20]0版欧洲心肌再血管化指南解读

2010年9月欧洲心脏病协会（ESC）和欧洲心胸外科协会（EACTS）领导下的联合项目组、指南委员会及其评审专家共N起草的一份经多方权衡、以患者为中心、以证据为导向的关于心肌再血管化治疗的操作指南。指南涉及冠心痛患者的评估、治疗决策、二级预防等,第一次将冠状动脉旁路移植和经皮介入治疗在同一指导性文件中加以讨论。为利于临床医师阅读,撰写本指南解读。     

孤立性心肌桥-壁冠状动脉患者的多层螺旋CT及临床分析

试图分析孤立性心肌桥-壁冠状动脉（MB—MCA）病变患者的多层螺旋CT（MSCT）的影像学特点与临床表现之间的内在联系。回顾性收集自2003年1月至2007年3月,在我院住院并行MSCT,保存有清楚影像学资料,临床排除有其他心脏病合并症的MB—MCA患者,共53例,发现MB—MCA病变65处。平均年龄（57．3±12．6）岁,其中男性27例,LAD病变59例。MCA长度（20．8±11．2）mm,MB厚度（2．0±1．6）mm。58．5％的患者有心电图改变,大部分为女性,有胸部不适症状者占90．6％。单纯应用非二氢吡啶类钙离子拮抗剂者15例,治疗有效率达到73．3％（11例）,单纯应用β受体阻滞剂者12例,症状缓解率达到66．7％（9例）。单纯应用硝酸酯类药物者16例,仅有2倒（12．5％）缓解。MB—MCA可能导致心肌缺血和临床症状,可进行干预性治疗;对硝酸酯类药物不能缓解的胸痛患者要想到MB—MCA可能,有条件者应该进行MSCT等影像学检查,诊断明确的可以试用β受体阻滞剂及非二氧吡啶娄拮抗剂．     

升高高密度脂蛋白胆固醇（HDL-C）面临的挑战——升HDL-C药物的不同机制和HDL-C升高的疗效评价

高密度脂蛋白胆固醇（HDL-C）水平与发生冠心病的危险性呈负相关。HDL通过促进胆固醇逆转运、改善内皮功能、抗氧化、抗炎和抗血栓而发挥心血管保护作用。HDL已成为冠心病防治工作的新靶点,生活方式和调脂药物的干预能升高HDL-C,然而HDL的功能比HDL-C血浆水平更重要,多项以HDL为靶点新的治疗措施正在研究中,临床上如何评价HDL-C升高的疗效价值及升高HDL-C的药物和策略有着重要意义。进一步研究HDL的结构、代谢和功能能够深入了解脂质代谢过程和动脉粥样硬化发生机制,使干预HDL成为动脉粥样硬化防治新的目标。     

氯吡格雷在冠状动脉支架植入术前术后的应用

冠状动脉支架植入术是冠心病治疗的最有效手段之一,但术后支架内血栓形成及再狭窄等影响了其远期疗效。血小板激活是支架植入术后血栓形成过程中最关键的环节。氯吡格雷作为有效的抗血小板药物之一,近年来多个大规模临床试验已经逐渐确立了其在支架植入术前术后应用的地位,但其应用的量、时机、持续时间等问题尚存在争议。     

激素替代治疗对绝经妇女心脏保护效应的重新认识

激素替代疗法（HRT）已有数十年历史,但是否具有心脏保护效应一直存在争议。早期研究提示HRT可维持血管正常功能,但大样本随机对照研究却发现服用雌激素和孕激素妇女的心血管疾病较安慰剂组增加22％,这导致了HRT应用的急剧减少。而2007年妇女健康启动计划——冠状动脉钙化研究（WHI—CACS）却证实HRT能显著降低冠状动脉钙化,再次提起了人们对HRT心脏保护效应的关注。     

稳定型冠心病治疗方案的临床抉择

由于医疗技术水平的发展,稳定型冠心痛的治疗方案在不断地更新与变化。以往,经皮冠状动脉介入术被广泛应用到稳定型冠心痛的治疗上。但最近的COURAGE试验（the clinical outcomes utilizing revascularization and aggressive drug evaluation trial）使得这一治疗手段的合理性和必要性被质疑。我们必须重新考虑稳定型冠心病治疗方案的临床抉择。     

Psychosocial Variables as Predictors of Psychological Stress–Induced Ischemia in the Laboratory

This study examined ischemic reactivity to a psychological stress protocol and whether psychological variables could reliably classify individuals as ischemic reactors. Participants were 54 male Veterans Administration patients who had or were suspected of having CAD. Psychological inventories were administered prior to a psychological stress protocol consisting of a surgical video, the Stroop Color–Word task, an arithmetic task, and discussion of a stressful event. Cardiac functioning was evaluated using an ECG Holter monitor and 23.53% of participants were classified as reactors. Mean differences between reactors and nonreactors were found for State Anger, Health Locus of Control—Powerful Others (MHLC-PO), and Depression. State Anger and MHLC-PO emerged as significant predictors of reactor status in logistic regression analyses. Models based on individual scale items suggested three items could be used to achieve higher classification rates. Implications for revising screening procedures for determining risk and possible mechanisms underlying psychological stress–induced ischemia are discussed.     

Changes in physical activity among coronary and hypertensive patients: A longitudinal study using the Health Action Process Approach

Objectives: Physical activity (PA) is a key factor in cardiovascular disease prevention. Through the Health Action Process Approach (HAPA), the present study investigated the process of change in PA in coronary patients (CPs) and hypertensive patients (HPs).

Design: Longitudinal survey study with two follow-up assessments at 6 and 12 months on 188 CPs and 169 HPs.

Main outcome measures: Intensity and frequency of PA.

Results: A multi-sample analysis indicated the equivalence of almost all the HAPA social cognitive patterns for both patient populations. A latent growth curve model showed strong interrelations among intercepts and slopes of PA, planning and maintenance self-efficacy, but change in planning was not associated with change in PA. Moreover, increase in PA was associated with the value of planning and maintenance self-efficacy reached at the last follow-up

Conclusions: These findings shed light on mechanisms often neglected by the HAPA literature, suggesting reciprocal relationships between PA and its predictors that could define a plausible virtuous circle within the HAPA volitional phase. Moreover, the HAPA social cognitive patterns are essentially identical for patients who had a coronary event (i.e. CPs) and individuals who are at high risk for a coronary event (i.e. HPs).     

冠状动脉病变范围与心率变异性的相关性研究

本研究通过对69例CHD患者（完成冠状动脉造影）进行Gensini评分、分组,同时设正常对照组56例。全部进行24h动态心电图监测,并做时域指标和频域指标的HRV分析。结果显示CHD组HRV各项指标均低于对照组（P〈0．05）,不同冠状动脉病变范围和程度其时域指标及频域指标降低程度不同,各组对照具有显著性差异（P〈0．...     

冠心病调脂治疗过程中的哲学思考

他汀广泛用于冠心病的一级预防和二级预防,普遍源于循证医学的证据。首先,他汀治疗冠心病是从疾病的本质出发,采取有效方法稳定斑块、缓解缺血。调脂治疗中,以降低低密度脂蛋白胆固醇为主要目标,体现了抓主要矛盾和矛盾的主要方面的思路。调脂强调联合治疗,个体化治疗,同时一分为二看待药物的作用,适时减量或停药。