Background and Objective Atrial fibrillation (AF) and coronary heart disease (CHD) are closely related to metabolic dysregulation. However, the metabolic characteristics of AF patients with concomitant CHD remain unclear. The aims of this study were to elucidate the metabolic profiles of patients with AF and CHD to seek new therapeutic targets and related factors of AF combined with CHD.Methods Untargeted metabolomics and targeted oxylipins profiling were performed to characterize the serum metabolome landscape of patients with AF, CHD, and AF comorbid CHD.Results The serum metabolic fingerprints of patients with AF comorbid CHD were significantly differentiated from normal controls (NC) and individuals with AF or CHD alone, and the differentiated metabolites dominated by a variety of lipid alterations in the phospholipid and fatty acid metabolism. Furthermore, the targeted profiles of oxylipins demonstrated that the levels of arachidonic acid derivatives including prostaglandins, leukotrienes, hydroxy-docosahexaenoic acids, hydroxy-eicostetraenoic acids and hydroxy-eicosatrienoic acids in patients with AF and CHD were significantly different from those in the NC, AF, and CHD groups. Several prostaglandins were positively associated with echocardiographic indicators of myocardial remodeling.Conclusions This study updates metabolic insights of AF and CHD and provides potential therapeutic targets for preventing or treating AF comorbid CHD.

血栓栓塞性疾病的栓塞和出血风险并存已成为临床困境.疾病的多元化与药物更迭使抗栓治疗日益复杂和专业化,单一学科已不能胜任疑难病例的抗栓治疗.为更好地整合医疗资源,确保患者从规范化抗栓治疗中获益,北京大学第三医院突破学科间壁垒,组建了以心内科为主体,联合药剂科、检验科、神经内科、急诊科、消化科、心脏外科、呼吸科、介入血管外科、神经外科、风湿免疫科和血液科等12个科室参与的抗栓诊治专业团队,致力于制定合理的抗栓策略,着力解决临床血栓性疾病抗凝、抗血小板治疗中的关键问题,旨在探索一个"以心房颤动患者为中心"的多学科联合诊疗和精细化管理模式.

目的:本研究拟对标准化病人(SP)参与病例为基础的情景式教学(CBL)是否有助于提高医学生医患沟通能力进行探讨.方法:将临床医学八年制生产实习阶段医学生分为对照组、学生角色扮演CBL组、SP参与CBL组3组.研究终点为临床沟通技巧考试成绩及实习前后考试成绩的差值.结果:参加研究的医学生共68人,其中对照组23人,学生角色扮演CBL组22人,SP参与CBL组23人.3组学生的实习前临床沟通技巧考试成绩分别为 8.00(6.25,9.00)分、8.00(6.50,9.00)分和 8.25(6.50,9.00)分(P=0.790).3 组学生实习后临床沟通技巧考试成绩均较实习前的摸底考试成绩均有所提高,SP参与CBL组的分数较对照组提高得更加显著(P=0.047),与学生角色扮演CBL组相比提高的幅度也很明显(P=0.016),而学生角色扮演CBL组与对照组相比,成绩的变化并无差异(P=0.532).结论:SP参与的情景式教学可以明显提高临床沟通技巧的成绩.

With the development of medical education, it has become a trend to implement integrated curriculum education for undergraduate students of clinical medicine. Peking University Health Science Center has been exploring the " new era" integrated curriculum in 2021. Aiming at the characteristics and objectives of integrated curriculum, the teaching team of cardiovascular system has initiated a new model for collective lesson preparation, which is characterized by independent disease modules, discussion on top-level design, curriculum structure and implementation of teaching of different chapters and stages. This paper proposed the procedure, effects and challenges from this new model of education and provide suggestions for optimizing the curriculum in future.

