他汀类药物在急性冠状动脉综合征的早期应用

急性冠状动脉综合征（acute coronary syndrome,ACS）是冠心病的严重临床类型,是导致冠心病患者死亡和致残的主要原因,其病理基础是冠状动脉内不稳定的动脉粥样斑块出血或破裂,血管内皮损伤,血栓形成,动脉腔迅速出现严重的狭窄或堵塞。研究发现ACS早期使用他汀类降脂药物（羟甲基戊二酸单酰辅酶A还原酶抑制剂）,可使患者心血管事件复发（如再缺血、再梗死）危险性迅速减少及死亡率降低,并能改善患者长期服药的依从性,     

早期强化他汀类药物对急性冠脉综合征的影响

急性冠状动脉综合征（acute coronary svndrome．ACS）是在冠状动脉粥样硬化斑块破裂基础上继发血栓形成而引起的一组急性缺血性心脏病,包括不稳定型心绞痛（UAP）、非sT段抬高型心肌梗死（NSTEMI）、ST段抬高型心肌梗死（STEMI）和缺血性心脏猝死。ACS是目前发达国家和我国致死、致残的主要疾病之一。     

他汀类药物的安全性

近 30年来 ,一系列大规模临床试验证实 :药物性降脂治疗是冠心病一、二级预防的有效措施 ,他汀类是目前惟一能降低冠心病患者病死率和致残率的降脂药物。但理想的降脂药物不仅要有效调脂 ,同时应具有良好的安全性。我们就他汀类药物副作用、发生机制、预后作一简要概述。一、他汀类药物的药代动力学特点[1]见表 1。二、不良反应的临床表现及诊断(一 )临床表现消化系统 :消化不良、恶心、腹痛、轻微胃肠道症状 ,并有ＡＬＴ或ＡＳＴ升高 ;神经系统 :失眠、头痛、视觉障碍 ;泌尿系统 :肾功能衰竭 ;肌肉毒性 :肌磷酸激酶升高、肌痛、肌触痛、肌…     

他汀类药物的非降脂作用

他汀类药物的临床试验显示心血管终点和冠脉狭窄的改善 ,不能完全由基础或治疗后低密度脂蛋白 ( LDL) - C水平来解释 (表 1 )。他汀类药物对冠心病 ( CHD)事件的有益作用可能涉及下述的非降脂作用机制 :1改善内皮功能 ;2抗炎症反应 ;3脂质核的去除和斑块生理化学特性的稳定 ;4加强纤维帽 ;5抑制血小板血栓形成和沉积 ;6减少血栓形成的反应。表 1　他汀类药物对心血管事件减少和 L DL - C下降的作用临床试验药物 剂量(mg/d)样本大小(例 )基础LDL(mmol/L )L DL下降(% )治疗组LDL(mmol/L )CHD事件减少(% )4S 辛伐他汀 2 0～ 40 444 …     

他汀类药物在急性冠脉综合征中的非降脂作用

20世纪90年代进行的他汀类药物试验充分肯定了降脂治疗的临床益处,长期应用具有良好的安全性.本文就他汀类药物的非降脂作用(如稳定斑块、改善内皮功能、减少炎症反应和抑制血栓形成等),在急性冠脉综合征中的应用作一综述.     

急性冠脉综合征患者早期他汀类药物强化或常规降脂疗效比较

如众所知 ,他汀类药物治疗能降低心血管事件危险。然而 ,目前关于心血管病患者低密度脂蛋白胆固醇 (LDL C)最佳靶目标值 ,以及进一步强化降低LDL C可否增加裨益作用均未清楚。本文就早期他汀类药物强化或常规降脂对急性冠脉综合征 (ACS)患者预后影响的可能差异进行了分析。受试     

论急性冠状动脉综合征他汀类药物早期应用的益处

急性冠状动脉综合征 (ａｃａｔｅｃｏｒｏｎａｒｙｓｙｎｄｒｏｍｅｓ ,ＡＣＳ)如心肌梗死、不稳定性心绞痛为发达国家及我国人群致死致残主要原因之一。动脉粥样硬化(ａｔｈｅｒｏｓｃｌｅｒｏｓｉｓ ,ＡＳ)是个隐匿发展的慢性过程 ,为发生ＡＣＳ的基本原因。现有充分证据说明ＡＳ病人发生ＡＣＳ的关键因素为冠状动脉内粥样斑块破裂。ＨＭＧ ＣｏＡ还原酶抑制剂 (他汀类 )具有明显的抗ＡＳ、降低ＡＣＳ发生的效应。一、动脉粥样硬化的形成和急性冠状动脉综合征粥样斑块的特点动脉粥样硬化的发生发展是复杂的动态过程。始动步骤很可能是动脉…     

