慢性贫血对冠心病患者血运重建术后院内结果的影响

目的评价慢性贫血对冠心病患者血运重建术后院内临床结果的影响。方法选择2002年7月—2004年6月在首都医科大学附属北京安贞医院接受血运重建治疗（经皮冠状动脉介入治疗或冠状动脉旁路移植术）的3679例患者,按照世界卫生组织确定的贫血标准（血红蛋白：男性〈120g/L,女性〈110g/L）将患者分为贫血和非贫血两组。比较两组患者血运重建术后院内不良心脑血管事件（MACCE）的发生率（包括全因死亡、新发心肌梗死、卒中和再次血运重建）,并分析其可能的原因。结果3679例患者中有贫血患者426例（占11.6%）,非贫血患者3253例（占88.4%）。贫血组与非贫血组分别有10例（2.4%）和64例（1.9%）发生院内死亡（P〈0.05）;贫血组院内MACCE的发生率明显高于非贫血组（4.2%比3.2%,P〈0.05）,但两组新发心肌梗死（0.7%比0.6%）、卒中（1.2%比0.4%）和再次血运重建（0比0.2%）的发生率差异无统计学意义（P均〉0.05）。结论合并贫血的冠心病患者较非贫血患者血运重建术后院内MACCE发生率增加,其中全因病死率的增加更为显著。     

Coronary reoperation with and without cardiopulmonary bypass

Summary Redo coronary artery bypass grafting (CABG) is still associated with increased morbidity and mortality compared to primary operation. Myocardial protection is one of the key issues in redo on pump CABG and is still a matter of debate. Off pump redo CABG seems to be an attractive alternative as native coronary blood flow remains and cross clamping of the aorta is avoided. The aim of this retrospective study was to compare the outcome of redo CABG with and without CPB. From 1/1998 to 5/2004 redo CABG was performed in 195 patients (pts): 162 male (83.1%) and 33 female (16.9%) pts, age 66±9 years. In 160 pts, CPB with isolated antegrade myocardial protection was used for redo CABG. Off pump redo CABG was performed in 35 pts (30 male (85.7%) and 5 female (14.3%), age 67±8 years). Perioperative overall mortality rate was 3.6% (n=7) and comparable in both groups (on pump 3.8% versus off pump 2.9%; p=0.90), as well as perioperative myocardial infarction, intraaortic balloon pump implantation rate and secondary morbidity. Complete revascularization was achieved in 139 pts (86.9%) after on pump CABG and in 17 pts (48.6%) of the off pump group (p<0.01). The average number of grafts was significantly higher in the on pump group (2.8±0.78 versus 1.6±0.6; p=0.04). Furthermore, 20 pts (12.5%) in the on pump group died during follow-up (50±16 months). Five pts (25.0%) died due to cardiac reasons. In the off pump group 3 pts (8.6%) died during follow-up (44±13 months), noncardiac related. Overall survival was 83.8% in the on pump group and 88.6% in the off pump group (p=0.92). On pump redo CABG and off pump redo CABG can be safely performed with low mortality and morbidity. Off pump redo CABG might be limited due to incomplete revascularization.     

Best way to revascularize patients with main stem and three-vessel lesions. Patients should be operated!

Despite established guidelines for the treatment of coronary artery disease (CAD) by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI), everyday clinical practice has proven to differ substantially with even the most complex coronary lesions being targeted by PCI today. However, an abundancy of clinical trials, both observational and randomized has proven the superiority of coronary surgery over PCI in almost every type of multivessel or left main CAD in symptomatic patients. This holds true also for ‘hard’ endpoints like cardiac death or myocardial infarction as recently demonstrated by the landmark SYNTAX trial. These results have lead to the wording of appropriateness criteria, which integrate current guidelines, evidence from clinical trials and interdisciplinary expert opinion and which express essentially the same message as the SYNTAX trial: “CABG remains the standard of care for patients with three-vessel or left main coronary artery disease” (Serruys et al. in N Engl J Med 360:961–972, 2009).     