Background: The presence of left atrial/left atrial appendage thrombosis is associated with a higher risk of thromboembolic events in patients with atrial fibrillation. The optimal antithrombotic strategy is not established to date. Objective: Our aim was to compare the efficacy and safety profile of novel oral anticoagulants with warfarin in the treatment of left atrial/left atrial appendage thrombosis. Methods: We conducted a systematic search in PubMed, Embase, Cochrane Library, ClinicalTrials.gov , and 3 Chinese databases for all randomized controlled trials and cohort studies (PROSPERO, CRD42021238952) from inception to 7 May 2021. Two authors independently performed the articles selection, data extraction, and quality assessment. The efficacy outcome was the resolution of left atrial/left atrial appendage thrombosis, and the safety outcomes were bleeding and stroke/transient ischemic attack. Results: One randomized controlled trial and 5 cohort studies were included, with a total of 353 patients. Compared with warfarin, novel oral anticoagulants were associated with increased probability of left atrial/left atrial appendage thrombosis resolution (OR =2.20; 95% CI, 1.35-3.60; I-2 = 0%). Compared with warfarin, novel oral anticoagulants had a similar risk of bleeding (OR =0.91; 95% CI, 0.39-2.13; I-2 = 0%). There was no evidence of increased risk of stroke/transient ischemic attack (OR =0.42; 95% CI, 0.12-1.45; I-2 = 0%). Conclusions: Novel oral anticoagulants were more effective than warfarin in promoting the resolution of left atrial/left atrial appendage thrombosis, without increased risks of bleeding and stroke/transient ischemic attack. Our study provides valuable insight into clinical practice. Further well-designed randomized controlled trials are needed to fully evaluate the benefits and risks in these patients. (C) 2022 The Authors. Published by Elsevier Inc.

目的 采用CARTO 3 Version 6.0系统指导心房颤动(简称房颤)消融术后房性心动过速(简称房速)标测中的应用经验和技巧.方法 2020年7月至2020年12月因房速行导管消融术的11例患者(以上患者均曾接受房颤导管消融术).术中放置6F十极冠状静脉窦电极导管,在CARTO 3 Version 6.0系统指引下,利用PENT-ARAY高密度标测电极进行三维电解剖标测,在扩展的"早接晚"(EEML)功能中设置高阈值为75％ ～80％,对应的低阈值为25％ ～20％ 精准确认房速的关键部位及消融靶点,消融终止心动过速,验证消融线阻滞且心动过速不再自发及诱发则手术成功.结果 11例术中均为房速心律,EEML能够提供清晰的瘢痕阻滞区,明确其房速机制,经标测后证实其中8例为单源性房速,余3例可经心房刺激诱发或自行转化出2种以上不同机制的房速.房速平均周长为(256.5±37.1)m s.肺静脉相关房速4例,其余包括顶部依赖折返2例、二尖瓣环折返1例,左房瘢痕相关折返性房速3例,右房瘢痕相关折返性房速1例.首次消融中所有患者房速终止并无法再次诱发.中位数随访时间8个月,1例房速复发并接受第二次消融,证实为顶部依赖折返,1例复发房颤.消融术中未出现严重并发症.结论 CARTO 3 Version 6系统提供的EEML功能为识别瘢痕造成的阻滞区提供了更直观的手段.房颤消融术后房速的机制多样,通常与此前房颤消融造成的瘢痕有关.

目的 探讨心腔内超声(CartoSound)三维标测指导下射频消融室间隔治疗肥厚型梗阻性心肌病(HOCM)的安全性及疗效.方法 在CartoSound三维标测技术指导下,对5例HOCM患者行经皮室间隔射频消融治疗,以收缩期二尖瓣瓣叶前向运动(SAM)对应的左室室间隔部位作为消融靶点,应用Smartouch盐水灌注消融电极,消融能量35～40 W,冷盐水灌注流速20 m L/m in,温度43℃,贴靠压力5～10 g,每次放电时间60 s.以左室流出道(LVOT)压力阶差下降50％ 或SAM区域心肌活动显著减弱作为消融有效终点.比较术前、术后LVOT压力阶差变化,记录围术期并发症发生情况,评价疗效和安全性.结果 术中累计消融放电15～42次,消融范围占SAM区域比值22.9％ ～76.6％.术后即刻LVOT压力阶差由术前(105±93.6)mmHg下降至(40.6±37.2)mmHg(P<0.001).随访至术后6个月,患者临床症状消失,心功能改善;术后6个月室间隔厚度由术前(16.1±2.9)mm下降至(13.3±2.4)mm(P=0.115);LVOT压力阶差由术前(105±93.6)mmHg逐步下降至(94.7±71.9)mmHg(术后7日,P=0.146)、(30.72±12.9)mmHg(术后1个月,P<0.01)、(19.4±17.8)mmHg(术后6个月,P<0.01).5例患者均未出现手术并发症.结论 经心腔内超声CartoSound指导下室间隔射频消融术治疗HOCM安全、有效.