他汀类药物对冠心病强化降脂的研究进展

血脂异常在动脉粥样硬化（AS）、冠心病（CAD）发生发展和导致的心血管事件中起非常重要的作用。强化降脂治疗可显著降低心血管病发病率,也降低总死亡率。     

他汀类药物在急性冠状动脉综合征中抗炎作用的研究进展

［摘要］　急性冠状动脉综合征（ACS）是常见的冠状动脉粥样硬化性心脏病的急症,炎症在动脉粥样硬化过程中起重要作用。3-羟基-3-甲基戊二酰辅酶A还原酶抑制剂他汀类药物现已广泛应用于冠心病的一级、二级预防,越来越多的证据显示他汀类药物具有显著抗炎作用。该文对他汀类药物在ACS中的抗炎作用作一简要的综述。     

他汀类药物安全性再认识

大量研究奠定了他汀类药物在心血管疾病一级和二级预防中不可动摇的地位,强化调脂的理念已经深入临床。大剂量他汀类药物治疗对肝脏和肌肉潜在的不良反应已得到医患的重视,而近年来对他汀类药物肾脏损害、神经系统不良反应、新发肿     

老年人他汀类药物治疗的安全性

血脂异常是心血管疾病明确的危险因素,尽管血脂异常在老年人群中的发生率很高,但对老年人调脂治疗的副作用及安全性的顾虑一直存在.本文讨论了老年人血脂异常的特点、药代动力学和药效动力学的改变,通过一系列的临床研究证据评价他汀类药物在老年人群肝脏、肌肉、肾脏、神经系统和肿瘤发生等方面的安全性.     

阿托伐他汀联合依折麦布治疗急性冠状动脉综合征临床观察

目的观察联合应用阿托伐他汀和依折麦布治疗急性冠状动脉综合征的疗效。方法 306例急性冠状动脉综合征患者随机分为他汀常规剂量组(n=98,阿托伐他汀20 mg/d),他汀加倍剂量组(n=103,阿托伐他汀40 mg/d),联合治疗组(n=105,阿托伐他汀20 mg/d+依折麦布组10 mg/d)。治疗前和治疗24周后检测患者血清总胆固醇(TC)、低密度脂蛋白胆固醇(LDLC)、甘油三酯(TG)水平,并观察各治疗组不良反应和心血管事件的发生情况。结果经24周治疗后,各组TC、TG、LDLC低于治疗前,联合治疗组治疗后TC(2.51±0.51 mmol/L比3.22±0.53 mmol/L和3.10±0.63 mmol/L,P0.05)、LDLC(1.58±0.27 mmol/L比2.11±0.33 mmol/L和2.01±0.31mmol/L,P0.05)、TG(1.12±0.30 mmol/L比1.67±0.39 mmol/L和1.53±0.27 mmol/L,P0.05)下降较他汀常规剂量组、他汀加倍剂量组更明显。联合治疗组LDLC降低达标率(69.5%)明显优于他汀常规剂量组(43.9%)和他汀加倍剂量组(48.5%,P0.05)。联合治疗组不良反应发生率较他汀加倍剂量组低(P0.05),心血管事件(再发心绞痛、急性心肌梗死)发生率也低于其他两组(P0.05)。结论应用阿托伐他汀联合依折麦布治疗急性冠状动脉综合征较单用阿托伐他汀能更显著改善血脂水平,减少心血管事件,并具有良好的安全性。     

