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目前人们对急性冠状动脉综合征(ACS)的发病机制、高危因素认识的加深和防治手段的提高,使得其发病率和病死率呈逐年下降趋势;但是,关于特殊人群(女性冠心病患者、≥75岁的老年患者、糖尿病患者、慢性肾功能不全患者、贫血患者等)这种下降趋势似乎并不明显。由于相关临床试验中针对这部分人群的代表性不够,观察性研究和随机试验的结果不一致,其理想再灌注干预策略仍有争议,对于一般人群的干预方案是否适用这一特殊人群等问题还值得进一步探究。1女性急性冠状动脉综合征女性第一次心血管事件发生比男性平均晚10年。来自美国疾病控制中心的数…     

急性冠脉综合征治疗策略研究

随着冠心病患病率的逐年上升,急性冠脉综合征（ACS）的治疗方法越来越多,逐渐引起人们的重视。本文就近年来ACS治疗中,针对不同时期所采取的治疗策略进行综述。     

非ST段抬高型急性冠脉综合征的治疗

急性冠状动脉综合征(ACS)是一个疾病谱的统称,通常在冠状动脉粥样硬化的基础上,斑块破裂、破损或出血、痉挛,导致血栓形成。完全或不完全堵塞冠状动脉的急性病变为病理基础的一组临床综合征,包括不稳定型心绞痛(UA)、急性心肌梗死(AMI)或猝死。近年来的研究使人们对ACS从概念、     

Predicting outcomes in acute coronary syndrome using biochemical markers

Objectives

To assess risk prediction in patients with acute coronary syndrome (ACS) during the hospital stay, at 6 weeks and at 6 months period using high sensitivity C-reactive protein (hs-CRP), serum creatinine, cardiac troponin I, creatine kinase total, and MB levels.

Methods

It was a prospective observational study. The primary outcome was taken as all-cause mortality. Patients with ACS were enrolled and followed up at 6 weeks and 6 months duration from the index event. Mortality and cause of death were recorded. The hs-CRP was estimated on admission, at 6 weeks, and at 6 months. The estimated glomerular filtration rate (eGFR) was calculated using the abbreviated modification of diet in renal disease (MDRD) formula at admission, at 6 weeks, and 6 months.

Results

There were a total of 108 cases of ACS in the duration of 6 months who completed the follow-up. The hs-CRP level of >5 mg/dl was highly significant for predicting mortality during hospital stay and at 6 weeks (p < 0.001). There was 11% of in-hospital mortality (p < 0.001). At 6 months, the overall mortality was 28% (p < 0.001). There was a statistical significance with low eGFR (median eGFR 45 ml/min/1.73 m²) levels during the admission.

Conclusion

hs-CRP levels above 5 mg/dl and the eGFR levels ≤30 ml/min/1.73 m² were significant in predicting mortality of the patients with ACS. This may provide simple assessment tools for predicting outcome in ACS in resource-poor settings if validated further.     

进一步提高急性冠状动脉综合征的介入疗效

急性冠状动脉综合征(acute coronary syndrome,ACS)仍然是广大临床心脏病学医师感兴趣的研究课题,在本期就有三篇关于ACS的发生机制、治疗策略和二级预防的章。     

Plasma interleukin-10 levels and adverse outcomes in acute coronary syndrome

Purpose or Background

Interleukin (IL)-10 is an immunoregulatory cytokine that is produced by a variety of cell types, such as macrophages and activated monocytes. IL-10 possesses numerous anti-inflammatory, anti-thrombotic and anti-atherosclerotic properties. Furthermore, patients with acute coronary syndrome have been demonstrated to have reduced levels of IL-10 compared to their stable counterparts. For these reasons, it has been proposed that IL-10 plays a protective role in both atherogenesis and plaque vulnerability. However, 2 short-term studies on the prognostic utility of IL-10 in patients with acute coronary syndrome have provided conflicting results, with one study showing that reduced levels of IL-10 were predictors of adverse outcomes and another showing that elevated levels predicted poor outcomes. The objective of the present study was to investigate the long-term prognostic significance of baseline IL-10 levels in patients with acute coronary syndrome.

