2015年 · 第43卷第05期

Professor Yang Dingyi tragically passed away on 22 September 2014 at the age of 91 due to illness. Professor Yang is a famous cardiovascular disease expert in China and the outstanding founder of the Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi' an Jiaotong University School of Medicine.

In September 2011, the UN summit issued a political declaration to control chronic non-communicable diseases (NCDs) worldwide. A phased quantification target of 25×25 was then proposed, i.e., by 2025, to eliminate the premature (<70 years of age) decreased death by 25% and reduced or controlled 6 major risk factors. Now that 2025 is only 10 years away, the task of achieving the 25×25 goal is difficult and urgent.

Atherosclerosis and Coronary Heart Disease Group of Cardiovascular Disease Branch of Chinese Medical Association organized experts to conduct a 2010 "Guidelines for Diagnosis and Treatment of Acute ST-segment Elevation Myocardial Infarction"^[1]Updated (hereinafter referred to as the New Guide) and published in this issue^[2]。 The new guidelines briefly explain the current management strategies for acute ST-segment elevation myocardial infarction (STEMI), especially providing important guidance for standardized reperfusion treatment of STEMI in China.

In recent years, important progress has been made in the diagnosis and treatment of acute ST-segment elevation myocardial infarction (STEMI), and the third edition of "Global Definition of myocardial infarction" has been published^[1,2]The European Society of Cardiology, the American College of Cardiology Foundation and the American Heart Association revised the guidelines for the treatment of STEMI^[3,4], European guidelines for myocardial revascularization have also been published^[5]。 At the same time, a number of related randomized controlled clinical trials have been completed at home and abroad. Therefore, the Atherosclerosis and Coronary Heart Disease Group of the Cardiovascular Branch of the Chinese Medical Association organized experts to review the 2010 Guidelines for the Diagnosis and Treatment of Acute ST-segment Elevation Myocardial Infarction in China^[6]Make an update. The recommendations for treatment in this guideline are expressed in an internationally accepted manner: Class I recommendations refer to the proven and/or unanimous recognition that a treatment measure or operation is beneficial and effective and should be adopted; Class II recommendation means that the effectiveness of a treatment measure or operation is still controversial, among which Class IIA recommendation means that the relevant evidence and/or opinions tend to be effective, and the application of the treatment measure or operation is appropriate, while Class IIB recommendation means that the relevant evidence and/or opinions cannot be fully proved to be effective, and further research is needed; Class III recommendation refers to the fact that a treatment or operation has been proven and/or consistently recognized as useless and/or ineffective, and may be harmful to some cases, so it is not recommended. Level of evidence A refers to data derived from multiple randomized clinical trials or meta-analyses; Grade B refers to the data from a single randomized clinical trial or multiple large-scale non-randomized controlled studies; Grade C refers to data derived from expert consensus and/or small clinical trials, retrospective studies, or registrations.

Hypercholesterolemia is one of the most important risk factors for atherosclerotic cardiovascular disease (ASCVD) (including coronary heart disease, ischemic stroke/transient ischemic attack, atherosclerotic aortic disease and peripheral arterial disease). Lowering cholesterol levels with statins can significantly reduce the risk of ASCVD events. Therefore, the use of statins to reduce cholesterol levels and bring them below the corresponding target values is regarded as the core strategy of primary and secondary prevention of ASCVD. In clinical practice, many patients' cholesterol levels still can't reach the target value after receiving statin treatment, and some patients can't tolerate statin treatment, which has become an important shackle to achieve blood lipid standards. At the same time, the safety of high-dose, high-intensity statin therapy in Asian people is also attracting increasing attention. The widespread use of selective cholesterol absorption inhibitors provides a new option for lowering cholesterol safely and effectively. Cardiovascular Physicians Branch of Chinese Medical Doctors Association, Cardiovascular and Cerebrovascular Diseases Professional Committee of Chinese Gerontology Society, and Cardiovascular Diseases Branch of Chinese Medical Association organized domestic experts to formulate and update the "Chinese Expert Consensus on Clinical Application of Cholesterol Absorption Inhibitors" in 2010 and 2013. After the release of the consensus, it attracted widespread attention in China and played a positive role in enhancing clinicians' understanding of such drugs. Recently, the "Further Reduction of Endpoints: International Study on the Efficacy of Yishipure" (IMPROVE-IT) announced that IT was the first to prove that non-statin cholesterol-lowering therapy can also reduce the risk of cardiovascular events, providing new evidence for revealing the relationship between cholesterol reduction and clinical benefit. In this context, the Expert Committee of China Cholesterol Education Program, together with the Cardiovascular Physicians Branch of Chinese Medical Doctors Association, the Cardiovascular Disease Professional Committee of Chinese Rehabilitation Medicine Association and the Cardiovascular and Cerebrovascular Disease Professional Committee of Chinese Gerontology Society, organized experts to revise the clinical application of selective cholesterol absorption inhibitors. The consensus of Chinese experts provides clinical guidance and suggestions for the rational application of cholesterol-lowering drugs.

