急性心肌梗死患者冠状动脉内抽吸物成分与再灌注水平的关系

目的通过对急性ST段抬高型心肌梗死(STEMI)患者急诊经皮冠状动脉介入治疗(PCI)术中的抽吸物成分进行病理分析,研究不同抽吸物成分与心肌水平再灌注的关系。方法连续入选STEMI并行急诊PCI的患者150例,其中男性96例,女性54例。术者根据术中情况进行血栓抽吸。抽吸物用福尔马林固定后24 h内送病理科,行光学显微镜检查。根据病理检查结果将患者分为3组:血栓组、斑块组、混合组。分析3组患者的临床情况。结果 150例患者中,因病变迂曲钙化抽吸导管不能通过病变处致抽吸失败的4例,抽吸后未见固态物质未送病理检查的15例。资料完整者131例,其中男性87例,女性44例。抽吸成功率87.33%。3组患者TMP分级0²级的发生率:血栓组:43.86%(25/57),斑块组:14.81%(4/27),混合组:17.02%(8/47),多因素非条件Logistic分析结果显示,抽吸物病理结果为斑块成分是与急诊PCI术后心肌灌注水平关系密切的因素(OR:3.412,P=0.011)。结论 STEMI患者通过抽吸清除斑块成分对改善心肌灌注具有重要作用。     

Comprehensive analysis of intravascular ultrasound and angiographic morphology of culprit lesions between ST-segment elevation myocardial infarction and non-ST-segment elevation acute coronary syndrome

Background

Some plaques lead to ST-segment elevation myocardial infarction (STEMI), whereas others cause non-ST-segment elevation acute coronary syndrome (NSTEACS). We used angiography and intravascular ultrasound (IVUS) to investigate the difference of culprit lesion morphologies in ACS.

Methods

Consecutive 158 ACS patients whose culprit lesions were imaged by preintervention IVUS were enrolled (STEMI = 81; NSTEACS = 77). IVUS and angiographic findings of the culprit lesions, and clinical characteristics were compared between the groups.

Results

There were no significant differences in patients' characteristics except for lower rate of statin use in patients with STEMI (20% vs 44%, p = 0.001). Although angiographic complex culprit morphology (Ambrose classification) and thrombus were more common in STEMI than in NSTEACS (84% vs 62%, p = 0.002; 51% vs 5%, p < 0.0001, respectively), SYNTAX score was lower in STEMI (8.6 ± 5.4 vs 11.5 ± 7.1, p = 0.01). In patients with STEMI, culprit echogenicity was more hypoechoic (64% vs 40%, p = 0.01), and the incidence of plaque rupture, attenuation and “microcalcification” were significantly higher (56% vs 17%, p < 0.0001; 85% vs 69%, p = 0.01; 77% vs 61%, p = 0.04, respectively). Furthermore, the maximum area of ruptured cavity, echolucent zone and arc of microcalcification were significantly greater in STEMI compared with NSTEACS (1.80 ± 0.99 mm² vs 1.13 ± 0.86 mm², p = 0.006; 1.52 ± 0.74 mm² vs 1.21 ± 0.81 mm², p = 0.004; 99.9 ± 54.6° vs 77.4 ± 51.2°, p = 0.01, respectively). Quantitative IVUS analysis showed that vessel and plaque area were significantly larger at minimum lumen area site (16.6 ± 5.4 mm² vs 14.2 ± 5.5 mm², p = 0.003; 13.9 ± 5.1 mm² vs 11.6 ± 5.2 mm², p = 0.003, respectively).

Conclusion

Morphological feature (outward vessel remodeling, plaque buildup and IVUS vulnerability of culprit lesions) might relate to clinical presentation in patients with ACS.     

