Walk-throuth angina，warm-up angina和原位侧枝闭塞性心肌梗死临床特征及K~+通道阻滞剂的干预作用
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摘要
目的冠状动脉硬化性心脏病,简称冠心病(coronary heart disease)是当今世界的流行病,也是全世界范围内备受关注的公共卫生问题,据统计冠心病目前仍然居各种疾病死因的首位。目前冠心病分为五型即无症状性心肌缺血、心绞痛、心肌梗死、缺血性心肌病和原发性心脏骤停。临床实践表明上述分型标准已经不能满足临床需要。本研究旨在探讨三种特殊类型的冠心病(一种特殊类型的ST段抬高型急性心肌梗死和两种特殊类型的心绞痛:walk-through angina和Warm-up angina)的临床特征及发病机制,使人们对这三类少见的冠心病特殊临床类型有一较全面地了解。
方法和结果
1. Warm-up angina对心脏的保护及钾通道阻滞剂对此现象影响选择运动试验阳性和经冠脉造影证实的稳定型心绞痛病人作为研究对象。根据入选者是否合并糖尿病及其治疗方式分为三组:单纯稳定型心绞痛患者对照组(NDM组)25例;心绞痛合并糖尿病并服用格列本脲进入格列本脲组(DMG组)22例;心绞痛合并糖尿病仅以节食方式控制血糖进入节食组(DMD组)22例,共69例。所有入选病人均于运动当日分别进行连续两次踏车运动实验(EX1,EX2),且两次运动之间间隔15min。观察各组病人两次运动中运动时间(ED)、出现ST段压低0.1mv时间(T-STD)、极量运动时的ST段压低的最大值(STDmax)以及ST段压低0.1mv时的心率收缩压乘积(RPP值,亦称缺血阈值,mmHg/min×102)变化情况,并比较其组间各参数差异。结果如下:
1.1 NDM组所观察的各指标在EX2较EX1相比均有明显改善,表现为缺血阈值明显提高(173.77±34.73 vs 199.23±37.07 mmHg/min×102,P<0.05);ED和T-STD明显延长(546.04±103.78 vs 617.52±106.96s , P<0.05 & 385.64±92.34 vs 426.84±91.25s,P <0.05);STDmax明显减轻(2.06±0.37 vs1.75±0.41mm,P<0.05)。
1.2 DMG组除了T-STD在EX2与EX1相比有所延长(328.45±64.66 vs 363.00±81.48s,P<0.01)外,其余各指标的改善均不明显(P>0.05)。
1.3 DMD组结果,所有参数在两次运动比较,EX2比EX 1均有明显改善即缺血阈值明显提高(181.58±40.34 vs 204.51±30.91 mmHg/min×102 ,P < 0.05);T-STD无明显延长(366.95±86.93 vs 404.27±101.61s,P>0.05);STDmax有所减轻(2.10±0.46 vs 1.79±0.38mm,P<0.05),但在总体运动时间上EX2较EX1增加不明显(P>0.05)
2. walk-through angina的临床特征和发病机制的研究
选择住院walk-through angina和稳定劳累型心绞痛各28例,分别称为WTA组和SAP组。汇总患者和临床医师对本病认知情况,同时观察两组患者冠心病危险因素、临床特征、心电图表现、心脏超声结果、CAG的结果、运动平板试验以及心脏变时性功能,进行对比分析,结果如下:
2.1从对本病的认知情况来看,医患双方对本病的认知程度均较低,且在确诊本病之前至少误诊或漏诊一次以上,误诊和漏诊率达100%;
2.2从临床表现来看WTA患者心绞痛发作特征与SAP显著不同,患者最初活动时心绞痛发作,但继续增加活动量心绞痛不但不加重,反而会逐渐减轻甚至消失;而SAP典型的临床表现为劳累时心绞痛发作,休息后心绞痛症状迅速缓解。
2.3心脏超声结果:WTA组LVEF、LVFS较SAP组均显著降,P<0.01;两组E峰和A峰分别相比无显著差异,P值均>0.05。
2.4 CAG结果:WTA组三支病变、闭塞病变、冠脉侧枝循环形成与SAP组相比P值均<0.01。
2.5运动试验结果:WTA组与SAP组ST段压低持续时间分别是512.43±46.49秒和591.03±55.27秒,两组相比,P<0.01;ST段压低的导联数分别是3.01±0.51和6.10±0.76,两组相比,P<0.01;WTA组与SAP组患者的心脏变时性指数(CRI)分别是0.48±0.05和0.74±0.07,两组相比,P<0.01;运动中最大心率分别是124.32±6.89次/分和145.35±5.25次/分,P<0.01;极量运动代谢值分别是5.64±0.62 Mets和4.87±0.48 Mets,两组相比,P<0.01。
2.6治疗选择:WTA组患者更多选择了血运重建,SAP组更多选择了保守治疗,两组相比,P值均<0.01。
3.急性ST段抬高不宜溶栓心肌梗死的临床特征、发病机制及干预策略
选择住院冠心病0MI为研究对象,发作不稳定型心绞痛或/和急性左心衰竭时原梗死区域所对应的心电图导联ST段急性抬高大于0.2mv且口含硝酸甘油胸痛或/和呼吸困难不缓解,症状持续超过30分钟患者为入选对象。再梗死病例除外,共29例患者符合入选条件,称为SAMI组。同时选择同期住院的首次ST段抬高未溶栓的AMI患者36例,称为AMI组。对两组患者进行常规的检查和治疗,将两组患者的发病机制、临床表现、心电图动态演变、心肌酶学变化、肌钙蛋白水平、心脏超声、冠脉造影特征和治疗的选择进行对比分析,结果如下: 3.1 SAMI组患者符合AMI的诊断标准。SAMI组患者多以急性左心衰竭症状为主而不稳定型心绞痛的症状相对较轻。心电图在同一梗死区域导联只出现ST段的演变而不出现T波的动态演变, Q波也没有明显加深和增宽。
3.2在发病后6小时、12小时、24小时、48小时SAMI组CPK、CPK-MB以及TNI升高均较AMI组低,P值均<0.01。
3.3心脏超声指标:SAMI组LVEF、LVFS、E峰和A峰与和AMI组相应指标相比均有显著降低,P值均<0.01。
3.4冠脉造影结果:SAMI组三支病变、B型病变和C型病变以及侧支循环形成均较AMI组多,P值均<0.01。
3.5血运重建的选择:SAMI组更多选择了冠脉搭桥,而AMI组更多选择了冠脉介入,P值均<0.01。
结论:
1.对稳定型心绞痛的患者来说,运动可以诱发Warm-up angina发生。在稳定型心绞痛合并糖尿病以节食方式控制血糖良好的病人身上仍然具有发生Warm-up angina的能力。
2.钾通道阻滞剂实格列本脲能够阻断Warm-up angina发生,从而阻断这种心肌保护性现象。钾通道阻滞剂格列本脲在应用于冠心病合并糖尿病的人群时会阻断Warm-up angina的发生,消弱心脏对缺血的耐受性。
3.钾通道参与了Warm-up angina的发生机制。鼓励慢性稳定型心绞痛人群进行适当的运动,增加Warm-up angina发生,强化这种现象对缺血心脏的保护作用。
