2015年 · 第43卷第07期

In January 2015, I visited the cardiac rehabilitation project of Director Dong Shaohong of the Department of Cardiology of Shenzhen Hospital. Although the hospital's support is not strong, the venue is not large, and the equipment is relatively small, some directors attach great importance to it, choose core doctors who love and are enthusiastic about cardiac rehabilitation, and set up a team to implement the "five prescriptions" [drugs, psychology (including sleep management), exercise, nutrition and smoking cessation and alcohol restriction prescriptions], and the cardiac rehabilitation work is vigorously carried out.

The Consensus of Chinese Experts on Exercise Therapy for Coronary Heart Disease Patients (referred to as the Consensus) formulated by experts organized by the Prevention Group of Cardiovascular Disease Branch of Chinese Medical Association and the Cardiovascular Disease Professional Committee of Chinese Rehabilitation Medicine Association is the first guidance program for rehabilitation exercise therapy for coronary heart disease patients in China. The definition of exercise in the Consensus clarifies the relationship between physical activity and exercise, and expounds the benefits of exercise and the harm of lack of exercise for coronary heart disease patients. The exercise prescription mentioned in it is the core content of the Consensus and an important content of cardiac rehabilitation program.

March 25, 2014HeartPublished the third edition of the Consensus Recommendations for Cardiovascular Disease Prevention (JBS3) published by the United Kingdom Committee of Associations^[1]。 The consensus believes that the risk factors of cardiovascular mortality in North America, Western Europe and other high-income countries have declined in the past 40 to 50 years, but cardiovascular disease is still the main cause of death, and it has begun to spread to low-and middle-income countries. At the same time, especially among young adults, there is a tendency to prevent or even reverse the decline in mortality from cardiovascular diseases due to the increase in obesity and diabetes.

Cardiovascular and cerebrovascular diseases are the primary causes of disability and death in Chinese residents^[1]。 According to the 2011 China Cardiovascular Disease Report, according to the prediction of China's coronary heart disease policy model, the number of cardiovascular diseases (angina pectoris, myocardial infarction, sudden death from coronary heart disease and stroke) in Chinese people aged 35-84 years will increase by more than 50% from 2010 to 2030. Data from the Global Registry of Acute Coronary Events (GRACE) study indicate that the rate of death, stroke, and rehospitalization in patients with coronary heart disease within 6 months after discharge is as high as 25%^[2]The 4-year cumulative mortality rate was as high as 22.6%, and 50% of the dead patients died of recurrent myocardial infarction. Even if they survived, 30% of patients with coronary heart disease had limited activity, 30% were unable to work properly, and 45% had anxiety and depression. The essence of coronary heart disease is lifestyle disease. A large number of epidemiological studies and interventional studies have shown that the combination of drug treatment and lifestyle treatment is the most effective secondary prevention strategy for coronary heart disease.

A male, 8 years old, came to our hospital for diagnosis and treatment in September 2014 because of atrial septal defect (ASD) found by echocardiography in an outside hospital. Patients are usually prone to catching colds, and their physical strength and endurance are poor. Physical examination: blood pressure 90/60 mmHg (1 mmHg =0.133 kPa); Clear breathing sounds in both lungs; The heart rate was 90 beats/min, the rhythm was uniform, and a systolic murmur of grade 2/6 could be heard in the 2nd to 3rd intercostal area of the left margin of the sternum; No cyanosis and clubbed fingers. Blood, urine routine and blood biochemical examination were normal. Electrocardiogram revealed occasional premature ventricular contractions. X-ray chest radiograph showed increased blood in both lungs, slight bulge of pulmonary artery segment, full right atrial ventricle, and cardiothoracic ratio of 0.53. Echocardiography showed mild enlargement of the right atrium with right ventricular anteroposterior diameter of 2.5 cm, left atrial anteroposterior diameter of 2.4 cm, and left ventricular anteroposterior diameter of 3.1 cm at the end of diastole; Left ventricular ejection fraction 66.1%; Loss of echo in the atrial subaseptal cavity, 6.0 mm in diameter. Multi-slice CT showed right atrioventricular enlargement, left ventricular end-diastolic diameter 31 mm, main pulmonary artery diameter 21 mm, ascending aorta diameter 17 mm, right inferior pulmonary vein entrance diameter 14 mm; Defect between the proximal segment of the inferior vena cava and the anterior wall of the right inferior pulmonary vein, with a maximum diameter of 12 mm (Figure 1)。 Admission diagnosis: congenital heart disease, ASD (inferior cavity type), pulmonary hypertension.

