2017年 · 第45卷第10期

Guidelines for cardiovascular diagnosis and treatment have sprung up like mushrooms, which builds an important bridge between scientific evidence and clinical practice. They reflect the current situation of the best clinical evidence and are important guidance for clinicians in their practical work. Especially for young doctors who are new to the job and doctors working in grass-roots units, industry guidelines and consensus usually play a role in indicating the direction of career development and standardizing the professional code of conduct. Modern medicine has changed from relying on experience to a new model of evidence-based management of patients based on experience, which has significantly improved the quality of medical care and reduced medical expenses. Clinical guidelines are a summary of best medical practices for specific clinical problems, but we should know that this standardized medical treatment cannot replace clinical skills, clinical experience and clinical data. In clinical practice, we often face areas that are not covered by the guidelines, contradicted, and difficult to implement or even difficult to operate. As clinicians, we should realize that the development of clinical practice often precedes the publication of guidelines. While enthusiastic about the benefits of guidelines, we should calmly think about their limitations and difficulties, so that we can navigate clinical practice with ease and move from the "kingdom of necessity" to the "kingdom of freedom".

In recent years, transcatheter aortic valve replacement (TAVR) has been proved to be a safe and effective treatment for severe aortic stenosis. The 2017 U.S. Valvular Heart Disease Guidelines have expanded the indication for TAVR from patients at high risk for surgery to patients at medium risk^[1]。 However, perioperative complications remain a factor that cannot be ignored in the prognosis of patients. cerebrovascular events (CVE), including stroke, transient ischemic attack and asymptomatic cerebral infarction, are important complications after TAVR^[2]。 Asymptomatic cerebral infarction is often overlooked in clinical work, so the true impact of CVE after TAVR may be underestimated.

Secondary preventive measures for coronary heart disease, including lifestyle improvement, risk factor control, and adherence to drugs with evidence-based medical evidence, can significantly improve the prognosis of patients with coronary heart disease^[1]。 But at present, the compliance rate of secondary prevention of coronary heart disease is low worldwide, especially in developing countries^[2,3]。 For example, in the survey of 31 provinces and cities in China, the statin consumption rate of extremely high-risk coronary heart disease patients is only 57.9%, and the blood lipid compliance rate is only 29.8%^[2]。 Possible reasons include insufficient awareness and knowledge of patients' diseases, forgetting to take medication, economic reasons, etc. At the same time, due to the relative shortage of medical resources and the restriction of traditional medical mode, the out-of-hospital management of patients with coronary heart disease is weak.

Significant progress has been made in the prevention and treatment of cardiovascular diseases over the past few decades, and at the same time, the attention on strategies for cardiovascular disease prevention and treatment, as well as prognosis and treatment costs, has continued to increase^[1,2]。 Because individual differences cannot fully explain the difference in patient treatment and prognosis, and high medical expenses may not necessarily lead to better treatment or prognosis^[3,4]Therefore, how to reduce medical expenses and improve curative effect has become a hot spot in the current medical field. "learning health-care system" is praised by experts at home and abroad as a virtuous circle system in which "evidence guides practice and practice echoes evidence", and the key to "realizing medical learning system" lies in the effective use of data. At present, the effective data used to guide the "medical learning system" is growing rapidly. With the continuous expansion of electronic health medical records, wearable devices, Internet data, genetic information and other data materials, the amount of effective data is increasing exponentially. In addition, the development of computer storage and data technology has made it possible to analyze a large number of complicated data quickly. With the increase of effective data, enhanced data analysis capabilities, and the urgent need to improve treatment and prognosis, big data analysis in the medical field has emerged as the times require. Big data analysis in the field of cardiovascular medicine is defined as identifying the correlation between various variables and diseases by integrating and analyzing a large amount of data, and making risk predictions, ultimately improving the treatment and prognosis of cardiovascular diseases. Although big data analysis has great potential in the cardiovascular field, there is currently a lack of evidence to improve treatment and prognosis through big data analysis. This article will explain the sources and methods of big data analysis and its potential application value and challenges to improve the treatment and prognosis of cardiovascular diseases.

A 47-year-old male patient experienced repeated chest tightness and palpitations since 2012, which showed sudden arrest. Since October 2015, the patient's palpitations were difficult to stop, and the symptoms of chest tightness and shortness of breath were extremely severe. At the time of the attack, he needed to sit and breathe completely. The emergency electrocardiogram showed atrial fibrillation (AF) combined with pre-excitation syndrome, and was given drug cardioversion. He recurred on August 19, 2016, and was admitted to the hospital on August 24 after medication cardioversion in the emergency department. Physical examination: blood pressure 110/60 mmHg (1 mmHg =0.133 kPa), clear respiratory sounds in both lungs, without dry and wet rales; Heart rate 140 beats/min, atrial fibrillation rhythm; Biphasic murmur was accessible in the mitral valve area and diastolic murmur was accessible in the aortic valve area. Auxiliary examination: Atrial fibrillation, intermittent pre-excitation syndrome (Figure 1)； Type A preexcitation syndrome was shown after cardioversion (21 Oct 2015). Cardiac ultrasound: The anterior lobe of the mitral valve was swollen to the left ventricular outflow tract, the posterior lobe was elevated, the valve opening was obviously limited, and the valve orifice area was 0.5 cm respectively², 0.8 cm²； Aortic valve leaflet opening is limited and diastolic regurgitation is moderate; Moderate tricuspid regurgitation; Thrombosis in the left atrial appendage, approximately 1.86 cm ×3.97 cm, partially active with the heart beat; The left ventricular ejection fraction was 56%.