Methods

Baseline plasma IL-10 levels were measured in 193 well-characterized male patients with acute coronary syndrome who were referred for coronary angiography and followed prospectively for 5 years for the development of major adverse cardiovascular events.

Results

After controlling for a variety of baseline variables (including established biomarkers such as high-sensitivity C-reactive protein and N-terminal-pro-B-type natriuretic peptide), plasma IL-10 levels (whether analyzed as a continuous variable or as a categorical variable using receiver operating characteristic-derived cut point) were a strong and independent predictor of the composite outcome of death or non-fatal myocardial infarction when using a Cox proportional hazards model.

Conclusions

These data demonstrate that, despite biologic plausibility for IL-10 as being a cardioprotective cytokine, elevated baseline plasma levels of IL-10 are a strong and independent predictor of long-term adverse cardiovascular outcomes in patients with acute coronary syndrome.     

急性冠状动脉综合征的急诊介入治疗

目的评价急诊冠状动脉内介入治疗急性冠状动脉综合征的疗效和安全性。方法急性冠状动脉综合征患者87例,男72例,女15例。年龄37～82岁。其中ST段抬高心肌梗死62例,非ST段抬高心肌梗死和不稳定型心绞痛25例,行急诊冠状动脉内介入治疗,分析其临床表现,冠状动脉病变特点,处理以及并发症和预后。结果87例患者共成功置入支架169枚,其中直接支架术53次,经皮冠状动脉腔内成形术加支架术116次。单纯冠状动脉腔内成形术22次。有16例患者行血管内超声指导冠状动脉内介入。手术成功率96．5％,住院期间死亡1例。随访5～22月,生存率98.8％,无事件生存率86．0％。院外猝死1例,心肌梗死1例,心绞痛再发10例。结论急诊冠状动脉内介入治疗急性冠状动脉综合征安全有效,有助于改善预后。     

急性冠状动脉综合征合并尿毒症透析患者临床及介入治疗结果

目的:探讨急性冠状动脉综合征(ACS)合并尿毒症透析患者临床特征、冠状动脉特点、介入治疗及临床随访结果等。方法:研究入选2001年1月至2014年12月,在我院住院确诊ACS合并尿毒症透析的患者22例。选择同期住院30例无尿毒症ACS患者作为对照。入院后行急诊或常诊冠状动脉造影及介入治疗,比较两组患者临床特点、冠状动脉造影血管病变特点、介入治疗结果、住院期间及12个月随访结果。结果:1两组患者在吸烟史、血脂代谢异常、糖尿病及既往冠心病史等方面,差异无统计学意义(P0.05);ACS合并透析组胸痛症状、应用血小板糖蛋白IIb/IIIa受体拮抗剂比例较无尿毒症组少(P0.05);2ACS合并尿毒症透析患者冠状动脉造影3支血管病变比例增加,中重度钙化比例增加(P均0.05);ACS合并尿毒症患者总操作时间高于无尿毒症组(P0.05),而在靶血管部位、支架数量、操作成功比例、并发症、造影剂用量方面,两组差异无统计学意义。3两组患者在住院期间心血管事件差异无统计学意义(P均0.05);随访12个月结果,两组患者在死亡、再发心肌梗死、再次血运重建、支架内血栓、大出血等单一终点方面,差异无统计学意义(P均0.05),但ACS合并尿毒症组联合终点(包括死亡、再发心肌梗死、再次血运重建、支架内血栓及大出血等)高于无尿毒症组(P0.01)。结论:ACS合并尿毒症维持透析患者,冠状动脉钙化、多支、弥散病变多,采用介入治疗相对安全,有效,不增加住院期间心血管事件,但增加12个月随访时包括死亡、再发心肌梗死、再次血运重建、支架内血栓及大出血等联合终点发生。     

Costs and outcomes of Lynch syndrome screening in the Australian colorectal cancer population

Background and Aim

Individuals with Lynch syndrome (LS) are at increased risk of LS‐related cancers including colorectal cancer (CRC). CRC tumor screening for mismatch repair (MMR) deficiency is recommended in Australia to identify LS, although its cost‐effectiveness has not been assessed. We aim to determine the cost‐effectiveness of screening individuals with CRC for LS at different age‐at‐diagnosis thresholds.