The 85-year-old male was admitted to the hospital on May 15, 2014 due to "episodic chest tightness, shortness of breath for 4 years, aggravated for 2 days". Physical examination: heart rate 76 beats/min, blood pressure 135/85 mmHg (1 mmHg =0.133 kPa), clear breathing sounds in both lungs, harmonious heart rhythm, and grade 4/6 systolic jet-like murmur could be heard in the third intercostal at the left margin of the sternum. Outpatient transthoracic echocardiography showed a peak aortic valve flow velocity of 5.9 m/s, a peak pressure difference of 140 mmHg and a mean pressure difference of 71 mmHg, and a diagnosis of severe aortic stenosis and mild regurgitation. Enhanced CT of coronary artery and aorta showed scattered calcification of left anterior descending artery, left circumflex artery and right coronary artery, mixed plaque in the middle of left anterior descending artery, and local stenosis of about 50%; Thickening and calcification of aortic valve leaflets. Some of the parameters of transcatheter aortic valve implantation (TAVI) measured by CT were as follows: the diameter of the aortic annulus was 23.1 mm ×28.1 mm, the diameter of the aortic sinus was 28.9 mm ×31.7 mm, the opening of the right coronary artery was 18.0 mm from the sinus floor, the opening of the left coronary artery was 14.9 mm from the sinus floor, and the diameter of the ascending aorta was 31.0 mm (Figure 1)。 The DICOM images examined by CT are immediately imported into Fitme software (Feite Tu Meng Beijing Technology Co., Ltd.), and printable 3D graphics files are generated through computer-aided image processing such as image segmentation, three-dimensionalization, clipping, smoothing and retouching. Then a domestic 3D printer (Hangzhou Xianlin 3D Technology Co., Ltd.) is connected for printing. The left ventricle and most of the aorta are printed with red plastic, and the root of the aorta is made of transparent resin material (Figure 2，Figure 3，Figure 4)。

The patient was a 32-year-old male. He was admitted to hospital for "intermittent chest pain and chest tightness for more than 1 month". A coronary angiography was performed in an external hospital, showing 70% segmental stenosis of the proximal segment of the left anterior descending artery, and a distal fistula of the right coronary artery into the left ventricle. He was transferred to our hospital for further treatment in February 2014. The patient developed normally, and a systolic murmur of grade 2/6 could be heard in the intercostal area of 3~4 of the left margin of the sternum, and no tremor was palpable in the precordial area. There were no definite abnormalities in ECG. Echocardiography showed: slight enlargement of left atrium and left ventricle, left atrium 38 mm ×47 mm ×62 mm, left ventricular end-diastolic diameter 53 mm; In the four-chamber section, a color blood flow signal of about 3 mm width entered the left ventricular cavity at the mitral annulus of the left ventricular lateral wall, which originated from the right coronary artery, suggesting a right coronary artery-left ventricular fistula. Laboratory tests showed no abnormalities. Then, the left anterior descending artery fractional flow reserve (FFR) examination was performed to determine whether to perform percutaneous coronary intervention (PCI) for stenotic lesions and transcatheter coronary fistula occlusion at the same time.

The patient was a 32-year-old male with previous physical health. In August 2012, he was admitted to hospital with episodic palpitations, chest pain with dizziness and headache without obvious triggers. The blood pressure was 180/100 mmHg (1 mmHg =0.133 kPa) and the electrocardiogram showed sinus tachycardia. Clinically, coronary CT angiography (CTA) was performed to exclude coronary heart disease, which showed an irregular homogeneous fluid density mass on the lateral side of the middle mediastinum pericardium (right ventricle posterior lower right) (Figure 1), connected to the pericardium, with a CT value of about 2 HU, a size of about 3.3 cm ×1.2 cm ×1.7 cm, and a volume of about 5.32 cm³The cyst wall is clear and multiple folds are seen, and the tumor is not enhanced after enhancement; No abnormalities were observed in the coronary arteries. CT opinion: pericardial cyst. The clinical diagnosis was essential hypertension grade 3, sinus tachycardia, pericardial cyst. He was given symptomatic treatment with angiotensin converting enzyme inhibitors and sartans, and was discharged after improvement. He was instructed to regularly review the pericardial cyst. A reexamination of chest CT in September 2013 showed a significant increase in pericardial cyst (Figure 2), about 4.7 cm x 1.8 cm x 2.2 cm, volume about 10.03 cm³The cyst wall folds basically disappeared, and pericardial cyst excision was clinically recommended, but the patient refused surgery. In July 2014, the patient suffered from sudden tear-like pain in the chest and back at night without obvious trigger, lasting for about 10 minutes. Chest X-ray and electrocardiogram examination were performed in the emergency department, but no clear abnormalities were found. Later, the patient's symptoms gradually improved, and no further treatment was done. One month later, the chest CT showed that the pericardial cyst was significantly smaller (Figure 3), about 0.7 cm x 0.3 cm x 0.6 cm, volume about 0.18 cm³。

