Acute myocardial infarction and rescue percutaneous transluminal coronary angioplasty in a young HIV-infected patient

We report a case of acute myocardial infarction in an HIV-infected patient without significant coronary artery disease (CAD) risk factors. The patient underwent rescue percutaneous transluminal coronary angioplasty (PTCA), with a successful outcome. We presume a possible pathogenetic role of anti-retroviral therapy and/or direct viral action on ischaemic heart disease progression. We propose that the current approach to management of AIDS-affected patients needs close monitoring for CAD risk factors and symptoms, to improve prognosis and life expectancy.     

不同类型冠心病患者血浆游离脂肪酸水平变化及其与病变程度的关系

目的探讨血浆游离脂肪酸(NEFA)水平变化与冠心病(CAD)病变程度的相关性。方法选取疑为CAD患者84例,分别行生化检验和冠状动脉造影检查;根据冠状动脉造影结果将其分为4组,分别为不稳定型心绞痛组(n=46)、稳定型心绞痛组(n=9)、急性心肌梗死组(n=20)、阴性对照组(n=9),对比组间血脂指标与NEFA是否存在差异分析,CAD患者发生急性心肌梗死风险与造影特点。结果 CAD组NEFA水平均高于阴性对照组,差异有统计学意义(P0.05);急性心肌梗死组NEFA水平高于稳定型心绞痛组和不稳定型心绞痛组,差异有统计学意义(P0.05);Logistic回归分析显示,校正后NEFA≥0.415mmol/L组出现急性心肌梗死的风险是NEFA0.415mmol/L组的2.61倍,95%CI:1.33~5.02,P0.05;不同水平的NEFA患者GENSINI积分、狭窄冠状动脉支数与3支冠状动脉病变数量差异无统计学意义(P0.05)。结论 CAD患者血浆NEFA出现升高,急性心肌梗死患者升高明显,但其与病变程度相关性未明确。     

室壁节段性运动异常与冠状动脉疾病解剖学变化特点的超声研究

目的　应用超声心动图探讨室壁节段性运动异常对冠状动脉疾病心脏解剖结构的影响 ,以及对疾病严重程度的认定。方法　受检对象共 12 5例。冠状动脉疾病组 63例 (其中普通患者 41例 ,急性心肌梗死 7例 ,陈旧性心肌梗死 15例 ) ,全部病例分别经临床冠状动脉搭桥术、球囊扩张并支架安放术、冠脉造影及放射性核素扫描证实 ;正常对照组 62例。二维超声选用标准的左室短轴和长轴观声像图 ,显示室壁节段性运动异常构成心室整体的向心性非协调性运动和非向心性矛盾样运动 ;运用M型超声连续扫查观察室壁节段性运动异常的典型特征。结果　 63例冠状动脉疾病患者中的 43例 (68.2 % )显示为单发室壁节段性运动异常 ,2 0例 (3 1.8% )则显示为多发室壁节段性运动异常 (P <0 .0 1)。所有患者左室室壁节段性运动异常局部心内膜均显现回声增强 ,收缩运动幅度减低 ,舒张速度减慢。室壁节段性运动异常无论单发或多发 ,均被二维和M型超声清晰显示。 58例合并心房扩大 ,单纯左房扩大者 3 9例。发生心肌梗死的 2 2例重症患者中 ,有 17例合并左、右心室不同程度的扩大。结论　无创性超声心动图可对室壁节段性运动异常所致冠状动脉解剖结构变化特点以及病变的严重程度提供客观准确的诊断资料     

青年冠心病患者危险因素分析

目的　探讨 5 0岁以下冠心病患者危险因素 ,对高危青年人的冠心病一级预防提供参考。方法　根据 15 6例冠状动脉造影结果将 5 0岁以下行冠脉造影者分为冠心病组 (89例 )和非冠心病组 (6 7例 ) ,收集临床心血管危险因素资料进行Logistic多因素回归分析。结果　 15 6例冠状动脉造影者中 89例诊断为冠心病 (5 7.1% ) ,6 7例无冠心病(42 .9% )。Logistic多因素回归分析显示冠心病家族史、血浆总胆固醇水平及吸烟为冠心病的独立危险因素 ,其相关系数分别为 0 .6 3、0 .5 0、0 .97,优势比 (OR)分别为 1.0 6、1.6 5、2 .6 4 (P <0 .0 5 )。结论　冠心病家族史、高血浆总胆固醇水平及吸烟是青年人冠心病的发生的高危因素 ,对这类人群应尽早干预。     