The child was a female, 1 year and 1 month old. He was admitted to hospital on July 11, 2016 due to "cardiac murmur found for 1 year". When the child was born, he smelled a cardiac murmur during physical examination in an outside hospital, and echocardiography showed the right triatrial heart. Children are usually not prone to catching colds, and there is no cyanosis of the lips after crying, and there is no squat and syncope. Physical examination: blood pressure 88/55 mmHg (1 mmHg =0.133 kPa); The heart rate was 95 beats/min, the heart boundary enlarged to the lower left, the heart rhythm was uniform, and continuous murmur was heard between the costs at 3~4 of the left margin of the sternum; Physical examination of lung and abdomen showed no abnormalities. Echocardiography in our hospital showed that the right atrium was deformed by compression; The left and right coronary arteries were of normal origin; The inner diameter of the right coronary artery opening was normal; The opening of the left coronary artery was widened, with an inner diameter of 5 mm at the initial end, and the left circumflex branch tortuously folded to the right, with an inner diameter of 5 mm. The end showed tumor-like enlargement (24 mm ×25 mm) at the top of the right atrium. The tumor body communicated with the right atrium, and the fistula diameter was 4 mm. Color Doppler showed that thin bundles of continuous blood flow from the fistula were sprayed into the right atrium (Figure 1), the spectrum was predominantly diastolic, with a maximum velocity of 3.7 m/s and a pressure difference of 53 mmHg; The tumor compressed the right atrial entrance of the superior vena cava, and color Doppler showed that blood flow accelerated at the right atrial entrance of the superior vena cava (Figure 2)。 Echocardiographic diagnosis: left coronary artery branch-right atrial fistula; Giant aneurysm at the end of the branch of the left coronary artery; Compression of the right atrial entrance of the superior vena cava. Enhanced CT scan showed: right atrium enlargement; The branches of the left coronary artery seem to communicate with the right atrium; A tumor-like dilated vascular shadow was seen behind the right atrium, with a maximum diameter of 25 mm, locally connected to the branch of the left coronary artery (Figure 3)。 After definite diagnosis, the child underwent surgical corrective surgery under general anesthesia. Intraoperative left coronary aneurysm was observed in the same condition as preoperative echocardiography. The child recovered well after operation. Reexamination echocardiography showed that the blood flow at the left coronary artery-right atrial fistula disappeared, the tumor-like enlargement at the end of the coronary artery decreased to 17 mm ×20 mm, and the tumor cavity was weakly echoed.

A 68-year-old female was admitted to the hospital on 29-Apr-2016 due to "recurrent palpitations and chest pain aggravated for 1 day after 1 week". Physical examination at admission: heart rate 126 beats/min, blood pressure 125/73 mmHg (1 mmHg =0.133 kPa), negative cardiopulmonary auscultation. The electrocardiogram showed no obvious abnormalities, echocardiogram showed no obvious abnormalities in left ventricular systolic activity [left ventricular ejection fraction (LVEF) 69%], and chest radiograph showed no obvious abnormalities in heart and lung. Among the biochemical indexes, troponin I, creatine kinase, B-type natriuretic peptide, blood routine, blood lipid, liver and kidney function and thyroid function were all in the normal range. Fasting blood glucose was 9.85 mmol/L, and blood glucose at 2 h after prandial was 13.6 mmol/L. 24-h ambulatory blood pressure monitoring: mean blood pressure 120/75 mmHg, maximum systolic blood pressure 182 mmHg, minimum 76 mmHg, maximum diastolic blood pressure 103 mmHg, minimum 50 mmHg. Coronary angiography: left main artery normal, left anterior descending artery middle myocardial bridge, systolic stenosis 40% ~50%, anterior blood flow TIMI grade 3, circumflex artery and right coronary artery normal, anterior blood flow TIMI grade 3. Because the patient had a history of somatization disorder, was widowed recently, and no organic lesions were found in the examination, the symptoms of palpitations and chest pain were considered to be caused by psychological factors, and sertraline hydrochloride tablets and trazodone hydrochloride tablets were given to fight anxiety and depression, and metoprolol tartrate tablets were given to control his heart rate, and he was discharged. Within 30 hours of discharge, the patient suffered three times of syncope and loss of consciousness, lasting for about 1 min, accompanied by profuse sweating, no distortion of the corners of the mouth, foaming at the mouth, twitching of limbs, rotation of vision, and incontinence, so he was admitted to our department again. Previous history of diabetes for 2 years (untreated) with large blood pressure fluctuations.

