and ischemic heart disease: adverse prognosis despite coronary revascularization

In patients with ischemic heart disease, fascicular conduction disturbances are associated with increased mortality. This study reveals that increased mortality also exists for certain types of fascicular conduction disturbances after myocardial revascularization. In 227 consecutive patients undergoing bypass surgery, 24 had preoperative and an additional 52 developed at surgery a fascicular conduction disturbance. At 66 +/- 14 months of follow-up, 6 (4%) of 148 control patients without pre- or postoperative fascicular conduction disturbances had died from cardiac causes. Although right bundle branch block and left hemifascicular block were the most common form of fascicular conduction disturbance, only 1 of 55 of these patients died (p = NS). Mortality rates were much higher for patients with left bundle branch block or an intraventricular conduction defect; 8 (38%) of 21 died from cardiac causes (p less than 0.05). A high risk subgroup was identified by comparing 14 consecutive patients with left bundle branch block or an intraventricular conduction defect who survived more than 1 year postoperatively with 21 consecutive patients with these same conduction defects who died within 1 year of surgery. The following variables were significantly (p less than 0.05) different (survivors versus nonsurvivors): age (58 +/- 7 versus 65 +/- 9 years); class IV angina (2 of 14 versus 16 of 21), prior myocardial infarction (9 of 14 versus 21 of 21), left ventricular ejection fraction (53 +/- 18 versus 41 +/- 15%), three vessel disease (9 of 14 versus 20 of 21) and left ventricular aneurysm (2 of 14 versus 13 of 21).(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary revascularization improves long-term prognosis in diabetic and nondiabetic end-stage renal disease.

To test the hypothesis that coronary revascularization improves long-term prognosis in patients with hemodialysis, 80 of 121 patients (66%) on maintenance hemodialysis who had undergone initial coronary angiography had bypass surgery, catheter angioplasty, or both between 1983 and 1999. Multivessel disease was more frequent (p=0.01) and the duration of hemodialysis therapy was shorter (p=0.01) in patients with diabetes (n=61), than in nondiabetic patients (n=60). Of the patients who underwent revascularization, complete revascularization was achieved in 75% of those with diabetic nephropathy (30/40) and 83% in a similar number of nondiabetic patients (33/40). The 5-year survival rate from initiation of hemodialysis was 79% in diabetic and 96% in non-diabetic patients (p<0.01), exceeding published Japanese (53% vs 70%) and US (26% vs 60%) survival rates. When survival was studied from the date of revascularization, predictors of outcome were age and achievement of complete revascularization. Surprisingly, diabetes was not a predictor of survival outcome. Complete revascularization improves long-term survival in both diabetic and nondiabetic patients.     

血运重建方式对冠心病三支病变患者预后的影响

目的观察不同的冠状动脉血运重建方式——完全血运重建(冠状动脉介入治疗或冠状动脉旁路移植术)或部分血运重建(冠状动脉介入治疗)对冠心病三支病变患者死亡率和心功能的影响。方法共181名三支病变并行血运重建的患者,按血运重建方式分为两组:部分血运重建组行经皮腔内冠状动脉成形术和/或冠状动脉支架置入术,完全血运重建组行冠状动脉旁路移植术或支架置入术。手术后临床随访6~70个月(平均28.6±9.2个月),比较两组随访病例临床终点事件和心功能的差异。结果(1)基线资料:对部分血运重建组123例和完全血运重建组58例进行了临床随访,两组在年龄及性别方面差异无统计学意义。(2)临床事件:部分血运重建组死亡9例(7.32%),完全血运重建组死亡5例(8.62%);部分血运重建组再入院17人(13.8%),完全血运重建组再入院7人(10.3%),两组之间差异均无统计学意义(P>0.05)。选择完全血运重建或部分血运重建对患者28个月的死亡率和心功能无显著影响(P>0.05)。治疗前左室射血分数对患者的死亡率有显著影响(P=0.004,95%CI=0.893~0.978)。结论临床选择冠状动脉完全血运重建或部分血运重建对冠状动脉三支病变患者28个月死亡率和心功能的影响差异无统计学意义,而治疗前左室射血分数是影响其远期预后的重要因素。     