康复教育对急性心肌梗死恢复期患者生活质量的影响

背景急性心肌梗死恢复期的患者依然存在复发的危险,而且生活状况较差.研究证明,此与患者未掌握适合心肌梗死恢复的生活方式有关.目的采用康复教育的手段,帮助患者建立适合的生活方式,以期提高其生活质量.设计以急性心肌梗死恢复期患者为研究对象的对比观察.单位北京医科大学护理学院和两所大学医院.对象病例均为1999-04/1999-11北京医科大学第二、三附属医院心内科住院患者.纳入标准首次发病的急性心肌梗死患者,且自愿参加本研究.排除标准非首次发病的心肌梗死患者.对照组为1999-04/1999-06入院且符合上述纳入条件的患者,共35例;试验组为1999-08/1999-11入院且符合上述纳入条件的患者,共40例.除去一般情况特殊且无条件匹配者及试验组中途失访的患者,最后纳入分析两组均为30例,对照组中男23例,女7例,平均(60±14)岁;试验组中男22例,女8例,平均(62±10)岁,两组患者年龄、性别差异无显著性意义.方法以Neuman健康照顾系统模式为理论框架,对心肌梗死恢复期患者实施康复教育,即在试验组患者出院前采取集中授课和个别讲解并配合康复教育手册的形式提供康复教育,出院后3个月期间采用电话教育的形式进行督导,提供咨询,出院3个月时家访获得评价资料.主要观察指标两组患者生活质量及各维度的比较.结果试验组患者在总的生活质量得分以及躯体、心理、职责角色、健康意识等维度得分均显著高于对照组(t=11.03,3.26,3.62,2.05,15.48,P<0.05),而在社会维度方面二者差异无显著性意义(P>0.05).结论健康教育可使急性心肌梗死恢复期患者的生活质量得到显著提高.     

超声心动图对冠心病冠脉受累的评价及意义

【目的】探讨超声心动图（EcH0）评价冠心病（CAD）的价值。【方法】对111例拟诊为冠心病的病人行超声心动图检查和冠状动脉造影术（CAG）检查,以冠状动脉狭窄≥50％为CAG阳性来评价ECHO对冠心病的诊断价值。【结果】ECH0诊断CAD的敏感性和特异性分别为54．5％和91．7％;诊断心肌梗死的敏感性为83．7％（其中诊断急性心梗的敏感性90．3％;诊断陈旧性心梗的敏感性66．7％）;ECHO诊断单支病变和多支病变的敏感性分别29．0％和67．6％。【结论】ECH0对CAD和单支病变的敏感性较低,对心肌梗死和评价CAD严重程度有较高的诊断价值。     

Insulin resistance-related factors,but not glycemia,predict coronary artery disease in type 1 diabetes: 10-year follow-up data from the Pittsburgh Epidemiology of Diabetes Complications Study

OBJECTIVE: To determine the independent risk factors for coronary artery disease (CAD) in type 1 diabetes by type of CAD at first presentation. RESEARCH DESIGN AND METHODS: This is a historical prospective cohort study of 603 patients with type 1 diabetes diagnosed before 18 years of age between 1950 and 1980. The mean age and duration of diabetes at baseline were 28 (range 8-47) and 19 years (7-37), respectively, and patients were followed for 10 years. Patients with prevalent CAD were excluded from the study. Electrocardiogram (ECG) ischemia was defined by Minnesota Code (MC) 1.3, 4.1-3, 5.1-3, or 7.1; angina was determined by Pittsburgh Epidemiology of Diabetes Complications (EDC) study physician diagnosis; and hard CAD was determined by angiographic stenosis > or =50%, revascularization procedure, Q waves (MC 1.1-1.2), nonfatal myocardial infarction (MI), or CAD death. RESULTS: A total of 108 incident CAD events occurred during the 10-year follow-up: 17 cases of ECG ischemia, 49 cases of angina, and 42 cases of hard CAD (5 CAD deaths, 25 nonfatal MI or major Q waves, and 12 revascularization or > or =50% stenosis). Blood pressure, lipid levels, inflammatory markers, renal disease, and peripheral vascular disease showed a positive gradient across the groups of no CAD, angina, and hard CAD (P < 0.01, trend analysis, all variables), although estimated glucose disposal rate (eGDR) and physical activity showed inverse associations (P < 0.01, trend analysis, both variables). In addition, depressive symptomatology predicted angina (P = 0.016), whereas HbA(1) showed no association with subsequent CAD. CONCLUSIONS: These data suggest that although the standard CAD risk factors are still operative in type 1 diabetes, greater glycemia does not seem to predict future CAD events. In addition, depressive symptomatology predicts angina and insulin resistance (eGDR) predicts hard CAD end points.     

