2016年 · 第44卷第01期

Only 10 years remain before the phased target of a 25% reduction in premature deaths from non-communicable diseases, especially cardiovascular diseases, i.e. deaths before the age of 70, is achieved by 2025. China is not only a country with rapid economic development, but also a country facing severe challenges of non-communicable diseases (including cardiovascular diseases). Whether China can achieve the "25×25" goal is of great importance to the achievement of the global goal.

Controlling the mortality rate of coronary heart disease has always been a difficult problem in cardiovascular disease. In recent years, the number of Chinese residents with high salt, high fat and low fiber diet, less exercise lifestyle, and hypertension, diabetes, dyslipidemia, smoking, etc. has continued to increase, which has made the prevalence of coronary heart disease on the rise and the incidence of coronary heart disease on the rise. In the absence of any intervention, in general, coronary heart disease is a progressive process, a psychosomatic disease related to age. Therefore, the treatment of coronary heart disease is not only active vascular reconstruction after the onset of the disease, but should pay attention to the whole process management, and attach importance to the establishment and continuous development of the concept of cardiac rehabilitation treatment.

On September 18, 2015, a team of internationally renowned experts from the United States, the United Kingdom and China published a report in the Journal of Atherosclerosis (Atherosclerosis"familial hypercholesterolaemia: A global call to arms^[1]The aim is to call for global collaboration to strengthen the management of familial hypercholesterolaemia (FH). This paper briefly describes the current international form of FH and the consensus of international cooperation.

A large amount of evidence shows that more than 1/3 of patients with coronary heart disease can develop myocardial ischemia under psychological stress. This type of ischemia is called mental stress-induced myocardial ischemia (MSIMI). MSIMI not only affects the quality of life of patients, but also leads to worsening clinical prognosis and increased risk of death.

As defined in the 2013 European guidelines for the diagnosis and treatment of stable coronary heart disease, stable coronary heart disease includes chronic stable exertion angina, stable phase after acute coronary syndrome, asymptomatic myocardial ischemia, asymptomatic coronary atherosclerosis, coronary artery spasm, and coronary microangiopathy angina pectoris^[1]。 Coronary heart disease has the characteristics of chronic persistence and high recurrence. The mortality rate is effectively controlled by revascularization and drug therapy in the acute phase, but the death, stroke and rehospitalization rate is as high as 25% within 6 months after discharge, and the cumulative mortality rate in 4 years is 22.6%. 50% of the death causes are recurrent myocardial infarction^[2]。 Coronary heart disease is a lifestyle disease, and its treatment strategy should pay equal attention to drug treatment and lifestyle improvement, so as to effectively prevent recurrent cardiovascular events and sudden death, improve the quality of life, reduce repeated hospitalization and unnecessary revascularization, reasonably control medical expenses, and make patients recover their best physical strength, mental state and social function. Nearly 50 years of clinical practice have proved that cardiac rehabilitation is the best management mode for the treatment of coronary heart disease in stable phase.

A 73-year-old female was admitted to the hospital on April 3, 2013 due to "episodic precordial pain for more than 1 year and aggravated for more than 40 days". The pain in the precordial region of the patient lasts for several minutes to half an hour each time, which can be induced by activity or spontaneously, and can be relieved by itself without dyspnea. The chest pain worsened more than 40 days before admission and lasted for 1 h without relief. In the local hospital, the cardiac troponin I and creatine kinase isoenzyme (CK-MB) were significantly elevated, and there was no ST segment elevation in the electrocardiogram. Acute non-ST-segment elevation myocardial infarction was diagnosed and treated with medications including low molecular weight heparin, atorvastatin, metoprolol, aspirin, clopidogrel and ramipril. After treatment, his condition improved and he was discharged. After discharge, the patient had repeated attacks of angina pectoris and came to our hospital for further diagnosis and treatment. Has a history of hypertension for more than 20 years, dyslipidemia for more than 10 years, and denies a history of diabetes and a history of allergy to contrast agents. Smoked for 34 years, about 20 cigarettes a day. Family history: Father suffered myocardial infarction at 30 years old.