SYNTAX积分评估冠状动脉2支病变患者经皮冠状动脉介入术后预后的研究

目的评价SYNTAX积分对冠状动脉2支病变患者经皮冠状动脉介入术后临床预后的预测价值。方法行经皮冠状动脉介入术的冠状动脉2支病变的冠心病患者156例,根据冠状动脉造影结果按SYNTAX积分系统进行评分,并依据SYNTAX积分分为低分组（SYNTAX积分≤22分）65例、中分组（SYNTAX积分为23-32分）49例和高分组（SYNTAX积分≥33分）31例。观察3组临床主要不良心脑血管事件（major adverse cardiac and cerebral event,MACCE）发生率,采用Cox比例风险模型分析SYNTAX积分与冠状动脉2支病变患者经皮冠状动脉介入术术后MACCE发生的关系。结果 145例患者完成随访,随访率92.9%,随访时间（15.8±5.2）个月;所有患者SYNTAX积分为10-51（25.3±10.7）分;低分组、中分组和高分组患者经皮冠状动脉介入术术后MACCE发生率分别为4.6%、10.2%和22.6%,组间比较差异均有统计学意义（P〈0.05）;多因素分析结果显示SYNTAX积分是冠状动脉2支病变患者经皮冠状动脉介入术术后MACCE发生的独立预测因素（HR=1.05,95%CI：1.01-1.09,P=0.017）。结论SYNTAX积分对冠状动脉2支病变患者经皮冠状动脉介入术术后的临床预后有预测意义,SYNTAX积分增加,临床MACCE发生率升高。     

左心室功能不全冠心病患者支架术与冠状动脉旁路移植术的对比研究

目的 比较左心室功能不全的冠心病患者经皮冠状动脉介入治疗(PCI)支架术与冠状动脉旁路移植术(CABG)对住院与临床随访结果的影响.方法 147例左心室功能不全的冠心病患者,根据血运重建方式的不同将其分为PCI组(60例)和CABG组(87例),记录其,临床与冠状动脉造影特征、血运重建情况和住院,临床结果等资料,并进行临床随访.主要观察终点为住院与随访主要不良心脑血管事件(MACCE)(包括全因死亡、新发心肌梗死、卒中和再次血运重建).所有资料采用SPSS 13.0软件进行统计分析,以P＜0.05为差异有统计学意义.结果 PCI组和CABG组相比,院内MACCE发生率差异无统计学意义(1.7%与9.2%,P＞0.05);院内病死率差异无统计学意义(1.7%与8.0%,P＞o.05).多因素Logistic回归分析表明,院内MACCE风险相当(OR=3.03,95%C/0.27～34.48,P＞0.05).平均随访22个月(中位数时间668 d)显示,2组MACCE发生率差异无统计学意义(16.0%与13.8%,P＞0.05),再次血运重建差异均无统计学意义(8.0%与1.7%,P＞0.05).多因素Cox回归分析显蟊,2组随访MACCE风险基本相当(HR=1.35,95%CI 0.44～4.13,P＞0.05).结论 合并左心室功能不全的冠心病患者,PCI支架术与CABG的住院及随访MACCE发生率均相当.随着药物洗脱支架的广泛应用,PCI术的远期效果有望进一步提高.     

