2014年 · 第42卷第11期

HPS2 – THRIVE is a multicenter randomized double-blind placebo-controlled study in China and Europe. It is a secondary prevention trial of atherosclerotic cardiovascular disease (ASCVD). Enrolled patients receive simvastatin 40 mg/d first. If low-density lipoprotein cholesterol (LDL-C) cannot reach the standard, ezetimibe can be used in combination. On this basis, they were randomized to receive either sustained-release nicotinic acid formulation or placebo, respectively. A total of 25 673 patients were enrolled in the study, including 10 932 in mainland China and 1 474 in Europe; 78.4% had a history of coronary heart disease, 31.5% had a history of cerebrovascular disease, 12.5% had peripheral atherosclerotic disease, and 32.2% had a history of diabetes. The results of the study were negative, that is, on the basis of simvastatin 40 mg, ezetimibe if necessary, and LDL-C achievement, compared with placebo, niacin failed to reduce the main cardiovascular prognostic endpoint, but significantly increased adverse reactions, which is particularly prominent in Chinese patients.

Statins (statins for short) have good lipid-lowering efficacy and clear cardiovascular benefits, which have been repeatedly confirmed and fully affirmed. However, due to its wide application, many adverse reactions related to this drug have been frequently reported. It is very important to correctly understand and deal with the adverse reactions of statins in clinical application. In 2011, domestic experts in cardiovascular diseases and clinical lipidology carefully and seriously discussed five main issues such as statins and cancer risk, kidney damage, new diabetes risk, liver damage and myopathy, and published their main views in the Chinese Journal of Cardiovascular Diseases, Issue 3, 2011, which played a good role in promoting the correct use of statins by Chinese people^[1]。 In 2012, the U.S. Food and Drug Administration (FDA) issued a notice that statin instructions needed to be revised, which once again attracted people's attention to the safety of statins^[2]。 In October 2013, the China Food and Drug Administration (CFDA) issued a notice to revise statin instructions to further remind Chinese doctors and patients to pay attention to the safety of statins. Recently, the American Lipid Association published an updated expert consensus on statin safety^[3]。 The potential risks and benefits of statin use have become a public health issue of common concern for Chinese doctors and patients. Therefore, after full discussion, the expert group reached the following consensus on the main safety issues of statins at present and their treatment countermeasures.

Beta-blockers are one of the most commonly used drugs for the treatment of cardiovascular diseases, but the use of these drugs in the prevention of myocardial ischemia during the perioperative period in patients undergoing non-cardiac surgery is controversial. Recently Bouri et al.^[1]Published a meta-analysis stating that a large number of patients died due to the use of beta blockers during the perioperative period in accordance with the guidelines of the European Society of Cardiology (ESC). The Cardiovascular Branch of Chinese Medical Association pays attention to this debate that may affect clinical practice. Since February 2014, it has organized experts to carefully evaluate the relevant evidence and put forward Chinese expert suggestions on the perioperative application of beta blockers in non-cardiac surgery.

European authoritative scholars of cardiovascular diseases jointly published an article^[1]2013 American College of Cardiology (ACC) and American Heart Association (AHA) Guidelines for the Treatment of Cholesterol-Decreasing Atherosclerotic Cardiovascular Disease (ASCVD) in Adults (hereinafter referred to as "ACC/AHA Cholesterol Guidelines")^[2]and the 2011 European Society of Cardiology (ESC) /European Society of Atherosclerosis (EAS) Guidelines for the Prevention and Treatment of Dyslipidemia (hereinafter referred to as "ESC/EAS Guidelines on Lipids")^[3]After comparison and in-depth review, the main points are introduced as follows.

There is clear research evidence for both primary and secondary prevention of atherosclerotic cardiovascular disease by statins. Previous guidelines have been based on the achievement of low-density lipoprotein cholesterol (LDL-C) standards with different risk stratifications as treatment goals^[1]。 However, the 2013 guidelines of the American College of Cardiology/American Heart Association (ACC/AHA) recommend that all patients with clinically diagnosed atherosclerotic cardiovascular disease (ASVCD) should first choose booster dose statins, and believe that the current research evidence on targeting LDL-C is insufficient^[2]。 Following the publication of the guidelines, discussions about doses, especially fortified doses, were sparked. How much more benefit can enhanced dose statins bring to patients over conventional doses? It is necessary to analyze and interpret the study of comparison of different strengths of statins.