4. 0MI患者合并不稳定型心绞痛或/和急性左心衰竭时心电图在原梗死区域导联出现ST段抬高的临床意义是一种特殊类型ST段抬高AMI。发病机制是冠状动脉逆向血流中断即冠状动脉侧支循环减少和中断所致AMI。其临床特征以急性左心衰竭症状为主而心绞痛症状相对较轻。
5.这种特殊类型的心肌梗死表现为心电图梗死区域抬高的ST段逐渐回落至等电位线不出现AMI典型的T波演变;病理Q波没有明显的加深和加宽。心肌酶的水平和肌钙蛋白I增高不显著。心脏超声显示心脏收缩功能和舒张功能均较差。CAG显示为多支病变和冠脉侧支循环形成。常规静脉溶栓治疗不适合于这种特殊类型的ST段抬高AMI。
6.国人WTA临床特征为临床症状不典型且较轻,劳累时心绞痛发作,继续增加活动心绞痛不但不加重,反而逐渐减轻至消失。医患双方对本病认知程度均较低,在临床上容易导致对本病的漏诊和误诊。
7.运动试验表明WTA患者心肌缺血明显,心脏变时功能不良;心脏超声显示WTA心功能较差;CAG特点为冠脉狭窄程度非常严重和弥漫且多为双支或三支病变,均有明显侧枝循环形成;冠脉良好的侧枝循环参与了WTA的发病机制,血运重建是WTA患者的合理治疗选择。
Objective: Coronary arteriosclerotic heart disease, called for short coronary heart disease, is one of epidemic diseases today. It is also the problem of the public health in the world. Nowaday, all over the world people pay close attention to the topic problem. It is reported that coronary heart disease is the first place in all diease death cause. Coronary heart disease is classified to five types that are asymptomatic myocardial ischemia, angina pectoris, myocardial infarction, ischemic cardiomyopathy and primary heart arrest. Clinical practice indicates that the typing standard can not satisfied with the clinical demand nowadays. The aim of the study is to explore the three special types of coronary heart disease which are a special type of ST segment elevation acute myocardial infarction and two special type of angina pectoris (walk-through angina and warm-up angina), and to make people know roundly the three special and rare types of coronary heart diseases.
Methods and results
1. Protection of warm-up angina to heart and the effects of KATP channel blocker on it
Patients with the chronic stable angina who had positive exercise and was angiographically proven came into the study. They were divided into three groups according to the presence of diabetes and its treatment: 25 patients with the chronic stable angina only came into the NDM group, and 22 patients with diabetes came into the DMG group, and 22 patients with diabetes but on diet only came into the DMD group. The total number was sixty-nine. All the entry patients underwent sequential bicycle ergometer exercises test twice separated by 15min on the day of the study. We needed to investigate the changes of exercise duration (ED), the time to 1mm ST-segment depression (T-STD), maximum STD (mm) and the corresponding heart-rate systolic blood pressure product (RPP or ischaemic threshold, mmHg/min×102). Then the differences of these variable indexes among the three groups were compared. The results were as follows.
1.1 In group NDM,all the analysed variables improved significantly during the second test (EX2) in comparison with the first test (EX1), and which showed that the ischaemic threshold was increased significantly(173.77±34.73 vs 199.23±37.07 mmHg/min×102,P<0.05) and the ED and T-STD were prolonged (546.04±103.78 vs 617.52±106.96s,P<0.05 & 385.64±92.34 vs 426.84±91.25s, P<0.05) , and the STDmax was reduced (2.06±0.37 vs 1.75±0.41mm, P<0.05).