血清sTWEAK与冠心病严重程度的关系

目的:探讨可溶性肿瘤坏死因子样凋亡弱诱导因子(sTWEAK)与冠心病(CHD)的严重程度的关系及其对急性心肌梗死(AMI)发病的预测价值.方法:研究对象247例,其中AMI组78例、不稳定性心绞痛(UAP)组111例、稳定性心绞痛(SAP)组28例和对照组30例.采用ELISA测定血sTWEAK浓度.用Gensini评分评估CHD严重程度.结果:AMI组sTWEAK浓度显著高于其他各组(均P＜0.001).sTWEAK浓度与Gensini评分正相关(r=0.432,P＜0.001),是AMI发生的高危因素(P＜ 0.001,OR=5.814).结论:AMI组血清sTWEAK浓度高于非AMI组;sTWEAK是AMI发生的危险因素且与CHD严重程度正相关.     

Risk factors for sudden unexpected cardiac death in young women in Rochester, Minnesota, 1960 through 1974

A case-control study of sudden unexpected death (SUD) as the initial manifestation of coronary heart disease in women younger than 60 years of age was conducted in Rochester, Minnesota. Risk factors among the 15 SUD cases identified during the years 1960 through 1974 were compared with those in two control groups--a population group of 60 (4 age-matched controls per case) and the 59 cases of myocardial infarction diagnosed in women younger than 60 years of age in Rochester during the same period. By using Miettinen's matched analysis for comparison of SUD cases and matched controls, the relative risks for the accepted coronary heart disease risk factors of ever smoking and hypertension were 8.6 (95% confidence interval [CI], 1.3 to 57.3) and 5.7 (95% CI, 1.2 to 26.9), respectively. In a comparison of SUD cases and myocardial infarction cases by using the Mantel-Haenszel procedure and stratifying by five age groups, the odds ratios were 1.2 for ever smoking and 0.8 for hypertension. Six of the 15 SUD cases had a diagnosis of alcoholism compared with 2 of the 60 controls and 4 of the 59 myocardial infarction cases; thus, the relative risks were 12.0 (95% CI, 3.4 to 41.9) and 4.8 (95% CI, 1.3 to 18.2), respectively. Ever married SUD cases were nulliparous or had fewer children more often than the controls or the myocardial infarction cases. The combination of major psychiatric diagnosis and major tranquilizer use occurred with greater frequency among SUD cases than among controls (relative risk, 2.9; 95% CI, 0.6 to 14.1), whereas comparison of SUD cases and myocardial infarction cases for this variable resulted in a relative risk of 0.7 (95% CI, 0.3 to 1.9).     

Erectile dysfunction: is there silent obstructive coronary artery disease?

Erectile dysfunction (ED) has long been ascribed to the ageing process. Patients presenting with ED often have their symptoms ignored in terms of both underlying aetiology and treatment. It is now clear that, in many cases, the pathological processes in ED are common to those involved in vascular disease. Men with proven coronary artery disease (CAD) have a high incidence of ED when directly questioned. In some, the onset of ED pre-dates the symptoms and diagnosis of CAD as exemplified in our two cases. Patient 1 developed ED two months before an acute anterior myocardial infarction. Patient 2 had several cardiovascular risk factors but only the presence of ED prompted investigations which eventually led to an angiographic diagnosis of three-vessel disease. The presence of silent co-existing myocardial ischaemia should be considered in men who present with ED, particularly when they have other cardiovascular risk factors.     

