马文芳
中国医学科学院阜外医院 急诊科
BACKGROUND:Data are limited with regard to the relationship of albuminuria and major adverse cardiovascular events (MACE) in Chinese elder patients with high cardiovascular risk.METHODS:We did a retrospective cohort study using Chinese elder patients with high cardiovascular risks (n = 1474) to identify the association of albumin-to-creatinine ratio (ACR) and the incidence of MACE and all-cause mortality. Individuals were followed up from January, 2002 to November, 2007. The all-cause mortality and MACE, composite outcome of cardiovascular death, myocardial infarction, stroke and hospitalization of congestive heart failure were defined as primary endpoint.RESULTS:During the median following up of 56 months, 213 patients developed primary endpoint and 117 patients died. Patients with higher baseline urinary ACR (> 30 mg/g) experienced a nearly 2-fold of all-cause mortality and a 3-fold of heart failure hospitalization than those with lower baseline urinary ACR (≤10 mg/g).MACE, cardiovascular death, stoke and myocardial infarction showed no difference in three grades of urinary ACR (> 30 mg/g, 10 mg/g-30 mg/g, ≤10 mg/g) in this cohort. Patients above 65 years with increased ACR tended to experience higher mortality risks, and the association of increased ACR with higher hospitalization of congestive heart failure seemed to be more prominent in patients below 65 years than above 65 years.CONCLUSIONS:In this post hoc analysis of Chinese individuals with high cardiovascular risks, higher urinary ACR was associated with higher all-cause mortality and heart failure hospitalization. Further studies are needed to find out whether there is age-specific ACR cutoff point.
Clinical hypertension 2018
BACKGROUND:Fear of complications related to the procedure and unclear benefits in elderly patients are common reasons for invasive angiography being withheld.METHODS:We searched PubMed and Embase from inception until February 2016 for studies that enrolled individuals older than 75 years with non-ST-elevation acute coronary syndrome (NSTE-ACS) and allocated patients to either an invasive or conservative strategy.RESULTS:Thirteen studies (four randomised controlled trials (RCTs) and nine observational studies) enrolling 832,007 elderly NSTE-ACS patients were analysed. Compared with the conservative treatment, the early invasive approach does significantly reduce the risk of death at follow-up from 6 months to 5 years (risk ratio [RR] 0.65, 95% confidence interval [CI] 0.59-0.73, p<0.001); the definite benefit was mainly observed in observational studies (RR 0.63, 95% CI 0.57-0.70, p<0.001), and the risk of death also showed a strong trend toward reduction with invasive approach (RR 0.82, 95% CI 0.64-1.05, p=0.119) in RCTs. For the outcome of bleeding complications, there was a higher risk of any bleeding occurring in-hospital (RR 2.51, 95% CI 1.53-4.11, p<0.001) in patients treated with invasive strategy than those treated with conservative strategy. However, no difference of in-hospital major bleeding (RR 1.78, 95% CI 0.31-10.13, p=0.514) was observed between the two strategies.CONCLUSION:Elderly patients with NSTE-ACS might benefit from an early invasive strategy but with increasing risk of any bleeding complications. More RCTs are needed to assess early invasive strategies in the elderly.
Heart, lung & circulation 2018
INTRODUCTION:Behçet disease is a multisystemic chronic inflammatory disorder characterized by recurrent oral aphthous ulcers, genital ulcers, uveitis, and skin lesions. However, particularly part of patients would present cardiovascular involvements and vascular lesions could be the presenting sign of Behçet disease preceding classical symptoms. We presented a middle aged male patient, in whom abdominal aorta pseudoaneurysm was as the first leading sign to reveal Behçet disease, and with his coronary artery lesions progress through a 10-year period before Behçet disease was diagnosed.CONCLUSIONS:Coronary artery involvement of Behçet disease warrants more attention and investigation; repeated in-stent stenosis, aggressive progress, and elevated inflammation markers should be regard with more care earlier in clinical practice.