老年冠心病患者血运重建后影响预后的因素

目的 分析老年(≥65岁)冠心病患者接受血运重建后影响其预后的因素.方法 6005例接受了血运重建,包括经皮冠脉介入治疗(PCI)和冠状动脉搭桥(CABG)的冠心病患者根据年龄分为两组,老年组(≥65岁,3728例)和对照组(＜65岁,2277例),对患者进行电话或门诊随访,随访的中位数为555 d,比较两组间临床情况和预后.结果 两组间血运重建总死亡率和MACCE发生率差异有统计学意义,其中总死亡率(老年组与对照组)为3.5%与1.6%(P=0.001),MACCE为12%与3.9%(P=0.001).与对照组相比,老年患者合并高血压、糖尿病以及脑血管病史、陈旧心梗史的发生率明显要高,而ST段抬高心梗、三支病变、左主干病变、CTO发生率也明显高,内生肌酐清除率、完全血运重建率却低.Cox多因素回归分析发现,糖尿病(HR 2.011,95%CI 1.093～3.697,P=0.027)、三支血管病变(HR 2.036,95%CI 1.123～3.813,P=0.017)、老年(≥65岁,HR 5.605,95% CI 2.001～15.705,P＜0.001)是总死亡率增加的独立危险因素,而内生肌酐清除率(HR 1.923,95% CI 1.107～3.203,P=0.013)、左主干病变(HR 1.877,95% CI 1.193～2.978,P=0.001)、三支血管病变(HR 1.515,95% CI 1.243～1.806,P=0.007)是MACCE发生率增加的独立危险因素.结论 糖尿病、三支血管病变、老年(≥65岁)是老年冠心病患者血运重建后总死亡率增加的独立危险因素,而内生肌酐清除率、左主干病变、三支血管病变是MACCE发生率增加的独立危险因素.     

代谢综合征对老年血运重建术患者预后的影响

目的分析代谢综合征在老年血运重建患者中的临床特征和预后。方法选择2004年7月~2005年9月在我院接受血运重建治疗的临床资料记录完整的患者2882例,随访时间中位数为1年6个月,随访成功比例92.20%,将≥60岁的1512例患者分为老年组,<60岁的1370例分为中青年组。又将老年组中合并代谢综合征的患者分为Ⅰ组,未合并代谢综合征的患者分为Ⅱ组。记录两组随访期间临床不良心脑血管事件(MACCE)。结果老年组患者的病死率明显高于中青年组(3.40%vs1.02%,P=0.000),老年组合并代谢综合征的比例为39.95%,Ⅰ组随访期间的再住院率、MACCE和病死率均明显高于Ⅱ组的患者(30.80%vs26.32%,P=0.034;12.09%vs8.59%,P=0.018,3.31%vs1.65%,P=0.029)。只有年龄、肌酐水平和合并代谢综合征对病死率有明显影响(P<0.05)。结论合并代谢综合征的老年患者再住院率、MACCE和病死率均明显高于未合并代谢综合征者,合并代谢综合征和年龄、肌酐水平是增加随访期间MACCE和病死率的重要危险因素。     

Renal function, revascularization and risk.

In 1974, 14 years after the advent of regular maintenance haemodialysis,Linder et al.¹ first reported the powerful relationship betweenend-stage renal failure and cardiovascular complications. Thisis now generally recognized, and the statistics quantifyingthis excess risk, such as the 100-fold increase in cardiovascularmortality associated with a requirement for chronic dialysisbelow the age of 45 years, are frequently quoted. More recently,however, clinicians have become aware of the association betweenmilder degrees of renal dysfunction and cardiac morbidity andmortality. There are several reasons for an increased interest in the relationshipbetween kidney and cardiovascular disease. An ageing populationwith a greater prevalence of obesity, hypertension, and diabeteshas resulted in rising levels of chronic renal disease. Among6233 participants in the Framingham Heart Study, 8% had mildrenal insufficiency based on measures of serum creatinine.²Likewise, the third National Health     

Does myocardial revascularization with multiple arterial grafts improve the prognosis of dialysis patients?