颈动脉粥样硬化斑块性质与颅内血流动力学变化的相关性

目的利用16排螺旋CT血管成像及灌注成像探讨颈动脉粥样硬化斑块性质与颅内血流动力学的相关性。方法对42例颈动脉超声证实的颈动脉斑块患者行16排螺旋CT灌注成像-血管成像检查,根据CT值的不同分析斑块成分,并将脂肪斑块和纤维斑块定义为不稳定性斑块,钙化斑块定义为稳定性斑块;利用灌注成像分析颅内脑血流灌注情况。结果42例颈动脉斑块患者中不稳定性斑块25例,其中脂肪斑块10例,纤维斑块15例;稳定性斑块17例。14例表现为症状相应区域低灌注,其中脂肪斑块颅内低灌注的发生率为70%,纤维斑块颅内低灌注的发生率为47%,而钙化斑块无颅内低灌注表现。结论不稳定性斑块的存在比较稳定性斑块易于引起颅内血流动力学变化。     

易损斑块组织特征的影像学研究进展

动脉粥样硬化是心脑血管疾病的主要病因.早期、有效地识别易损斑块是目前研究热点,对动脉粥样硬化患者的治疗和判断预后具有非常重要的临床应用价值,而斑块组份及分布与斑块易损性及其破裂后导致的心脑血管事件密切相关.本文主要从易损斑块的组份特征入手,对其影像学检测手段的进展进行简单归纳.     

Culprit plaque characteristics in women vs men with a first ST‐segment elevation myocardial infarction: In vivo optical coherence tomography insights

Background

It is unclear whether more severe coronary atherosclerosis is a prerequisite to an initial acute coronary event in women vs men.

Hypothesis

Women may have more severe coronary atherosclerosis than men in patients with acute coronary event.

Methods

We used intravascular optical coherence tomography (OCT) to evaluate gender differences in culprit‐plaque morphology in patients with a first ST‐segment elevation myocardial infarction (STEMI).We retrospectively enrolled 211 consecutive patients who experienced a first STEMI and underwent an OCT examination of their infarct‐related artery before primary percutaneous coronary intervention.

Results

Of the 211 patients enrolled, 162 (76.7%) were men and 49 (23.2%) were women. The women were significantly older than the men (mean age, 60.2 ± 8.2 vs 55.7 ± 11.2 years; P = 0.01) and less likely to be current smokers (P = 0.02). Moreover, the delay from symptom onset to reperfusion was longer in women than in men (7.6 ± 6.1 vs 5.5 ± 4.4 hours; P = 0.01). The OCT data indicated that there were no gender differences in culprit‐plaque morphology, including lipid length, lipid arc, minimum fibrous cap thickness, or minimum lumen area. Additionally, no gender differences were found in the prevalence of plaque rupture, thin‐cap fibroatheroma, residual thrombus, microvessels, macrophages, cholesterol crystals, or calcification.

Conclusions

Among patients presenting with a first STEMI, there were no differences in culprit plaque features between women and men.

     

动脉粥样硬化易损斑块动物模型的建立

动脉粥样硬化进展、易损斑块破裂导致主要不良心血管事件发生。易损斑块形成机制和干预措施的研究一直备受瞩目。建立与人体斑块相似的进展性斑块是对易损斑块进行研究的基础及热点。目前,研究者已在多种动物体内建立了多种易损斑块模型。本文对目前建立的易损斑块动物模型进行综述与评价,为完善易损斑块模型的建立提供新思路。     

Can OCT change the therapeutic strategy in ACS due to plaque erosion?

The pathophysiology of acute coronary syndromes was thought to be coronary thrombosis over a plaque rupture. Autopsy studies revealed that not all cases were due to plaque rupture, even denuded endothelium or calcific nodule can beget a thrombus. Introduction of OCT made, in vivo recognition of lesion morphology clear. Plaque ruptures are most common and need primary angioplasty. Recent studies established plaque erosion is responsible for ACS in one third of the cases and majority of them present as Non ST elevation myocardial infarction and commonly found in young patients without major risk factors. Evidence from recent studies suggested that stenting can be deferred and they can be managed conservatively with good long term outcomes. More randomized trials are needed comparing plaque rupture and plaque erosion as regards conservative versus invasive management. If these studies substantiate the concept of conservative management, it will lead to a paradigm shift in their management.     