残存SYNTAX评分对311例冠心病PCI患者长期预后评价

目的 评价残存SYNTAX评分对冠心病经皮冠状动脉介入治疗（percutanous coronary intervention,PCI）患者长期预后的预测能力。 方法 连续入选2013年1月至2014年5月于内蒙古自治区人民医院心内科一病区住院冠心病并行PCI患者311例,收集性别、年龄、临床诊断、血脂、肾功能等临床资料,进行SYNTAX评分和残存SYNYTAX评分,同时进行2~4年临床随访,随访不良心脑血管事件（MACCE）,包括全因死亡、卒中、血运重建、心力衰竭。 结果 311例患者发生MACCE 48例,其中全因死亡14例;再次血运重建23例;缺血性卒中9例;心力衰竭2例。MACCE组与无MACCE组比较年龄大（64.13±8.45岁 vs 60.79±10.12岁,P=0.03）、糖尿病患者比例高（39.58% vs 18.63%,P=0.001）、SYNTAX评分高（15.16±6.53 vs 12.94±7.44,P=0.017）和残存SYNTAX评分高（7.52±6.54 vs 4.23±5.50,P=0.000)。SYNTAX评分、残存SYNTAX 评分、目测冠状动脉病变预测终点事件的曲线下面积分别为0.608（P=0.018）、0.665(P=0.000)、0.668(P=0.000)。完全血运重建组与不完全血运重建组MACCE发生率分别为5.98%和20.42%(P=0.003),两组再次血运重建率分别为0.85%和12.37%(P=0.000)。糖尿病患者和非糖尿病患者SYNTAX评分为15.09±7.69和12.78±7.17(P=0.026),残存SYNTAX评分为6.15±6.32和4.34±5.57(P=0.016)。糖尿病患者和非糖尿病患者MACCE发生率分别为27.9%和11.8%(P=0.001),再次血运重建率分别为19.1%和4.9%(P=0.000)。 结论 ①冠心病PCI患者完全血运重建优于不完全血运重建,残存冠状动脉病变越多MACCE发生率越高。②残存SYNTAX评分、SYNTAX评分和冠状动脉病变均能预测长期预后。③糖尿病患者冠状动脉病变程度重,MACCE发生率高,主要原因是再次血运重建。     

左心室射血分数≤40%冠心病患者不同血运重建策略的比较

目的 探讨左心室射血分数(LVEF)≤40%的冠心病患者接受经皮冠状动脉介入治疗术(PCI)或冠状动脉旁路移植术(CABG)两种不同血运重建策略的效果.方法 将196例LVEF≤40%的冠心病患者分为PCI和CABG组.回顾性比较其临床资料、血运重建情况、药物治疗效果、院内及随访不良心血管事件(MACCE),并进行生存分析.结果 寿命表法示PCI组与CABG组30 d生存率(96%与94%)、1年生存率(95%与92%)、2年生存率(93%与87%)相似,并且2组COX生存曲线差异无统计学意义(P=0.249);PCI组与CABG组30 d无MACCE事件生存率(92%与92%)、1年无MACCE事件生存率(86%与88%)相似,而CABG组2年无MACCE事件生存率略高于PCI组(83%与72%),但2组COX无MACCE事件生存曲线差异无统计学意义(P=0.662).结论 LVEF≤40%患者接受PCI治疗可以取得与接受CABG治疗相似的急性期和长期生存率.     

Best way to revascularize patients with main stem and three vessel lesions: patients should undergo PCI!

The optimal revascularization strategy for multivessel disease is under controversial discussion for long time. Until now, technical innovations have been faster than performance of clinical trials, making results of randomized studies outdated at the time of appearance. Recently, the SYNTAX trial has been published, which compared drug elutings stents (DES) implantation with Coronary artery bypass graft (CABG) patients with multivessel or left main disease in a clinically stable population. Overall, CABG was superior with respect to the clinical endpoint of death, myocardial infarction, stroke, or revascularization. However, the difference is driven by the “weakest” end point, namely repeated revascularization, whereas combined “hard” events did not demonstrate a difference. More detailed analysis demonstrates that only patients with most complex coronary anatomy gain definite benefit from CABG. In addition, SYNTAX demonstrated that left main disease is no longer a domain of CABG, since DES implantation revealed comparable results, as long as there is no concomitant multivessel disease. Regardless the results of SYNTAX, one should not forget that SYNTAX represents only a minority of daily patients in a catheterization laboratory, excluding patients with one- or two-vessel disease and those with an acute coronary syndrome. Especially in the latter, percutaneous coronary intervention has demonstrated to improve prognosis.     

Coronary surgery for acute coronary syndrome: which determinants of outcome remain?