Numerous observational studies and meta-analyses suggest that increased postprandial blood glucose values may increase the risk of cardiovascular disease (CVD). This hypothesis is further supported by the randomized double-blind placebo-controlled trial Study on the Prevention of Non-Insulin-Dependent Diabetes Mellitus (STOP-NIDDM), in which subjects with impaired glucose tolerance (IGT) were given acarbose to reduce postprandial hyperglycemia, with secondary endpoint analysis showing its ability to reduce the risk of cardiovascular events.

The 89-year-old male was admitted to the hospital on April 25, 2014 due to "repeated chest tightness, shortness of breath and palpitation for more than 20 years, and recurrent aggravation for 1 d". The admission diagnosis was "coronary atherosclerotic heart disease, ischemic cardiomyopathy, first-degree atrioventricular block, complete left bundle branch block, cardiac function grade IV; chronic renal insufficiency". History of hypertension and diabetes is denied. Physical examination on admission: pulse 91 beats/min, blood pressure 100/70 mmHg (1 mmHg =0.133 kPa), cyanotic lip, full jugular vein, obvious expansion of heart boundary percussion to the lower left, heart rate 91 beats/min, low heart sound, harmonic heart rhythm, grade 3/6 systolic blow-like murmur can be heard in the mitral valve auscultation area, and mild depressed edema of both lower limbs. ECG: Sinus rhythm, complete left bundle branch block, first degree atrioventricular block, left ventricular hypertrophy. Laboratory test: Blood routine showed white blood cell number 15.91×10⁹/L, the proportion of neutrophils was 87.4%. Number of red blood cells 3.72×10¹²/L, hemoglobin 117 g/L, platelets 684×10⁹/L. Renal function: creatinine 177 μ mol/L, uric acid 706 μ mol/L, urea nitrogen 12.1 mmol/L. Electrolyte: Sodium 132.0 mmol/L, Chlorine 92.8 mmol/L. B-type natriuretic peptide (BNP)>5 000 ng/L. Liver function: alanine aminotransferase (ALT) 14 U/L, aspartate aminotransferase (AST) 31 U/L, aspartate mitochondrial isoenzyme (M-AST) 7 U/L, glutamyl transpeptidase (GGT) 45 U/L, alkaline phosphatase (ALP) 82 U/L. Echocardiography: Whole heart enlargement, left ventricular ejection fraction 34%. The patient had been hospitalized 4 times for heart failure within six months, so he was given a new type of Ca^2＋The sensitizer levosimendan increases myocardial contractility and improves the symptoms of heart failure and hemodynamics of patients. Dosing method: 12.5 mg (5 ml) of levosimendan plus 5% glucose diluted to 50 ml, micropump bolus injection, initial loading of 12 μ g/kg, 10 min, then 0.1 μ g kg^－1• min^－1Micropump bolus, increased to 0.2 μ g·kg after 1 h^－1• min^－1And continuously pump through. Dosing was repeated after 1 week for a total of 4 doses. Patients took clopidogrel 75 mg once daily, benazepril 2.5 mg once daily, metoprolol 6.25 mg twice daily, spironolactone 20 mg once daily, and furosemide 20 mg once daily during dosing.