Methods

We developed a decision analysis model to estimate yield and costs of LS screening. Age‐specific probabilities of LS diagnosis were based on Australian data. Two CRC tumor screening pathways were assessed (MMR immunohistochemistry followed by MLH1 methylation (MLH1‐Pathway) or BRAF V600E testing (BRAF‐Pathway) if MLH1 expression was lost) for four age‐at‐diagnosis thresholds—screening < 50, screening < 60, screening < 70, and universal screening.

Results

Per 1000 CRC cases, screening < 50 identified 5.2 LS cases and cost $A7041 per case detected in the MLH1‐Pathway. Screening < 60 increased detection by 1.5 cases for an incremental cost of $A25 177 per additional case detected. Screening < 70 detected 1.6 additional cases at an incremental cost of $A40 278 per additional case detected. Compared with screening < 70, universal screening detected no additional LS cases but cost $A158 724 extra. The BRAF‐Pathway identified the same number of LS cases for higher costs.

Conclusions

The MLH1‐Pathway is more cost‐effective than BRAF‐Pathway for all age‐at‐diagnosis thresholds. MMR immunohistochemistry tumor screening in individuals diagnosed with CRC aged < 70 years resulted in higher LS case detection at a reasonable cost. Further research into the yield of LS screening in CRC patients ≥ 70 years is needed to determine if universal screening is justified.     

Register of acute coronary syndromes in Russia: treatment and in hospital outcomes in non-ST elevation acute coronary syndrome

Data from about 50 consecutive patients with acute coronary syndromes aged > or =18 years admitted to 59 hospitals in different Russian cities were collected between November 2000 and July 2001. In addition to presumably ischemic symptoms within previous 24 hours they were to have ischemic ECG changes, documented coronary heart disease or positive markers of myocardial necrosis. Of 2806 patients included into registry 1394 (49.7%) had non-ST elevation acute coronary syndrome. Markers of myocardial necrosis (mainly CK activity) were evaluated in 59.5% of them. Frequency of interventions known to improve outcome was rather low: aspirin in acute phase was used in 73% (contraindications were reported just in 6%), thyenopyridines - in few cases, unfractionated heparin intravenously only with APTT control - in 11.8%, low-molecular weight heparins - in 7.4% of patients. Beta-blockers were prescribed in 55.6% of cases (with fist dose intravenously in 2.9%). Lipid lowering drugs were recommended on discharge to 15% of patients (to 20% with known hypercholesterolemia). Coronary angiography and revascularization procedures were performed in 25 (1.8%) and 11 (0.8%) patients, respectively. However hospital mortality appeared to be relatively low (3.8%). Meanwhile rates of (re)infactions and angina recurrences during hospitalization were high - 16.5 and 25.1% of cases, respectively.     

贫血对急性冠状动脉综合征患者预后的影响

目的:探讨贫血对急性冠状动脉(冠脉)综合征患者主要不良心血管事件的影响。方法:纳入行冠脉造影术的急性冠脉综合征患者428例,测定血红蛋白水平并进行临床随访;据血红蛋白水平分为贫血组和非贫血组,随访终点为心源性死亡、脑卒中、心力衰竭、非致死性心肌梗死以及因心绞痛再入院。建立Cox相对风险比例回归模型分析危险因素与终点事件间的关系,采用Kaplan-Meier法比较2组间生存率的差异。结果:贫血组的血红蛋白水平为107.5(81～120)g/L,非贫血组为136.0(111～178)g/L,平均随访期为20(1～120)个月,随访结束时共104例达终点。Cox回归模型显示血红蛋白(RR=0.363,95%CI:0.171～0.770,P=0.008)与急性冠脉综合征预后相关,Kaplan-Meier分析显示贫血组30d(92.0%∶96.9%,P=0.018)、90d(86.8%∶92.4%,P=0.048)及随访结束时(42.2%∶53.6%,P=0.035)的无事件累积生存率均低于非贫血组。结论:血红蛋白水平是影响急性冠脉综合征患者预后的因素之一,贫血的急性冠脉综合征患者预后较差。     