1.2 In group DMG,there was no difference in these analysed variables except T-STD between the first and second test (P>0.05).The T-STD in the second test was significantly longer than that in the first test (328.45±64.66 vs 363.00±81.48s, P<0.01).
1.3 In group DMD, all analysed parameters improved significantly in the second test (EX2) in comparison with the first test (EX1). For example, the ischaemic threshold was increased(181.58±40.34 vs 204.51±30.91 mmHg /min×102, P<0.05),as well as the T-STD was not prolonged (366.95±86.93 vs 404.27±101.61s, P>0.05) and the STDmax was reduced (2.10±0.46 vs 1.79±0.38mm, P<0.05). However, the exercise duration (ED) had no the same behavior (P>0.05).
2. Study of clinical characteristics and pathogenesis of walk-through angina
28 cases of inpatients with walk-through angina (WTA) and 28 cases of stable angina pectoris (SAP) respectively were selected to the study, which were called WTA group and SAP group respectively. We summarized both patient’s attitude and doctor’s knowledge about the disease. At the same time, we observed the risk factors of coronary heart disease, clinical features, ECG performance, the results of heart ultrasound, the results of coronary angiography, treadmill exercise testing, and the ability of heart rate response in the two groups with coronary heart disease. The results were analysed and compared between the two groups. The results were as follows.
2.1. According to the asking history, doctors and patients paid no attention to the importance of the disease. Before the diagnosis of WTA,they had been at least once misdiagnosed and/or missed diagnose in a hospital, and the rate of misdiagnosis and/or missed diagnosis was one hundred percent.
2.2 Judging from the clinical manifestations, the symptoms of WTA patients were quite different from those suffering from SAP. The WTA patients felt typical angina pectoris with initial activities. As the activity continues, angina did not aggravate, but gradually reduced or even disappeard instead. Labour induced angina attacks and rest could relieve angina symptom rapidly in SAP patients.
2.3 Heart ultrasound parameters: The number of LVEF and LVFS in the WTA group was lower significantly than those in SAP group (P<0.01). However, the number of E peak and A peak was no difference between the two groups (P>0.05).
2.4 The results of CAG:Three bronch lesions, total occlusion lesions, type C lesions and the formation of collateral circulation of coronary artery in WTA groups were more than those in SAP group (P<0.01).
2.5 The results of WTA group and SAP group exercise test indicated that ST-segment depression lasted for 512.43±46.49s and 591.03±5.27s (P<0.01); Number with ST segment depression of leads was 3.01±0.51 and 6.10±0.76 (P<0.01); Chronotropicresponse index (CRI ) was 0.48±0.05 and 0.74±0.07 (P<0.01); Maximal heart rate in movement was 124.32±6.89 beat /min and 145.35±5.25 beat/min (P<0.01); The metabolic cost of maximum exercise was 5.64±0.62 Mets and 4.87±0.48 Mets,respectively (P<0.01).
2.6 Revascularization: More patients in WTA group were selected to revascularization, and more patients in SAP group were selected to drug treatment,P<0.01.
3. Clinical feature and pathogenesis and intervention strategy for acute ST segment elevation acute myocardial infarction which is not fitted for thrombosis therapy.
Patients with old myocardial infarction (OMI) were selected to the study objects. When the patients with unstable angina pectors or/and acute left heart failure attack, glycerinum in hypoglossis administration could not relieve the symptom and the symptom lasted for more than thirty minutes and the level of ST segment elevation was still more than 0.2mv. Patients with reinfarction were excluded. 29 patients were selected to the study, which was called SAMI group. On the other hand, inpatients who were not used thrombosis with the first ST segment elevation AMI therapy were called control group. The two groups were treated with routine check-up and therapy. The pathogenesis, clinical manifestation, electrocardiogram (ECG) dynamic variation, the level of myocardial creatase, the level of troponin, the results of heart ultrasound, the characteristic of coronary artery angiography and the treatment of the two groups were compared and analyzed .The results were as follows:
3.1 Patients in SAMI group were consistent with the diagnostic criteria of acute myocardial infarction (AMI). The clinical features manifested more symptoms of acute left cardiac failure and less symptoms of myocardial ischemia. ST segment variation appeared in infracted zone leads. However, the variation of T wave and Q wave were not observed variation remarkablely.
3.2 The level of CPK,CPK-MB and TNI was lower in the SAMI group than those in AMI group after attack 6hours, 12hours, 24hours, 48hours, respectively, P<0.01.
3.3 Heart ultrasound parameters: The number of left ventricular ejection fraction (LVEF), left ventricular fractional shortening (LVFS), E peak and A peak in the SAMI group were lower significantly than those in AMI group, P<0.01.
3.4 The results of coronary artery angiography (CAG) :Three bronch lesions, type B lesions, type C lesions and the formation of collateral circulation of coronary artery in SAMI group were more than those in AMI group, P<0.01.
3.5 Revascularization: The majority of patients in SAMI group were selected to coronary artery bypass grafting (CABG) and the majority of patients in AMI group were selected to Percutaneous coronary intervention (PCI), P<0.01.
Conclusion
1. Exercise test can induce the warm-up angina in patients with stable angina pectoris. Warm-up phenomenon can also occur in patients with stable angina patients pectoris combined with diabete mellitus who are well-controlled with diet only for the blood glucose level.
2. The KATP channel blocker glibenclamide can block the warm-up angina when it use for patients with coronary artery combined with diabete, which can block myocardial self protection.
