2014年 · 第42卷第04期

The treatment of dyslipidemia became the most popular topic in cardiovascular medicine in the second half of 2013. Following previously published guidelines from the European Society of Cardiology and the European Society of Atherosclerosis, the International Society of Atherosclerosis (IAS) recommendations and the American Heart Association (AHA) /American Society of Cardiology (ACC) guidelines were published in July and December 2013, respectively. These three guidelines with great academic influence have great differences in form and connotation, which have aroused the attention and doubt of academic institutions and clinicians at home and abroad. Many discussions have been carried out in China, and the 2007 Guidelines for the Prevention and Treatment of Adult Dyslipidemia in China (hereinafter referred to as the 2007 Guidelines) have also entered the revision process, and the revision work was completed as early as 2015.

American Heart Association and American Heart Association (ACC/AHA) 2013 Guidelines for the Treatment of Blood Cholesterol in Adults to Reduce the Risk of Atherosclerotic Cardiovascular Disease (the "New Guidelines")^[1]Since its publication, due to its unique discussion on the selection of cholesterol-lowering drugs, low-density lipoprotein cholesterol (LDL-C) target targets, and suitable treatment populations, it has aroused widespread attention and heated discussion among domestic scholars, and has a positive impact on the current domestic lipid-lowering treatment. It has had a positive impact, but it has also brought some confusion to clinicians. Therefore, the Cardiovascular Disease Branch of Chinese Medical Association organized domestic experts engaged in clinical and basic research in the fields of blood lipid, atherosclerosis, coronary heart disease and other fields to discuss the "new guidelines". While appreciating its main spirit, combined with China's national conditions and the current situation of lipid-lowering treatment, the principles that should be followed in the management of domestic dyslipidemia at this stage were put forward.

As a non-invasive and routine clinical diagnostic tool, echocardiography can not only play a diagnostic role in some cardiovascular diseases such as structural heart disease, cardiomyopathy, intracardiac tumor, aortic dissection, pericardial effusion, etc., but also guide treatment, monitor disease, evaluate efficacy and complications in catheterization, emergency room and operating room. Moreover, echocardiography has become an intermediate index, measurement means and follow-up tool in randomized clinical trials. With the advent of bedside color ultrasound, echocardiography has become a "must-have weapon" for cardiovascular specialists, and it is also a powerful assistant in emergency departments, intensive care units, anesthesiology departments, cardiac surgery and coronary care units. For a long time, because cardiovascular specialists have not implemented standardized echocardiography training, the clinical application, popularization and improvement of echocardiography have been seriously restricted, which seriously affects the improvement of personal comprehensive quality of cardiovascular physicians, and also affects the development of the whole cardiovascular medicine. Therefore, how to carry out standardized echocardiography training for cardiovascular specialists has become an urgent task, and it is also one of the problems that health administrative departments and industry societies must seriously consider.

Multiple risk factors for atherosclerotic cardiovascular disease (ASCVD) increased in postmenopausal women^[1], is a high-risk group for ASCVD. The Framingham Heart Study shows that while young women have a lower risk of ASCVD than men^[2]However, the incidence of ASCVD in women after menopause increased rapidly, and the incidence of coronary heart disease increased by 2 to 3 times compared with non-menopausal women of the same age^[3]。 After menopause, the incidence of dyslipidemia increased significantly, and the levels of total cholesterol (TC) and low density lipoprotein cholesterol (LDL-C) in women over 50 years old in China were significantly higher than those in men of the same age^[4]。 Postmenopausal women are listed as the key management population in the management guidelines of dyslipidemia at home and abroad^[5,6]。 At present, the awareness rate, treatment rate and compliance rate of dyslipidemia in Chinese population are seriously insufficient^[7]The awareness, treatment and control rates of hypercholesterolemia (TC ≥6.22 mmol/L) were lower in women than in men^[4]。 In order to promote the management of dyslipidemia in postmenopausal women in China and effectively reduce the risk of ASCVD in postmenopausal women, we learn from the management guidelines of dyslipidemia at home and abroad^[5,6,8,9,10]This consensus was jointly formulated by the Women Physicians Working Committee of the Cardiovascular Physicians Branch of the Chinese Medical Association and relevant experts from the Women's Heart Health Group of the Cardiovascular Disease Branch of the Chinese Medical Association.