BACKGROUND: The mortality risk associated with coronary artery bypass grafting (CABG) after acute myocardial infarction remains controversial. The objective of the present study was therefore to analyze the outcome and predictors of in-hospital mortality in patients (pts) referred to CABG with acute coronary syndrome (ACS). PATIENTS AND METHODS: Between January 2003 and May 2005, a total of 3,127 pts underwent primary isolated CABG at our institution, including 220 pts with ACS. Out of these, unstable angina pectoris was present in 88 pts (group I), 97 pts (group II) had non-ST-elevation infarction, whereas 35 pts (group III) had ST-elevation infarction. Clinical data, in-hospital morbidity and mortality were recorded and studied retrospectively. RESULTS: Overall in-hospital mortality was 6.4% (n = 14) in the complete cohort, being 2.2% in group I (n = 2), 9.2% in group II (n = 9) and 8.5% (n = 3) in group III (P < 0.05). Logistic regression and receiver operating characteristic analyses identified age, NYHA, ejection fraction < 45%, catecholamine support, cardiogenic shock, renal disease and the additive EuroSCORE > 10 (P < 0.0001) as significant predictors related to in-hospital mortality. The mean time from the onset of symptoms to revascularization differed significantly between survivors (5.1 +/- 2.7 h) and no survivors (11.4 +/- 3.2 h) (P < 0.0007) in the STEMI group. Preoperative cTnI did not provide any prognostic information. CONCLUSION: CABG in pts with ACS can be performed with good clinical results. The clinical outcome is particular depending on the different groups of ACS. Therefore an individual risk stratification of each pts in ACS is necessary. The time interval of 6 h seems to be crucial as prognostic variable in the STEMI-group.     

主动脉内球囊反搏在急性心肌梗死并发心源性休克中的应用

目的　评价主动脉内球囊反搏 (IABP)对急性心肌梗死合并心源性休克患者在不同血管再通治疗中的疗效和短期生存的影响。方法　回顾性分析了 10 8例接受IABP治疗的急性心肌梗死合并心源性休克患者 ,分别分析了溶栓治疗组、介入治疗组和冠脉搭桥 (CABG)手术治疗组患者的基本特征和血流动力学情况 ,并比较IABP治疗对住院病死率和 30d病死率的影响。结果　患者的基本特征包括年龄、冠心病的危险因子等在各组间差异无显著性意义 (P >0 0 5 ) ,但手术治疗组的男性患者显著少于其它两组 (P <0 0 5 ) ;IABP治疗前血流动力学状态各组间也无显著性意义 ,住院病死率和 30d病死率手术治疗组均显著低于溶栓组和介入组 ,分别为 18 9%、 6 2 8%和 6 0 7% ,16 2 %、 6 0 5 %和 6 0 7% ,P值均 <0 0 0 1。结论　IABP支持下进行CABG治疗可显著减低心肌梗死合并心源性休克患者的近期死亡率 ,且显著优于溶栓治疗和介入治疗     

Intramyocardial dissecting hematoma in anterior wall ST elevation myocardial infarction: impact on left ventricular remodeling and prognosis

Intramyocardial dissecting hematoma is an uncommon complication of myocardial infarction potentially leading to cardiac rupture. The aim of the present study was to investigate coronary reperfusion results, left ventricular (LV) function recovery and remodeling and clinical outcomes in patients with anterior STEMI complicated by intramyocardial hematoma. We prospectively studied 87 patients (mean age 59?±?10 years; 88% male) with anterior STEMI (42 with intramyocardial hematoma) in order to evaluate coronary reperfusion results, LV remodeling (≥15% increase in end-systolic volume) and clinical outcomes (cardiac death, non-fatal reinfarction, and hospitalization for congestive heart failure) at 24 months. Thrombolysis in myocardial infarction (TIMI) flow score and myocardial blush grade (MBG) were assessed both pre- and post-percutaneous coronary intervention (PCI) and speckle-tracking echocardiography was performed post PCI and at 6-month follow-up. Patients with hematoma had lower post-PCI TIMI score and MBG, higher heart rate, worse LV ejection fraction and longitudinal or rotational function than their counterparts. LV remodeling occurred in 33 (78.6%) patients with hematoma and 11 (24.4%) patients without (p?<?0.001). Independent predictors of LV remodeling were heart rate (p?=?0.018), MBG (p?=?0.036) and presence of hematoma (p?<?0.001). Hematoma (log-rank test, χ²?=?9.849; p?=?0.002) and LV remodeling (log-rank test, χ²?=?13.770; p?<?0.001) were associated to a higher rate of adverse events. Cox analysis identified LV remodeling as the only independent predictor of adverse events (hazard ratio?=?3.912; 95% confidence interval, 1.429–10.714; p?=?0.008). Intramyocardial dissecting hematoma complicating anterior STEMI is an independent determinant of LV remodeling and is associated to poor prognosis.     

