2017年 · 第45卷第06期

In recent years, milestone progress has been made in the diagnosis and treatment of valvular heart disease. The era of transcatheter aortic valve replacement (TAVR) has arrived. In 2017, the latest guidelines for the management of patients with valvular heart disease of the American Heart Association (AHA) /American College of Cardiology (ACC) recommend that TAVR can be applied to patients with symptomatic aortic stenosis who are contraindicated to surgery (Ⅰ, A), high risk (Ⅰ, A) and medium risk (Ⅱa, B-R). However, although TAVR technology is booming worldwide, devices are constantly improving and updating, and prosthetic valve products have developed to the second and third generations, there are still many problems in clinical practice that have not been solved.

In January 2015, the U.S. government announced the launch of the "Precision Medicine Program" in its State of the Union Address. This plan immediately caused strong repercussions all over the world. Major countries and regions in the world interpreted this plan, and made corresponding analyses from the aspects of medical research, clinical model, fund funding, financial investment and industrial development, trying to find the direction and opportunity of development. In the past two years, the concept and practice mode of precision medicine have gained a certain consensus. This article combs the ins and outs of precision medicine from the aspects of historical origin, birth background and development status, and reviews the practice course of precision medicine program in China over the past year, and puts forward some suggestions for promoting the healthy development of precision medicine in China.

Since 1984 Dougherty et al.^[1]Since diastolic heart failure (HF) was first reported, more and more studies have found that patients with systolic heart failure have diastolic dysfunction, while patients with diastolic heart failure may have mild abnormalities in systolic function. Therefore, heart failure with preserved ejection fraction (HFpEF) is proposed to replace diastolic heart failure, and heart failure with reduced ejection fraction (HFEF) is proposed to replace systolic heart failure^[2,3]。 However, the use of left ventricular ejection fraction (LVEF) as a classification index of heart failure has led to debate about whether HFpEF is an independent clinical syndrome, that is, are HFpEF and HFrEF two stages of disease, or are they two different clinical syndromes? Yi Shixin and Lai Liwen in this issue^[4]And Liu Jun and Dong Yugang^[5]There has been a debate on this issue, and we will make a comment on it.

Precision medicine, undertaken by the Human Genome Project, refers to the analysis, identification, verification and application of biomarkers for large sample populations and specific disease types through genomic, proteome and other omics technologies, so as to accurately find the cause and treatment of the disease. Targets, and accurately subclassify a disease, so as to finally achieve the purpose of personalized and precise treatment of diseases and specific patients, and improve the benefits of disease diagnosis, treatment and prevention. In 2011, the National Academy of Sciences (NAS), the National Academy of Engineering (NAE), the National Institutes of Health (NIH) and the National Science Council (NSB) jointly launched an initiative towards precision medicine, and published a national think tank report "Towards Precision Medicine" co-drafted by a number of scientists. In January, 2015, then-President Barack Obama announced the "Precision Medicine Plan" in his State of the Union address, proposing a new medical model of "precision, punctuality, sharing and individualization". He planned to invest 130 million US dollars to establish a research cohort of one million people, collect genomic data and clinical information, realize accurate disease classification and diagnosis based on individual genome and specific molecular changes, carry out precise and effective medication, and provide personalized preventive care for healthy people. Precision medicine is the basis for realizing individualized medicine.

After more than 50 years of efforts in the scientific and technological circles and medical circles, many patients with cardiovascular diseases have brought hope^[1], especially single-gene cardiovascular diseases, are expected to be accurately predicted, accurately diagnosed, and targeted therapy.

Precision medicine is a new term, but by no means a new concept. It originates from the Human Genome Project and is in the same vein as personalized medicine. The purpose of the two is very similar, and both are to "treat by syndrome differentiation", that is, to identify a type of disease defined by traditional medicine, such as hypertension, more accurately. Phenotype, and select the most suitable treatment, or intervention and management plan for each patient according to the individual differences of patients. Compared with individualized medicine, precision medicine emphasizes the combination of the latest science and technology, such as genome, transcriptome, proteome, metabolome, and even biomics technologies such as metagenome and cutting-edge technologies such as bioinformatics, to carefully analyze and identify large sample populations and specific diseases, establish a large database of three-dimensional data at different levels, accurately find the causes and treatment targets of diseases, accurately classify different states and processes of a disease, and finally realize four "right"-"right time", "right patient", "right treatment" and "right dose". These four "RIGHTS" are the starting point for the current traditional medicine diagnosis and treatment model to turn to the precise management model of future medicine, and they are also the basic criteria for our team to measure their own behavior for nearly 20 years.

In the guidelines for the diagnosis and treatment of acute and chronic heart failure (heart failure) issued by the European Society of Cardiology (ESC) in 2016, a brand-new concept was proposed. Patients with heart failure with left ventricular ejection fraction (LVEF) ranging from 40% to 49% were defined as heart failure with mid-range ejection fraction (HFmrEF), thus filling in heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). The blank area between. That is to say, even if the LVEF is>40%, as long as there are symptoms and signs of heart failure, accompanied by elevated B-type natriuretic peptide (BNP), or related structural heart disease, or diastolic dysfunction, it can be classified into the corresponding heart failure classification. In past clinical studies and guideline development, much less emphasis has been given to HFpEF than to HFrEF. However, recent studies have found that HFpEF can also lead to poor prognosis and increase the medical burden of patients and society, and HFpEF has gradually received attention.