Medicine 2017
Current guidelines recommend maintaining serum potassium levels between 4.0 and 5.0 mEq/L (1 mEq/L = mmol/L) in patients with acute myocardial infarction. However, these guidelines are based on studies conducted before the β blocker and reperfusion era. We retrospectively analyzed 6613 patients diagnosed with ST-segment elevation myocardial infarction (STEMI) who presented without renal insufficiency. Patients were categorized into 5 groups according to mean serum potassium levels: <3.5, 3.5 to <4.0, 4.0 to <4.5, 4.5 to <5.0, and ≥5.0 mEq/L. Patients with potassium levels of 4.0 to <4.5 mEq/L had the lowest predefined event rates, which were 6.4% for 7-day malignant arrhythmia, 3.7% for 7-day mortality, and 5.3% for 30-day mortality. Compared with the reference group (4.0 to <4.5 mEq/L), multivariate regression analysis revealed significantly higher 30-day mortality risk in patients with potassium level of 4.5 to <5.0 (hazard ratio [HR]: 1.52, 95% confidence interval [CI]: 1.17-1.98; P = .002) and even higher risk in patients with potassium level of ≥5.0 mEq/L (HR: 1.80, 95% CI: 1.22-2.66; P = .002). The lowest 30-day mortality was observed in patients with STEMI having potassium levels between 4.0 and 4.5 mEq/L, and a level >4.5 mEq/L significantly increased mortality risk.
Angiology 2016
BACKGROUND:We compared admission systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and mean arterial pressure (MAP) in predicting 30-day all-cause mortality in patients with ST-segment elevation myocardial infarction (STEMI) without cardiogenic shock.METHODS:A retrospective study was performed in 7,033 consecutive STEMI patients. Multivariate-adjusted hazard ratios (HRs) with a 10mm Hg increment and quartiles of each blood pressure were determined by Cox proportional hazard analyses; Wald χ (2) tests were used to compare the strength of relationships.RESULTS:Totally 593 (8.4%) patients died during follow-up. Of 4 indexes, only SBP (HR 0.94 per 10mm Hg, 95% confidence interval (CI) 0.91 to 0.98; P = 0.001) and PP (HR 0.89 per 10 mmHg, 95% CI 0.85 to 0.94; P < 0.001) were significantly associated with 30-day all-cause mortality; these in the highest vs. lowest quartiles of SBP (≥140 vs. <110mm Hg) and PP (≥60 vs. <40mm Hg) had HRs of mortality of 0.70 (95% CI 0.55 to 0.87; P = 0.003) and 0.60 (95% CI 0.47 to 0.75; P < 0.001), respectively. Compared with SBP, PP was a better predictor for mortality no matter in men (χ (2) = 5.9 for per 10mm Hg, χ (2) = 10.8 for quartiles) or women (χ (2) = 15.1 for per 10mm Hg, χ (2) = 19.5 for quartiles), and the relationship remained significant after adjustment of SBP. There was a pattern of declining risk with increasing blood pressures for mortality, and this trend was mainly observed in age groups of more than 70 years.CONCLUSIONS:Pulse pressure was an independent predictor of mortality in patients with STEMI, and low admission blood pressure should serve as a warning sign.
American journal of hypertension 2016
BACKGROUND AND AIMS:Asians have very different genotype distributions of cytochrome P450 2C19 (CYP2C19), ATP-binding cassette, sub-family B, member 1 (ABCB1), and paraoxonase-1 (PON1), in whom relevant studies based on large samples are scarce. The purpose of this study was to evaluate the effects of these genes on outcomes of in-stent restenosis and re-stenting in Chinese patients after coronary stenting.METHODS:A total of 2569 acute coronary syndrome (ACS) patients were enrolled in a gene database study. Among the 1674 patients receiving coronary stenting, 504 patients performed repeated coronary angiography within the next year after discharge and were eligible to complete our final cohort.RESULTS:The prevalence of the CYP2C19 loss-of-function carriers (had at least 1 allele of *2, *3 and *4) was considerable high (52.2%). During re-angiography, in-stent restenosis occurred in 106 (21.0%) out of the 504 patients; the mean restenosis degree was 71.3% and 152 (30.2%) patients received re-stenting treatment. In multivariate regression, only age and left ventricular ejection fraction (LVEF) were significantly associated with in-stent restenosis. As for predictors of re-stenting, multivariate regression identified variables of LVEF, coronary artery lesions, and PON1 Q192R genotype. Genotype RR of PON1 Q192R was an independent risk factor predicting re-stenting compared with genotypes of QQ and QR (OR 1.95, 95% CI 1.30-2.93, p = 0.001). The genotypes of CYP2C19, ABCB1 C3435T, and PON1 L55M showed no significant associations with in-stent restenosis or re-stenting.CONCLUSIONS:Genotype RR of PON1 Q192R was an independent risk factor predicting re-stenting in Chinese ACS patients after coronary stenting.
