血管紧张索受体-脑啡肽酶抑制剂(ARNI)是近年来心力衰竭治疗上最重要的发现,目前国内外ARNI的使用率仍很低.本文就ARNI的研发背景、作用机制以及临床研究结果等方面作一全面阐述.

1 临床资料 患者,女,36岁.因“突发胸闷、气促5d”于2012年7月15日入院.患者入院前7d出现尿频、尿急,于当地医院就诊,诊断为尿路感染,予抗炎治疗.入院前5d患者突发胸闷、气促,不能平卧,伴咳痰,痰为粉红色泡沫样,伴有头痛、恶心、呕吐、发热,体温最高38℃,于当地医院就诊.诊断为肺部感染,予抗炎、解痉、平喘等治疗后患者上述症状无明显缓解,故转入我院治疗.患者2年来有反复头痛病史,未予就诊治疗.否认高血压、糖尿病等疾病史;否认家族性遗传疾病史;否认吸烟、饮酒史.

目的 探讨口服葡萄糖耐量试验(OGTT)1 h血糖(1hPG)与冠状动脉病变程度的相关性.方法 回顾分析312例拟诊冠心病且既往无糖尿病史患者,并根据OGTT结果除外糖尿病患者后,将OGTT 1hPG分为＜8.6 mmol·L-1组(157例)和1hPG≥8.6 mmol·L-1组(98例).冠状动脉病变程度以冠脉造影结果判断是否诊断冠心病、冠脉病变支数、弥漫性病变情况以及Gensini总评分来表示.比较两组冠心病危险因素和冠脉病变程度,并对1hPG水平与冠脉病变程度进行单因素和多因素分析.结果 与1hPG＜ 8.6 mmol·L-1组比较,1 hPG≥8.6 mmol·L-1组代谢谱更差,该组患者体重指数、收缩压、空腹血糖、OGTT 2 h血糖、甘油三酯显著升高,而高密度脂蛋白胆固醇(HDL-C)水平显著降低(P＜0.05);超敏C反应蛋白在后组中也有显著升高.1hPG≥8.6 mmol· L-1组冠心病患病率、多支病变、弥漫性病变发生率及Gensini总积分明显升高(P＜0.05),而1 hPG＜ 8.6 mmol·L-1组患者单支病变发生率明显升高(P＜0.05).多元回归分析表明hsCRP是1hPG的最强影响因素(β=0.259,P＜0.05);Logistic回归分析表明1hPG为冠心病独立危险因素(OR值1.043,95％ CI:1.051～1.627,P=0.042).结论 负荷后1hPG≥8.6 mmol·L-1的患者代谢谱更差,可能是前期糖尿病的标志;升高的1hPG与冠状动脉粥样硬化密切相关.

A 58-year-old man presented with atypical chest pain without specific characteristics of thyrotoxicosis,the 12-lead electrocardiogram(ECG)showed ST-segment elevation in V1-V4 leads.Initial laboratory tests were abnormal:hs-troponin T 0.015ng/ml,TT3 33.28 ng/ml↑,TT4 415.26 μg/dl↑,FT3 11.43pg/ml↑,FT4 42.87 ng/dl↑and also found the coronary angiographic evidence of severe ostial vasospasm in the left main and left circumflex coronary arteries.Subsequently,he was diagnosed with hyperthyroidism which was suspected to be the cause of the coronary spasm.The patient treated with antithyroid therapy,oral nitrates,diltiazem with resolution of his symptoms.This unusual case highlights the importance of considering hyperthyroidism in the differential diagnosis of recurrent chest pain and coronary artery spasm.We suggest routine thyroid function testing in patients with coronary spasm.

Objective To investigate the effects of domestic bivalirudin on coagulation during percutaneous coronary intervention(PCI) therapy. Methods Fifty patients underwent select PCI were randomly divided into bivalirudin group(intravenous domestic bivalirudin,n=25) and control group(intravenous heparin,n=25).Activated clotting time(ACT) was tested at pre-PCI,5 minutes after using anticoagulants,and 0,30 minutes,2 hours after PCI.Activated partial thromboplastin time(APTT),prothrombin time(PT),thrombin time(TT) and fibrinogen(FIB) were also measured at pre-PCI,6,24 and 72 hours after PCI. Results ACT was significantly longer in bivalirudin group than in heparin group at 5 minutes after using anticoagulants and 0 minute after PCI(both P<0.001).There was no significant difference of ACT between bivalirudin group and heparin group at pre-PCI and 30 minutes after PCI(P=0.362 and 0.732,respectively).ACT was significantly shorter in bivalirudin group than in heparin group at 2 hours after PCI [(208.27±34.84)s vs.(241.48±41.34)s,P=0.01].There were no significant differences between the two groups in regard to APTT,PT,TT and FIB(all P>0.05).No clinical events occurred in both groups.Bleeding events were similar in the two groups(P=1.00). Conclusions Domestic bivalirudin takes effect and recoveries more rapidly and is more efficient than heparin during PCI therapy.