In the present study it was examined whether myocardial revascularization with multiple arterial grafts improves the prognosis of dialysis patients. The 20 subjects underwent coronary artery bypass grafting over 2 vessels (extra-corporeal circulation in 11 patients, off-pump bypass in 9 patients) and were divided into 2 groups according the number of arterial grafts. Group A consisted of 9 patients in whom more than 2 arterial grafts were used and Group B, 11 patients requiring 1 internal thoracic artery and additional saphenous vein grafts. The surgical procedure was examined, as well as the short-term and long-term results of both groups. There were no differences in the profiles of the 2 groups. The mean arterial graft number in group A was 2.2+/-0.6 and 1.0+/-0.0 in group B. There was neither mediastinitis nor brain complication in either group. There were no operative deaths in group A and 1 in group B. The 55-month actuarial survival rate including all deaths, and estimated by cardiac deaths, was, respectively, 0.53+/-0.21 and 0.80+/-0.18 in group A and 0.42+/-0.21 and 0.53+/-0.23 in group B. The survival rate estimated by cardiac death in group A was better, but there was not a significant difference. Myocardial revascularization with multiple arterial grafts for dialysis patients had good short-term results without increased operative risk and may improve the long-term results related to cardiac death. However, there was no significant difference in survival including all deaths because of the numerous non-cardiac deaths.     

Indication for coronary revascularization for angina pectoris: correlation with prognosis of medically-treated patients

To assess the indication for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG), we studied 93 patients with angina pectoris but without myocardial infarction. All patients had significant stenosis (greater than 50%) in at least one coronary artery, including the left anterior descending artery. Fifty-eight patients received medical treatment (Group I), 12 had PTCA (Group II) and 23 had CABG (Group III). Findings of coronary angiography, treadmill exercise tests and dipyridamole perfusion scintigraphy as well as the frequency of cardiac events during follow-up were assessed in each group. 1. Coronary angiography revealed 1 vessel disease in 38% of the patients in Group I, 58% in Group II, and 13% in Group III; 2 vessel disease in 33%, 25% and 61%; and 3 vessel disease in 29%, 17% and 26%, respectively. 2. Exercise duration with the treadmill test was 4.7 min in Group I, 4.0 min in Group II and 3.7 min in Group III. ST depression (greater than or equal to 1 mm) was induced in 75%, 83% and 95%, respectively. Exercise duration improved from 4.0 to 6.0 min after PTCA and from 3.7 to 4.5 min after CABG. Exercise-induced ST depression also became less frequent; from 83% to 25% after PTCA and from 95% to 32% after CABG. Dipyridamole perfusion scintigraphy showed reversible defects in 86% of the patients in Group I and in all patients in Groups II and III. Reversible defects were observed in 17% of the patients after PTCA and in 21% after CABG. 3. During a mean follow-up period of 26 months, cardiac deaths occurred in one patient (2%) in Group I and 2 (7%) in Group III. Nonfatal cardiac events (myocardial infarction and unstable angina or those necessitating revascularization--late PTCA or CABG) were observed in 12 patients (21%) in Group I, 4 (24%) in Group II and 10 (36%) in Group III. Anginal attacks at least once weekly remained in 12% of the patients in Group I, 19% in Group II and 14% in Group III at the last follow-up. In conclusion, PTCA and CABG appear to be effective methods for improving ischemia and exercise tolerance. However, preventive PTCA and CABG may not be indicated in patients with mild angina, because the prognosis is also excellent in medically-treated patients with angina but without myocardial infarction or left main coronary artery disease.     

肾小球滤过率对冠心病多支病变患者血运重建预后的影响

目的 分析不同肾小球滤过率水平的冠脉多支病变患者的临床特征及肾小球滤过率对血运重建远期预后的影响.方法 选取2003年7月～2005年9月在安贞医院接受经皮冠状动脉成形术或冠状动脉旁路移植术的多支病变患者4072例,将入选患者按照肾小球滤过率分为4组,记录各组患者的临床资料并进行随访,分析各组的临床特点、死亡率和主要心脑血管事件的发生情况.结果 肾小球滤过率下降的多支病变患者年龄偏大,女性患者多,合并糖尿病、高血压者较多,各组中的开口处病变及前降支近端病变所占比例增大,且差异均有统计学意义（P＜0.05）.左室射血分数、血红蛋白及白细胞水平在4组中有显著的统计学差异（P＜0.01）.COX多因素回归分析结果显示随着肾小球滤过率的下降多支病变患者血运霞建后死亡率增高,但各组的主要心脑血管事件的发生情况与组别无相关性.结论 不同程度的肾小球滤过率下降对冠心病多支病变患者血运重建的预后有不同的影响,GFR＜60 ml/min是冠心病多支病变患者血运重建的独立危险因素,特别是GFR＜45 ml/min的多支病变患者合并有更多的危险因素,血运重建后的病死率高,预后不佳.     