3. KATP channel is related to the happening of the warm-up angina mechnism. We should encourage the patients with SAP to considerable exercise in order to strengthen protection on ischemic myocardium.
4. The clinical significance of acute ECG ST segment elevation in the same infarction zone in patients with OMI combined with acute left heart failure or/and unstable angina pectoris is that the infarction is a special type of acute myocardial infarction. Its pathogenesis is that collateral circulation in the infarction zone reduces remarkablely even stops completely. The clinical feature manifests more symptoms of acute left cardiac failure and less symptoms of myocardial ischemia.
5. The variation of ECG is that elevated ST segment falls down to isoelectric level in infracted zone leads gradually and the variation of T wave and Q wave does not appeare remarkablely. The level of cardiac myocardial creatase raises up lightly. The thrombolytic therapy does not suit for this situation absolutely.
6. The clinical characteristic of WTA is not typical of in Chinese and the clinical symptom is relative light. Patients feel typical angina pectoris with initial activities. But as the activity continues, angina does not show increase, it will gradually reduce or even disappear instead. Both doctors and patients pay no attention to the importance to the disease. This type of angina is easily missed diagnosis and misdiagnosised by clinicians.
7. The excise test shows that the condition in patients with WTA is severer in myocardial ischemia and worse in the ability of heart rate response and the results of CAG shows that ressel lesions are severe and widespread and always two or three branch lesions in coronary arteries as well as there are obvious collateral circulation in patients with WTA. Obvious collateral circulation is one of the pathogenesis in the patients with WTA. Revascularization is reasonable selection for the patients with WTA.
方法和结果
1. Warm-up angina对心脏的保护及钾通道阻滞剂对此现象影响选择运动试验阳性和经冠脉造影证实的稳定型心绞痛病人作为研究对象。根据入选者是否合并糖尿病及其治疗方式分为三组:单纯稳定型心绞痛患者对照组(NDM组)25例;心绞痛合并糖尿病并服用格列本脲进入格列本脲组(DMG组)22例;心绞痛合并糖尿病仅以节食方式控制血糖进入节食组(DMD组)22例,共69例。所有入选病人均于运动当日分别进行连续两次踏车运动实验(EX1,EX2),且两次运动之间间隔15min。观察各组病人两次运动中运动时间(ED)、出现ST段压低0.1mv时间(T-STD)、极量运动时的ST段压低的最大值(STDmax)以及ST段压低0.1mv时的心率收缩压乘积(RPP值,亦称缺血阈值,mmHg/min×102)变化情况,并比较其组间各参数差异。结果如下:
1.1 NDM组所观察的各指标在EX2较EX1相比均有明显改善,表现为缺血阈值明显提高(173.77±34.73 vs 199.23±37.07 mmHg/min×102,P<0.05);ED和T-STD明显延长(546.04±103.78 vs 617.52±106.96s , P<0.05 & 385.64±92.34 vs 426.84±91.25s,P <0.05);STDmax明显减轻(2.06±0.37 vs1.75±0.41mm,P<0.05)。
1.2 DMG组除了T-STD在EX2与EX1相比有所延长(328.45±64.66 vs 363.00±81.48s,P<0.01)外,其余各指标的改善均不明显(P>0.05)。
1.3 DMD组结果,所有参数在两次运动比较,EX2比EX 1均有明显改善即缺血阈值明显提高(181.58±40.34 vs 204.51±30.91 mmHg/min×102 ,P < 0.05);T-STD无明显延长(366.95±86.93 vs 404.27±101.61s,P>0.05);STDmax有所减轻(2.10±0.46 vs 1.79±0.38mm,P<0.05),但在总体运动时间上EX2较EX1增加不明显(P>0.05)
2. walk-through angina的临床特征和发病机制的研究
选择住院walk-through angina和稳定劳累型心绞痛各28例,分别称为WTA组和SAP组。汇总患者和临床医师对本病认知情况,同时观察两组患者冠心病危险因素、临床特征、心电图表现、心脏超声结果、CAG的结果、运动平板试验以及心脏变时性功能,进行对比分析,结果如下:
2.1从对本病的认知情况来看,医患双方对本病的认知程度均较低,且在确诊本病之前至少误诊或漏诊一次以上,误诊和漏诊率达100%;
2.2从临床表现来看WTA患者心绞痛发作特征与SAP显著不同,患者最初活动时心绞痛发作,但继续增加活动量心绞痛不但不加重,反而会逐渐减轻甚至消失;而SAP典型的临床表现为劳累时心绞痛发作,休息后心绞痛症状迅速缓解。
2.3心脏超声结果:WTA组LVEF、LVFS较SAP组均显著降,P<0.01;两组E峰和A峰分别相比无显著差异,P值均>0.05。
2.4 CAG结果:WTA组三支病变、闭塞病变、冠脉侧枝循环形成与SAP组相比P值均<0.01。
2.5运动试验结果:WTA组与SAP组ST段压低持续时间分别是512.43±46.49秒和591.03±55.27秒,两组相比,P<0.01;ST段压低的导联数分别是3.01±0.51和6.10±0.76,两组相比,P<0.01;WTA组与SAP组患者的心脏变时性指数(CRI)分别是0.48±0.05和0.74±0.07,两组相比,P<0.01;运动中最大心率分别是124.32±6.89次/分和145.35±5.25次/分,P<0.01;极量运动代谢值分别是5.64±0.62 Mets和4.87±0.48 Mets,两组相比,P<0.01。