The child was a female, 8 years old. Due to "discomfort in the precordial area after activity for more than 1 year", I came to our hospital on October 26, 2014. The patient had undergone echocardiography 2 years ago, showing severe mitral insufficiency, and undergone mitral valve replacement in an external hospital. Physical examination: blood pressure 90/60 mmHg (1 mmHg =0.133 kPa); Dry and wet rales were not heard in both lungs; The heart rate was 86 beats/min, the rhythm was uniform, and no pathological murmur was heard in the auscultation area of each valve; The abdomen is flat and soft, without tenderness; There was no edema in both lower limbs. There were no abnormalities in the ECG. Echocardiography (Figure 1): left atrial diameter 32 mm, left ventricular end-diastolic diameter 39 mm, left ventricular end-systolic diameter 26 mm, ventricular septal thickness 7 mm, left ventricular posterior wall thickness 7 mm, left ventricular short axis shortening rate 34%, left ventricular ejection fraction 64%, right atrial and right ventricular diameters normal, left ventricular segment systolic activity no abnormality, mitral valve position artificial mechanical valve echo, diastolic mitral valve flow rate 2.3 m/s, mean pressure difference across mitral valve 3 mmHg, pulmonary artery widening; The left coronary artery did not originate from the left coronary sinus, but the right coronary artery originated from the right coronary sinus, running tortuously, with an inner diameter of 4 mm. The left coronary artery opening was visible in the left posterior wall above the pulmonary valve near the main pulmonary artery, with an inner diameter of 3 mm. Color Doppler showed abnormal blood flow signals in the pulmonary artery, that is, the blood flow from the left coronary artery originating from the pulmonary artery directly flows into the main pulmonary artery. Spectral Doppler showed a turbulent spectrum dominated by diastole, and abundant collateral circulation blood flow was seen between the left ventricular muscle wall, which was obvious at the interventricular septum. Echocardiography suggested that the abnormality of the left coronary artery originated in the pulmonary artery (anomalous origin of the left coronary artery from the pulmonary artery, ALCAPA).

Transcatheter ablation of tachyarrhythmias is one of the milestones in the history of cardiovascular treatment^[1]。 This technique was limited to the ablation of paroxysmal supraventricular tachycardia at the beginning of its application; Since then, a few researchers have explored ablation treatments such as atrial and ventricular tachycardia, but simply X-ray-guided downward mapping and ablation are more difficult and have a lower success rate^[2]。 This limitation is largely due to the practical difficulty of operating and moving mapping electrodes under the guidance of two-dimensional images to carry out mapping and ablation of three-dimensional heart chamber; For "four-dimensional" arrhythmias that require agitation mapping to clarify the agitation sequence, such as atrial tachycardia and ventricular tachycardia, the challenge of relying solely on X-ray images to guide the operation is self-evident.

Bilirubin has been considered a toxic metabolite in the human body and is used clinically to assess liver function and jaundice. In recent years, a large number of studies have found that bilirubin is a natural endogenous antioxidant with important physiological functions, including anti-free radical, anti-inflammatory, anti-complement, anti-immune and anti-vascular smooth muscle proliferation, which can protect vascular endothelial function and inhibit platelet activation. This article reviews the physiological function of bilirubin, the relationship between bilirubin level and risk of coronary heart disease, and the physiological protective effect of bilirubin in the pathogenesis of coronary heart disease.

The mechanism by which coronary artery disease progresses from asymptomatic atherosclerotic plaques to thin fibrous plaque caps or unstable plaques is not fully understood. Microvessels in atherosclerotic plaques play a very important role in the growth and changes of coronary plaques. The microvessels allow inflammatory cells and cytokines to enter the atherosclerotic plaque by increasing the blood flow that supplies the plaque. Studies have proved that the cell membrane of red blood cells is rich in phospholipids and free cholesterol. By transporting red blood cells into the plaque, the microvessels in the plaque make the cell membrane of red blood cells accumulate in the plaque, further expanding the extent of the necrosis center of the plaque, thus stimulating the growth of unstable plaques and increasing the risk of plaque rupture^[1]。 Therefore, it is of great significance for the prevention and treatment of coronary heart disease to identify and explore microvessels in coronary plaque through the latest development of interventional imaging technology, and then explore the mechanism of microvessels' influence on atherosclerotic plaque.

Valve aging, tissue degeneration or congenital developmental abnormalities (such as bivalvulation) can lead to aortic stenosis, and are the main factors of non-rheumatic aortic stenosis in middle-aged and elderly people. The 1-year survival rate of patients with severe aortic stenosis without surgical valve replacement is only about 50%. However, many elderly patients cannot undergo surgery due to their advanced age and many comorbidities, or the surgery is extremely risky. transcatheter aortic valve repalcement (TAVR) provides a new treatment for patients with aortic stenosis by inserting the aortic valve through a catheter without thoracotomy.