Statins have been shown to reduce plasma low-density lipoprotein cholesterol (LDL-C) levels and have a clear effect on both primary and secondary prevention of coronary heart disease^[1,2]。 The results of the main trial analysis of statin drugs published by the Cholesterol Treatment Trial Collaborative Group showed that for every 1.0 mmol/L decrease in LDL-C levels, the annual incidence of major cardiovascular events (including cardiogenic death, myocardial infarction, coronary revascularization, and ischemic stroke) decreased by nearly 20%^[3]So the current guidelines or consensus^[4,5,6]All recommended an aggressive statin treatment regimen. However, statin therapy still has deficiencies. Even with intensive statin therapy, high-risk patients still have a high cardiovascular risk. In addition, 10% to 20% of patients are unable to tolerate statins due to adverse reactions to the musculoskeletal system^[7]。

A 55-year-old male with World Health Organization (WHO) pulmonary hypertension functional class III. The patient had heart murmur in childhood, difficulty in feeding, lack of weight gain, excessive sweating, easy fatigue, and recurrent respiratory tract infections. In recent years, there has been exertion dyspnea, sometimes cyanosis of the lips and fingers after walking hundreds of meters, and you can still lie down at night without amaurosis and syncope. Physical examination on admission showed enlarged heart boundary, grade 3/6 systolic murmur under xiphoid process, P2 hyperactivity, positive peripheral vascular sign, and no pestle finger. The percutaneous oxygen saturation of the upper limb was 92%, and the oxygen saturation of the lower limb was 88%. Echocardiography showed thick tubular patent ductus arteriosus (PDA, bi-directional shunt), right ventricular hypertrophy, left atrial and ventricular enlargement, severe tricuspid valve insufficiency, pulmonary artery enlargement, mild pulmonary valve regurgitation, estimated pulmonary artery pressure 110 mmHg (1 mmHg =0.133 kPa). The 6 min walking distance is 250 m. After admission, cardiac catheterization and angiography showed that PDA diameter was 12 mm, pulmonary artery pressure 130/70 mmHg, descending aortic pressure 130/70 mmHg, pulmonary arteriolar wedge pressure and right atrial pressure were within the normal range, descending aortic oxygen saturation was 87%, Qp/Qs =0.98, Pp/Ps =1, and total pulmonary resistance was 25.4 wood units. A domestic 22~24 mm PDA occluder was selected for trial occlusion (Figure 1，Figure 2), the pulmonary systolic pressure decreased by about 20% after 15 minutes of occlusion, and the aortic pressure was unchanged. However, the patient immediately experienced headache and chest tightness, so the occluder was withdrawn to terminate the operation. After discharge, the patient started oral pulmonary hypertension-targeting drug bosentan 62.5 mg twice daily, which was adjusted to 125 mg twice daily after 4 weeks of administration until 3 months after surgery. After a follow-up visit 3 months later, a domestic 22-24 mm PDA occluder was placed again. After 30 minutes of placement, the pulmonary systolic blood pressure decreased by about 40%, the aortic pressure increased, and the oxygen saturation was 97%. The patient did not feel discomfort, and the occluder was released. Bosentan 125 mg was administered orally twice daily after discharge. After 3, 6 months and 1 year follow-up, clinical symptoms improved, and the functional classification of pulmonary hypertension in WHO recovered to grade I. After reexamination 1 year later, echocardiography showed complete PDA closure, good right ventricular function, mild tricuspid valve regurgitation, mild pulmonary valve regurgitation, mean pulmonary artery pressure 31 mmHg, and 6 min walking distance of 620 m. Right cardiac catheterization was satisfactory.