2.6治疗选择:WTA组患者更多选择了血运重建,SAP组更多选择了保守治疗,两组相比,P值均<0.01。
3.急性ST段抬高不宜溶栓心肌梗死的临床特征、发病机制及干预策略
选择住院冠心病0MI为研究对象,发作不稳定型心绞痛或/和急性左心衰竭时原梗死区域所对应的心电图导联ST段急性抬高大于0.2mv且口含硝酸甘油胸痛或/和呼吸困难不缓解,症状持续超过30分钟患者为入选对象。再梗死病例除外,共29例患者符合入选条件,称为SAMI组。同时选择同期住院的首次ST段抬高未溶栓的AMI患者36例,称为AMI组。对两组患者进行常规的检查和治疗,将两组患者的发病机制、临床表现、心电图动态演变、心肌酶学变化、肌钙蛋白水平、心脏超声、冠脉造影特征和治疗的选择进行对比分析,结果如下: 3.1 SAMI组患者符合AMI的诊断标准。SAMI组患者多以急性左心衰竭症状为主而不稳定型心绞痛的症状相对较轻。心电图在同一梗死区域导联只出现ST段的演变而不出现T波的动态演变, Q波也没有明显加深和增宽。
3.2在发病后6小时、12小时、24小时、48小时SAMI组CPK、CPK-MB以及TNI升高均较AMI组低,P值均<0.01。
3.3心脏超声指标:SAMI组LVEF、LVFS、E峰和A峰与和AMI组相应指标相比均有显著降低,P值均<0.01。
3.4冠脉造影结果:SAMI组三支病变、B型病变和C型病变以及侧支循环形成均较AMI组多,P值均<0.01。
3.5血运重建的选择:SAMI组更多选择了冠脉搭桥,而AMI组更多选择了冠脉介入,P值均<0.01。
结论:
1.对稳定型心绞痛的患者来说,运动可以诱发Warm-up angina发生。在稳定型心绞痛合并糖尿病以节食方式控制血糖良好的病人身上仍然具有发生Warm-up angina的能力。
2.钾通道阻滞剂实格列本脲能够阻断Warm-up angina发生,从而阻断这种心肌保护性现象。钾通道阻滞剂格列本脲在应用于冠心病合并糖尿病的人群时会阻断Warm-up angina的发生,消弱心脏对缺血的耐受性。
3.钾通道参与了Warm-up angina的发生机制。鼓励慢性稳定型心绞痛人群进行适当的运动,增加Warm-up angina发生,强化这种现象对缺血心脏的保护作用。
4. 0MI患者合并不稳定型心绞痛或/和急性左心衰竭时心电图在原梗死区域导联出现ST段抬高的临床意义是一种特殊类型ST段抬高AMI。发病机制是冠状动脉逆向血流中断即冠状动脉侧支循环减少和中断所致AMI。其临床特征以急性左心衰竭症状为主而心绞痛症状相对较轻。
5.这种特殊类型的心肌梗死表现为心电图梗死区域抬高的ST段逐渐回落至等电位线不出现AMI典型的T波演变;病理Q波没有明显的加深和加宽。心肌酶的水平和肌钙蛋白I增高不显著。心脏超声显示心脏收缩功能和舒张功能均较差。CAG显示为多支病变和冠脉侧支循环形成。常规静脉溶栓治疗不适合于这种特殊类型的ST段抬高AMI。
6.国人WTA临床特征为临床症状不典型且较轻,劳累时心绞痛发作,继续增加活动心绞痛不但不加重,反而逐渐减轻至消失。医患双方对本病认知程度均较低,在临床上容易导致对本病的漏诊和误诊。
7.运动试验表明WTA患者心肌缺血明显,心脏变时功能不良;心脏超声显示WTA心功能较差;CAG特点为冠脉狭窄程度非常严重和弥漫且多为双支或三支病变,均有明显侧枝循环形成;冠脉良好的侧枝循环参与了WTA的发病机制,血运重建是WTA患者的合理治疗选择。
Objective: Coronary arteriosclerotic heart disease, called for short coronary heart disease, is one of epidemic diseases today. It is also the problem of the public health in the world. Nowaday, all over the world people pay close attention to the topic problem. It is reported that coronary heart disease is the first place in all diease death cause. Coronary heart disease is classified to five types that are asymptomatic myocardial ischemia, angina pectoris, myocardial infarction, ischemic cardiomyopathy and primary heart arrest. Clinical practice indicates that the typing standard can not satisfied with the clinical demand nowadays. The aim of the study is to explore the three special types of coronary heart disease which are a special type of ST segment elevation acute myocardial infarction and two special type of angina pectoris (walk-through angina and warm-up angina), and to make people know roundly the three special and rare types of coronary heart diseases.
Methods and results
1. Protection of warm-up angina to heart and the effects of KATP channel blocker on it
Patients with the chronic stable angina who had positive exercise and was angiographically proven came into the study. They were divided into three groups according to the presence of diabetes and its treatment: 25 patients with the chronic stable angina only came into the NDM group, and 22 patients with diabetes came into the DMG group, and 22 patients with diabetes but on diet only came into the DMD group. The total number was sixty-nine. All the entry patients underwent sequential bicycle ergometer exercises test twice separated by 15min on the day of the study. We needed to investigate the changes of exercise duration (ED), the time to 1mm ST-segment depression (T-STD), maximum STD (mm) and the corresponding heart-rate systolic blood pressure product (RPP or ischaemic threshold, mmHg/min×102). Then the differences of these variable indexes among the three groups were compared. The results were as follows.