一般人们所说的起搏器,是指整个起搏系统,由起搏器、起搏电极导线及程控仪组成,其中起搏器和起搏电极导线植入人体.起搏器在需要的时候向心脏发出微小的电脉冲,起搏电极导线负责向心脏传送微小电脉冲,刺激心脏跳动. 但是人们在使用永久起搏器时容易产生五个误区.

Objective: To explore the practice patterns and the related factors of oral antiarrhythmic drug (AAD) treatment in Chinese patients with atrial fibrillation (AF), and to evaluate the compliance of AAD application to atrial fibrillation management guidelines. Methods: From August 2011 to August 2016, medical records from 18 014 patients with AF were analyzed based on data from the Chinese Atrial Fibrillation Registry trial. Patients were divided into AAD group (7 788 cases, 43.23%) and non-AAD group (10 226 cases, 56.77%) according to whether AAD was used at baseline or at the time of first use during follow-up. Amiodarone (4 129 cases, 53.02%) and propafenone (3 211 cases, 41.23%) were the mostly prescribed AAD and subgroup analysis was performed accordingly. Medical records were analyzed by random forest regression to evaluate the use of AAD and related factors in patients with AF, and the rationality of AAD was analyzed according to the guidelines for the management of atrial fibrillation. Result: A total of 18 014 patients were included in this study, of which 60.48% (10 895/18 014) were male patients, 22.65% (4 081/18 014) were elderly patients(≥75 years old), there were 7 788 patients (43.23%) in AAD group, and 10 226 patients(56.77%) in non-AAD group. Compared with the non-AAD group, the elderly patients (≥75 years old, 13.74%(1 070/7 788) vs. 29.44%(3 011/10 226)), persistent AF (28.95% (2 250/7 788) 45.80% (4 683/10 226)), heart failure(8.29% (646/7 788) vs. 21.95% (2 245/10 226)), stroke and (or) TIA(12.15% (946/7 788) vs. 19.95% (2 040/10 226)), renal dysfunction(16.36%(1 274/7 788) vs. 29.37% (3 003/10 226)), and high thromboembolism risk(60.17% (4 748/7 788) vs. 76.40% (7 813/10 226)) were less prevalent in the AAD subgroup (P<0.001). Multivariate analysis showed that patients in tertiary hospitals (OR=3.72, 95%CI 3.17-4.37) were more likely to use AAD, elderly patients (≥75 years old, OR=0.47, 95%CI 0.39-0.55), persistent atrial fibrillation (OR=0.66, 95%CI 0.60-0.72), and patients with heart failure (OR=0.54, 95%CI 0.47-0.63), stroke and (or) TIA (OR=0.77, 95%CI 0.68-0.87), renal dysfunction (OR=0.75, 95%CI 0.59-0.95) and high thromboembolism risk(OR=0.7, 95%CI 0.58-0.84) were more likely not to use AAD(P<0.05). In the AAD group, amiodarone and propafenone were the most commonly used AAD, accounting for 53.02% (4 129/7 788) and 41.23% (3 211/7 788), respectively. Multivariate analysis showed that patients with persistent atrial fibrillation (OR=4.57, 95%CI 3.94-5.29) and coronary heart disease (OR=4.14, 95%CI 3.03-5.64), heart failure (OR=2.07, 95%CI 1.48-2.89), non-ischemic cardiomyopathy (OR=4.84, 95%CI 2.41-9.73) were more likely to use amiodarone, and those with normal left ventricular ejection fraction (OR=0.31, 95%CI 0.15-0.65) and low thromboembolism risk (OR=0.78, 95%CI 0.63-0.97) were more likely to use propafenone (P<0.001). The overall incidence of AAD treatment, which was not indicated by the guidelines was 6.5% (480/7 340); 5.1% (212/4 129) in the amiodarone group and 8.3% (268/3 211) in the propafenone group, respectively. Compared with the rational AAD use group, the proportion of irrational drug use was higher in the elderly (≥75 years old) (20.4% (98/480) vs. 12.9% (887/6 860)), patients of high thromboembolism risk (77.1% (379/480) vs. 59.0% (4 047/6 860)), and in non-tertiary hospitals (7.1% (34/480) vs. 3.3% (299/6 860)), but lower in men(50.8% (244/480) vs. 64.5% (4 427/6 860)), P<0.001. Conclusions: The patients with paroxysmal atrial fibrillation, who were treated with AAD, were mostly patients with fewer complications, and the patients who were treated with amiodarone were mostly patients with persistent atrial fibrillation, patients were more likely to complicate with organic heart disease. The incidence of AAD that do not comply with the guidelines was low, and it was more common in non-tertiary hospitals and the elder patients with high thromboembolism risk.