Brain cancer mimicking an acute coronary syndrome

The authors report the case of a 62-year-old woman admitted to hospital for episodes of chest pain with ischemic abnormalities at ECG without enzyme release. Coronography confirmed a normal coronary tree with mild ascending aortic dilatation. Subsequent diagnostic and clinical examinations resulted normal. Episodes of chest pain and dyspnea persisted over the following days. Administration of nitrates, calcium antagonist, diuretic, antidepressant agents for suspected syndrome X led to partial improvement of clinical symptoms. The patient was discharged from the hospital. A few days later she was referred to the neurology department because of an episode of transient dysarthria, hyposthenia and paresthesis localized to the right lower and upper limbs associated with chest pain. A brain computed tomography showed an expansive solid mass. Nuclear magnetic resonance imaging and stereotaxis biopsy confirmed the etiology of the lesion to be a glioblastoma. The patient died soon thereafter from respiratory and cardiocirculatory arrest.     

Treatment modalities of diabetes mellitus and outcomes of acute coronary syndromes

BACKGROUND: Oral treatments for diabetes mellitus (DM) may have a deleterious effect on acute coronary syndromes (ACS) outcomes. AIM: We aimed to examine in-hospital mortality among patients with ACS and DM and the impact of anti-DM treatment modalities. METHODS AND RESULTS: The Euro Heart Survey ACS prospectively enrolled 10484 patients across Europe and the Mediterranean basin. Of the 10214 patients with recorded DM status, 2352 (23.0%) had DM, of whom 562 were on diet alone, 1112 received oral hypoglycaemics, 561 received insulin, and 117 received both. The in-hospital mortality for ST-elevation-ACS was 9.8 and 5.7% for patients with and without DM, respectively, with an adjusted risk (95% confidence interval) of in-hospital mortality of 1.6 (1.2, 2.1). The in-hospital mortality for non-ST-elevation-ACS was 2.8 and 2.0%, accordingly, with an adjusted risk (95% confidence interval) of in-hospital mortality of 1.2 (0.8, 1.9). The in-hospital mortality for undetermined-electrocardiographic-pattern-ACS was 11.5 and 10.9%, accordingly, with an adjusted risk of in-hospital mortality of 1.1 (0.6, 2.0). Among DM patients with ST-elevation-ACS, the adjusted risks of in-hospital mortality were 1.0 for diet therapy, 0.8 (0.4, 1.5) for oral hypoglycaemics, and 1.9 (1.0, 3.8) for insulin; for DM patients and non-ST-elevation-ACS, 1.0 for diet therapy, 2.2 (0.6, 7.8) for oral hypoglycaemics, and 3.5 (1.0, 12.5) for insulin; for DM patients and undetermined-electrocardiographic-pattern-ACS, the adjusted risks of in-hospital mortality were 1.0 for diet therapy, 0.9 (0.2, 4.6) for oral hypoglycaemics, and 2.1 (0.5, 9.5) for insulin. CONCLUSIONS: Acute coronary syndrome patients with DM, especially those with ST-elevation, had increased in-hospital mortality. Among ACS patients with DM, those receiving insulin had worse outcomes. Outcomes were similar for those on hypoglycaemics or on diet alone.     

替格瑞洛用于急性冠脉综合征冠脉多支病变行PCI术治疗效果的中期随访

【摘要】目的：探讨替格瑞洛用于急性冠脉综合征冠脉多支病变行PCI术治疗的有效性及安全性。 方法：选取2013年8月至2015年8月入住我院的急性冠脉综合征多支病变患者226例为研究对象,并随机将患者分为替格瑞洛组（试验组,n=99,术前顿服180mg,术后每次90mg,每次2次）和氯吡格雷组（对照组,n=127,术前顿服300mg顿服,术后每次75mg,每日1次）。术后均对患者随访6个月,比较两组患者基本临床资料、冠脉病变特征、药物使用情况及6个月内主要不良心血管事件、不良反应发生率。 结果 两组患者在基本临床资料、冠脉病变特征、药物使用情况比较中差异无统计学意义（P >0.05）,具有可比性。试验组患者随访期间（6个月内）MACE发生率显著低于对照组,差异有统计学意义（P＜0.05）;呼吸困难发生率显著高于对照组,差异有统计学意义;出血事件及总不良反应发生率两组患者比较差异无统计学意义（P＞0.05）。结论 替格瑞洛用于急性冠脉综合征冠脉多支病变行PCI术患者具有良好的有效性及安全性。     