1.1 In group NDM,all the analysed variables improved significantly during the second test (EX2) in comparison with the first test (EX1), and which showed that the ischaemic threshold was increased significantly(173.77±34.73 vs 199.23±37.07 mmHg/min×102,P<0.05) and the ED and T-STD were prolonged (546.04±103.78 vs 617.52±106.96s,P<0.05 & 385.64±92.34 vs 426.84±91.25s, P<0.05) , and the STDmax was reduced (2.06±0.37 vs 1.75±0.41mm, P<0.05).
1.2 In group DMG,there was no difference in these analysed variables except T-STD between the first and second test (P>0.05).The T-STD in the second test was significantly longer than that in the first test (328.45±64.66 vs 363.00±81.48s, P<0.01).
1.3 In group DMD, all analysed parameters improved significantly in the second test (EX2) in comparison with the first test (EX1). For example, the ischaemic threshold was increased(181.58±40.34 vs 204.51±30.91 mmHg /min×102, P<0.05),as well as the T-STD was not prolonged (366.95±86.93 vs 404.27±101.61s, P>0.05) and the STDmax was reduced (2.10±0.46 vs 1.79±0.38mm, P<0.05). However, the exercise duration (ED) had no the same behavior (P>0.05).
2. Study of clinical characteristics and pathogenesis of walk-through angina
28 cases of inpatients with walk-through angina (WTA) and 28 cases of stable angina pectoris (SAP) respectively were selected to the study, which were called WTA group and SAP group respectively. We summarized both patient’s attitude and doctor’s knowledge about the disease. At the same time, we observed the risk factors of coronary heart disease, clinical features, ECG performance, the results of heart ultrasound, the results of coronary angiography, treadmill exercise testing, and the ability of heart rate response in the two groups with coronary heart disease. The results were analysed and compared between the two groups. The results were as follows.
2.1. According to the asking history, doctors and patients paid no attention to the importance of the disease. Before the diagnosis of WTA,they had been at least once misdiagnosed and/or missed diagnose in a hospital, and the rate of misdiagnosis and/or missed diagnosis was one hundred percent.
2.2 Judging from the clinical manifestations, the symptoms of WTA patients were quite different from those suffering from SAP. The WTA patients felt typical angina pectoris with initial activities. As the activity continues, angina did not aggravate, but gradually reduced or even disappeard instead. Labour induced angina attacks and rest could relieve angina symptom rapidly in SAP patients.
2.3 Heart ultrasound parameters: The number of LVEF and LVFS in the WTA group was lower significantly than those in SAP group (P<0.01). However, the number of E peak and A peak was no difference between the two groups (P>0.05).
2.4 The results of CAG:Three bronch lesions, total occlusion lesions, type C lesions and the formation of collateral circulation of coronary artery in WTA groups were more than those in SAP group (P<0.01).
2.5 The results of WTA group and SAP group exercise test indicated that ST-segment depression lasted for 512.43±46.49s and 591.03±5.27s (P<0.01); Number with ST segment depression of leads was 3.01±0.51 and 6.10±0.76 (P<0.01); Chronotropicresponse index (CRI ) was 0.48±0.05 and 0.74±0.07 (P<0.01); Maximal heart rate in movement was 124.32±6.89 beat /min and 145.35±5.25 beat/min (P<0.01); The metabolic cost of maximum exercise was 5.64±0.62 Mets and 4.87±0.48 Mets,respectively (P<0.01).
2.6 Revascularization: More patients in WTA group were selected to revascularization, and more patients in SAP group were selected to drug treatment,P<0.01.
3. Clinical feature and pathogenesis and intervention strategy for acute ST segment elevation acute myocardial infarction which is not fitted for thrombosis therapy.
Patients with old myocardial infarction (OMI) were selected to the study objects. When the patients with unstable angina pectors or/and acute left heart failure attack, glycerinum in hypoglossis administration could not relieve the symptom and the symptom lasted for more than thirty minutes and the level of ST segment elevation was still more than 0.2mv. Patients with reinfarction were excluded. 29 patients were selected to the study, which was called SAMI group. On the other hand, inpatients who were not used thrombosis with the first ST segment elevation AMI therapy were called control group. The two groups were treated with routine check-up and therapy. The pathogenesis, clinical manifestation, electrocardiogram (ECG) dynamic variation, the level of myocardial creatase, the level of troponin, the results of heart ultrasound, the characteristic of coronary artery angiography and the treatment of the two groups were compared and analyzed .The results were as follows:
3.1 Patients in SAMI group were consistent with the diagnostic criteria of acute myocardial infarction (AMI). The clinical features manifested more symptoms of acute left cardiac failure and less symptoms of myocardial ischemia. ST segment variation appeared in infracted zone leads. However, the variation of T wave and Q wave were not observed variation remarkablely.
3.2 The level of CPK,CPK-MB and TNI was lower in the SAMI group than those in AMI group after attack 6hours, 12hours, 24hours, 48hours, respectively, P<0.01.
3.3 Heart ultrasound parameters: The number of left ventricular ejection fraction (LVEF), left ventricular fractional shortening (LVFS), E peak and A peak in the SAMI group were lower significantly than those in AMI group, P<0.01.
