2014年 · 第42卷第05期

In recent years, the guidelines for the diagnosis and treatment of various diseases at home and abroad have attracted extensive attention from the government, doctors and the public. This is a good thing, but it is difficult to understand the essence of the guide without sitting down and reading it carefully if it is just a walk-through study guide; More importantly, when implementing the guidelines, we should not intentionally distort the recommendations of the guidelines, incorporate commercial interests, and shout for the inappropriate use, excessive use or even abuse of drugs, devices or imaging technologies.

Atrial fibrillation (AF) in China is characterized by a large number of patients and a high incidence of stroke^[1,2]The traditional anticoagulant drug warfarin is low in proportion and compliance rate. Whether it is valvular or non-valvular atrial fibrillation, warfarin is the most well-documented and commonly used oral anticoagulant. However, due to large individual variations in dosage, common drug-drug or drug-food interactions, frequent monitoring of coagulation indicators, and doctors' excessive concern about warfarin-induced bleeding, its wide application in clinical practice has been affected^[3,4]。 new oral anticoagulant (NOAC) compensates for the deficiency of warfarin, and recent large-scale clinical studies have confirmed its better risk/benefit ratio in patients with non-valvular atrial fibrillation^[5,6,7,8]。 However, NOAC has only been evaluated in a limited number of patients with non-valvular atrial fibrillation, and some clinical problems have not been clarified, and the application evidence in patients with valvular atrial fibrillation is insufficient. Clinicians need to master the pharmacological characteristics of these drugs and their treatment under special circumstances to ensure their rational use in clinical practice. The purpose of this recommendation is to provide guidance and recommendations for NOAC in the treatment of non-valvular atrial fibrillation according to common practical problems in clinical practice^[9]Many problems are still being explored.

Since the 21st century, anticoagulant therapy for high-risk non-valvular atrial fibrillation (AF) has received unprecedented attention. Although there is clear evidence of warfarin, its use rate is only about 60% even in developed countries. The use rate in China is even lower. In a recent registry study of emergency atrial fibrillation, the anticoagulant treatment rate of high-risk non-valvular atrial fibrillation in China is only 13.1%^[1]。 This situation is partly related to the limitations of warfarin itself. The drug has a long half-life, slow onset of action, high protein binding rate, great differences in metabolism between different races and individuals, greater interference of blood drug concentration by food and drugs, narrow range of effective and safe doses, and needs frequent monitoring and dose adjustment. These problems are difficult to overcome with warfarin treatment itself, which in turn affects its usage rate and patient compliance. Therefore, finding treatments or drugs other than warfarin has become the direction of efforts for more than ten years.

Atrial fibrillation (AF) and coronary heart disease have many common risk factors, and both diseases often coexist in clinical practice. 10% to 15% of patients with coronary heart disease have atrial fibrillation at the same time, and the proportion of patients after percutaneous coronary intervention (PCI) has atrial fibrillation is 5% to 7%. Because of the different mechanisms of thrombosis in atrial fibrillation and intracoronary thrombosis, different antithrombotic therapies are needed. Antiplatelet therapy is the key to secondary prevention of coronary heart disease and stent thromboprophylaxis after PCI, and dose-adjusted warfarin plays an important role in preventing atrial fibrillation-related stroke and systemic embolism. Clinical decision-making is often in a dilemma when the above two clinical conditions exist at the same time. How to balance the risk of hemorrhage and thrombosis in such patients has become a real issue.

An 85-year-old male was admitted on 3 May 2013 due to "intermittent claudication for 18 months, aggravated with nocturnal resting pain in both lower limbs for 20 d". Eighteen months ago, intermittent claudication of both lower limbs occurred without obvious inducement, accompanied by chill, numbness and paresthesia in both lower limbs. The external hospital diagnosed it as "lumbar spinal stenosis", and surgical treatment was recommended, but the patient refused. In the past 20 days, claudication was significantly aggravated, and it was accompanied by resting pain in both lower limbs at night. Has a history of hypertension for 6 months, without diabetes and dyslipidemia. 50 years of smoking history. Physical examination: blood pressure 136/68 mmHg (1 mmHg =0.133 kPa), bilateral femoral and popliteal artery pulsation was weakened, bilateral dorsal pedis artery pulsation was weakened, the left side was weaker than the right side, the skin temperature of both lower limbs was reduced, the color was white, the nutrition was poor, the hair was reduced, the muscle was mildly atrophied, and the ankle-brachial index was 0.40 on the left side and 0.52 on the right side. Vascular enhancement CT from the abdominal aorta to the level of both feet showed thrombosis of the abdominal aorta (far from the level of the renal artery opening), complete lumen occlusion, severe calcification of the abdominal aortic wall, collateral circulation established, and no stenosis of bilateral renal arteries. Arterial ultrasound of both lower limbs showed atherosclerosis of both lower limbs with plaque formation. Diagnosis: Prostrenal abdominal aortic occlusion, Pan Atlantic Collaborative Group (TASC) type II D, Fontaine grade 3.

Since 1950 Pfister and Plice^[1]Since reporting the cases of acute myocardial infarction (AMI) secondary to penicillin allergic reaction, more than 300 cases of acute coronary syndrome (ACS) secondary to allergic reaction have been reported at home and abroad. In 1991, Greek scholar Kounis et al. linked allergic reactions, inflammatory mediators and associated angina pectoris, and clearly put forward the concept of anaphylactic angina pectoris^[2]Subsequently, ACS caused by allergic reactions, including unstable angina pectoris and AMI, is called Kounis syndrome^[3]。 We have also reported cases of allergic AMI secondary to wasp stings^[4]。 In recent years, coronary stent thrombosis associated with anaphylactic reactions has also attracted attention.

ryanodine receptor (RyR) 2 is the cardiac Ca^2＋One of the release channels, it is named because of its high affinity and specificity with a plant alkali-ryanodine. It is a homotetrameric intracellular Ca^2＋It is a member of the large family of release channels and is one of the RyR subtypes. It is mainly expressed in myocardium.

The incidence of coronary heart disease is increasing year by year in China, and it has become the main cause of death. Acute myocardial infarction (AMI) is a critical disease in cardiovascular diseases. With the improvement of medical level, its mortality rate is lower than before, but its long-term prognosis fails to meet people's expectations. Therefore, it is very important to prevent ventricular remodeling after myocardial infarction. connective tissue growth factor (CTGF), as a newly discovered fibroblast growth factor with multiple biological functions, has been confirmed by many studies to be closely related to the repair of infarction foci and subsequent ventricular remodeling. Therefore, the research on CTGF in ventricular remodeling after myocardial infarction has been carried out successively, aiming at finding the prognostic indexes of myocardial infarction patients and finding new targets of anti-fibrosis therapy in myocardial infarction patients^[1]。