2018年 · 第46卷第05期

The diagnosis and treatment of classical medicine originated from the observation and experience summarization of the appearance of patient behavior and symptomatology. With the development of modern medicine, the corresponding molecular detection technologies derived from biological specimens are constantly introduced, and the results are more objective, stable and repeatable. It is the best detection method for outcome discrimination and has become the prototype of precision medicine in a narrow sense. Cardiovascular disease is a subject that synthesizes a large amount of clinical information and involves multiple pathogenic links, especially arrhythmia. Modern medical thinking, whether in diagnosis, decision-making or treatment, emphasizes the application of multi-dimensional, multi-platform and multi-technology to achieve individualization, and finally derives precision medicine in its broad sense.

Since the presence of cholesterol in atherosclerosis (AS) plaques was first described by British pathologist Vogel J in 1847, AS has been considered to be a lipid-depositing lesion caused by the penetration of serum cholesterol into the tube wall^[1]。 Interestingly, after 11 years, German pathologist Virchow R pointed out that some AS lesions have the nature of active inflammation, but this view has never been taken seriously^[2]。 In 2017, the CANTOS study^[3]The success of AS has opened the door to anti-inflammatory treatment of AS and declared that the treatment of AS has entered a new era. This article will review the brief history and current situation of AS inflammation hypothesis, summarize the contribution of Chinese scholars in this field, and look forward to the prospect of anti-inflammatory treatment of AS.

Whether the pleiotropy of statins beyond their lipid-lowering effects has clinical value has been a controversial topic. Some basic and clinical studies suggest that high-dose statins have a certain degree of anti-inflammatory, antioxidant, improving vascular endothelial function, anti-platelet aggregation and immune regulation effects, but they can also lead to adverse reactions such as skeletal muscle and myocardial lysis and necrosis. In recent years, with the disclosure of more research data, most clinical experts believe that the source of benefit of statins in the treatment of patients with coronary heart disease should return to the origin of lipid-lowering therapy, and should not over-emphasize its pleiotropy beyond lipid-lowering.

The "inflammatory hypothesis" of atherosclerosis (AS) has been proposed for more than 20 years^[1]。 With the deepening of research, the structure of this hypothesis becomes more and more complete^[2,3]: Various risk factors cause vascular endothelial dysfunction. Lipoproteins rich in apolipoprotein B (Apo B) (low density lipoprotein, very low density lipoprotein residue and chylomicron residue) enter and remain under the endothelium. After modification, they activate the endothelium, induce a large number of inflammatory cells, especially monocytes, to enter the local area, engulf lipids to form foam cells, and form a cascade amplified inflammatory response, leading to the formation and progression of atherosclerotic plaques; As inflammation persists, it causes plaque instability, leading to plaque rupture, fissures or erosion, and inducing thrombosis leading to myocardial damage and necrosis. Thus, inflammation is involved throughout the chain of coronary heart disease events. Although the pathogenic role of inflammation has been clearly defined, and many animal studies have suggested that anti-inflammatory therapy can inhibit the process of atherosclerosis, whether anti-inflammation can treat coronary heart disease is still unknown, and the "inflammation hypothesis" needs to be demonstrated in clinical practice of therapeutics.

intravascular ultrasound (IVUS) delivers a miniature ultrasound probe into the lumen of a blood vessel by catheter technology to display a cross-sectional image of the blood vessel, thereby providing an in vivo lumen image of the blood vessel. IVUS can accurately measure lumen and vessel diameter and judge the severity and nature of coronary artery disease. It plays a very important role in improving the understanding of coronary artery disease and guiding interventional therapy. Based on the results of IVUS clinical research at home and abroad, combined with domestic clinical application experience and experience, and with the main purpose of practicality, this consensus expert group has drawn up this consensus, in order to standardize the operation and improve the application and interpretation level of endovascular imaging by clinicians.

The patient, a 17-year-old male, was admitted to the hospital on 20 July 2016 due to "palpitations pending investigation". Palpitations lasted for 1 year, and each attack lasted for several minutes. It could alleviate on its own. No electrocardiogram was recorded at the time of attack, and no regular diagnosis and treatment was made. One month before admission, palpitations recurred without trigger, and the symptoms were the same as before. The electrocardiogram of the local hospital showed "type B pre-excitation syndrome". No previous hypertension, diabetes, coronary heart disease, cardiomyopathy and other diseases. After admission, the thyroid function was normal, and no abnormalities in cardiac structure and function were found on chest X-ray and cardiac color ultrasound.