Heart failure (HF) is a clinical syndrome caused by structural and functional abnormalities of the heart. Although there are classification methods such as acute and chronic, left ventricular and right ventricular, systolic and diastolic function and different etiologies, they are often classified and treated according to left ventricular ejection fraction (LVEF) in clinical work. In recent years, the classification of heart failure with insignificant LVEF reduction has attracted more and more attention. The 2016 European Society of Cardiology (ESC) Heart Failure Diagnosis and Treatment Guidelines define LVEF 40% ~50% as intermediate heart failure. Clinically, the therapeutic efficacy of heart failure patients with reduced LVEF is affirmed, while the therapeutic efficacy of heart failure patients with insignificant LVEF reduction is uncertain. In addition, during the development and treatment of heart failure, some patients with reduced LVEF can increase their LVEF to more than 50% after treatment, while some patients with LVEF>50% will progress to less than 40%. It has been proposed that for patients with heart failure whose LVEF is not significantly reduced, besides the treatment of ventricular remodeling, it is more important to treat different causes. In response to these controversies, we have argued that heart failure with preserved ejection fraction (HFpEF) is a special type of heart failure.

A 54-year-old female was admitted to the hospital on November 24, 2014 due to "repeated chest tightness and palpitations for more than 2 years, aggravated for 4 days". In the past 2 years, the patient repeatedly experienced chest tightness and palpitations without obvious inducement, each lasting for several minutes to several hours. On December 30, 2013, the abdominal color Doppler ultrasound showed small polyps in the gallbladder, and the local intrahepatic bile duct was slightly dilated, but no abnormalities were found. On March 3, 2014, the chest radiograph showed an enlarged heart shadow with a cardiothoracic ratio of 0.66. Echocardiography left ventricular ejection fraction (LVEF) 65.5%, whole heart enlargement, left atrial diameter (LAD) 46 mm, right atrial diameter (RAD) 45 mm, left ventricular diastolic diameter (LVDd) 55 mm, right ventricular diastolic diameter (RVDd) 41 mm, pulmonary systolic pressure 52 mmHg (1 mmHg =0.133 kPa). After catching a cold 4 d ago, I felt that chest tightness and palpitations aggravated, which persisted and could not be relieved, accompanied by vomiting 4 times, which was stomach contents. The electrocardiogram showed sinus rhythm, frequent premature atrial beats with differential conduction, and the symptoms did not alleviate after taking beta blockers. He has a history of rheumatoid arthritis for more than 1 year and has been menopausal for 11 years. During the course of the disease, there was poor food and appetite.

Heart failure (HF) is a clinical syndrome of structural or functional ventricular filling or ejection disorders of the heart caused by various heart diseases, with a prevalence of 0.9% to 2% and increasing with age. At present, angiotensin converting enzyme inhibitors (ACEI) or angiotensin II receptor antagonists (ARBs), beta blockers and aldosterone antagonists have become the standard treatment drugs for patients with heart failure, but the prognosis of patients with heart failure is still not optimistic. Therefore, it is of great clinical significance to develop more effective drugs for the treatment of heart failure. Recently, a new drug, valsartan/sacubitril (LCZ696, trade name Entresto ™ ) has achieved good results in the treatment of heart failure, and was approved by the U.S. Food and Drug Administration for the treatment of heart failure in 2015. This article reviews the application of this drug in the treatment of heart failure.

In 2014, the American Heart AssociationCirculationA scientific statement published on the New York Times listed depression as a risk factor for heart disease on the same level as obesity, hypertension, diabetes and smoking^[1]。 The incidence of depression in patients with chronic heart failure (HF) in China is about 40.1%^[2]In some European countries, the incidence of heart failure combined with depression is 10% to 79%^[3]。 Depression, as a common comorbidity of heart failure, is an independent predictor of poor prognosis of heart failure^[3]。 Studies have shown that depression not only reduces the quality of life of patients with heart failure, increases the rehospitalization rate, but also increases the morbidity and mortality of heart failure, reduces heart function, and affects the prognosis of patients.

Mortality among oncology patients has decreased significantly over the past 30 years, largely due to advances in therapeutic approaches. However, cancer patients are at risk of premature heart disease^[1]Once heart failure (heart failure) occurs, the 2-year mortality rate is as high as 60%^[2],Early detection of myocardial injury and related treatment are particularly important. Because the heart is susceptible to both chemotherapy drugs and tumor-related cardiovascular diseases, the incidence of myocardial injury is higher than that of normal people^[1,3]。 This article reviews the progress of cardiovascular magnetic resonance (CMR) in evaluating the effects of chemotherapy on cardiac structure and function.

Atrial fibrillation (AF) is one of the common tachyarrhythmias in clinic, which is difficult to cure. The incidence of cerebral embolism is high and the disability rate is high. Although the basic research and clinical treatment of AF have made gratifying progress in recent years, the incidence of AF is still increasing year by year because its exact pathogenesis has not been fully elucidated. Studies have shown that atrial electrical remodeling and structural remodeling are the key links in the development of atrial fibrillation, and the role of oxidative stress and inflammatory factors in it has been paid much attention in recent years. homocystine (Hcy) has attracted more and more attention as a newly discovered vascular damage factor of oxidative stress. Some studies have found that Hcy is significantly related to the prognosis of atrial fibrillation, and it has been preliminarily confirmed that the occurrence and development of atrial fibrillation is related to the increase of Hcy level^[1]。 This article reviews the research progress of Hcy and the development of atrial fibrillation.