A prospective randomized trial comparing stenting to internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis: the SIMA trial. Stenting vs Internal Mammary Artery

OBJECTIVE: To compare coronary artery bypass grafting (CABG) with percutaneous transluminal coronary angioplasty (PTCA) in patients with proximal, isolated de novo left anterior descending coronary artery disease and left ventricular ejection fraction of 45%. PATIENTS AND METHODS: In the multicenter Stenting vs Internal Mammary Artery (SIMA) study, patients were randomly assigned to PTCA and stent implantation or to CABG (using the internal mammary artery). The primary clinical composite end point was event-free survival, including death, myocardial infarction, and the need for additional revascularization. Secondary end points were functional class, antianginal treatment, and quality of life. Analyses were by intention to treat. RESULTS: Of 123 patients who accepted randomization, 59 underwent CABG, and 62 were treated with stent implantation (2 patients were excluded because of protocol violation). At a mean +/- SD follow-up of 2.4+/-0.9 years, a primary end point had occurred in 19 patients (31%) in the stent group and in 4 (7%) in the CABG group (P<.001). This significant difference in clinical outcome is due to a higher incidence of additional revascularization in the stent group, the incidence of death and myocardial infarction being similar (7% vs 7%, respectively; P=.90). The functional class, need for antianginal drug, and quality-of-life assessment showed no significant differences. CONCLUSIONS: Both stent implantation and CABG are safe and highly effective treatments to relieve symptoms in patients with isolated, proximal left anterior descending coronary artery stenosis. Both are associated with a low and comparable incidence of death and myocardial infarction. However, similar to PTCA alone, a percutaneous approach using elective stent placement remains hampered by a higher need for repeated intervention because of restenosis.     

Long-term follow-up after coronary stenting with the sirolimus-eluting stent in clinical practice: results from the prospective multi-center German Cypher Stent Registry

Aims

To obtain long-term follow-up data of the sirolimus-eluting coronary stent (SES) and to determine factors associated with clinical events and target vessel revascularization (TVR).

Methods and results

Between 2002 and 2005, 5,946 patients were treated with at least one SES. A follow-up after a median of 4.1?years was obtained in 5,247 patients (88.2?%). During the follow-up, death occurred in 9.2?% of patients, nonfatal myocardial infarction in 5.9?%, nonfatal stroke in 2.2?% and MACCE (death/myocardial infarction/stroke) in 16.3?%. Any TVR was performed in 20.3?%. Independent predictors of MACCE were: older age (p?p?p?p?p?=?0.0002), three-vessel disease (p?=?0.0012), reduced left ventricular function (p?=?0.0048), target vessel?=?bypass graft (p?=?0.0122), indication for treatment?=?ACS (p?=?0.0181) and PCI before implantation (p?=?0.0308). Independent predictors of TVR were target vessel?=?coronary bypass (<0.0001), two- or three-vessel disease (p?p?p?=?0.0012) and older age being a protective factor (p?=?0.0187).

Conclusions

Long-term follow-up of the SES in clinical practice showed clinical event rates that were comparable to randomized trials with a MACCE rate of 16.3?% and TVR rate of 20.3?%.     