Preoperative Statin Therapy Decreases Risk of Postoperative Renal Insufficiency

Introduction: Although current guidelines recommend withholding statins in perioperative patients, little information is available on whether perioperative statin use increases risk for postoperative renal failure. Aims: We examined the relation between preoperative statin therapy and postoperative risk for renal insufficiency in patients undergoing cardiac surgery. Methods: Retrospective cohort review from the Texas Heart Institute research database was performed. Patients were divided into two groups: those who received preoperative statins and those who did not. Primary outcome was the development of postoperative renal insufficiency (requiring dialysis or not). Outcomes were assessed in the entire cohort and in subgroups undergoing isolated coronary artery bypass grafting (CABG), isolated valve surgery, or combined CABG and valve surgery. Results: Of 3001 patients, 56% received preoperative statins. In multivariate logistic regression analysis, preoperative statins were associated with significant reductions in risk for postoperative renal insufficiency in the entire cohort (odds ratio [OR]= 0.60, 95% confidence interval [CI] 0.38–0.95) and in patients undergoing isolated CABG (OR = 0.34, 95% CI 0.17–0.68). In patients undergoing isolated valve surgery (OR = 1.35, 95% CI 0.61–2.96) or combined CABG and valve surgery (OR = 1.39, 95% CI 0.48–3.99), preoperative statins were not associated with decreased incidence of postoperative renal insufficiency. Age >65 years, preoperative renal insufficiency, history of congestive heart failure, preoperative intra‐aortic balloon pump insertion, and total cardiopulmonary bypass time >80 min were also independent predictors associated with increased risk for postoperative renal insufficiency. Conclusions: Preoperative statin therapy was associated with decreased incidence of postoperative renal insufficiency in patients undergoing cardiac surgeries, particularly in patients undergoing isolated CABG.     

Effects of Statin Plus Ezetimibe on Coronary Plaques in Acute Coronary Syndrome Patients with Diabetes Mellitus: Sub-Analysis of PRECISE-IVUS Trial

Aim: Coronary plaque regression is weak in acute coronary syndrome (ACS) patients with diabetes mellitus (DM). We evaluated whether dual lipid-lowering therapy (DLLT) with ezetimibe and atorvastatin attenuates coronary plaques in ACS patients with DM.Methods: The prospective, randomized controlled, multicenter PRECISE-IVUS (Plaque Regression with Cholesterol Absorption Inhibitor or Synthesis Inhibitor Evaluated by Intravascular Ultrasound) trial assigned 246 patients undergoing percutaneous coronary intervention to DLLT or atorvastatin monotherapy and evaluated IVUS-derived changes in percent atheroma volume (ΔPAV), at baseline and 9–12-month follow-up, in 126 ACS cases, including 25 DM patients. The atorvastatin dose was up-titrated to achieve low-density lipoprotein cholesterol (LDL-C) < 70 mg/dL.Results: In DM patients, the monotherapy group (n = 13) and the DLLT group (n = 12) showed a similar prevalence of coronary risks and baseline lipid profiles. During the study, the change in LDL-C level was similar between DM and non-DM patients. Compared with non-DM patients, DM patients showed weaker regression of ΔPAV by DLLT than those who underwent monotherapy (DM: −2.77 ± 3.47% vs. −0.77 ± 2.51%, P = 0.11; non-DM: −2.01 ± 3.36% vs. −0.08 ± 2.66%, P = 0.008). The change in LDL-C level was not correlated with ΔPAV in non-DM patients, but there was significant correlation between the change in LDL-C level and ΔPAV in DM patients (r = 0.52, P = 0.008).Conclusions: ACS patients with DM showed weaker coronary plaque regression than their counterparts. A significant correlation between the change in LDL-C level and ΔPAV in DM patients suggested that more intensive lipid-lowering therapy is required in ACS patients with DM.     

Benefits and Risks of Statin Therapy in the HIV-Infected Population

Purpose of Review

HIV-infected patients face an increased risk for cardiovascular disease (CVD), estimated at 1.5- to 2-fold as compared to HIV-uninfected persons. This review provides a recent (within preceding 5 years) summary of the role of statin therapy and associated role in CVD risk reduction among HIV-infected patients on anti-retroviral therapy.

Recent Findings

Statins remain the preferred agents for reducing risk for CVD among HIV-infected populations based on guidance extrapolated from general population (HIV-uninfected) cholesterol treatment guidelines across different settings globally. However, HIV-infected patients are consistently under prescribed statin therapy when compared to their HIV-uninfected counterparts. The most commonly studied statins in clinical care and small randomized and cohort studies have been rosuvastatin and atorvastatin. Both agents are preferred for their potent lipid-lowering effects and their favorable or neutral pleotropic effects on chronic inflammation, renal function, and hepatic steatosis among others. However, growing experience with the newer glucuronidated pitavastatin suggests that this agent has virtually no adverse drug interactions with ART or effects on glucose metabolism—all marked additional benefits when compared with rosuvastatin and atorvastatin while maintaining comparable anti-lipid effects. Pitavastatin is therefore the statin of choice for the ongoing largest trial (6500 participants) to test the benefits of statin therapy among HIV-infected adults.

