2016年 · 第44卷第03期

Let's talk about the recent medical experience of two patients. One is a 41-year-old patient. Physical examination found premature ventricular beats, and the symptoms were not obvious. He went to a hospital to see an arrhythmia expert clinic. The expert didn't ask the patient what discomfort he had. After looking at the electrocardiogram, he said that "the location of the origin of premature beats is not good, and the radiofrequency ablation operation is not easy to succeed". The patient was stunned and immediately decided not to see this expert. In fact, the patient's heart structure and function are normal, and there are no obvious symptoms of premature ventricular contractions, and there is no need for drug treatment, let alone radiofrequency ablation. I explained the condition to the patient carefully and patiently, and the patient went home happily and at ease. During the follow-up, the patient felt well and could live and work normally. Another patient is a 71-year-old male who went to a hospital in Beijing for interventional treatment due to coronary heart disease and angina pectoris. When he was discharged, he saw the echocardiogram report saying that the mitral and aortic valves were mildly insufficient, so he asked the doctor in charge "How to treat valve insufficiency?", and the doctor answered "Come back and change the valve". After the patient went home, he had been anxious, insomnia, worried about the aggravation of his condition, and didn't know when to undergo valve replacement surgery.

acute pulmonary embolism (APE) is a common cardiovascular disease in China and one of the three most common fatal cardiovascular diseases in the world. A large-scale clinical epidemiological survey in six European countries showed that in 2004, about 317,000 people died of venous thromboembolism (VTE) -related diseases, of which 34% died suddenly due to APE, while as many as 55% died of APE that could not be diagnosed before death^[1]。 China's Pulmonary Embolism Prevention and Treatment Project conducted a registration study on pulmonary embolism patients in more than 60 tertiary hospitals in China from 1997 to 2008. Among 16 792 182 hospitalized patients, a total of 18 206 cases were diagnosed with pulmonary embolism, with an incidence of 0.1%^[2]。 APE should arouse a high level of clinical alarm because of its high morbidity and latent lethality. In 2010, the Pulmonary Vascular Disease Group of Cardiovascular Disease Branch of Chinese Medical Association and the Expert Group of Cardiovascular Physicians Branch of Chinese Medical Doctors Association wrote the "Chinese Expert Consensus on the Diagnosis and Treatment of Acute Pulmonary Thromboembolism"^[3]It has played a great role in standardizing the diagnosis process and treatment strategy of APE in China and improving the diagnosis and treatment level. However, with the increasing awareness of APE in recent years, the European Society of Cardiology (ESC) continuously updated the diagnosis and treatment guidelines of APE in 2000, 2008 and 2014, integrating emerging evidence-based medical evidence and clinical expert opinions. It has strong guiding significance for clinical practice. However, the guidelines are limited by the timeliness of evidence and the scope of the audience, which may omit the latest concepts and developments at present. Combined with the new version of ESC guidelines, this paper mainly introduces the clinical practice experience of treating acute pulmonary embolism in the thromboembolic disease diagnosis and treatment center of Fuwai Hospital from two aspects: diagnosis and evaluation and anticoagulation therapy.

There is a long history of controversy over target levels of blood pressure. Although many recent hypertension guidelines recommend controlling systolic blood pressure below 140 mmHg (1 mmHg =0.133 kPa) in most hypertensive patients, the evidence is insufficient. The 2014 evidence-based guidelines for the management of adult hypertension (commonly known as JNC 8) in the United States recommend that the systolic blood pressure of the general population under 60 years old and patients with diabetes and chronic kidney disease should be controlled below 140 mmHg, but its evidence level is only level E, that is, the consensus opinion of experts^[1,2]。 In contrast, the guidelines recommend that the evidence for diastolic blood pressure to be controlled below 90 mmHg is more adequate. Some early randomized controlled clinical trials (RCTs), such as the Medical Research Council Trial (MRC) and the Veterans Management System Collaborative Trial, have found that diastolic blood pressure dropping below 90 mmHg can significantly reduce major vascular events^[1]。 And what are the benefits of further lowering diastolic blood pressure? The above experiments failed to give an answer. The optimal treatment for hypertension (HOT) trial has explored this problem^[3]。 HOT uses a prospective, randomized, open, blind endpoint (PROBE) design to evaluate the association of target diastolic blood pressure ≤90, ≤85, and ≤80 mmHg with major cardiovascular events (non-fatal myocardial infarction, non-fatal stroke, and death from cardiovascular disease) in the treatment of hypertension. The trial included 18 790 hypertensive patients with diastolic blood pressure of 100 to 115 mmHg, with a mean age of 61.5 years. The antihypertensive treatment steps of initial single drug, combination, increased dose and re-combination were adopted. It was found that patients with diastolic blood pressure 83 mmHg (systolic blood pressure 139 mmHg) had the fewest major cardiovascular events, whereas patients with diastolic blood pressure 87 mmHg had the lowest risk of cardiovascular death and no further benefit from further decreases in blood pressure. In combination with the aforementioned trials, controlling diastolic blood pressure below 90 mmHg has received a higher level of recommendation in the guidelines^[1]。

