2015年 · 第43卷第10期

In recent years, large public hospitals have been fighting for scale, gross income, outpatient volume, number of beds, number of operations and number of stents, comparing who has more CT rows and who has advanced equipment, but what is extremely lacking is soft power-service, medical quality and medical safety. In terms of drug use alone, large public hospitals do not lack the most advanced new drugs, but pharmaceutical services are absent. How to use good drugs safely and effectively? The key is to implement three aspects of drug prescription services.

Atherosclerotic cardiovascular disease is the main cause of death and disability. In addition to dyslipidemia, inflammation and oxidative stress are also important mechanisms in the development and development of atherosclerosis. At present, both domestic and foreign guidelines recommend the use of traditional risk factor-based models to predict the short-term and long-term risk of atherosclerotic cardiovascular disease^[1,2]。 However, there are still shortcomings in using only traditional risk factors. For example, individuals with the same risk factors have different risks of cardiovascular events, some patients without traditional risk factors still have cardiovascular events, and patients who receive adequate statin therapy still have residual risks, etc. Biomarkers are considered to be an important complement to traditional hazard assessment. Unlike C-reactive protein (CRP), lipoprotein-associated phospholipase A2 (LP-PLA2) is a vascular-specific inflammatory marker. Studies have found that LP-PLA2 is an independent risk factor for coronary heart disease and ischemic stroke. It was recently approved by the U.S. Food and Drug Administration for predicting the risk of coronary heart disease and ischemic stroke. In order to actively explore biomarkers with clinical application value and make clinicians better understand and use LP-PLA2 rationally, the Cardiovascular and Cerebrovascular Disease Professional Committee of Chinese Gerontology Society and the Cardiovascular and Cerebrovascular Disease Expert Committee of Laboratory Physicians Branch of Chinese Medical Doctors Association organized experts in related fields such as cardiovascular medicine, neurology and laboratory departments to discuss and suggest as follows.

The patient was a 62-year-old male. Intermittent fever for 3 months, chest CT examination at the local hospital showed bilateral pleural effusion, mainly on the left side, and a small amount of pericardial effusion. Routine biochemistry of pleural effusion showed leakage fluid, and cardiac color ultrasound showed: left atrial occupation? Neoplasms? The clinical diagnosis was "infectious endocarditis, bilateral pleural effusion", and the effect of antibiotic treatment was poor. Later, in our hospital, physical examination: body temperature 38.4℃, blood pressure 152/102 mmHg (1 mmHg =0.133 kPa), swollen lymph nodes palpable under both jaws and groin, with a maximum of about 3.0 cm ×2.0 cm, smooth surface, medium quality, movable, no tenderness, no obvious mass palpable in the abdomen, no tenderness and rebound pain, and no edema in both lower limbs. Auxiliary examination: There was no obvious abnormality in blood routine. Color ultrasound report: multiple swollen lymph nodes in the neck and groin, left atrial occupation, severe tricuspid valve insufficiency, and pulmonary hypertension (moderate-severe). Consider lymphoma, Castleman's disease, left atrial mass occupation (myxoma is likely), severe tricuspid insufficiency, and pulmonary hypertension (moderate-severe). Whole body PET-CT showed that multiple soft tissue nodules of different sizes were seen next to the retroperitoneal abdominal aorta, and the metabolism was slightly active. Abdominal CT (Figure 1) shows that multiple round soft tissue density shadows can be seen in the left adrenal area, around the abdominal aorta, and retroperitoneum, with unclear boundaries. Results of adrenal medulla fusion imaging: normal position and morphology of bilateral adrenal glands, no uptake of m-iodobenzylguanidine (MIBG), multiple retroperitoneal soft tissue density nodules, no uptake of MIBG, systemic I¹³¹-Negative MIBG imaging. Pathology of retroperitoneal space-occupying puncture biopsy: small follicles were observed in puncture tissue, germinal center was reduced, FDC and vascular proliferation, and surrounding small lymphocytes were matured. Medullary vascular proliferation, a large number of plasma cells can be seen. Cervical lymph node biopsy pathology: small blood vessel proliferation between follicles, obvious proliferation of germinal center, hyaline change in blood vessel wall, surrounding mantle cells arranged like onion skin, and a large number of plasma cells proliferated between follicles (Figure 2)。 Combined with the patient's clinic, the diagnosis: (retroperitoneal) multicenter, mixed Castleman's disease. Surgical treatment is recommended after a multidisciplinary consultation. After the consent of the patient and his family, he underwent left atrial space-occupying excision + tricuspid valvuloplasty + retroperitoneal mass resection in our hospital on March 10, 2014. General surgery and cardiac surgery were combined to perform surgery. Retroperitoneal mass removal was performed first, and then left atrial space-occupying excision + tricuspid valvuloplasty was performed under routine cardiopulmonary bypass. The mass was completely removed, and the pathology was routinely sent. The operation course was smooth. Postoperative pathological findings (Figure 3) Left atrial myxoma, retroperitoneal mixed Castleman's disease. After the CHOP chemotherapy regimen (cyclophosphamide + vincristine + prednisone) was given, and the tricuspid valve function was good and the pulmonary artery pressure returned to normal after 1 week of reexamination. Pulmonary hypertension caused by left atrial space-occupying obstruction was considered. The patient recovered well and is now being followed up.