Summary

Statins are underutilized in the prevention of CVD in HIV-infected populations based on criteria in established cholesterol guidelines. There is a potential role for statin therapy for HIV-infected patients who do not meet guideline criteria which will be further delineated through ongoing clinical trials.

     

心电图表现酷似急性冠状动脉综合征的急性病毒性心肌炎20例临床分析

目的探讨心电图表现酷似急性冠状动脉综合征的急性病毒性心肌炎的临床表现、诊断和治疗。方法回顾2008年6月至2014年6月期间上海市第一人民医院收治的20例心电图表现酷似急性冠状动脉综合征的急性病毒性心肌炎患者的临床资料,其中男12例,女8例,年龄17~60岁,平均年龄38岁,住院6~14天。结果入院时所有患者心肌损伤标志物均明显增高,心电图下壁或前壁ST段呈弓背向下抬高。住院期间20例患者均经冠状动脉造影或冠状动脉CT血管造影检查排除急性心肌梗死,经心脏核磁共振、心内膜心肌活检等检查诊断为急性病毒性心肌炎,其中4例诊断为急性重症病毒性心肌炎。经抗心力衰竭、营养心肌、降低心肌氧耗、血管紧张素转换酶抑制剂等综合治疗,19例治愈,1例诊断为急性重症病毒性心肌炎患者死亡。结论部分急性病毒性心肌炎患者心电图及临床表现酷似急性冠状动脉综合征,易误诊,需结合患者病史、临床表现、心电图、冠状动脉造影、心脏增强核磁共振等检查作出及时诊断。     

肾功能与冠状动脉病变程度及PCI术患者预后的关系

目的探讨肾功能与冠状动脉病变严重程度及急性冠状动脉综合征(ACS)之间的关系。方法收集2010年1月至2010年10月因怀疑冠心病至山西医科大学第二医院行冠状动脉造影的344例住院患者,男性237例,其中不稳定型心绞痛(UA)组165例,急性心肌梗死(AMI)组93例,冠状动脉造影阴性设为对照组,共86例。以酶法测定血脂[总胆固醇(TC),低密度脂蛋白胆固醇(LDLC),高密度脂蛋白胆固醇(HDLC)],使用免疫透射比浊法测定Lp(a),以苦味酸法测定血浆肌酐(Scr);e GFR计算方法:a MDRD公式;根据改良Gensini积分对冠状动脉病变程度积分。结果 (1)对照组,UA组与AMI组Scr值分别为64.32±10.53μmol/L,70.54±13.42μmol/L及85.47±13.52μmol/L,对照组低于AMI组(P0.05);三组e GFR值分别为113.52±17.47 m L/(min·1.73 m2),88.54±14.53 m L/(min·1.73 m2)与80.53±13.63 m L/(min·1.73 m2)(P值均0.05);UA组与AMI组Gensini评分为40.54±23.45分与54.78±23.78分(P值0.05)。(2)e GFR与Gensini评分呈负相关关系(r=-0.507),LDLC(r=0.865)、TC(r=0.743)、Lp(a)(r=0.221)与Gensini评分呈正相关关系(P0.001)。(3)通过将TC、TG、LDLC、HDLC、Lp(a)、Scr、e GFR七项进行多因素Logistic回归分析,e GFR(OR=0.249,95%CI为0.132~0.472,P0.001)与LDLC(OR=15.724,95%CI为8.042~30.732,P0.001)及TC(OR=7.402,95%CI为4.534~12.083,P0.001)一同进入方程。(4)PCI术患者随访结果:随访时间、全因死亡率、MACE、阿司匹林及氯吡格雷服药时间、因心绞痛再住院率等差异均无统计学意义(P0.05).结论急性冠状动脉综合症与肾功能之间存在联系,肾功能越差急性冠状动脉综合征患者冠状动脉病变越严重。慢性肾功能不全是急性冠状动脉综合症诊断的独立危险因素。本研究尚未观察到肾功能损害影响PCI术患者的短期预后。