Objective To investigate the levels of endothelial microparticles(EMPs) in the peripheral blood of patients with coronary heart disease(CHD) and its correlation with clinical parameters,and to explore the relationship between CD144+/Annexin V+EMPs and acute ischemic event in CHD patients.Methods Totally 81 CHD patients confirmed by coronary angiography were enrolled in this study.According to clinical symptoms,electrocardiogram(ECG) and high sensitivity troponin(hs-TnT),they were divided into group A(acute coronary syndrome,n=51) and group B(stable angina,n=30).CD144+/Annexin V+EMPs in the peripheral blood were measured by flow cytometry.The correlations between the level of CD144+/Annexin V+EMPs and various clinical parameters including age,heart rate,blood pressure,blood fat,blood glucose,inflammation markers,cardiac markers were evaluated.Results The level of CD144+/Annexin V+EMPs was significantly higher in group A than that in group B(P<0.01).It was positively correlated with lipoprotein a(r=0.886,P=0.001),high sensitivity C-reactive protein(r=0.404,P=0.002),creatine kinase isoenzyme(r= 0.471,P<0.001) and hsTnT(r=0.240,P=0.042),and not correlated with age,heart rate,systolic pressure,diastolic pressure,pulse pressure,fasting glucose,postprandial glucose,glycosylated hemoglobin,total cholesterol,triglycerides,high density lipoprotein cholesterol or low density lipoprotein cholesterol(all P>0.05).Conclusion The level of CD144+/Annexin V+EMPs in peripheral blood is correlated with lipoprotein α,high sensitivity C-reactive protein,creatine kinase isoenzyme and high sensitivity troponin,and is helpful for the evaluation of high risks in CHD patients.

Objective:The purpose of this study was to determine the effect of LA circumferential ablation on left atrial(LA) function in patients with paroxysmal atrial fibrillation(PAF) after long-term follow-up.Methods:Thirty-seven consecutive patients with PAF were treated by circumferential radiofrequency pulmonary vein ablation(CPVA) and thirty-one patients were treated by drugs.The mean follow-up duration was(10.5±4.7) months(range,3 to 19 months).To evaluate the change of LA function in all patients for a long-term follow-up,we examined the LA diameters by M-mode and 2-dimensional echocardiography,mitral inflow by Doppler echocardiography before and after ablation.And we measured the velocity of mitral annulus motion(Va) in late diastolic phase by tissue Doppler image.Results:① Twenty patients(64.52%) out of thirty-one in control group maintain sinus rhythm.Twenty-six(70.27%) patients out of thirty-seven in CPVA group were successfully treated,and nine patients failed;② After long-term maintenance of sinus rhythm,the left atrial volume has become smaller.No statistical significance in different periods after treatment compared with before treatment in control group.Six months after ablation,the left atrial volume was significantly smaller in patients who had sinus conversion by the RF procedure,no further reduction 12 months after the treatment.The left atrial diameter was significantly smaller in patients who remained in sinus rhythm.In contrast,in patients with recurrences of AF,LA dimension and left atrial volume were not changed;③ One month after ablation,the LAAEF,A-VTI,VA and AFF decreased and recovered 12 months later.The Va significantly decrease after RF ablation.Conclusion:Circumferential radiofrequency pulmonary vein ablation for PAF is effective.This study demonstrates reverse morphological remodeling of the LA after restoration of sinus rhythm by ablation and no difference in patients with AF recurrence.LA catheter ablation results in decreased LA local systolic function.

Objective To study the relationship between the severity of coronary lesions and level of plasma homocysteine in type 2 diabetic patients.Methods One hundred and sixty-nine type 2 diabetic patients were selected for coronary angiography and analyzed retrospectively.They were divided into four groups according to the number of stenosed branch and their levels of plasma homocysteine and other biochemical parameters were determined.Results The levels of homocysteine in the subgroups of the CHD were higher than that in the control group(P0.05).The level of homocysteine positively related with the severity of CHD(P0.05).From analyzing with multivariate Logistic and stepwise regression,the plasma homocysteine had obvious relation with the occurrence of CHD and coronary stenosis index(P0.05).Conclusion In type 2 diabetic patients,the elevated level of plasma homocysteine may exacerbate coronary athersclerosis.