A 42-year-old male patient suffered from repeated chest tightness, asthma, palpitation and palpitation for more than 6 years. He was definitively diagnosed with dilated cardiomyopathy. He was hospitalized for many times and had progressive decline in cardiac function. By January 2014, the patient developed heart failure. Cardiac color ultrasound showed that the inner diameter of left atrium and left ventricle was significantly increased, the end-diastolic diameter of left ventricle was 88 mm, and the left ventricular ejection fraction (LVEF) was 30%. Chest X-ray: Enlarged heart, cardiothoracic ratio 0.7. Orthotopic heart transplantation was performed in a local hospital. Color ultrasound and X-ray showed: left ventricular end-diastolic diameter 50 mm, LVEF 68%, and cardiothoracic ratio 0.4 at the time of discharge. In April 2014, when the patient came to the cardiopulmonary rehabilitation center of our hospital, his cardiac function was grade I, and he complained of pain at the surgical incision. The examination found that the patient was prone to fatigue, limb muscle atrophy, exercise endurance decreased, and daily life ability was limited.

A 41-year-old man coughed and expectorated for more than 1 month. It was yellow purulent sputum with a large amount and blood in the sputum, about 5 to 6 mouths of bloody sputum a day, accompanied by chest tightness, discomfort and sore throat when coughing. The chest radiograph showed double lung inflammation, which was proposed to be diagnosed as "double lung inflammation". After 3 days of treatment with cefthiamidine anti-infection, hemostatic acid and hemostatic aromatic acid for hemostasis, the patient's symptoms were not significantly relieved. He was upgraded to cefminol and levofloxacin combined with anti-infection for 4 days, and the symptoms were relieved. One week before admission, he still had cough and expectoration with blood in the sputum. Admitted to our department for further treatment. The patient reported a history of "tuberculosis". Physical examination: temperature 36.5 ℃, pulse 95 beats/min, breathing 13 beats/min, blood pressure 120/90 mmHg (1 mmHg =0.133 kPa). There was no bulge in the precordial area, no tremor was palpated, the heart boundary was enlarged, the heart rate was 95 beats/min, premature beats were accessible, and no pathological murmur was heard. CT examination showed the soft tissue density shadow in the right atrium with unclear boundary, and irregular filling defect shadow in the right atrium after enhancement, with a size of about 5.7 cm ×3.6 cm. The CT value of plain scan was about 27 HU, the artery after enhancement was 42 HU, and the venous phase was about 68 HU (Figure 1)。 Watery density shadows were seen in pericardium and right chest cavity, and right lung atelectasis was observed. A rounded area without lung texture was seen in the right upper lung. CT diagnosis showed right atrial mass, considering tumor or thrombus. Pericardial and right pleural effusion with right atelectasis. Right upper bullae. Clinical preoperative diagnosis: right atrial mass occupation. Right atrial tumor resection and right atrial repair were performed under general anesthesia and cardiopulmonary bypass. During the operation, extensive loose adhesion in the pericardium was found, and the right atrial tumor invaded the pericardium. A 5 cm ×5 cm mass was seen in the right atrium, and the tricuspid valve was not obviously involved. The right atrial tumor was resected and the right atrial defect was repaired with bovine pericardial patch. The operation was smooth. Postoperative pathology showed that most of them were epithelial-like round polygonal cells diffused into patches, with a small number of short fusiform cells mixed in them, and there were round glandular cavity-like voids. Immunolabeling results: Vimentin (+), CD31 (+), CD34 (+), Bcl-2 (small focal +), Ki67 (50% +). Right atrial angioendothelial sarcoma was considered in combination with immunoenzyme labeling (Figure 2)。 CT re-examination showed multiple nodules in both lungs, the degree of enhancement was clear after plain scan and enhancement, and multiple metastases were considered. Multiple high-density nodules were found in plain CT scan of the head, with a CT value of 54 HU, and edema surrounding the periphery, and multiple metastases of the head were considered (Figure 2)。 The patient died 10 months after surgery.