Patients with hypertensive disease during pregnancy are at high risk of cardiovascular disease in women, and hypertensive disease during pregnancy is an important predictor or even pathogenic factor of cardiovascular disease in women in the long term after delivery^[1]。

Acute pulmonary embolism is a common cardiovascular disease^[1]It is also one of the three common fatal cardiovascular diseases^[2]。 In recent years, the awareness of acute pulmonary embolism has been increasing, but there are still cases of misdiagnosis, missed diagnosis or untimely diagnosis, and irregular treatment in clinical practice. In 2010, the Pulmonary Vascular Disease Group of Cardiovascular Disease Branch of Chinese Medical Association and the Expert Group of Cardiovascular Physicians Branch of Chinese Medical Doctors Association wrote the "Chinese Expert Consensus on the Diagnosis and Treatment of Acute Pulmonary Thromboembolism"^[3]It has played a positive role in standardizing the diagnosis process and treatment strategy of acute pulmonary embolism in China and improving the diagnosis and treatment level of acute pulmonary embolism in China. In the following five years, the field of pulmonary vascular diseases has developed rapidly, and a large number of clinical trials have been published, which provide new research evidence for the diagnosis, evaluation and treatment of patients with acute pulmonary embolism. Based on the consensus of experts in 2010, the Pulmonary Vascular Disease Group of Cardiovascular Disease Branch of Chinese Medical Association systematically studied and judged the recent clinical evidence, and referred to the latest international guidelines for the diagnosis and treatment of acute pulmonary embolism^[4]After careful study and discussion, this consensus was formulated. Compared with the 2010 expert consensus in China, this consensus has been updated in the aspects of predisposition factors, risk stratification, diagnosis and treatment strategies, new oral anticoagulants, chronic thromboembolic pulmonary hypertension, etc., and gives formal recommendations for the treatment of acute pulmonary embolism in pregnancy and tumor patients, aiming at providing the basis and principles for the diagnosis and treatment of acute pulmonary embolism in China and helping clinicians make medical decisions. It should be noted that when facing specific patients clinically, diagnosis and treatment measures should be formulated according to the principle of individualization.

In the past 20 years, the prevalence of obesity and hypertension has shown a significant upward trend worldwide, and the two often coexist. Obesity can not only increase the difficulty of blood pressure control in hypertensive patients, but also promote the aggregation of multiple cardiovascular and metabolic risk factors, aggravating cardiovascular and cerebrovascular damage. Since 2003, the American Heart Association (AHA) and the American College of Cardiology (ACC) have published a series of statements and guidelines on the assessment, prevention and treatment of obesity and its relationship with cardiovascular disease. The European Society for hypertension (ESH) obesity Working Group published obesity-related hypertension target organ damage from 2009 to 2011^[1]Antihypertensive effect of weight loss therapy^[2]And cardiovascular effects of weight loss drugs^[3]of expert consensus, and a statement on obesity and refractory hypertension was published in 2012 in conjunction with the European Society for the Study of Obesity (EASO)^[4]。 In 2013, the American Hypertension Society (ASH) and the American Obesity Association (TOS) jointly issued a position statement on the pathophysiological mechanisms, cardiovascular risk and treatment of obesity-related hypertension^[5]。 2013 AHA, ACC and TOS jointly launched guidelines for the management of overweight and obesity in adults^[6]The 2010 edition of the Chinese Hypertension Prevention and Treatment Guidelines pointed out that obesity combined with hypertension and abnormal glucose and/or lipid metabolism are the most important manifestations of metabolic syndrome in Chinese people^[7]。 In view of the high prevalence and harmfulness of obesity-related hypertension, its evaluation and prevention are special, and it has attracted attention at home and abroad, this expert consensus is written based on the research results of obesity-related hypertension at home and abroad, so as to promote the prevention and treatment of obesity-related hypertension.

