2014年 · 第42卷第08期

While attending the 2013 American Heart Association (AHA) Annual Academic Conference in Dallas, USA, reading the conference daily news, I was very pleased to receive an article introducing my old friend, Professor Kenneth H. Cooper, the father of aerobic metabolic exercise (aerobic exercise for short). The article is titled "At 82 years old, the father of aerobics is still full of vitality". In the evening, Professor Cooper and his wife were met at a dinner hosted by AHA. I asked if I could organize some Chinese doctors attending the AHA annual meeting to visit Cooper Aerobic Research Institute and Aerobic Center. He readily agreed, but sorry to say that he was busy receiving patients the next day and couldn't receive them in person, so he would arrange for a special person to show us.

Chest pain is a common clinical symptom with complex causes, involving multiple organs and systems, and the severity of the disease varies. Standardized evaluation and diagnosis of chest pain is of great significance for early identification of chest pain causes, life saving, prognosis improvement and rational use of medical resources. Therefore, the editorial board of Chinese Journal of Cardiovascular Diseases invited experts from pre-hospital emergency medical system, emergency department, cardiovascular medicine, respiratory department, gastroenterology department, laboratory department, imaging department and other disciplines to jointly formulate this consensus.

Dyslipidemia includes four types: hypercholesterolemia, hypertriglyceridemia, hypohyperdensity lipoproteinemia and mixed hyperlipidemia. Among them, hypercholesterolemia, which is mainly manifested by increased low density lipoprotein cholesterol (LDL-C), is the most important risk factor for atherosclerotic cardiovascular disease (ASCVD, including coronary heart disease, ischemic stroke and peripheral artery disease). In the past 30 years, the epidemic trend of dyslipidemia among Chinese residents has become increasingly serious, which poses a severe challenge to the prevention and treatment of ASCVD. In order to further improve the prevention and treatment of dyslipidemia, the Cardiovascular Branch of Chinese Medical Association, together with the Diabetes Branch of Chinese Medical Association and other academic institutions, organized experts to formulate and promulgate the Guidelines for the Prevention and Treatment of Dyslipidemia in Adults in China in 2007^[1]。 Since the promulgation of this guideline, it has played an active role in promoting the standardized prevention and treatment of dyslipidemia in China. In recent years, a series of new research results have been published one after another, which provides a lot of new information for the management strategy of dyslipidemia. Recently, the American College of Cardiology (ACC) and the American Heart Association (AHA) published guidelines for cholesterol-lowering treatment in adults at the end of 2013^[2]。 Although this guideline is formulated for American patients, it may still have a certain impact on the current lipid-lowering treatment concept and medical practice in China. How to evaluate this guideline and how to actively and reasonably carry out the prevention and treatment of dyslipidemia and ASCVD in China is an urgent problem to be solved. Before the revision of the guidelines for the prevention and treatment of dyslipidemia in China is completed, in order to standardize the clinical prevention and treatment practice of dyslipidemia in China, on the occasion of the 10th anniversary of China's National Cholesterol Education Program (CCEP), the CCEP Committee organized experts to formulate this expert suggestion, aiming at explaining some key issues in the prevention and treatment of dyslipidemia at present, and providing scientific and reasonable guidance and suggestions for Chinese clinicians.

Chest pain is one of the main clinical manifestations of multidisciplinary acute and severe disease, and there are professional routines and procedures for early identification, transportation, sorting and treatment of patients with chest pain. How to integrate the treatment process to make it more efficient and targeted can adopt the chest pain center model widely promoted internationally. The establishment of chest pain center often takes the treatment of acute myocardial infarction as the starting point, and integrates public education, emergency transport system, hospital treatment and rehabilitation, which makes pre-hospital emergency and in-hospital treatment have an efficient junction point, and drives the treatment of acute and severe cardiovascular diseases as a whole. The Cardiovascular Branch of Chinese Medical Association has made useful attempts in promoting the construction of chest pain centers suitable for China's national conditions, which will effectively improve the treatment level of acute myocardial infarction and even all cardiovascular emergencies in China.