一种大鼠动脉粥样硬化斑块模型的建立

目的试建立一种大鼠动脉粥样硬化斑块模型。方法给予大鼠一次维生素D33×105U/kg体重肌肉注射、球囊损伤主动脉内皮和饲以含2％胆固醇、0.5％胆酸钠、0.2％丙硫氧嘧啶、3％猪油和维生素D31.25×106U/kg的高脂饲料90 d。结果90 d后大鼠血脂明显增高,胸主动脉形成明显的动脉粥样硬化斑块,斑块内有大量的泡沫细胞、脂质、巨噬细胞及钙化,中膜平滑肌明显萎缩;而仅饲以高脂饲料的大鼠胸主动脉结构未见改变。结论血管钙超载、内皮损伤和高脂可使大鼠主动脉形成较典型的动脉粥样硬化斑块。     

动脉粥样硬化不稳定斑块的研究现状

随不稳定斑块发展而继发的血栓形成是导致急性冠状动脉综合征的重要原因。在内外因素的共同作用下,不稳定斑块可能发生破裂、糜烂以及钙化等现象。斑块中存在许多直接和间接的致血栓形成的物质,它们同血液一起促进了血栓的产生。人们已经建立多种自发或诱发的不稳定斑块的动物模型。针对各种不同的影响斑块稳定性的因素,人们正从不同角度寻找能有效的稳定斑块的治疗方法。     

超声造影评价颈动脉斑块内新生血管的研究进展

动脉粥样硬化斑块与心脑血管事件的发生密切相关,早期评估动脉粥样硬化斑块的稳定性对于预防心脑血管事件发生及制定治疗方案十分重要。大量研究证实斑块内新生血管与斑块的稳定性有关,超声造影可显示和评估颈动脉斑块内新生血管,是近年来斑块稳定性研究的热点技术之一。     

心脑血管病危险因素与颈动脉粥样硬化的相关性

目的 探讨心脑血管病危险因素与颈动脉粥样硬化的相关性。方法 选择2010年8月～2013年8月健康体检者916例,依据合并危险因素的数量将受试者分为4组,即0个危险因素组（对照组）226例,1个危险因素组239例,2个危险因素组234例,≥3个危险因素组217例。所有受试者均进行颈动脉超声检测及血生化检测。结果 对照组患者斑块发生率为7.52%,1个危险因素组为15.06%,2个危险因素组为23.93%,≥3个危险因素组为45.16%,从对照组到合并≥3个危险因素组斑块发生率显著上升（P<0.01）。4组受试者IMT分别为0.94±0.32 mm、1.12±0.34 mm、1.25±0.33 mm及1.37±0.39 mm,斑块Crouse积分分别为0.24±0.64、0.58±1.21、0.85±1.26及1.32±1.64。从对照组到合并≥3个危险因素组IMT及斑块Crouse积分逐渐增高（P<0.01）。Logistic回归分析显示,1个危险因素组颈动脉粥样硬化斑块发生率为对照组的1.27倍,2个危险因素组为2.31倍,≥3个危险因素组为4.68倍（P<0.01）。结论 危险因素之间对缺血性脑血管病高危人群颈动脉粥样硬化及斑块的发生具有显著的联合协同作用。     

冠状动脉轻中度狭窄病变的血管内超声特征

通过分析病变的结构特点 ,探讨轻中度狭窄病变斑块不稳定的机制。对冠状动脉造影显示轻中度狭窄(直径狭窄率 2 0 %～ 6 0 % ) 6 2例及重度狭窄 2 6例冠心病患者行血管内超声显像检查 ,分析粥样硬化斑块性质及其狭窄程度。结果发现 ,轻中度狭窄患者中软斑块 (6 8.2 %比 15 .4 % ,P <0 .0 1)、薄纤维帽 (6 5 .9%比 7.7% ,P <0 .0 1)显著多于重度狭窄患者 ,并且斑块破裂 (2 8.2 %比 7.7% ,P <0 .0 1)及正性重构 (5 1.8%比 0 % ,P <0 .0 1)也显著多于重度狭窄患者。轻中度狭窄患者偏心斑块检出率显著多于重度狭窄者 (84 .7%比 30 .1% ,P <0 .0 1) ,但钙化少见 (16 .5 %比 84 .6 % ,P <0 .0 1)。结果提示 ,冠状动脉造影轻中度狭窄患者多数具有不稳定性斑块的结构特点 ,这些特点导致轻中度狭窄者容易发生急性冠状动脉综合征。     