国产药物涂层支架用于CABG术后冠状动脉再次血管重建及1年随访结果分析

目的 评估国产药物涂层支架( drug-eluting stent,DES)治疗冠状动脉旁路移植术(coronary artery bypass graft,CABG)后心肌缺血患者的疗效,明确相关因素对植入国产DES术后主要心脑血管不良事件(major adverse cardiovascular and cerebral events,MACCE)发生率的影响。方法 入选2008年9月至2009年10月于北京安贞医院接受国产DES治疗的CABG术后病例83例,随访1年,观察国产DES植入治疗CABG术后心肌缺血患者的疗效,并利用Logistic回归分析相关因素与MACCE的相关性。结果 国产DES植入手术成功率97.5％,随访结果显示10例患者发生MACCE (12.0％),其中死亡1例(1.2％),缺血性脑中风l例(1.2％),心肌梗死l例(1.2％),再次血管重建8例(9.6％),靶病变重建l例(1.2％)。结论 国产DES植入治疗CABG后心肌缺血患者安全,近中期疗效良好,血栓发生率低。罪犯血管完全血管重建是MACCE的独立预测因子。     

Pre-procedural renal resistive index accurately predicts contrast-induced acute kidney injury in patients with preserved renal function submitted to coronary angiography

The study aimed to evaluate the clinical utility of ultrasonographic intra-renal blood flow parameters, together with the wide range of different risk factors, for the prediction of contrast-induced acute kidney injury (CI-AKI) in patients with preserved renal function, referred for coronary angiography or percutaneous coronary interventions (CA/PCI). This prospective study covered 95 consecutive patients (69.5% men; median age 65 years) subject to elective or urgent CA/PCI. Data regarding 128 peri-procedural variables were collected. Ultrasonographic intra-renal blood flow parameters, including renal resistive index (RRI) and pulsatility index (RPI), were acquired directly before the procedure. CI-AKI was defined as ≥50% relative or ≥0.3 mg/dL absolute increase of serum creatinine 48 h after procedure. CI-AKI was confirmed in nine patients (9.5%). Patients with CI-AKI had higher SYNTAX score (p?=?0.0002), higher rate of left main disease (p?<?0.00001), peripheral artery disease (PAD; p?=?0.02), coronary artery anomaly (p?=?0.017), more frequently underwent surgical revascularization (p?=?0.0003), ‘had greater...’ intima-(p?=?0.004) and extra-medial thickness (p?=?0.001), and received higher contrast media dose (p?=?0.049), more often overused non-steroidal anti-inflammatory drugs (p?=?0.001), and had substantially higher pre-procedural RRI (0.69 vs. 0.62; p?=?0.005) and RPI values (1.54 vs. 1.36; p?=?0.017). Logistic regression confirmed age, SYNTAX score, presence of PAD, diabetes mellitus, and pre-procedural RRI independently predicted CI-AKI onset (AUC?=?0.95; p?<?0.0001). Pre-procedural RRI?>?0.69 had 78% sensitivity and 81% specificity in CI-AKI prediction. High pre-procedural RRI seems to be a useful novel risk factor for CI-AKI in patients with preserved renal function. Coronary, peripheral and renal vascular pathology contribute to the development of CI-AKI following CA/PCI.     