A 56-year-old male was admitted to the hospital on December 17, 2014 due to "shortness of breath after activity with edema of both lower limbs for more than 2 years, aggravated for 20 days". The patient had postactive shortness of breath with edema of both lower limbs since 2012. He went to a local hospital. Coronary angiography showed no obvious stenosis in the left and right coronary arteries, and echocardiography showed thickening of the ventricular septum and the posterior wall of the left ventricle. After taking drugs such as spironolactone and captopril, the patient still had postactive shortness of breath and edema in both lower limbs. In May 2014, the above symptoms were significantly aggravated, accompanied by anorexia, abdominal distension, etc., and I went to the local hospital again. Pulmonary artery CT showed no obvious abnormalities in each pulmonary artery, which excluded pulmonary embolism and was diagnosed as hypertrophic cardiomyopathy. After treatment with spironolactone, hydrochlorothiazide, furosemide, captopril, digoxin and other drugs, shortness of breath and edema of both lower limbs progressively aggravated after activity. On 17 December 2014, shortness of breath aggravated after upper respiratory tract infection, accompanied by inability to lie down at night, and severe edema of both lower limbs. No prior history of hypertension and diabetes.

A 33-year-old male was admitted to the hospital on 4 July 2013 due to "episodic precordial pain for 1 week". Admission physical examination: pulse 82 beats/min, blood pressure 130/80 mmHg (1 mmHg =0.133 kPa); The breathing sounds of both lungs were clear, and no rales were heard; The heart rhythm was uniform, and no pathological heart murmur was heard. On admission, serum troponin I was 0.519 μ g/L (normal value 0-0.056 μ g/L), and creatine kinase (CK) and creatine kinase isoenzyme (CK-MB) levels were in the normal range. ECG showed sinus rhythm, V₂Lead ST segment arch dorsal upward elevation 0.1~0.3 mV, V₂~ V₅Lead T-wave inversion. Echocardiography showed a localized tumor-like enlargement at the onset of the left coronary artery, measuring 3.40 cm ×3.52 cm (Figure 1), in which blood flow signals are seen. Coronary angiography showed tumor-like widening at the beginning of the left coronary artery, with slow filling of contrast agent (Figure 2)。 Clinical diagnosis: acute myocardial infarction, coronary artery aneurysm.

The patient was a 37-year-old female with 2 pregnancies and 1 flow 1 (G2P1L1), who came to the clinic at 38 weeks of gestation. Ultrasound examination showed that a fetal structure was detected in the uterine cavity, the cranial halo was intact, the fetal head was located on the pubis, the biparietal diameter was about 9.2 cm, the femur was about 7.4 cm long, the head circumference was about 32.8 cm, the abdominal circumference was about 40.5 cm, the spine was continuous, the fetal heart beat was regular, the placenta was located on the anterior wall, and there was semi-annular calcification inside, and the amniotic fluid index was 12.0 cm. The fetal cardiothoracic ratio was 0.54, the wall was hypertrophic, the left ventricular lateral wall was 11 mm, the interventricular septal thickness was 12 mm, and the right ventricular anterior wall was about 12 mm thick (Figure 1), mitral valve chordae tendineae hypertrophy about 6 mm (Figure 2), the ventricular wall thickness near the apex of the right ventricle is about 15 mm (Figure 3), the left ventricular transverse diameter was 8 mm, the right ventricular transverse diameter was 9 mm, the thickened myocardial echo was thickened and enhanced, the motion amplitude was reduced, and the left ventricular outflow tract was narrowed. The maximum forward blood flow velocity of the left ventricular outflow tract was about 136 cm/s, the inner diameter of the aortic valve was about 5.9 mm, the maximum forward blood flow velocity of the PW aortic valve was about 96 cm/s, the inner diameter of the pulmonary artery was about 7.4 mm, and the maximum forward blood flow velocity of the PW pulmonary valve was about 81 cm/s. Umbilical artery flow parameters: Maximum flow velocity 39.2 cm/s, reverse flow in diastole (Figure 4)。 The internal diameter of the inferior vena cava was widened by about 9 mm, the volume of the liver was increased, the internal echo was enhanced, and the free anechoic area with a depth of 6 mm was explored in the abdominal cavity of the fetus. Ultrasound suggests: (1) Single fetal cephalic position; (2) placental maturity degree II; (3) Fetal hypertrophic cardiomyopathy with mild stenosis of left ventricular outflow tract; (4) The fetal liver is abnormally enlarged with a small amount of peritoneal effusion, and congested liver is considered; (5) Reverse blood flow in late diastolic phase of umbilical artery, considering fetal distress.