Impact for incomplete correction of myocardial ischemia on long-term prognosis in patients with revascularization

正Objective To compare the prognosis between complete and incomplete revascularization(RVS)based on myocardial perfusion imaging(MPI)and coronary angiography(CAG)in patients with coronary artery disease(CAD).Methods A total of 202 patients with MPI confirmed myocardial ischemia and receiving RVS within 3months of diagnosis in our hospital from 2007-10 to 2010-12 were retrospectively studied.Based on CAG and MPI     

代谢综合征对冠心病血运重建患者预后的影响

目的 探讨集中了5个心血管病危险因素(肥胖、糖代谢异常、高血压、高甘油三酯血症、低高密度脂蛋白胆固醇血症)的代谢综合征在冠心病患者中的流行趋势和预后意义.方法 研究对象来自单中心注册研究DESIRE(drug-eluting stent impact on revascularization),入选2003年7月1日至2004年9月30日在首都医科大学附属安贞医院接受血运重建治疗[经皮冠状动脉介入(PCI)或冠状动脉旁路移植术(CABG)]的2368例患者,选择其中身高、体重、血压、血糖和血脂等记录完整的患者共1911例,平均年龄(60±10)岁,记录其临床资料及随访期间临床不良事件,患者死亡为随访终止,记录死亡时间.代谢综合征定义采用2005年美国胆固醇教育计划成人治疗专家组修订(NCEP ATP Ⅲ)的定义,以体重指数(BMI)≥25 kg/m2代替腹围指标.计量资料均值应用-x±s表示,两组间比较采用t检验,多组间比较采用方差分析,计数资料采用x2检验,不良事件与代谢综合征患者的相关性应用Logistic和Cox回归分析.结果 相应临床资料记录完整的患者1911例,其中男性1458例占76.3%.截至2007年底随访时间中位数为3.5年(293～1855 d).按照是否合并代谢综合征将患者分为2组,发现合并代谢综合征对住院期间和随访期间的死亡率没有影响,但明显增加随访期间主要不良心脑血管事件(MACCE)的发生率(P＜0.05).随访3.5年,合并代谢综合征患者增加的MACCE事件主要表现在:再次血运重建事件、脑卒中事件和再入院事件(P＜0.05);把性别、年龄、血脂等心血管危险因素放入Logistic模型中,比较影响总MACCE发生的危险因素,仅发现合并代谢综合征是影响总MACCE发生的惟一因素(OR 1.319,95%CI 1.020～1.706,P＜0.05).应用Logistic回归分析代谢综合征5个组成成分对随访MACCE的影响,发现糖代谢异常(OR 1.047,95% CI 1.005～1.091,P＜0.05)和低高密度脂蛋白胆固醇血症(OR 0.777,95%CI0.610～0.989,P＜0.05     

老年冠心病患者血运重建后远期预后及影响因素分析

目的研究老年冠心病患者血运重建后远期预后及影响因素。方法选择连续就诊的经PCI或冠状动脉旁路移植术治疗的老年冠心病患者223例,根据年龄分为A组(60～69岁)128例,B组(≥70岁)95例,比较2组临床特点及主要心脑血管事件(MACCE)的发生率。结果与B组比较,A组高脂血症的比例较高(P=0.040),心律失常(P=0.026)和既往脑卒中史比例(P=0.013)较低,病变血管和靶病变数(P=0.002,P=0.013)比例较低。2组总MACCE发生率差异显著(P=0.033),其中靶血管或靶病变血运重建发生率差异显著(P=0.034);A组生存率显著高于B组(P=0.04)。年龄、病变血管数和收缩压是MACCE发生的独立预测因素。结论在老年冠心病中,危险因素随年龄增长明显增多;年龄、病变血管数及较高的收缩压是MACCE发生的独立预测因素。     