非酒精性脂肪肝对急性心肌梗死患者预后的影响

目的探讨急性心肌梗死(acute myocardial infarction, AMI)并发非酒精性脂肪肝(non-alcoholic fatty liver disease, NAFLD)患者血脂、血清炎性因子水平变化,及NAFLD对AMI预后的影响。方法 AMI患者712例,其中350例有NAFLD者为观察组,362例无NAFLD者为对照组。比较2组入院时年龄,性别比例,体质量指数(body mass index, BMI),合并高血压、2型糖尿病情况,ST段抬高型心肌梗死(ST-segment elevation myocardial infarction, STEMI)及非STEMI比率,冠状动脉病变支数,行经皮冠状动脉介入术(percutaneous coronary intervention, PCI)比率,药物治疗情况以及血清肌钙蛋白I(cardiac troponin I, cTnI)、尿酸(uric acid, UA)、同型半胱氨酸(homocysteine, Hcy)、C反应蛋白(C-reactive protein, CRP)、总胆固醇(total cholesterol, TC)、三酰甘油(triacylglycerol, TG)、高密度脂蛋白胆固醇(high-density lipoprotein cholesterol, HDL-C)、低密度脂蛋白胆固醇(low-density lipoprotein cholesterol, LDL-C)、白细胞计数(white blood cell count, WBC),D-二聚体(D-dimer, D-D)、血小板/淋巴细胞比值(platelet lymphocyte ratio, PLR);随访观察主要心脑血管不良事件(major cardiovascular and cerebrovascular adverse events, MACCE)发生率及生存时间;Pearson相关分析SYNTAX积分与UA等指标的相关性。结果观察组BMI[(29.00±1.41)kg/m^2]、合并2型糖尿病比率(60.57%)、SYNTAX积分[(24.50±2.37)分]及血清TC[(5.67±0.63)mmol/L]、TG[(2.31±0.27)mmol/L]、LDL-C[(3.13±0.51)mmol/L]、UA[(502.20±31.51)μmol/L]、Hcy[(16.91±1.85)μmol/L]、CRP[(22.30±0.37)mg/L]、WBC[(13.08±2.09)×10^9/L]、D-D[(1.36±0.32)g/L]、PLR(191.34±8.15)均高于对照组[BMI:(27.00±1.69)kg/m^2,合并糖尿病比率:41.99%,SYNTAX积分:(19.60±3.95)分,TC:(5.02±0.35)mmol/L,TG:(1.91±0.40)mmol/L,LDL-C:(2.38±0.55)mmol/L,UA:(446.20±51.08)μmol/L,Hcy:(13.63±1.50)μmol/L,CRP:(13.20±0.33)mg/L,WBC:(11.16±0.98)×10^9/L,D-D:(0.95±0.26)g/L,PLR:158.85±8.35](P<0.05);2组年龄,性别比例,合并高血压比率,冠状动脉病变支数,STEMI、非STEMI、PCI比率,阿司匹林等药物应用比率,血清HDL-C、cTnI水平比较差异无统计学意义(P>0.05);观察组MACCE发生率(9.71%)高于对照组(5.52%)(P<0.05),中位生存时间(14.5个月)较对照组(15.4个月)短(P<0.05);Pearson相关分析显示,SYNTAX积分与UA(r=0.876,P<0.001)、Hcy(r=0.736,P<0.001)、CRP(r=0.278,P=0.038)、TC(r=0.644,P<0.001)、TG(r=0.641,P<0.001)、LDL-C(r=0.633,P<0.001),BMI(r=0.599,P<0.001)、PLR(r=0.456,P<0.001)均呈正相关。结论 NFALD可能加剧AMI患者炎性反应,增高血脂,加重冠状动脉血管狭窄程度,增加MACCE发生率,影响AMI患者预后。     

Efficacy and Safety of Different Antiplatelet Strategies in Survivors of Myocardial Infarction With Acute Coronary Syndrome

PurposeMany patients with acute coronary syndrome may experience recurrent myocardial infarction although they are receiving optional therapy, but they are still associated with poor clincial outcomes. The goal of this study was to assess different antiplatelet strategies in these patients.MethodsThis retrospective trial compared ticagrelor (180-mg loading dose, 90-mg BID maintenance dose) and clopidogrel (300- to 600-mg loading dose, 150-mg daily maintenance dose) for the prevention of cardiovascular events in 1083 patients with acute coronary syndrome and recurrent myocardial infarction admitted to the hospital undergoing percutaneous coronary intervention.FindingsAt the 24-month follow-up, a major adverse cardiovascular and cerebrovascular event (MACCE) occurred in 10.5% of patients receiving ticagrelor compared with 13.2% in the clopidogrel group (P = 0.023). Meanwhile, ticagrelor caused a higher rate of minor bleeding (18.1% vs 15.3%; P = 0.008). A survival analysis showed that ticagrelor decreased the incidence of MACCE (log-rank test, P < 0.001) and all-cause death (log-rank test, P = 0.001). The advantage of ticagrelor was also presented according to analysis of Seattle Angina Questionnaire scores.ImplicationsIn patients with recurrent myocardial infarction, the ticagrelor antiplatelet strategy significantly reduced the MACCE rate without increasing the risk of major bleeding, although patients did have a higher risk of minor bleeding.     