The patient was an 80-year-old male who sought medical attention in September 2013 due to "fever and fatigue for 1 d". One day ago, I took 1 pill of Angong Niuhuang Pill due to fever and runny nose and fell asleep. After waking up, I found that I fell from bed, sweated heavily, felt weak, sleepy, and had difficulty walking. There was no obvious muscle pain, limb swelling, dark brown urine color, and no macroscopic hematuria. The next day, due to fever, I went to an outpatient clinic in a foreign hospital, and my muscle enzymes were increased, so I was admitted to the hospital. Previous history of hypertension, hyperlipidemia and prostatic hyperplasia. In 2006, he underwent coronary artery bypass grafting (CABG) for coronary heart disease, and used secondary preventive drugs for coronary heart disease regularly. He has successively used atorvastatin (trade name Lipitor) and rosuvastatin (trade name Keding) for lipid-lowering treatment. For the past 2 years, we have been orally taking aspirin (trade name: Baiaspirin) 100 mg, once/d, amlodipine (trade name: Norhuoxi) 5 mg, once/d, bisoprolol (trade name: Kangxin) 5 mg, once/d, rosuvastatin (trade name: Keding) 10 mg, once/d, niergoline (trade name: Fulutong) 10 mg, three times/d, ethyl polyenoate capsules 0.5 g, three times/d, finasteride (trade name: Baoliezhi) 5 mg, once/d, and tamsulosin (trade name: Harle) 0.2 mg, once/d. At outpatient follow-up, the creatine kinase (CK) and its isoenzyme (CK-MB) were high regularly, the highest CK was 460 U/L (reference value 25-195 U/L), and the highest CK-MB was 11 μ g/L (reference value<5 μ g/L). Physical examination at admission: body temperature 38 ℃, heart rate 80 beats/min, blood pressure 130/80 mmHg (1 mmHg =0.133 kPa). Conscious, weak spirit, untouched bilateral thyroid glands, mild pharyngeal congestion, small bilateral tonsils, clear breathing sounds in both lungs, no obvious dry and wet rales, uniform heart rhythm, soft abdomen, no tenderness, slight decrease in muscle strength of limbs, no obvious muscle tenderness.

The patient, an 81-year-old male, developed flaky erythema and scattered red papules on the limbs and trunk, accompanied by itching in the past 1 month. He had suffered from "rheumatic heart disease, mitral stenosis and atrial fibrillation" for more than 30 years, during which the symptoms of exertion dyspnea recurred, and he was hospitalized in the cardiology department of our hospital many times. Percutaneous balloon mitral valvuloplasty (PBMV) was performed in 2001. Postoperatively, atrial fibrillation was still in rhythm. He was taking warfarin for anticoagulation for a long time. However, in 2010, he stopped taking warfarin and switched to clopidogrel to prevent embolism due to hematuria. On 29 August 2014, the blood test routine showed low platelets, so clopidogrel was stopped and changed to oral dabigatran etexilate 150 mg, 2 times/d anticoagulant therapy. After 1 month of taking the drug, the patient developed the above rash. On October 21, 2014, I went to another hospital due to bloody stools. The allergen test showed that dabigatran etexilate capsules were positive for sensitization, so I stopped taking dabigatran and received desloratadine tablets 5 mg/d for anti-allergic treatment. After the rash improved. After changing to warfarin 0.75 mg/d anticoagulant therapy for 1 month, the international standardized ratio (INR) of retest was 1.66. Clinical diagnosis: drug eruption caused by dabigatran etexilate.