基线C反应蛋白水平对老年冠心病血管重建患者预后的影响

目的探讨基线C反应蛋白(CRP)水平对老年冠心病血管重建患者预后的影响。方法选择冠心病血管重建患者209例,根据CRP水平分为低CRP组(CRP≤5 mg/L)113例,高CRP组(CRP>5 mg/L)96例。比较不同基线CRP水平患者长期随访的临床结果,中位随访时间为551 d。结果与低CRP组比较,高CRP组患者随访主要不良心脑血管事件(MACCE)的相对危险度为3.208(95%CI:1.415～7.274,P=0.003)。高CRP组发生再次血管重建的危险为低CRP组的3.841倍(95%CI:1.299～11.357,P=0.008)。Cox回归分析显示,CRP对随访MACCE有显著的独立预测意义,高CRP组无MACCE发生率明显低于低CRP组。结论基线CRP水平仍是老年冠心病血管重建患者预后的独立预测因素。     

Viability of Q-wave infarcted myocardium with restored positive and persistent negative T waves after optimal revascularization compared with dobutamine stress echocardiography

To clarify the clinical difference in viability of myocardium with negative and positive T waves in Q-wave anterior or anteroseptal myocardial infarction, we performed low-dose dobutamine stress echocardiography in 17 patients with negative T waves and in 13 patients with positive T waves with optimal revascularization of infarct-related arteries in the chronic phase of infarction. At baseline the wall motion score (WMS) of the negative and positive T groups was 25.8 +/- 3.0 and 22.3 +/- 2.2 points (p <0.05), respectively. At peak stress WMS in each group was 27.2 +/- 4.2 and 19.8 +/- 2.4 points (p <0.0001), respectively. With dobutamine stress WMS in the positive T group was more decreased than that of the negative T group (p <0.0001). We conclude that the restored positive T waves in Q-wave myocardial infarction indicate a significantly greater amount of viable myocardium than the negative T waves, showing better regional wall motion improvement with low-dose dobutamine stress.     

完全血运重建对老年急性NSTEMI合并多支血管病变患者长期预后的影响

目的探讨完全血运重建(CR)对老年急性非ST段抬高型心肌梗死(NSTEMI)合并多支血管病变(MVD)患者长期预后的影响。方法连续入选603例老年急性NSTEMI合并MVD患者,根据患者冠状动脉血管处理情况分为2组:(1)单纯处理罪犯血管(SR)组(n=260);(2) CR组(n=343)。研究终点设定为术后1年的全因死亡、心血管死亡、非致死性再发心肌梗死及非计划再次血运重建。通过COX回归分析探讨CR对老年急性NSTEMI合并MVD患者长期预后的影响。结果与SR组相比,CR组既往接受PCI治疗的比例更低,3支病变、术前血流TIMI 0或1级比例更高,植入支架个数更多,长度更长,替格瑞洛的使用比例更高,而硝酸酯类的使用比例更低。随访期内,整体全因死亡率为4.8%(SR组比CR组为6.2%比3.8%,P=0.179),心源性死亡率为4.1%(SR组比CR组为4.6%比3.8%,P=0.615),非致死性再发心肌梗死率为2.5%(SR组比CR组为1.2%比3.5%,P=0.067),非计划再次血运重建率为6.8%(SR组比CR组为9.6%比4.7%,P=0.017)。单因素COX回归分析显示,CR可以显著降低老年NSTEMI合并MVD患者的非计划再次血运重建率(HR 0. 471,95%CI 0. 251~0. 882,P=0.019);在校正了各项临床因素之后,多因素COX回归分析也得到了相同的结论(HR 0.438,95%CI 0.229~0.837,P=0.012)。但是,无论单因素分析,还是多因素分析,CR对老年NSTEMI合并MVD患者的全因死亡、心源性死亡及非致死性再发心肌梗死均无显著影响。围手术期并发症方面,2组的BARC 3或5级出血、造影剂肾病、卒中及急性支架内血栓等发生率无显著差异。结论对于老年NSTEMI合并MVD患者,CR可以显著降低术后非计划再次血运重建率,同时围手术期也是较为安全的。