Atherosclerosis 2016
The CURRENT-OASIS 7 (Clopidogrel and Aspirin Optimal Dose Usage to Reduce Recurrent Events-Seventh Organization to Assess Strategies in Ischemic Symptoms) trial showed that a 7-day 150-mg maintenance dose (MD) clopidogrel could reduce cardiovascular events in subgroup patients who underwent percutaneous coronary intervention (PCI) compared with the 75 mg/day regimen, although whether prolonging the high MD clopidogrel (≥150 mg) treatment period to at least 4 weeks can reduce major adverse cardiac events in the patients who underwent PCI with and without high on-clopidogrel platelet reactivity (HPR) is still controversial. We searched Pubmed, Embase, and Cochrane Library from inception until September 2014 for randomized controlled trials that compared high versus standard MD clopidogrel in patients who underwent PCI. Seventeen trials involving 4,822 patients who underwent PCI included 2,879 patients who were allocated to the "HPR patients" subgroup and 1,943 to the "native patients" subgroup without paying attention to the clopidogrel reactivity before randomization. Compared with the standard therapy, the high MD clopidogrel was associated with a significant reduction in the risk of major adverse cardiac events (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.39 to 0.71, p <0.0001) in patients who underwent PCI. The HPR patients subgroup was also benefited from such high MD treatment (OR 0.54, 95% CI 0.38 to 0.77, p = 0.0007). The observed benefits were mainly attributed to treatment-associated reduction in stent thrombosis (OR 0.43, 95% CI 0.23 to 0.78, p = 0.006) and target vessel revascularization (OR 0.38, 95% CI 0.20 to 0.74, p = 0.004). There was no difference in the rate of major/minor bleeding event between the high and standard MD group (OR 0.80, 95% CI 0.56 to 1.13, p = 0.21). In conclusion, the efficacy and safety of at least 4 weeks' high MD clopidogrel is greater than that of standard therapy for patients who underwent PCI with and without HPR.
The American journal of cardiology 2015
We evaluated the combined effect of admission systolic blood pressure (SBP) and antecedent hypertension on short-term outcomes in patients with ST-segment elevation myocardial infarction (STEMI). Data were derived from a multicenter survey of 7303 consecutive patients with STEMI. Patients were divided into 4 groups according to different blood pressure status: high SBP without hypertension, high SBP with hypertension, low SBP without hypertension, and low SBP with hypertension. The primary endpoints were 7 and 30-day all-cause mortality. The prevalence of hypertension was 40.7%, and the best cutoff of admission SBP for predicting 30-day mortality was 108 mmHg by receiver-operating characteristic curve. Patients with hypertension were older, more often female, also had longer onset-to-admission time, more comorbidities, and higher Killip class. Patients with both low SBP (≤108 mmHg) and hypertension group had significantly higher 7 and 30-day mortality than those in other groups (all P < 0.001). After multivariate adjustment, low SBP with hypertension group was still an independent risk factor for predicting 7-day mortality (hazard ratios [HR] 1.86, 95% confidence interval [CI] 1.41-2.46; P < 0.001) and 30-day mortality (HR 1.88, 95% CI 1.46-2.43; P < 0.001). In patients with SBP > 108 mmHg, a history of hypertension could increase the risk of 30-day mortality by 27% (HR 1.00 vs 1.27, P = 0.012), while in patients with SBP ≤ 108 mmHg, this increased risk reached to 37% (HR 1.51 vs 1.88, P < 0.001). In conclusion, low admission SBP was the relatively dominant contributor for predicting 7 and 30-day all-cause mortality, and a concurrent antecedent hypertension increased the corresponding risk of mortality.
Medicine 2015