3.4 The results of coronary artery angiography (CAG) :Three bronch lesions, type B lesions, type C lesions and the formation of collateral circulation of coronary artery in SAMI group were more than those in AMI group, P<0.01.
3.5 Revascularization: The majority of patients in SAMI group were selected to coronary artery bypass grafting (CABG) and the majority of patients in AMI group were selected to Percutaneous coronary intervention (PCI), P<0.01.
Conclusion
1. Exercise test can induce the warm-up angina in patients with stable angina pectoris. Warm-up phenomenon can also occur in patients with stable angina patients pectoris combined with diabete mellitus who are well-controlled with diet only for the blood glucose level.
2. The KATP channel blocker glibenclamide can block the warm-up angina when it use for patients with coronary artery combined with diabete, which can block myocardial self protection.
3. KATP channel is related to the happening of the warm-up angina mechnism. We should encourage the patients with SAP to considerable exercise in order to strengthen protection on ischemic myocardium.
4. The clinical significance of acute ECG ST segment elevation in the same infarction zone in patients with OMI combined with acute left heart failure or/and unstable angina pectoris is that the infarction is a special type of acute myocardial infarction. Its pathogenesis is that collateral circulation in the infarction zone reduces remarkablely even stops completely. The clinical feature manifests more symptoms of acute left cardiac failure and less symptoms of myocardial ischemia.
5. The variation of ECG is that elevated ST segment falls down to isoelectric level in infracted zone leads gradually and the variation of T wave and Q wave does not appeare remarkablely. The level of cardiac myocardial creatase raises up lightly. The thrombolytic therapy does not suit for this situation absolutely.
6. The clinical characteristic of WTA is not typical of in Chinese and the clinical symptom is relative light. Patients feel typical angina pectoris with initial activities. But as the activity continues, angina does not show increase, it will gradually reduce or even disappear instead. Both doctors and patients pay no attention to the importance to the disease. This type of angina is easily missed diagnosis and misdiagnosised by clinicians.
7. The excise test shows that the condition in patients with WTA is severer in myocardial ischemia and worse in the ability of heart rate response and the results of CAG shows that ressel lesions are severe and widespread and always two or three branch lesions in coronary arteries as well as there are obvious collateral circulation in patients with WTA. Obvious collateral circulation is one of the pathogenesis in the patients with WTA. Revascularization is reasonable selection for the patients with WTA.
引文
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1 Nomenclature and Criteria for Diagnosis of Ischemic Heart Disease. Report of the Joint International Society and Federation of Cardiology / World Health Organization Task Force on Standardization of Clinical Nomenclature. Circulation, 1979,59:607
2 Rizi HR, Kline RC, Besozzi MC, et al Walk-through angina phenomenon demonstrated by graded exercise radionuclide ventriculography. Possible coronary spasm mechanisms. Am Heart J, 1982,103(2):292-295
3 姜志安, 张永健, 付向华. 一种特殊类型的心绞痛 walk-through angina的临床特征和发病机制的探讨. 临床心血管病杂志, 2007,23(1):26-27
4 Stewart RAH, Simmonds MB, Williams MJA. Time course of “warm-up” in stable angina. Am J Cardiol, 1995,76(1):70-73
5 Tomai F, Crea F, Danesi A, et al. Mechanisms of the warm-up phenomenon. Eur Heart J 1996,17(7): 1022-1027.
6 Bogaty P, Kingma JG, Robitaille N-M, et al. Attenuation of myocardial ischemia with repeated exercise in subjects with chronic stable angina: relation to myocardial contractility, intensity of exercise and the ATP-sensitive potassium channel. J Am Coll Cardiol, 1998,32(6): 1665-1671.
7 ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation. 2007, 116(17): 1971-1996
8 Guidelines on the management of stable angina pectoris: executive summary: the Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J, 2006,27(11): 1341-1381.
9 ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation, 2007, 116(7):e148-304
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19 Williams DO, Bass TA, Gewirtz H, et al. Adaptation to the stress of tachycardia in patients with coronary artery disease: insight into the mechanism of the warm-up phenomenon, 1985,71(4): 687-692
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22 Arstall M A, Zhao Y Z, Homberger L, et al. Human ventricular myocytes invitro exhibit both early and delayed preconditioning responses to simulated ischemia. J Mol Cell Cardiol ,1998,30(5): 1019-1025
23 Tuomainen P, Vanninen E, Halonen P, et al. Characterization of the warm-up phenomenon in patients with coronary artery disease. Am Heart J, 2002,144(5): 870-876
24 Napoli C, Liguori A, Cacciatore F, et al. "Warm-up" phenomenon detected by electrocardiographic ambulatory monitoring in adult and older patients. J Am Geriatr Soc,1999,47(9):1114-1117
25 Lupi A, Lanza GA, Lucente M, et al. The "warm-up" phenomenon occurs in patients with chronic stable angina but not in patients with syndrome X. Am J Cardiol, 1998,81(2): 123-127.