Coronary heart disease is a polygenic hereditary disease that threatens health, with high disability and death rate. In June 2017, the latest "China Cardiovascular Disease Report 2016" pointed out that cardiovascular deaths accounted for the first place in the total death causes of urban and rural residents, with 45.01% in rural areas and 42.61% in urban areas. The risk factors of cardiovascular diseases in China are not controlled, resulting in an increase in the incidence of cardiovascular diseases. It is expected that in the next 10 years, the number of cardiovascular diseases will continue to increase rapidly, and the age of onset will tend to be younger, bringing a great social burden^[1]。 Therefore, it is of great significance to prevent and control cardiovascular diseases more effectively.

China Cardiovascular Disease Report 2016^[1]It is pointed out that according to the long-term nutritional health status of residents and the results of chronic disease monitoring, the prevalence of hypertriglyceridemia (HTG) in China is higher than that of hypercholesterolemia, and the prevalence of HTG in men is about 4 times that of hypercholesterolemia, and that in women is about 2.5 times. In clinic, there are still a large number of patients with triglycerides (TG) that do not meet the standard after statin treatment. The general clinical test for HTG is the plasma TG level in fasting state. However, even in physiological condition, TG level is in a fluctuating state of rapidly increasing and then slowly decreasing^[2]Within 10-30 min after eating, the release from the storage pool of small intestinal cells leads to a pulse peak of plasma TG level, and the absorption reaches a peak at about 3 h after eating, and returns to the pre-meal level at 6-8 h. Different peak and decreasing velocity of TG after meals have different effects on organs. Therefore, focusing only on fasting TG levels will ignore the cardiovascular effects of this period of postprandial TG elevation.

Previous views suggest that venous system diseases and arterial vascular diseases have different pathophysiological processes, that is, the disease separation of arteries and veins. However, it has been observed in clinical work that venous thrombotic disease is associated with an increased risk of arterial disease^[1,2]。 Since Prandoni et al.^[3]With the deepening of research on the mechanism of venous thrombosis in recent years, it is found that venous thrombosis is related to the traditional risk factors of cardiovascular diseases. Therefore, it is boldly hypothesized that venous system diseases and arterial vascular diseases may have a common pathophysiological process.CirculationTwo articles on the relationship between venous thromboembolism (VTE) and traditional cardiovascular disease risk factors were published in 2008 and 2016, respectively^[4,5], through a meta-analysis of a large number of existing studies, the conclusions reached are completely different. At present, there is still controversy about whether venous thrombosis is related to cardiovascular disease risk factors. This paper reviews the research on VTE and cardiovascular disease risk factors in recent ten years.

long QT syndromes (LQTS) refer to abnormal ion channels of myocardial cells and prolonged repolarization time caused by various causes, manifested by prolonged QT interval of electrocardiogram and can cause ventricular arrhythmias, especially torsade de pointes (TdP), syncope or sudden death. Clinical syndromes, including acquired and primary. Acquired LQTS can be caused by electrolyte abnormalities (low potassium, low calcium, etc.), drugs or organic heart disease, etc. Primary hereditary LQTS are caused by abnormalities in genes encoding ion channels, with a population incidence ranging from 1/10 000 to 1/2 500, and 20 subtypes have been identified, the most common being types 1, 2 and 3, accounting for more than 90%. LQT1 and LQT2 were relatively common, and arrhythmias occurred when catecholamine stimulation such as exercise and swimming, sound stimulation or emotional agitation increased, respectively. β-blockers reduced the risk of cardiac events by>95% and 70-80%, respectively^[1]； LQT3 accounts for about 5% ~10% of the total, but the mortality rate is relatively higher. Cardiac events often occur when the heart rate is relatively slow, such as rest and sleep, and the relationship with sympathetic nerve stimulation is not closely related. The efficacy of β-blockers is controversial^[2]。 Implantable cardioverter defibrillator (ICD) can reduce the risk of sudden cardiac death, but it cannot prevent malignant arrhythmias, so it is difficult to use in children. 10-year survival rate of untreated primary LQT due to early onset age<50%, the severity of the disease can be aggravated or relieved with age and sex hormone levels, and correct treatment may bring long-term survival to patients. With the late sodium current (lateI_NaOrI_Na-L) and its understanding, development and application of traditional and novel inhibitors, inhibitingI_Na-LThe drug can shorten the QT interval of LQT3 patients and has the effect of directly preventing and treating ventricular arrhythmia,I_Na-LInhibitors, as gene-specific and ion-channel-specific therapeutic methods, have brought the treatment of LQT3 into a new stage.