The abnormal origin of coronary arteries is not uncommon in clinical practice, but the abnormal origin of the left coronary artery from the right coronary sinus is rare. The detection rate of the abnormal origin of coronary arteries is 0.022%^[1]。 Patients with heterogeneous left main origin usually have a poor prognosis, especially those who travel between the ascending aorta and the pulmonary artery are prone to syncope and myocardial infarction, and even sudden death in minority. This young patient achieved a good prognosis after timely diagnosis and treatment, so the report is as follows.

Senile degenerative valvular heart disease, also known as senile calcified valvular heart disease, is mainly manifested by valve fibrosis and calcium salt deposition, which makes the valve stiff, resulting in valve stenosis or insufficiency. The main valves involved in China are aortic valve and mitral valve. With the aging of China's population, the incidence of degenerative valvular heart disease in the elderly is gradually increasing. This disease can lead to cardiac hemodynamic changes, arrhythmia, myocardial infarction and heart failure, and is the main cause of cardiovascular events in the elderly. Previous studies suggest that senile degenerative valvular heart disease is a manifestation of aging and an inevitable process of apoptosis^[1,2]。 The current view is that its pathogenesis is a series of active regulatory processes to stimulating factors. This article reviews its pathogenesis and provides help for its clinical prevention and treatment.

As a leading cause of morbidity and mortality worldwide, coronary heart disease has become a serious global health problem. At present, the prevalence of cardiovascular diseases in China is on the rise. One in every five adults suffers from heart disease, and two in every five deaths die from heart disease. The proportion of coronary heart disease among cardiovascular diseases ranks first^[1]。 Therefore, in order to prevent and delay the progression of coronary heart disease, early detection of coronary calcification status in asymptomatic individuals is imperative. In recent years, nonalcoholic fatty liver disease (NAFLD) has become a new health problem, and its prevalence in the general population is as high as 15% ~30%^[2,3]。 According to the results of a long-term study, a higher proportion of patients with NAFLD ultimately die from coronary heart disease than from cirrhosis^[4]。 Therefore, the researchers speculated that NAFLD may be associated with atherosclerosis. In this paper, the research progress of the relationship between NAFLD and coronary artery calcification at home and abroad is reviewed.

Hyperuricemia has long been recognized as the leading cause of gout and is an important biomarker for assessing renal impairment. In recent years, a large number of studies have found that high concentration uric acid has a pro-oxidation effect, which can induce a series of reactions such as oxidative stress, and have adverse effects on the body. A systematic review and meta-analysis suggests that hyperuricemia is a risk factor for coronary heart disease morbidity and mortality^[1]。 Prospective cohort studies have also shown that hyperuricemia is an independent predictor of death from multiple cardiovascular and cerebrovascular diseases (coronary heart disease, chronic heart failure and stroke) in elderly and postmenopausal women^[2]。 On the other hand, some studies have also shown that hyperuricemia has no effect on the occurrence and development of coronary artery disease^[3]。 The inconsistent results may be related to the differences in the subjects selected and ethnicity of the various studies. Vascular calcification is the common pathophysiological basis of atherosclerosis, diabetes, chronic kidney disease (CKD), hypertension and other diseases. It is one of the main factors of high morbidity and mortality of cardiovascular and cerebrovascular diseases^[4]。 Recent studies have found that hyperuricemia may be closely related to vascular calcification. This article summarizes the risk factors of vascular calcification, the pathophysiological function of uric acid, the relationship between hyperuricemia and vascular calcification, and the possible mechanism of uric acid promoting vascular calcification.

Cardiovascular diseases and tumors are the main diseases that threaten human health. Cardiovascular disease accounts for 1/3 of all annual deaths in the United States each year^[1]The number of deaths from cardiovascular disease accounts for 45% of the total annual deaths in Europe each year^[2]。 In China, the mortality rates of cardiovascular diseases were 44.6% in rural areas and 42.5% in urban areas, respectively^[3]。 At present, the incidence of tumor at home and abroad is increasing year by year^[4,5]。 In 2016, the United States had an estimated 1,685,210 new tumors and 595,690 tumor deaths; There were 62 700 new renal tumors and 14 240 deaths; 180,890 new cases of prostate cancer and 26,120 deaths^[4]。 It is estimated that there were 4,292,000 new tumors and 2,814,000 tumor deaths in China in 2015; 668,000 new cases of kidney cancer and 234,000 deaths; 603,000 new cases of prostate cancer, 266,000 deaths^[5]。 The survey results suggest that the incidence and death of renal cancer and prostate cancer in China are severe.