The patient was an 84-year-old female. Due to severe aortic stenosis, transcatheter aortic valve implantation (TAVI) was planned, and he was admitted to our hospital on January 23, 2015. The patient was admitted to the hospital 8 years ago due to "chest tightness and shortness of breath after activity". He had no nocturnal dyspnea and orthopaedic breathing, dizziness, headache, abdominal pain, abdominal distension and oliguria. Coronary angiography showed: 30% stenosis of the distal left main trunk; Proximal left anterior descending artery stenosis 99%, blood flow TIMI grade 2; Proximal left circumflex artery stenosis 40%; Long-segment diffuse lesion of the right coronary artery, 70% proximal stenosis, 70% ~80% middle stenosis, and complete occlusion of the distal posterior branch of the left ventricle. Echocardiography revealed an old anterior parietal myocardial infarction with thinning of the anterior wall of the left ventricle, below the level of the anterior septal papillary muscle and the ventricular wall at the apex of the left ventricle, mild to moderate aortic stenosis with mild regurgitation, peak transaortic flow rate of 2.7 m/s, peak pressure difference of 30 mmHg (1 mmHg =0.133 kPa), mean pressure difference of 20 mmHg, and left ventricular ejection fraction of 49%. On September 3, 2007, the patient underwent coronary artery bypass grafting under general anesthesia. Two great saphenous vein bridges were located in the left anterior descending branch and the posterior descending branch, respectively. The postoperative recovery was good and the symptoms improved. Echocardiography repeated 4 years after surgery showed that the transvalvular pressure difference increased significantly (the peak transvalvular pressure difference was 66 mmHg and the mean pressure difference was 40 mmHg).

Protein O-glycosylation modification refers to the formation of a glycoprotein by a polysaccharide linking a silk/threonine hydroxyl group via an O-glycosidic bond. In the past, it has been believed that O-glycosylation modification only occurs on membrane proteins. In recent 30 years, it has been confirmed that O-glycosylation modification widely exists in more than 1,000 proteins such as cytoplasm, nucleus and mitochondria^[1,2]Similar to phosphorylation, it is an important post-translational modification of proteins. It plays an important role in regulating cell proliferation, differentiation, migration, adhesion, apoptosis and autophagy by regulating gene transcription, signal transduction and interaction between proteins^[3,4]。

Cardiovascular disease is currently the biggest killer of human death worldwide^[1]。 According to statistics, in 2008, 1/3 of the deaths in the United States were caused by cardiovascular diseases, which brought a heavy burden to the society, health care system and economy. It is estimated that more than 40% of the U.S. population will suffer from cardiovascular disease by 2030^[2,3]。 In China, the incidence and mortality of cardiovascular diseases are also increasing year by year, with an average of about 3.5 million people dying of cardiovascular diseases every year^[4]。 Therefore, how to effectively control the occurrence and development of cardiovascular diseases is a difficult problem to be solved urgently. It has been reported that the pathological process of cardiovascular disease is closely related to autophagy of cardiomyocytes. This paper reviews the role and mechanism of autophagy in various cardiac pathological processes.

atherosclerosis (AS) cardiovascular and cerebrovascular diseases (including coronary heart disease, stroke, peripheral vascular disease, etc.) are the "number one killer" that endanger human health. Its essence is a process in which the long-term interaction between modified lipoproteins and various cellular components of the artery wall leads to a continuous amplification of chronic inflammatory damage in a cascade reaction. Macrophages play an extremely important role in the progression of inflammation, plaque, thrombosis and acute cardiovascular and cerebrovascular clinical events. However, recent studies have shown that macrophages also play an important role in the regression of atherosclerotic plaques^[1,2,3]。 Therefore, this article makes a summary of this progress.