With the arrival of an aging society, the incidence of valvular heart disease has increased significantly. In Western society, the incidence of aortic valve disease exceeds 5%, among which the incidence of aortic stenosis is 4.6%, and the incidence of aortic regurgitation (AR), also known as aortic insufficiency, is 1.7%^[1]。 Some patients with severe aortic valve disease are at high risk for surgical thoracotomy and aortic valve replacement because of their advanced age and multiple comorbidities^[2]。 In recent years, transcatheter aortic valve implantation (TAVI) has been developed rapidly because of its advantages of less trauma and quick recovery, and has been widely used in clinical practice^[3,4]。 TAVI has emerged as an alternative treatment for surgery in patients with severe calcified aortic stenosis who cannot tolerate the risks of surgery^[5,6]。 Severe AR is still listed as a contraindication for TAVI^[5]。 With the development of new devices and the improvement of technology, the research on the application of TAVI in AR has gradually increased in recent years, and some studies have shown good clinical results. This article introduces the application and research progress of TAVI in AR.

How to correctly choose the treatment strategy of coronary bifurcation lesions has always been a test for interventional cardiologists. With the advent of the era of "functional revascularization" in coronary interventional therapy, interventional doctors seem to see the solution from another angle when they are at a loss in the face of complex bifurcation lesions. Coronary artery imaging alone can provide accurate anatomical information of lesions, but the effect is not satisfactory in assessing the functional status of lesions. fractional flow reserve (FFR), as a specific physiological functional parameter of coronary artery stenosis, can objectively reflect the degree of myocardial ischemia caused by coronary artery disease itself, and can be used to evaluate the function of coronary artery bifurcation lesions, and has its irreplaceable role.

Atherosclerosis is a chronic non-infectious inflammatory reaction of artery wall. Cardiovascular and cerebrovascular diseases caused by atherosclerosis are one of the main causes of death in developed countries. With the improvement of people's living standard and the change of diet structure, the disease has also become the main cause of death of Chinese residents. Atherosclerosis is a multifactorial disease, and endothelial injury, lipid metabolism disorder and chronic inflammation are the key factors in its formation. Lipid-lowering therapy is the cornerstone of the prevention and treatment of atherosclerosis at present. Statins have been widely used in the prevention and treatment of atherosclerotic cardiovascular disease (ASCVD)^[1]。 Statins can significantly reduce plasma low density lipoprotein cholesterol (LDL-C) levels, reduce mortality and improve prognosis in patients with ASCVD. However, some patients still fail to achieve plasma LDL-C levels when receiving adequate statin therapy. Ezetimibe is a selective cholesterol absorption inhibitor, which acts on the brush edge cells of the small intestinal mucosa, inhibits the absorption of food cholesterol, and can effectively reduce the plasma total cholesterol and LDL-C levels. It has been used as the first choice drug in patients with hypercholesterolemia clinically. Or in combination with statins. The IMPROVE-IT study presented at the American Heart Association (AHA) Annual Meeting in 2014 showed that ezetimibe in combination with statins can further reduce cardiovascular events, showing good prospects for its clinical application. In this paper, the pharmacokinetics, pharmacological mechanisms and pharmacogenomics of ezetimibe in vivo, as well as its animal experiments and clinical research progress in ASCVD are reviewed.

In 1988, Pickering et al.^[1]First time inLancet11 cases of renal artery stenosis (RAS) complicated with hypertension with recurrent transient acute pulmonary edema were reported above, of which 7 cases were bilateral renal artery stenosis, 2 cases were isolated renal artery stenosis, and 2 cases were unilateral renal artery stenosis; The occurrence of pulmonary edema is independent of the patient's cardiac function level; After renal artery stenting, blood pressure decreased in all patients, pulmonary edema did not recur in 10 cases, and renal function improved significantly. In a subsequently published series of 55 cases, Pickering further confirmed the argument made in the initial report that bilateral or solitary renal artery stenosis is more likely to develop pulmonary edema than unilateral renal artery stenosis, and that successful renal artery revascularization can reduce the occurrence of pulmonary edema, speculating that bilateral renal artery stenosis is a special and treatable risk factor for pulmonary edema in azotemic hypertensive patients. Since then, 29 case reports, 9 case series, and 10 clinical trials on renal artery stenosis combined with acute pulmonary edema have been published one after another, of which 16 case reports, 2 case series, and 7 clinical trials, with a total of 87 patients supporting the theory of bilateral RAS-related transient pulmonary edema. At the 20th European Congress on Hypertension held in Oslo in 2010, it was proposed to name the condition Pickering syndrome.