A 40-year-old female was admitted to the hospital on 5 March 2013 due to "upper abdominal discomfort for 3 months". Physical examination 20 days before admission revealed space-occupying lesions in the pericardial cavity. Admission physical examination: blood pressure 130/90 mmHg (1 mmHg =0.133 kPa), heart rate 89 beats/min, breathing 20 beats/min; The respiratory sounds of both lungs were clear during auscultation, and no dry and wet rales were heard; There was no depression or abnormal bulge in the precordial area, the apical beat was located 1 cm within the midline of the left clavicle in the fifth intercostal edge of the left sternum, no tremor was palpable on the heart surface, the turbidity boundary of the percussion heart increased to the left, and a grade 2/6 systolic blowing-like murmur could be heard in the second intercostal edge of the left sternum; Soft abdomen, unpalpable mass, unpalpable liver and spleen. The electrocardiogram was sinus rhythm. X-ray chest radiograph showed an enlarged heart shadow with a cardiothoracic ratio of 0.66, and abnormal bulging shadow in the proximal pulmonary artery segment of the left heart margin, suggesting space-occupying lesions. Echocardiography (Figure 1) An abnormal echo mass was detected in the pericardial cavity in front of the right ventricle. The size of the mass was 120 mm ×107 mm ×59 mm, with clear boundary and relatively regular shape. The interior was moderate intensity echo with uniform echo, and the mass pressed the right ventricular outflow tract and the root of the pulmonary artery backward; There was no stenosis in the right ventricular outflow tract, with an internal diameter of 11 mm; A liquid dark area was detected in the pericardial cavity in the right anterior of the right ventricle, with a width of 11 mm; The left heart diameter was normal, and the wall movement was not abnormal; There were no obvious abnormalities in the morphology, structure and opening and closing movement of each valve; Color Doppler echocardiography showed no abnormal blood flow signals in all parts of the heart. Cardiac magnetic resonance (Figure 2) shows that there is a space-occupying lesion in the pericardial cavity of the right heart margin, reaching the aortic arch level upward and the proximal diaphragm level downward, and squeezing the aortopulmonary artery, right atrium, right ventricle and superior vena cava; The shape of the space-occupying lesion is irregular, and the separation can be seen inside it, the maximum is 80 mm ×49 mm, and the overall signal is uneven. The T1 and T2 phases are moderately low signals, there is no obvious signal change in the lipid pressure phase, and the signal of the water-lipid separation phase is uneven; Delayed scanning showed a sheet-like non-uniform strengthening visible within it; There is a small amount of effusion signal in the pericardial cavity adjacent to the space-occupying lesion; The inner diameter of left atrium and left ventricle was normal, the wall thickness of each segment of left ventricle was normal, and the overall heart movement was good; There were no abnormalities in myocardial first-pass perfusion and delayed enhancement; No regurgitation signal was observed in the atrioventricular and aortic valves. The results of magnetic resonance examination were considered as solid space-occupying lesions of intrapericardial capsule, with a high possibility of benignity.

A 21-month-old male with a body weight of 13 kg was admitted to the hospital because of "cardiac murmur found for more than 1 year". Physical examination: heart rate 120 beats/min, regular heart rhythm, P₂>A₂Grade 3/6 rough systolic murmur could be heard in the 3rd and 4th intercostal areas of the left margin of the sternum. Echocardiography showed ventricular septal defect (VSD) with membranous neoplasia (left-to-right shunt at ventricular level). The left ventricular surface diameter of VSD was 3.8~6.9 mm, and the right ventricular surface diameter was 2.6~3.1 mm. It was 1.9 mm from the right coronary valve of the aorta and 3.4 mm from the tricuspid septal valve. Chest X-ray showed increased pulmonary blood with a cardiothoracic ratio of 0.50. There were no abnormalities in the ECG. Clinical diagnosis: congenital heart disease, VSD (perimembranous part).

A 76-year-old male was admitted to hospital for more than half a year due to repeated chest tightness and discomfort, which was aggravated for 2 months. Six months ago, the patient had chest tightness without obvious trigger, no shoulder and back radiant discomfort, and there was no obvious relationship with activity. Each time lasted for about 20 minutes, and no attention was paid to it. Two months ago, chest tightness and discomfort occurred again when going out for activities, and oral Musk Baoxin Pill could not relieve it. In an external hospital, the ECG showed acute inferior myocardial infarction; Echocardiography showed asymmetric left ventricular myocardial hypertrophy, weakened systolic function, abnormal segmental activity of left ventricular inferior wall, mild left atrial enlargement, aortic valve degeneration, mild mitral regurgitation, left ventricular ejection fraction 40.9%; The cardiac markers were troponin T 456.8 ng/L, creatine kinase (CK) 620 U/L, and creatine kinase isoenzyme (CK – MB) 82.3 U/L. Emergency percutaneous coronary intervention (PCI) was performed in a foreign hospital on 12 November 2013. Coronary angiography showed: right coronary artery stenosis in the proximal segment of 40%, and stenosis in the proximal middle segment of 60%; The left anterior descending artery is completely occluded from the middle segment after issuing the first diagonal branch; Proximal left circumflex artery stenosis was 40% and mid-distal stenosis was 95%. Considering the lesion of the middle and distal left circumflex artery as a criminal lesion, one stent was placed in the lesion of the middle and distal left circumflex artery.

familial hypercholesterolaemia (FH) is the most common dominant genetic disease, and its main pathological basis is low-density lipoprotein receptor (LDLR) gene mutation, which leads to a decrease in plasma clearance of LDL and a significant increase in LDL-C levels. Patients with FH usually develop clinical manifestations of coronary atherosclerotic cardiovascular disease between 10 and 40 years of age. Recent studies have shown that the incidence of FH in the population is 1/137~1/500. There may be 15 million FH patients in the world, but the diagnosis rate of FH patients in most countries is less than 1%, and only 5% of them have received appropriate treatment. The important reason for this treatment is that doctors lack awareness of the risk of FH coronary heart disease. In order to better prevent coronary heart disease, strengthen the standardized management of FH population, and use the latest contemporary technology to achieve the best diagnosis and treatment, the International FH Foundation invited famous experts from all over the world for the first time to analyze and discuss all the current FH guidelines and consensus, and published an authoritative, standardized, practical, reliable and guiding integrated guideline (abbreviated as the guideline), in order to realize early diagnosis and intervention of FH patients and prevent early onset of coronary heart disease^[1]。