急性冠脉综合症患者血糖异常与预后关系的研究

目的:探讨急性冠脉综合征(ACS)患者血糖含量异常与预后的关系。方法:对165例住院的ACS患者做标准75g口服葡萄糖实验。据血糖水平,把患者分为血糖正常组,空腹血糖异常组,餐后血糖水平增高组和糖尿病组(DM)。利用心电图和B型超声心动图检测各组中心肌梗塞及/或缺血的范围,心力衰竭发生率,以及住院期间死亡率。结果:(1)空腹血糖水平增高者为13.3%,血糖正常者及餐后2h血糖水平增高者各为22.4%,DM患者占41.8%,比例显著大于前三组(P<0.05)。全组ACS患者血糖异常总检出率为77.5%,性别间差别不显著;(2)血糖正常及空腹血糖异常者心肌梗塞及/或心肌缺血的范围差别不显著,而餐后血糖水平增高者及DM者显著大于前二组(P<0.05),但后二组差别不显著(P>0.05);(3)血糖正常组及空腹血糖水平增高组心衰的检出率基本相同,餐后血糖水平增高组的检出率虽高于前两组,但差别不显著(P>0.05)。糖尿病组心衰的检出率为65.2%,显著高于前三组(P<0.01)。心衰的总检出率为41.2%,性别间差别不显著(P>0.05);(4)住院期间DM共有5例死亡,占7.2%;余各组死亡率为零;以上各种异常检出率在性别间差别均不显著(P>0.05)。结论:ACS患者血糖异常水平与心肌梗塞及/或心肌缺血范围,心力衰竭的发生率呈正相关,餐后血糖水平增高及糖尿病患者不良事件的发生率明显增加。     

Renal function and outcomes in acute coronary syndrome: impact of clopidogrel.

INTRODUCTION: Patients with renal dysfunction are more prone to bleeding when receiving antithrombotic drugs. The aim of the study was to assess the impact of clopidogrel on safety and efficacy in patients with renal dysfunction in non-ST elevation acute coronary syndromes. METHODS AND RESULTS: Patients in the Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial were analysed to assess the relationship of chronic kidney disease to cardiovascular outcomes. Renal function was estimated by the glomerular filtration rate computed from the baseline serum creatinine measurements in 12 253 (97.5%) patients enrolled in the trial. Patients were grouped into tertiles of glomerular filtration rate. The primary outcome (cardiovascular death, myocardial infarction, stroke combined) occurred more frequently in the lowest glomerular filtration rate tertile. The bleeding risk was also significantly increased in patients in this tertile, compared with the other two. The beneficial effect of adding clopidogrel to standard treatment in non-ST elevation acute coronary syndrome was observed in all three tertiles of renal function {(lower third relative risk (RR)=0.89 [95% confidence interval (CI) 0.76-1.05]; medium third RR=0.68 (95% CI 0.56-0.84); upper third RR=0.74 (95% CI 0.60-0.93) (P for heterogeneity=0.11)}. Clopidogrel treatment significantly increased the risk of minor bleeding in all tertiles of renal function. The risk of major or life-threatening bleeding increased moderately with the addition of clopidogrel to standard treatment [lower third RR=1.12 (95% CI 0.83-1.51); medium third RR=1.4 (95% CI 0.97-2.02); upper third RR=1.83 (95% CI 1.23-2.73)], but this did not appear to be greatest in those with the lowest renal function. CONCLUSIONS: Even mild chronic kidney disease worsens the prognosis in patients with non-ST elevation acute coronary syndromes. Clopidogrel was beneficial and safe in patients with and without chronic kidney disease.