26 Bilinska M, Potocka J, Korzeniowska-Kubacka I, et al. ‘Warm-up’ phenomenon in diabetic patients with stable angina treated with diet or sulfonylureas. Coron Artery Dis. 2007, 18(6): 455-462
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29 Kelion AD, Webb TP, Garsner MA, et al. The warm-up effect protests against ischemic left ventricular dysfunction in patients with angina. J Am Coll Cardiol, 2001, 37 (3): 705-710
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1 Nomenclature and Criteria for Diagnosis of Ischemic Heart Disease. Report of the Joint International Society and Federation of Cardiology / World Health Organization Task Force on Standardization of Clinical Nomenclature. Circulation,1979,59:607
2 ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation,2007, 116(7):e148-304
3 姜志安, 张晓光, 肖文良等. 陈旧性心肌梗死梗死区域 ST 段急性抬高的临床意义. 河北医科大学学报, 2006, 27(2):98-100
4 姜志安, 张晓光, 肖文良等.陈旧性心肌梗死合并急性左心衰时心电图梗死区域导联 ST 段急性抬高的临床意义. 临床心血管病杂志, 2006, 22(9):559-560
5 ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation, 2007, 116(17):1971-1996
6 Guidelines on the management of stable angina pectoris: executive summary: the Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J. 2006,27(11):1341-1381
7 姜志安, 张永健, 付向华. 一种特殊类型的心绞痛 walk-through angina 的临床特征和发病机制的探讨. 临床心血管病杂志,2007,23(1):26-27
8 Jaffe MD, Quinn NK. Warm-up phenomenon in angina pectoris Lancet 1980;2:934-936
9 Joy M, Cairns AW, Sprigings D. Observations on the warm up phenomenon in angina pectoris. Br Heart J, 1987;58:116-121
10 Stewart RAH, Simmonds MB, Williams MJA. Time course of “warm-up” in stable angina. Am J Cardiol,1995;76:70-73
11 Mabaum S, Ilan M, Mogilevsky J, Tzivoni D. Improvement at ischemic parameters during repeated exercise testing: a possible model for myocardial preconditioning. Am J Cardiol. 1996;78:1087-1091
12 Tomai F, Crea F, Danesi A, et al. Mechanisms of the warm-up phenomenon. Eur Heart J, 1996;17:1022-1027
13 Bogaty P, Kingma JG, Robitaille N-M, et al. Attenuation of myocardial ischemia with repeated exercise in subjects with chronic stable angina: relation to myocardial contractility, intensity of exercise and the ATP-sensitive potassium channel. J Am Coll Cardiol, 1998;32:1665-1671
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5 Jaffe MD, Quinn NK. Warm-up phenomenon in angina pectoris. Lancet, 1980,(8201)2:934-936
6 Joy M, Cairns AW, Sprigings D. Observations on the warm up phenomenon in angina pectoris. Br Heart J, 1987,58(2):116-121
7 Stewart RAH, Simmonds MB, Williams MJA. Time course of “warm-up” in stable angina. Am J Cardiol, 1995,76(1):70-73
8 Mabaum S, Ilan M, Mogilevsky J,et al. Improvement at ischemic paramenters during repeated exercise testing: a possible model for myocardial preconditioning. Am J Cardiol 1996,78(10):1087-1091
9 Tomai F, Crea F, Danesi A, et al. Mechanisms of the warm-up phenomenon. Eur Heart J ,1996,17(7):1022-1027
10 Bogaty P, Kingma JG, Robitaille N-M, et al. Attenuation of myocardial ischemia with repeated exercise in subjects with chronic stable angina: relation to myocardial contractility, intensity of exercise and the ATP-sensitive potassium channel. J Am Coll Cardiol, 1998, 32(6): 1665-1671
11 Edwards RJ, Redwood SR, Lambiase PD,et al. Anti-arrhythmic andanti-ischaemic effects of angina in patients with and without coronary collaterals. Heart ,2002,88(6):604-610
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14 Kelion AD, Webb TP, Garsner MA, et al.The warm-up effect protests against ischemic left ventricular dysfunction in patients with angina. J Am Coll Cardiol, 2001,37(3):705-710
15 Tomai F. Warm up phenomenon and preconditioning in clinical practice. Heart, 2002,87(2):99-100
16 Tomai F, Crea F, Chiariello L, et al. Ischemic Preconditioning in Humans Models, Mediators, and Clinical Relevance. Circ 1999,100(5):559-563
17 Tuomainen P, Vanninen E, Halonen P, et al. Characterization of the warm-up phenomenon in patients with coronary artery disease. Am Heart J ,2002,144(5):870-876
18 Okazaki Y, Kodama K, Sato H, et al. Attenuation of increased regional myocardial oxygen consumption during exercise as a major cause of warm-up phenomenon. J Am Coll Cardiol,1993,21(7):1597–1604
19 Bilinska M, Potocka J, Korzeniowska-Kubacka I, et al.‘Warm-up’ phenomenon in diabetic patients with stable angina treated with diet or sulfonylureas. Coron Artery Dis,2007,18(6):455-462
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62 Redel A, Lange M, Jazbutyte V, et al. Activation of mitochondrial large-conductance calcium-activated K+ channels via protein kinase A mediates desflurane-induced preconditioning. Anesth Analg, 2008, 106 (2): 384-391
63 Liem DA, Verdouw PD, Ploeg H, et al. Sites of action. of adensine ininterorgan preconditioning of the heart. Am J Physiol Heart Circ Physiol, 2002,283(1): H29-37
64 Mullenheim J, Schlack W, Frassdorf J, et al. Additive protective effect s of late and early ischaemic preconditioning are mediated by the opening of KATP channels in vivo Pflugers Arch, 2001,442(2): 1789-1871
65 Napoli C, Pinto A, Cirino G. Pharmacological modulation, preclinical studies, and new clinical features of myocardial ischemic preconditioning. Pharmacol & Ther, 2000, 88 (3): 311-331
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