The common Y402H variant in complement factor H gene is not associated with susceptibility to myocardial infarction and its related risk factors

Recently, the genetic variant Y402H in the CFH (complement factor H) gene was associated with an increased risk for MI (myocardial infarction) in a prospective Caucasian cohort. In another nested case-control study, however, the CFH-Y402H variant did not carry susceptibility to MI. The aim of the present study was to test for an association between the CFH-Y402H variant and MI in a large case-control sample with a familial background for CAD (coronary artery disease). A total of 2161 individuals from the German MI family study were studied by questionnaire, physical examination and biochemical analyses. MI patients (n=1188; 51.4+/-8.6 years at first MI) were recruited from families with at least two members affected by MI and/or severe CAD. Spouses, sisters-in-law and brothers-in-law respectively, without MI/CAD were included as unaffected controls (n=973; 56.9+/-9.8 years). Genotyping was performed using a TaqMan assay. The common Y402H variant in the CFH gene was not associated with classical cardiovascular risk factors (diabetes, hypercholesterolaemia, hypertension, obesity, smoking and C-reactive protein serum levels). No association was found between the CFH-Y402H variant and susceptibility to MI. Separate analyses in both men and women revealed no gender-specific influence of the gene variant on cardiovascular risk factors or MI. This investigation was unable to replicate the association between the common CFH-Y402H variant and susceptibility to MI in our large Caucasian population which is enriched for genetic factors. We conclude that the CFH-Y402H variant has no relevant risk-modifying effect in our population.     

The discovery of genes implicated in myocardial infarction

Summary.  The era of Genome-Wide Association Studies (GWAS) commenced in 2007 with the study of the Wellcome Trust Case Control Consortium (WTCCC) which for the first time ever showed that risk loci can be identified by scanning the complete genome for sequence variation in large numbers of cases of disease and healthy controls. We and others have expanded on this effort and successfully identified the first 11 risk loci for myocardial infarction (MI) and coronary artery disease (CAD). Studies on quantitative traits provide an alternative approach to identify MI/CAD risk loci. This review captures the early successes in the emerging field of disease genomics.     

Emergency department evaluation of the chest pain patient

The emergency physician must have a high degree of suspicion for myocardial ischemia in patients presenting with no obvious for their chest pain. The role of the emergency physician is to determine a relative risk for each patient and to order the appropriate studies to minimize the risk of missed myocardial infarction as well as to recognize acute ischemia or infarction and manage it aggressively. It is not possible to rule out myocardial ischemia or infarction subjectively. It is the opinion of these authors that some form of further testing should be performed on patients in all categories, except those determined to be at very low risk.     

High-risk carotid plaques identified by CT-angiogram can predict acute myocardial infarction

Prior studies identified the incremental value of non-invasive imaging by CT-angiogram (CTA) to detect high-risk coronary atherosclerotic plaques. Due to their superficial locations, larger calibers and motion-free imaging, the carotid arteries provide the best anatomic access for the non-invasive characterization of atherosclerotic plaques. We aim to assess the ability of predicting obstructive coronary artery disease (CAD) or acute myocardial infarction (MI) based on high-risk carotid plaque features identified by CTA. We retrospectively examined carotid CTAs of 492 patients that presented with acute stroke to characterize the atherosclerotic plaques of the carotid arteries and examined development of acute MI and obstructive CAD within 12-months. Carotid lesions were defined in terms of calcifications (large or speckled), presence of low-attenuation plaques, positive remodeling, and presence of napkin ring sign. Adjusted relative risks were calculated for each plaque features. Patients with speckled (<3 mm) calcifications and/or larger calcifications on CTA had a higher risk of developing an MI and/or obstructive CAD within 1 year compared to patients without (adjusted RR of 7.51, 95%CI 1.26–73.42, P?=?0.001). Patients with low-attenuation plaques on CTA had a higher risk of developing an MI and/or obstructive CAD within 1 year than patients without (adjusted RR of 2.73, 95%CI 1.19–8.50, P?=?0.021). Presence of carotid calcifications and low-attenuation plaques also portended higher sensitivity (100 and 79.17%, respectively) for the development of acute MI. Presence of carotid calcifications and low-attenuation plaques can predict the risk of developing acute MI and/or obstructive CAD within 12-months. Given their high sensitivity, their absence can reliably exclude 12-month events.     

Longevity syndromes: familial hypobeta and familial hyperalpha lipoproteinemia.