患者男性,81岁,病窦综合征,起搏器植入术后心悸.起搏器程控显示阵发性房性心动过速和心房颤动频繁发生.开启起搏器治疗房性心动过速/心房颤动的特殊功能后,患者临床症状明显改善,起搏器程控显示房性心动过速和心房颤动的发生明显减少.

生长分化因子-15(GDF-15)是转化生长因子-β超家族成员的一种应激蛋白,已证实是冠心病、心力衰竭等心血管疾病的标志物.近年研究发现GDF-15在心房颤动人群中表达升高,并对预后具有一定预测作用;然而,具体作用和机制未明.现对GDF-15在心房颤动发生和发展中的研究进展做一综述.

Abstract Background The optimal level of heart rate (HR) control in patients with atrial fibrillation (AF) is unknown. To assess the effect of rate control on cardiopulmonary exercise capacity and quality of life (QoL) in permanent AF. Methods One hundred forty-three patients with permanent AF were enrolled in this study. All patients received rate control medications and were followed up for 1 year. After 1-year therapy, the exercise capacity and QoL were evaluated by cardiopulmonary exercise testing (CPET) and 36-item Short-Form Health Survey, respectively. Data were compared by dividing the patients according to the following criteria: (1) whether the resting HR was ≤80 or > 80 bpm; (2) whether the exercise HR during moderate exercises on CPET was ≤110 or > 110 bpm; and (3) whether the resting HR was ≤80 bpm and exercise HR was ≤110 bpm. Results No significant differences in peak oxygen uptake, peak metabolic equivalent, and anaerobic threshold were found between the strict control and lenient control groups. Both physical component summary (PCS) and mental component summary (MCS) were significantly higher for the strict rate control group than for the lenient control group. The single-factor correlation analysis revealed a negative correlation between resting HR and both PCS and MCS. The multivariable linear regression analysis indicated that both exercise HR and duration of AF linearly correlated with PCS and MCS. Conclusions Therefore, in patients with permanent AF, exercise capacity may not be affected by the stringency of rate control, and strict rate control may be associated with better QoL.

患者男性,22岁,主因"发作性心悸伴黑矇12年"入院.患者自12年前开始经常发作心动过速,突发突止,7年前确诊为心肌致密化不全并发预激综合征、室上性心动过速,7年来先后出现5个部位的右侧房室旁道,均行射频消融术成功.

Objective To establish a humanized doxorubicin-induced cardiomyocyte injury model by using human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs). Methods The human induced pluripotent stem cells were induced to differentiate into hiPSC-CMs. Then the phenotypes of hiPSC-CMs such including cell viability, calcium transients, oxidative stress and DNA damage were detected after treated with various concentrations of doxorubicin for 24 hours. Results Doxorubicin induced a decrease in cell viability of hiPSC-CMs, destroyed calcium transients, increasing oxidative stress, leading to decrease of mitochondrial membrane potential and causing DNA damage, meanwhile dexrazoxane had cardioprotective effects on hiPSC-CMs. Conclusion Doxorubicin induced cardiomyocyte injury model is successfully established with hiPSC-CMs, overcoming the limitation of difficult access to human cardiomyocytes and the different reaction to drug between species, so could to better study on the mechanism of doxorubicin-induced cardiotoxicity and drug screening.