Comparison of SYNTAX score II efficacy with SYNTAX score and TIMI risk score for predicting in-hospital and long-term mortality in patients with ST segment elevation myocardial infarction

SYNTAX score II (SS-II) has a powerful prognostic accuracy in patients with stable complex coronary artery disease who have undergone revascularization; however, there is limited data regarding the prognosis of patients with ST segment elevation myocardial infarction (STEMI). The aim of this study is to examine both the predictive performance of SS-II in determining in-hospital and long term mortality of STEMI patients and to compare SYNTAX score (SS) and TIMI risk score (TRS). Consecutive 1912 STEMI patients treated with primary percutaneous coronary intervention (p-PCI) retrospectively reviewed, and the remaining 1708 patients constituted the study population after exclusion. The patients were divided into three groups according to increased SS-II value: low (n:562; SS-II?≤?24.6); intermediate (n:563; 24.6?<?SS-II?<?34.4); and high tertile (n:583; SS-II?≥?34.4). In-hospital and long term mortality rate from all causes (0 vs. 0.5 vs. 10.6% and 1.8 vs. 3.2 vs. 18.1% respectively, p?≤?0.001) were significantly increased with SS-II tertiles and SS-II was found to be independent predictor of in-hospital and long term mortality (HR: 1.076 95% CI 1.060–1.092, p?<?0.001) and (HR: 1.070 95% CI 1.050–1.090, p?<?0.0001). The predictive power of SS-II, SS, and TRS were compared by ROC curve and decision curve analysis. SS-II surpassed SS and TRS in long-term and in-hospital mortality prediction. SS-II is a powerful tool to predict in-hospital and long-term mortality from all causes in STEMI patients treated with p-PCI.     

Dipyridamole stress echocardiography stratifies outcomes of asymptomatic patients with recent myocardial revascularization

Background Patients with previous myocardial revascularization, even if symptom-free, remain at risk of subsequent cardiac events, so that a non-invasive tool able to stratify this population is wishful. Objectives To assess the prognostic value of dipyridamole stress echocardiography (DipSE) in a population of asymptomatic patients following complete myocardial revascularization, either by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Methods We retrospectively evaluated 104 consecutive symptom-free patients (mean age 67 ± 9.3 years, 75 males) with recent (<12 months) complete myocardial revascularization (48% PCI, 52% CABG) undergoing DipSE. Ischemia was defined as the onset of a new or worsening wall motion abnormality during DipSE. The composite end point of the study was cardiac death and non-fatal acute coronary syndrome. Results Myocardial ischemia was identified in 23 patients (22.1%). During a mean follow up of 21 months, 7 (30.4%) out of these patients suffered cardiac events. Among the remaining 81 patients (77.9%) with negative DipSE results, 7 (8.6%) experienced cardiac events. At multivariable analysis only a positive DipSE (odds ratio 3.9, P = 0.03), wall motion score index at peak of stress (OR 3.6, P = 0.04) and a prior myocardial infarction (odds ratio 3.5, P = 0.04) achieved statistical significance for cardiac events. Moreover, DipSE effectively stratified patients into a high and low risk group according to presence of inducible ischemia (event rate per year 16% vs 4.8%, P = 0.02). Conclusions DipSE yields appropriate risk stratification and provides incremental prognostic value over clinical variables even in asymptomatic patients with prior complete myocardial revascularization. A negative DipSE portends a benign prognosis (<5% event rate/year) in such population.