Vascular restenosis usually refers to the permanent reduction of the lumen diameter of the vessel 3 to 8 months after surgery and less than 50% of the reference vessel^[1]。 However, some other definitions of vascular restenosis have also been proposed and applied^[2]。 Although many drugs and methods have been used clinically to reduce the incidence of restenosis, the incidence of restenosis is still high in patients undergoing revascularization. After revascularization of coronary, carotid and peripheral arteries, the incidence of vascular restenosis ranges from 30% to 50%.

Amyloidosis is a heterogeneous group of diseases in which precursor proteins misfolded into beta sheets abnormally aggregate outside the cell, leading to tissue and organ dysfunction^[1]。 Various types of precursor proteins can act on the heart, including light chain immunoglobulins, mutated hereditary transthyretin, wild-type transthyretin, mutated apolipoproteins, and serum amyloid A proteins, among others^[2]。 Cardiac amyloidosis is due to the abnormal accumulation of these insoluble protein fibers in the extracellular matrix, and constantly infiltrate and damage cardiomyocytes, which ultimately leads to heart disease with progressive systolic and diastolic heart failure as the main manifestation. These amyloids can be stained brick red by Congo red under light microscope, and appear characteristic apple green under polarized light, so endocardial biopsy is the "gold standard" in the diagnosis of cardiac amyloidosis^[3]。 However, endocardial biopsy is an invasive operation, and the incidence of clinical complications is 6%, including arrhythmia, cardiac perforation and pneumothorax, etc., which increases the life risk of patients. At the same time, endocardial biopsy cannot assess the severity of disease, dynamically monitor the progress of disease and follow-up evaluation of treatment effect. In contrast, radionuclide tracing technology can not only overcome these shortcomings, but also be applied to the typing diagnosis of amyloidosis. At present, many radiotracers have been successfully applied in the diagnosis and risk stratification of cardiac amyloidosis^[4]。 Although these tracers have been studied for nearly 20 years, until recently, the effects of⁹⁹Tc^m-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) and⁹⁹Tc^m-Studies on pyrophosphate (PYP)^[5]Only then did we make an important breakthrough. This article will briefly review the types of cardiac amyloidosis and several major types of radionuclide tracers.

The incidence of venous thromboembolism is 100/100,000~200/100,000, which is the third leading cause of vascular disease-related death after myocardial infarction and stroke^[1]。 Current standard therapy is rapid parenteral anticoagulation for 5 to 7 days followed by vitamin K antagonist use for at least 3 months^[2]。 In the past many years, warfarin has been recognized as an oral anticoagulant with clear effects, safety and high price. However, due to its vulnerability to drug-food interactions, the need to monitor coagulation function and international normalized ratio (INR), narrow safety window, and risk of bleeding, its clinical application is often limited. In order to overcome the shortcomings of traditional anticoagulants, new anticoagulants are constantly emerging, and apixaban is one of them. Agnelli et al.^[3]Studies have shown that apixaban is not inferior to warfarin and can significantly reduce the risk of bleeding. In May 2011 and December 2012, apixaban was approved by the European Union and the food and drug administration (FDA), respectively, for the prevention of venous thromboembolism after elective hip or knee arthroplasty in adults. In July 2014, it became the recommended drug for deep vein thrombosis and pulmonary embolism in the European Union, and was subsequently approved by the FDA for leg and lung thrombosis. This article will review the clinical efficacy and safety of apixaban in the prevention and treatment of deep vein thrombosis and pulmonary embolism.

Recently, I had the privilege of having an in-depth conversation with my mentor and helpful friend Professor Hu Dayi on medical review and humanities education, and was unexpectedly given his new book "Medical Review and Humanities Essays". This collection contains not only the medical reviews published by the author in various newspapers and periodicals in recent years, but also the affectionate humanistic essays that moved the author, highlighting the benevolence of doctors passed down from generation to generation in this medical family. On the title page of this book, Professor Hu Dayi wrote: Learn from parents and be a doctor who loves his profession, loves clinical work and has a conscience. He has always advocated holding high the four banners of public welfare, prevention, standardization and innovation, and promoted the return of medicine to humanities, clinical practice and basic skills. I think that in the current domestic academic publications, there is a scarcity of medical reviews with insights, and humanistic education full of human care is even rarer. At a time when the medical environment is poor and the relationship between doctors and patients is tense, studying this book carefully may help us reflect on our medical behavior, abide by the conscience of doctors who treat diseases and save lives, and contribute to the creation of a harmonious society.