A 78-year-old male suffered from paroxysmal atrial fibrillation (AF) for 5 years with continuous episodes for 5 months. He had been treated with various antiarrhythmic drugs such as amiodarone, but the effect was poor. This time, he was admitted to the hospital with atrial fibrillation catheter ablation on December 4, 2013. Physical examination: heart rate about 63 beats/min, atrial fibrillation rhythm. Color ultrasound showed that the anteroposterior diameter of the left atrium was 35.4 mm, the size of the left ventricle was normal, and the ejection fraction of the left ventricle was 61%. Esophageal ultrasound showed no left atrial thrombosis. On December 9th, atrial fibrillation catheter ablation was performed. During the operation, bilateral femoral veins and right internal jugular veins were routinely punctured. A ten-pole catheter (produced by Biosense Webster Company, USA) was placed into the coronary sinus (CS), and a radiofrequency ablation catheter (produced by Biosense Webster Company, USA) was placed in the superior vena cava. The SL1 long sheath was placed into the right femoral vein, and after successful atrial septal puncture, bilateral pulmonary venography was performed. The guidewire was kept in the left superior pulmonary vein, and the 15F controlled long sheath (FlexCath, manufactured by Medtronic, USA) was replaced. The Archieve mapping catheter (manufactured by Medtronic, USA) was placed in the target pulmonary vein through the controlled long sheath, and a 28 mm cryoablation Balloon catheter (Arctic Front Balloon, manufactured by Medtronic, USA) was placed in the left atrium-pulmonary vein junction (FIG. 1a）。 At this time, Archieve catheter can not only play the role of mapping catheter, mapping pulmonary vein potential, but also play the role of supporting guide wire. The balloon is then inflated (FIG. 1b), retract the Archieve catheter to the mouth of the pulmonary vein, and start cryoablation, and rapidly reduce the temperature of the balloon to-40 ℃ ~ -60 ℃, thereby achieving the purpose of electrically isolating the pulmonary vein.

A 66-year-old female was admitted to the hospital for "sudden chest tightness and unconsciousness for 1 h". The patient developed chest tightness without obvious trigger 1 h before admission, followed by pale complexion, cyanosis, sweating, refraining from responding, and quickly stopped breathing and heartbeat. The patient was hospitalized in a local hospital at that time and was immediately given artificial cardiopulmonary resuscitation. Bedside electrocardiogram showed ventricular fibrillation, and the patient's heartbeat and spontaneous breathing gradually recovered after 4 repeated defibrillation. At the time of admission, the patient was unconscious, spontaneous breathing was weak, limbs were cold and cyanotic, bilateral pupils were dilated, and there was no light response. The apical beat was located 2 cm outside the 5th intercostal area of the midline of the right clavicle, the heart sounds were low, the respiratory sounds of both lungs were low, and dry and wet rales were smelled. Emergency bedside ECG showed "paroxysmal atrial fibrillation, paroxysmal ventricular tachycardia, ST segment elevation in anterior wall lead" (FIG. 1a), immediately given dopamine booster, amiodarone anti-arrhythmia, tirofiban anti-platelet treatment. Because the patient's family did not agree to percutaneous coronary intervention (PCI), the patient was given thrombolytic therapy with urokinase 1.5 million U. One hour later, the patient's family decided to undergo PCI, so coronary angiography was performed under intravenous anesthesia and ventilator-assisted ventilation. Angiographic results showed that left main trunk stenosis was 70%; Diffuse lesion of left anterior descending artery, 85% stenosis in the most severe part, blood flow TIMI grade 3; Diffuse lesion of left circumflex artery, blood flow TIMI grade 3; Complete occlusion of the proximal right coronary artery (Figure 2、Figure 3）。 Two drug-eluting stents were placed in the right coronary artery (Figure 4）。 Intra-aortic balloon counterpulsation was applied to maintain perfusion pressure after operation. Postoperative bedside electrocardiogram showed sinus rhythm and ST segment retraction of anterior wall leads (FIG. 1b）。 The bedside X-ray chest radiograph showed mirror dextrocardiac position, the heart shadow was obviously enlarged, and the texture of both lungs was thickened and blurred. The patient had postoperative anuria, progressive aggravation of acidosis and disseminated intravascular coagulation. The family of the patient gave up rescue at 10 hours after operation and was discharged spontaneously.

A 12-year-old male was admitted to the hospital due to "chest tightness and shortness of breath after activity, with edema of both lower limbs for 2 months". Physical examination: The boundary of heart turbidity was enlarged, the heart rhythm was uniform, a systolic jet-like murmur of grade 3/6 was heard in the 2nd to 3rd intercostal areas on the left margin of the sternum, a diastolic murmur was heard in the second auscultation area of the aortic valve, the second heart sound in the auscultation area of the pulmonary valve was normal, and the peripheral vascular signs were negative. Electrocardiogram showed complete right bundle branch block. CT angiography of cardiac large vessels showed a coordinated atrioventricular connection, the thoracic aorta descended from the left side of the spine, and an abnormal channel was seen next to the right coronary sinus of the aorta communicating between the aorta and the left ventricle, with an internal diameter of 4.5 mm at the widest point and 1.5 mm at the narrowest point (Figure 1), localized stenosis of the descending aortic arch, enlargement of the left atrium and left ventricle, widening of the main pulmonary artery, and tubular channels in the middle of the atrial septum (Figure 2), there was no defect in the interventricular septum. Color Doppler echocardiography showed enlargement of left atrium and left ventricle; The interatrial septum is patent foramen ovale, and there is a thin bundle of left-to-right septal blood flow in the middle segment. A tunnel can be seen at the junction of the right and left coronary valves of the aortic root sinus connecting the aorta and the left ventricle (Figure 3), in which there is diastolic return of left ventricular blood flow, partial attachment of the left coronary valve of the aorta to the tunnel wall, prolapse of the aortic valve leaflet, and moderate to severe aortic regurgitation; narrowing of the isthmus of the aorta; The pulmonary artery widened and the peak of pulmonary blood flow moved forward. Preoperative CT and echocardiography diagnosed congenital heart disease with aortic-left ventricular tunnel, patent foramen ovale, coarctation of aortic isthmus, and aortic valve prolapse with moderate to severe regurgitation. Aortic-left ventricular tunnel correction and aortic valve replacement were performed. Intraoperatively, the left atrium and left ventricle were enlarged, the pulmonary artery was thickened, and the descending aortic arch was narrowed. The maximum diameter of the tunnel opening outside the aortic annulus at the junction of the right coronary sinus near the left coronary valve and the right coronary valve was 13 mm, and the maximum diameter of the tunnel opening on the left ventricular side under the annulus was 10 mm. The right coronary leaflet was thickened and contracted here, the annulus position was higher than the left annulus, the alignment was incomplete, and the maximum diameter of the patent foramen ovale was 8 mm. The child was discharged from hospital 1 month after operation, and there was no obvious discomfort after a follow-up visit 1 year later.