目的 探讨静脉联合应用硝酸异山梨酯和盐酸艾司洛尔治疗伴快速心率急性心力衰竭(acute heart failure,AHF)的疗效和安全性.方法 2016年1月至2018年1月,清华大学第一附属医院收治的伴快速心率AHF患者75例,分为联合用药(combined treatment,CT)组、硝酸异山梨酯(isosorbide dinitrate,ID)组和盐酸艾司洛尔(csmolol hydrochloride,EH)组,每组25例.CT组采用ID联合EH静脉泵入治疗,ID组仅采用ID静脉泵入,EH组仅采用EH静脉泵入.三组患者用药方法相同,用药时间均为48 h.观察比较三组患者治疗前后的肌酸激酶(creatine kinase,CK);肌酸激酶MB同工酶(creatine kinase-MB isoenzyme,CK-MB);肌钙蛋白T(troponin T,TnT);肌红蛋白(myoglobin,MYO);N-末端B型钠尿肽原(N-terminal B natriuretic peptide,NT-proBNP);左心室射血分数(left ventricular ejection fraction,LVEF);心率;尿量和不良反应发生率.结果 与治疗前比较,CT组、ID组、EH组患者治疗后的CK-MB (P=0.00、0.017、0.024);TnT (P=0.00、0.031、0.028);NT-proBNP (P=0.00)和心率(P=0.00)均降低,LVEF(P=0.00)和尿量(P=0.00)增加,CK和MYO差异无统计学意义(P＞0.05);与ID组和EH组相比,CT组CK-MB、TnT、NT-proBNP和心率水平降低,差异有统计学意义(P＜0.05),LVEF和尿量增加,差异有统计学意义(P＜0.05).三组的不良反应发生率差异无统计学意义(P＞0.05).结论 静脉注射硝酸异山梨酯和盐酸艾司洛尔治疗伴快速心率AHF的疗效、安全性优于单独应用硝酸异山梨酯或盐酸艾司洛尔.

心房颤动(atrial fibrilation,AF,房颤)是最常见的持续性心律失常,心力衰竭和卒中是房颤致残和致死的首要原因.房颤及其并发症给人民健康和国民经济造成了沉重负担[1-3].Ha(x)ssaguerre等[4]发起的一系列里程碑式研究,揭示肺静脉电位是房颤重要的触发和维持机制,奠定了肺静脉消融治疗房颤的理论基础.现行临床指南和专家共识均推荐肺静脉和(或)肺静脉-心房隔离作为药物难治症状性房颤的I类适应证.肺静脉隔离是房颤消融的经典术式[1-2,4].

Induced pluripotent stem cell is a landmark in the stem cell study field, which has rapidly developed in the past 10 years.By obtaining induced pluripotent stem cells from somatic cell, and then differentiating into cardiomyocyte, various cardiomyocyte disease models could be established,which can be used for research of disease mechanisms, drug screening and gene therapy.This review introduces the successfully established cardiomyocyte disease models from human induced pluripotent stem cells, and points out the problems and prospects.