颈动脉粥样斑块对冠心病的预测价值

目的探讨颈动脉粥样斑块对冠心病的预测价值。方法对39例行冠状动脉造影术者同时做颈动脉超声检查,将冠状动脉造影结果与颈动脉超声结果进行对比分析。结果颈动脉粥样斑块形成者与正常者冠脉造影阳性率分别为74%和25%(P<0.01),双侧和单侧颈动脉斑块形成者冠脉造影阳性率分别为92%和20%(P<0.05),颈动脉粥样斑块对冠心病诊断的敏感度、特异度、诊断价值分别为81%、67%和74%。结论颈动脉粥样斑块对冠心病有较高的预测价值,双侧颈动脉粥样斑块较单测者预测性更高。     

血管内皮生长因子165对实验性兔动脉粥样硬化斑块形成的影响

目的观察血管内皮生长因子165对动脉粥样硬化斑块形成与发展的影响。方法利用高胆固醇饲料复制动脉粥样硬化兔模型。15只兔随机分为正常对照组、高胆固醇组和血管内皮生长因子组。42天时处死动物,截取胸主动脉进行计量组织学及免疫组织化学分析。结果正常对照组、高胆固醇组和血管内皮生长因子组的斑块面积(0%比1.81%±0.61%比24.12%±3.58%)、斑块周径(0比6.05%±1.62%比25.71%±1.97%)以及斑块最大厚度(0比0.06mm±0.002mm比0.16mm±0.007mm)均存在显著差异(P<0.05)。3组CD34阳性细胞数(cellsmm2)分别为0、12.35±2.02和61.15±7.55(P<0.05)。电镜显示新生血管与动脉粥样斑块相邻,新生血管腔内可见淋巴细胞。血管内皮生长因子组CD34阳性细胞数与斑块面积之间呈正相关(r=0.989,P<0.001)。结论血管内皮生长因子165能促进兔动脉粥样硬化斑块的形成与发展。     

冠心病患者外周血细胞外基质金属蛋白酶诱导因子表达量与斑块特征相关性分析

目的 分析冠状动脉粥样硬化性心脏病(冠心病)患者外周血细胞外基质金属蛋白酶诱导因子(EMMPRIN)表达量与斑块特征的相关性.方法 选取2017年6月至2019年6月于山东第一医科大学附属济南人民医院心内科就诊的急性冠脉综合征患者(ACS组)82例和稳定型心绞痛患者(SAP组)57例作为研究对象,另选取同期于体检的健康...     

血管新生对动脉粥样硬化斑块稳定性影响的研究进展

斑块内血管新生由低氧和炎症等因素诱导形成,在动脉粥样硬化斑块的发生发展中发挥了重要作用。一方面通过加剧炎症反应和诱发斑块内出血,影响斑块的稳定性,从而诱发死亡率极高的急性冠状动脉综合征;另一方面可缓解斑块内低氧状态,减少细胞坏死,为斑块内有害物质的移出提供通道。抗血管生成治疗虽已投入临床应用,但在动脉粥样硬化方面进展甚小。本文就斑块内新生血管形成发生机制、血管新生对动脉粥样硬化斑块稳定性的影响及其相关临床应用进展作一综述。     

冠脉斑块稳定性与肿瘤坏死因子相关研究

目的 探讨肿瘤坏死因子(Tumor necrosis fac-tor-alpha,TNF-α)与冠状动脉粥样硬化斑块稳定性的相关性。方法 以血管内超声(Intravascular Ultrasound,IVUS)检出冠状动脉粥样硬化斑块的软硬特性,通过临床是否为急性冠脉综合征患者,将具有软斑块特性,同时急性冠脉综合征者分为不稳定斑块组;而硬斑块特性,且不符合急性冠脉综合征者为稳定斑块组。测定两组间冠状窦及外周血血浆TNF-α浓度,结果与IVUS测定的斑块大小、斑块纤维帽厚度、脂核或无回声带大小、脂核或无回声带/斑块比及面积狭窄率进行相关性分析。结果 不稳定斑块组TNF-α值明显高于稳定斑块组[(o.11o±O.045)ng/mL vs(0.097±0.137)ng/mL,P<0.01和(0.111±0.037)ng/mL vs(0.042±0.022)ng/mL,P<0.05;将测得TNF-α与IVUS所测得纤维帽厚度、脂核或无回声带大小、斑块大小、脂核/斑块、面积狭窄率等进行相关分析,未见明显相关。结论TNF-α与斑块的稳定性有关,同时其在冠状循环与体循环中的量无差异,可望作为冠脉斑块不稳定性的判定指标。