On March 28, 2014, the American Heart Association (AHA), the American College of Cardiology (ACC) and the Heart Rhythm Society (HRS) jointly released the 2014 Guidelines for the Treatment of Patients with Atrial Fibrillation.^[1]In lieu of the 2006 edition of the Guide^[2]And two updated parts in 2011^[3,4], and reflects the 2012 European Society of Cardiology (ESC) Atrial Fibrillation (AF) guidelines^[5]Parts of the content. The new edition of the guidelines reviews the relevant literature from 2006 to February 2014 and summarizes the latest consensus of clinical experts in the field of atrial fibrillation treatment, including adult cardiology, electrophysiology, cardiothoracic surgery, and heart failure. The new version of the guide mainly includes the following seven aspects.

The number of AIDS deaths worldwide in 2011 was 1.7 million, a decrease of about 24 percent compared with 2005^[1]。 21,000 in China, up 11.8% from before^[2]The situation of AIDS prevention and control in China remains grim. Among them, the incidence and mortality of cardiovascular diseases, especially coronary heart disease, among people infected with human immunodeficiency virus (HIV) are increasing year by year^[3]The mortality rate of myocardial infarction is about 1.5 to 1.7 times that of the general population, and the average median age of death is about 48 years old, which is far lower than that of the general population^[4,5]。 Although HIV-infected people have a high level of risk perception of traditional risk factors for coronary heart disease, this does not reduce their incidence of coronary heart disease, which may be determined by the specificity of HIV-infected people themselves^[6]。 This paper reviews the risk factors of coronary heart disease in HIV infected patients from the aspects of genetic background, traditional risk factors, HIV infection and antiretroviral therapy.

p66Shc is a novel longevity regulatory gene, which plays an important role in the regulation of oxidative stress and apoptosis. Since it was first reported in 1999 that the lifespan of p66Shc gene knockout mice was prolonged, the reactive oxygen species (ROS) and its induced apoptosis were significantly reduced, domestic and foreign scholars have carried out a lot of research on the function of p66Shc. It is now generally believed that p66Shc is a new longevity gene, which is involved in energy metabolism and oxidative stress, especially plays an important role in mitochondrial ROS formation. The study of p66Shc and oxidative stress damage related diseases has become one of the hot spots.

Malignant arrhythmias are a large class of diseases that seriously threaten patients' lives. Among them, ventricular tachycardia (VT) or ventricular fibrillation is the most common cause of sudden cardiac death. In developed countries, the incidence can range from 1/1 000 to 2/1 000 per year^[1]。 The occurrence of ventricular arrhythmia is often based on organic heart disease. In western countries, the most common cause of sudden cardiac death or ventricular tachycardia in people over 30 years old is coronary heart disease, while the most common cause of sudden cardiac death or ventricular tachycardia in people under 30 years old is hypertrophic cardiomyopathy, myocarditis and congenital heart disease^[1]。 Risk stratification of sudden cardiac death is very important for effective preventive treatment, but there is still a lack of recognized effective methods to screen out patients with high risk of sudden cardiac death. Cardiac magnetic resonance (CMR) imaging is a new technology in the field of imaging diagnosis of cardiovascular diseases, and it has unique advantages in myocardial histological evaluation. In recent years, research has gradually shown that CMR has a unique value in the assessment of ventricular arrhythmia. This paper intends to summarize the latest progress of CMR in the diagnosis and treatment of ventricular arrhythmia as follows.

The article "CHADS" by Xiang Wei et al. was published in the 5th issue of the Chinese Journal of Cardiovascular Diseases in 2014₂Scoring vs. CHA₂DS₂– Comparison of VASc scores "(abbreviated as Xiang Wen), analyzed the differences of the two scores before stroke in 599 patients with non-valvular atrial fibrillation (AF) who had suffered from ischemic stroke, and obtained CHA₂DS₂– VASc score predicts ischemic stroke better than CHADS in patients with non-valvular atrial fibrillation₂The conclusion of the scoring. The basis of this analysis was to divide patients into low, medium and high risk groups according to the scores of the two scores, and compare the differences between the two scoring systems in the same risk groups. In the author's opinion, does this practice conform to CHA₂DS₂– The idea of VASc scoring is debatable.

"CHADS₂Scoring vs. CHA₂DS₂-Comparison of the advantages and disadvantages of VASc scores "was published in the 5th issue of Chinese Journal of Cardiovascular Diseases, 2014. Thank you Liang Yan for your valuable opinions.