Chest Pain Center is a rapid diagnosis and treatment channel for patients with acute chest pain, so as to shorten the diagnosis and treatment time of patients with fatal acute chest pain including acute coronary syndrome, aortic dissection, pulmonary embolism, etc., improve the success rate of treatment, improve the prognosis and avoid waste. Although ST-segment elevation acute myocardial infarction (STEMI) is the most important treatment target of chest pain center and the most important disease used to investigate the operation quality of chest pain center, the construction of standardized chest pain center must include the above-mentioned fatal acute chest pain patients.

A 54-year-old male was admitted for "episodic syncope for more than 1 month". One month ago, the patient suffered from sudden chest tightness without obvious trigger, followed by brief syncope accompanied by sweating and shortness of breath to the local hospital. A large amount of pericardial effusion was found on chest CT, and a pericardial catheter was placed. A total of 400 ml of hemorrhagic pericardial effusion was drained and improved. Two hours before this admission, the patient fainted again when climbing the stairs and had shortness of breath after waking up. The patient denied a history of trauma. Physical examination at admission: body temperature 36.5 ℃, pulse 110 beats/min, breathing 24 beats/min, blood pressure 55/30 mmHg (1 mmHg =0.133 kPa), no pallor of conjunctiva, no cyanosis of lips, and full jugular vein. Dry and wet rales were not heard in both lungs. The heart rate was 110 beats/min, the rhythm was uniform, the heart sounds were not distant, and no pathological murmur was heard in each valve area. The abdomen is soft, and the liver and spleen are not reached under the ribs. There was no edema in both lower limbs. Blood routine: hemoglobin 132 g/L, white blood cell count 7.3×10⁹/L, platelets 147×10⁹/L. Cardiac troponin Ⅰ 0.22 μ g/L, coagulation was normal. Electrocardiogram showed sinus tachycardia, complete right bundle branch block. Cardiac ultrasound showed that the size and shape of each chamber were normal, no change in the space occupation of the chamber was observed, left ventricular ejection fraction (LVEF) was 53%, and a large amount of pericardial effusion (FIG. 1a）。 Considering acute pericardial tamponade, after pericardial catheter aspiration, the patient's shortness of breath improved, the pericardial effusion test showed hematogenicity, the number of cells was 3,000/μ L, of which 75% were multinucleated cells, Li Vanta test (+). During hospitalization, many tumor markers in peripheral blood, such as carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), carbohydrate antigen (CA) 125 and CA199, were found to be normal, and tuberculosis-related tests were also negative. CT examination showed no enlargement of mediastinal lymph nodes, no signs of pulmonary embolism and aortic dissection, and a small amount of pleural effusion on the left side. On the 4th day after admission, the patient's condition was stable for many days, and the cardiac ultrasound repeated at the same time showed that pericardial effusion disappeared (FIG. 1b), and remove the pericardial indwelling tube. However, 4 h after extubation, the patient suddenly experienced chest tightness, fainted, and sweated profusely again during waking up and urination. His heart rate was 105 beats/min, and his blood pressure was 100/50 mmHg. Later, his blood pressure progressively dropped to 40/31 mmHg. Emergency bedside cardiac ultrasound showed a large amount of pericardial effusion. Considering the patient's acute pericardial tamponade, the patient's symptoms were relieved and his blood pressure recovered after 100 ml of blood fluid was drawn by pericardial catheter. However, within the next 3 h, the patient was relieved after 100 ml of blood fluid was drawn by pericardial catheter. Cardiac ultrasound revealed complete disappearance of pericardial effusion after 3 h.