cardiopulmonary exercise testing (CPET) is to monitor full-lead electrocardiogram and blood pressure changes from resting state to exercise load (once mistakenly called cardiac exercise test), as well as metabolic indicators such as pulmonary ventilation, oxygen uptake and carbon dioxide emission (once mistakenly called pulmonary exercise test). The latter mainly reflects changes in cellular respiratory function other than external respiration^[1,2]。 Professor Wasserman, who was honored by the American Heart Association (AHA) as the "Father of Cardiopulmonary Exercise", made it clear in the 1960s that it is impossible to load the heart or lungs alone. All exercises require the coordination of the heart and lungs and the coordination of the peripheral circulation and the pulmonary circulation to complete the gas exchange needed for survival and work^[1]。 CPET emphasizes the interaction of cardiorespiratory function and the role of gas exchange during exercise, emphasizing external respiration and cellular respiration coupling^[2]。 CPET is an integrated joint measurement that integrates the heart and lung and their regulation, as well as the interconnection of muscle metabolism in the human body, with special emphasis on the objective quantification of cardiopulmonary metabolic function. It is currently the only clinical detection technology that can comprehensively evaluate the overall multi-system function of the human body in one trial^[3,4,5]。 As a non-invasive, objective, quantitative, continuous and repeatable clinical test, the main application areas of CPET include the evaluation of exercise tolerance and intolerance, the evaluation of patients with cardiovascular diseases (such as heart failure, coronary heart disease, cardiac rehabilitation, transplantation and exercise prescription, etc.) and respiratory diseases (such as chronic obstructive pulmonary disease, interstitial pulmonary disease, pulmonary vascular disease, cystic fibrosis, exercise-induced bronchospasm and respiratory disease rehabilitation, etc.), as well as some special clinical applications, such as preoperative risk assessment, exercise rehabilitation and exercise prescription^[5,6]。

telocyte is a new type of interstitial cell recently discovered^[1]It has been found in the cardiovascular system, respiratory system, digestive system, nervous system, urinary system, reproductive system and motor system of humans and rodents. Under transmission electron microscope, the characteristic structure of this cell population is that the cell body is small (several microns), and 1 to 6 slender (tens to hundreds of microns) protrusions (telopode, TP) that alternate with enlarged and fine segments emit outward from the cell body. The appearance is rosary-like or bamboo-shaped. The enlarged part is called podom, and the fine segment part is called podomer. podom contains Ca^2＋Organelles such as mitochondria, endoplasmic reticulum and plasma membrane microcapsules^[1]。 Different TPs are interconnected to form a three-dimensional network support framework, which cooperatively maintains the real-time three-dimensional shape of each organ. According to the morphological characteristics, spatial distribution and Chinese transliteration of telocyte protrusion TP, we named it "(tái) network (luò)" cell. "" Meaning bamboo shoots^[2], meaning the rosary-like (bamboo-like) structure characteristic of cell processes TP, and "collateral" refers to the veins of the human body^[3]In particular, the three-dimensional network structure formed by telocytes is like the meridians in human tissues and organs. In addition, the Chinese transliteration of the word "telo" is the Greek prefix "telo –"^[1]。 The main membrane-expressed immune markers of telocyte are CD34 and CD117/c-kit, which are mostly distributed in interstitial tissues around capillaries and nerve endings, and have localization characteristics with stem cells, epithelial cells, smooth muscle cells and nerve cells, and transmit some biological information through direct contact between cells or paracrine mode, thus participating in various physiological and pathological reactions of the body. This paper reviews the spatial relationship between telocytes and blood vessels in different tissues and their possible biological effects.

Cardiovascular disease is an important disease that threatens human health and life worldwide, and ranks the first cause of death in China. With the rapid development of China's economy and society, as well as the acceleration of urbanization and aging, and the change of lifestyle, the level of cardiovascular disease risk factors continues to rise, and the prevalence of cardiovascular diseases increases rapidly, which seriously threatens national health and brings huge economic burden to families and society. This paper briefly expounds the prevalence and development trend of common cardiovascular diseases and risk factors in China, and the intervention research and results in recent years in China, so as to provide ideas for prevention and control.