Longevity and morbidity and death from myocardial infarction were examined in eight kindreds with familial hypobeta lipoproteinemia and in 18 kindreds with familial hyperalpha lipoproteinemia. Expectation of life for males and females from kindreds with hypobeta lipoproteinemia was 9 and 12 years longer (p less than or equal to 0.002) than that indicated by population statistics for U.S. white populations, whereas expectation of life for males and females from kindreds with hyperalpha lipoproteinemia was 5 and 7 years longer (p less than 0.02). Morbidity from myocardial infarction in 115 living first-degree adult relatives of probands with hypobeta and hyperalpha lipoproteinemia and in 364 living first-degree adult relatives of normolipemic spouse controls were compared. Nonfatal myocardial infarction (MI) was reported for 18 of 364 (5 per cent) relatives of normal spouse controls and in 0 of 115 relatives of hypobeta and hyperalpha subjects (p less than 0.05). The ratios (mean+/-S.E.) of C-LDL to C-HDL in familial hypobeta and hyperalpha lipoproteinemia were 0.79+/-0.06 and 1.21+/-0.06, as compared to 2.41+/-0.12 in a control population (p less than 0.001). If high-density lipoproteins confer protection against development of atherosclerosis, whereas low-density lipoproteins have opposite effects, then we speculate that the low ratio of C-LDL:C-HDL may be related to prolonged longevity and decreased morbidity from myocardial infarction in familial hypobeta and hyperalpha lipoproteinemia.     

速度向量成像评价冠心病介入治疗前后左心室整体收缩功能

目的 探讨速度向量成像(VVI)技术评价冠心病患者整体功能及介入治疗后的变化。方法 选择18例正常成人和22例冠心病患者作为研究对象。在VVI成像模式下采集标准经胸心尖四腔观、二腔观和胸骨旁二尖瓣尖、心尖水平的左室短轴二维动态图像。所有冠心病患者分别于经皮冠状动脉介入治疗(PCI)前1d及治疗后1周、1个月、3个月时采集图像,应用VVI软件测量左室旋转运动的心底、心尖旋转角度、旋转速率,计算左室扭转角度和扭距等整体运动信息。结果 心肌梗死组左室射血分数(LVEF)和左室扭矩(Ptor)均低于正常人和非心肌梗死组。PCI术后心肌梗死组和非心肌梗死组的LVEF均逐渐改善,心尖旋转角度、心尖旋转速率、左室扭转角度和Ptor变化趋势却相反：前者为术后1周或1个月内增高,术后3个月降低的趋势;后者为术后1周降低,术后1个月、3个月又逐渐增高的趋势。结论 VVI技术能定量评价左室扭转运动。与LVEF相比,左室扭转和扭矩更能体现两组冠心病患者在冠脉再通后左室整体收缩功能恢复过程中的不同特点。     

Assessing the clinical and economic burden of coronary artery disease: 1986-1998

BACKGROUND: The acute phase of coronary artery disease (CAD) is dramatic and receives much attention because of its high mortality and associated treatment cost. However, the acute phase typically resolves within 30 days whereas CAD is a chronic disease, which most patients will live with for more than a decade. We compared the clinical and economic burden of CAD during the acute phase (first 30 days) with that in the postacute phase (31st day through 10 years). METHODS: We included acute coronary syndrome (ACS) patients with significant CAD receiving an initial cardiac catheterization at Duke University Medical Center between 1986 and 1997 with follow-up continuing through 1998. Inpatient medical costs were estimated from ACS clinical trial and economic study data. Costs were adjusted to 1997 values and discounted at 3% per annum. RESULTS: Our study included 9,876 ACS patients (5,557 with an acute myocardial infarction [MI] and 4,319 with unstable angina [UA]). Acute MI patients had higher 30-day mortality than UA patients (5.6% vs. 2.3%, P <0.001). In addition, acute MI and UA patients had significant 10-year unadjusted and adjusted survival differences (both P <0.001). For patients who survived to 30 days, there was no difference in 10-year survival between acute MI and UA patients before adjustment (P = 0.472). After adjustment, however, unstable angina patients who survived to 30 days had greater survival than myocardial infarction patients (P = 0.011). Mean 10-year discounted ACS inpatient medical costs were $45,253 ($23,510 acute phase and $21,819 postacute phase, P = 0.002). Ten year costs for unstable angina patients were $46,423 ($21,824 acute phase and $24,599 postacute phase, P = 0.003); ten year costs for myocardial infarction patients were $44,663 ($24,823 acute phase and $19,840 postacute phase, P <0.001). CONCLUSIONS: We found that the clinical and economic burden of CAD continues long after a patient's acute event has resolved and that postacute CAD cardiac event rates and inpatient medical costs may be higher than previously estimated. With much of all medical costs occurring in the postacute phase, the potential for effective secondary prevention therapies is substantial.