A male child, 2 years and 11 months, was admitted to the hospital on 16 November 2013 due to "cardiac murmur found for 1 year". One year ago, the child was found to have a heart murmur in a local hospital due to a "cold". The child has poor exercise endurance, shortness of breath after no activity, no syncope, and is usually prone to "cold". He has been treated in pediatrics for pneumonia many times. Echocardiography was examined in our hospital, which revealed congenital heart disease, mitral valve prolapse with severe regurgitation, coronary-pulmonary fistula, and patent foramen ovale. Admission to hospital with proposed surgery. Physical examination: body temperature 36.5 ℃, pulse 112 beats/min, breathing 24 beats/min, blood pressure 90/56 mmHg (1 mmHg =0.133 kPa); Height 91 cm, weight 12 kg; Pale complexion without lip cyanosis; The breathing sounds of both lungs were clear, and no dry and wet rales were heard; Lift-like beats can be palpable at the apex of the heart, the heart turbidity boundary is large, the heart rate is 112 beats/min, the rhythm is uniform, and a systolic murmur of grade 2/6 can be heard in the precordial area; Liver and spleen were not palpable under the costs; No pestle fingers, no edema in both lower limbs.

Rational anticoagulation therapy can significantly reduce the incidence, recurrence and mortality of cardiovascular events in high-risk groups such as atrial fibrillation (AF), acute coronary syndrome (ACS) and venous thromboembolism (VTE). Therefore, anticoagulation therapy has become one of the main measures for the prevention and treatment of these cardiovascular diseases^[1,2,3]。 Traditional oral anticoagulants such as warfarin are widely used in clinical practice because of their positive efficacy and cheap price. Earlier randomized controlled studies confirmed that warfarin was significantly better than placebo in secondary prevention in patients with ACS^[4]And aspirin^[5]。 Meta-analysis^[6,7]It was also found that the application of moderate strength warfarin on the basis of aspirin [International Standardized Ratio (INR): 2.0-3.0] reduced myocardial infarction (MI) by 44%-52%, stroke by 53%-54%, and revascularization events by 20% compared with aspirin monotherapy; However, the incidence of major hemorrhage events increased by about 2.5 to 8 times; Does not reduce the overall mortality rate. However, due to the interaction between warfarin and many drugs or foods, there are limitations such as narrow treatment window and regular testing, which limit the application of warfarin in patients with coronary heart disease. Therefore, exploring alternative treatments and drugs for warfarin has become a breakthrough in the current situation of cardiovascular anticoagulation. In recent years, the hot spot of clinical research has mainly focused on the research and development and application of new oral anticoagulants (NOAC), among which direct thrombin inhibitors (DTI) represented by dabigatran etexilate and direct factor Xa inhibitors represented by rivaroxaban and apixaban have the most sufficient evidence-based medical evidence in the prevention and treatment of VTE and the prevention of non-valvular atrial fibrillation embolic events, and have been recommended by relevant guidelines. However, in recent years, there have been some new progress and controversy between NOAC and the prevention of coronary heart disease. This article intends to review the research progress of NOAC in the secondary prevention of ACS.

At the same time as mankind enters the 21st century, a new concept of health with global significance will be born in China. It will inject strong social motivation into the progress of modern medicine, improve the living environment and quality of life of human beings in promoting the organic and close combination of medicine and society, and reconstruct the medical system. It will provide a good ecological and social environment for human health, and further improve the level of human health. This is the scientific view of health.

red blood cell distribution width (RDW) is an objective index for quantitative detection of RBC heterogeneity, which reflects the heterogeneity of RBC volume change, and is usually used for differential diagnosis of anemia^[1]。 In recent years, it has been found that RDW is a strong predictor of acute and chronic cardiovascular diseases, and it is also a new index to independently predict the prognosis of cardiovascular diseases. For example, changes in RDW are strong predictors of long-term poor prognosis after treatment in patients with heart failure (heart failure)^[2]。 The mechanism may be related to the deformability of RBC. The increase of RDW and the decrease of RBC deformability make the microcirculation blood flow impaired, which in turn leads to hypoxia, contributing to the explanation of the correlation between increased RDW and cardiovascular disease^[1]。