Objective To assess the difference in left atrial properties between elderly and younger control subjects and the role of left atrium remodeling in patients of different ages with atrial fibrillation.Methods A total of 194 patients with non-valvular atrial fibrillation were enrolled from September 2014 to June 2016.Based on age,patients were divided into an elderly group (≥60 years,n=129) and a younger group (＜60 years,n=65).We evaluated remodeling parameters for the left atrium using an Ultrasound Cardiography (UCG) system in 125 elder subjects,together with 64 control subjects.All remodeling parameters were recorded,including left atrial diameter (LAD),left atrial square (LAS),left atrial pressure (LAP) and left ventricular end-diastolic dimension (LVEDD).Results The elderly group had more female patients and more patients with persistent atrial fibrillation.Meanwhile,scores of CHA2DS2Vsc and levels of N-terminal pro-brain natriuretic peptide (NT-ProBNP) were significantly increased in elderly patients (both P＜0.05).Moreover,the elderly group was associated with increased values of LAD and LAS[(39.1±4.4)mm vs.(37.1±5.3)mm,P＜0.01;and(23.3±4.5)cm2 vs.(21.4±4.8)cm2,P＜0.01;respectively],compared with those in the control group.Spearman's correlation analysis showed that LAD,LAS and LAP were all markedly related to age (r=0.213,P＜0.05;r=-0.175,P＜0.05;r=0.170,P＜0.05;respectively),persistent onset of atrial fibrillation (r=0.401,P＜0.05;r=0.446,P＜0.05;r=0.160,P＜0.05;respectively),and impaired heart function,measured by left ventricular ejection fraction (r=-0.4371,P＜0.05;r=-0.403,P＜0.05;r=-0.364,P＜0.05;respectively) and NT-ProBNP (r=0.485,P＜0.01;r=0.483,P＜ 0.01;r =0.293,P＜ 0.01;respectively).Conclusions Left atrial remodeling properties measured by the UCG system in the elderly with non-valvular atrial fibrillation are more serious than those in mid-aged and young subjects.As a convenient and accurate assessment of remodeling parameters,the UCG system is an excellent option for measuring left atrial remodeling in the elderly population.

Objective To evaluate the correlation between RPA or the polymorphism of CYP 2C19 and the incidence of ischemic events and the influence on the clinical prognosis .Methods A case-control study was used.A total of 202 patients [male 66%,(63 ±11) years] with ACS on aspirin and clopidogrel treatment were recruited , whose RPA were measured by whole blood aggregometry ( WBA ) , and their CYP2C19 polymorphism were also tested .Their clinical ischemic events were recorded in the mean follow-up period of 16 months.The RPA cut-off values for antiplatelet low-responsiveness were defined by the receiver operator characteristic curve ( ROC); the relationships of clinical outcomes with RPA and CYP 2C19 were assessed by the Kaplan-Meier survival analysis.Results CYP2C19*2 (681G>A) present in 52.5% of recruited patients and*3 (636G>A) present in12.9%.RPA induced by adenosine diphosphate ( ADP) showed significant difference among CYP 2C19*2 or *3 heterozygotes, CYP2C19*2 or *3 homozygotes and noncarriers (χ2 =9.318, P=0.009);whereas, RPA induced by arachidonic acid (AA) (χ2 =2.441, P=0.295) and the incidence of ischemic events (χ2 =0.513, P=0.774) were not.During follow-up, 18 (9%) patients experienced clinical ischemic episodes , and their RPA were higher than patients without ischemic episodes [(8.6 ±4.8) Ωvs (5.2 ±3.7) Ω, P =0.013; (8.6 ±6.8) Ωvs (1.6 ±3.7) Ω, P <0.001].Moreover, employing 6.5 Ω(induced by ADP) and 2.5 Ω(induced by AA) as cutoff values,RPA showed optimal negative predictive values (97%, 96%) and poor positive predictive values (16%,29%).Survival analysis showed, statistically, patients with clopidogrel low-responsiveness had higher riskof ischemic episodes than patients with clopidogrel responsiveness (HR =2.86, χ2 =11.27,P =0.0008);however, patients with aspirin low responsiveness (HR =1.77, χ2 =1.74, P =0.19) or patients withCYP2C19*2 or *3 (HR =0.89, χ2 =0.12, P =0.73) did not.Conclusion Clopidogrel lowresponsiveness is associated with the occurrence of clinical ischemic events ; however, patients withCYP2C19 function reduced genetypes do not show higher risk of ischemic episodes though it presented slighlyhigher RPA.

Although the ligament of Marshall ( LOM) has been implicated in the genesis of atrial arrhythmia , the important cardiac muscle fibers ( Marshall bundles , MB) within this LOM is not well concerned .The paper reviews the anatomy of MB and its electrophysio-logical characteristics and mechanism in atrial arrhythmia .