A 36-year-old male was admitted to the hospital due to "repeated dizziness, chest tightness for 8 years and syncope once after exercise". No previous history of smoking, special medication, occasional small amount of alcohol, no family history of epilepsy and sudden death. In the past 8 years, the patient had dizziness and chest tightness more than during activity. On June 23, 2013, the patient felt chest tightness and dizziness when playing basketball, fainted a moment after stopping exercise, and recovered spontaneously after losing consciousness for about 30 s. After waking up, he had nausea, dizziness and other discomfort. Physical examination at admission: temperature 36.3 ℃, pulse 48 beats/min, breathing 20 beats/min, blood pressure 110/80 mmHg (1 mmHg =0.133 kPa). Electrocardiogram: Sinus bradycardia, heart rate 50-52 beats/min, QTc 360 ms, no abnormal J wave. Chest X-ray, coronary CT angiography (CTA) and head CT examination showed no abnormalities. Echocardiography: Left atrium 30 mm, left ventricular end-diastolic anterior-posterior diameter 49 mm, left ventricular ejection fraction 68%, no obvious abnormalities in intracardiac structure and blood flow at rest. X-ray of the cervical spine revealed slight bone hyperplasia. Holter electrocardiogram showed sinus bradycardia with irregular heart rate, mean heart rate 52 beats/min, slowest heart rate 35 beats/min (occurred at 0:24), and fastest heart rate 114 beats/min.

sudden cardiac death (SCD) is the most serious complication after acute myocardial infarction^[1]。 Although evidence-based therapeutic strategies such as emergency coronary revascularization and ideal drug therapy significantly reduced overall mortality during hospitalization, the incidence of SCD in the early stage of myocardial infarction remained high, especially in patients with left ventricular ejection fraction (LVEF) ≤30% within 30 days after myocardial infarction^[2]。 implanted cardioverter-defibrillator (ICD) can effectively reduce the overall mortality of high-risk patients with SCD, and has been written into the guidelines as primary and secondary preventive measures for SCD^[3]。 The results of domestic prospective studies also show that ICD can reduce the incidence of cardiac events and significantly improve the survival rate and quality of life of patients at high risk of sudden cardiac death^[4]。 However, that DINAMIT and IRIS study showed that early placement of ICD in myocardial infarction did not reduce overall mortality compared with drug alone^[5,6]。 The American College of Cardiology (ACC) /American Heart Association (AHA) /American Heart Rhythm Society (HRS) guidelines do not recommend the installation of ICDs within 40 days after myocardial infarction or within 3 months after coronary revascularization^[3]。 A wearable cardioverter-defibrillator (WCD) is a wearable external automatic defibrillator that requires bystander intervention when wearing. The indications include high short-term risk of sudden cardiac death but no temporary indication for ICD placement (such as patients with acute myocardial infarction with severe impairment of LVEF, including after coronary revascularization), undeterminable duration of SCD risk (such as non-ischemic cardiomyopathy or arrhythmic syncope with unknown prognosis), blank period after ICD infection removal, waiting for bridging therapy before heart transplantation, etc.^[7,8]。 At present, medical insurance in European and American countries has covered most WCD indications, and the number of users exceeds 100,000. In 2002, the US FDA approved patients with early LVEF ≤35% after myocardial infarction as one of the applicable populations and was subsequently recommended by the guidelines^[9]。 As a bridging treatment after myocardial infarction waiting for left ventricular function to improve or before ICD placement, WCD can effectively avoid the risk of SCD during evaluation, improve long-term survival and reduce dependence on emergency medical services.

Coronary heart disease is the biggest threat to women's health. According to the WHO report, the total number of deaths from heart disease and stroke in women is twice as high as the total number of deaths from various cancers in women. The epidemiological survey in China shows that although the incidence of coronary heart disease in women is lower than that in men, the upward trend is obvious, and the risk factors in women are on the rise.

Cardiovascular disease has become a major disease that threatens human health and causes death in modern society. Since the 1930s, cardiovascular diseases in developed countries have ranked first in the ratio of causes of death. According to the cause of death surveillance data of the Chinese Center for Disease Control and Prevention, the mortality rate of cardiovascular diseases in China's total population in 2009 was 236.8/100,000, accounting for 40.6% of the total deaths in that year. How to reduce the morbidity, mortality and disability of cardiovascular diseases has become the focus of attention of the whole world and the whole society.