THE EXERCISE TEST IN ELECTROCARDIOGRAPHY—Detection of Coronary Artery Disease

Master has proposed a test for detection of latent coronary artery disease by means of electrocardiograms made after standard exercises consisting of walking back and forth over two steps. This test was used in routine examinations of airline employees, with the special purpose of evaluating the test for use on apparently normal persons.Of 526 males tested, 283 were under 40 years of age and 243 were aged 40 years or more. Coronary artery disease was indicated in 16 males in whom there was no other evidence of the disease, five of whom had hypertension. No electrocardiographic evidence of coronary artery disease was obtained for three males in whom the disease was diagnosed or was strongly suspected. The test gave nagative results for 16 males whose electrocardiograms made at rest were compatible with coronary artery disease. The percentage of positive results in men under 40 years of age was 4.3; in men over 40, 0.6.Of a control group of 60 women under the age of 35 years, in none of whom coronary artery disease was detected by other means, six had positive response to the test.It is concluded that Master''s criterion for the most common positive finding, a depression in the ST segment of over 0.5 mm., allows too many false positive findings and that a figure of 1.0 mm. to 1.5. mm. would be a better index. A negative finding apparently does not exclude the possibility of coronary artery disease or of coronary occlusion. The usual 12-lead electrocardiogram made at rest appeared to be of greater value in detection of latent coronary artery disease in apparently normal persons.     

Socioeconomic Status Correlates with the Prevalence of Advanced Coronary Artery Disease in the United States

Background

Increasingly studies have identified socioeconomic factors adversely affecting healthcare outcomes for a multitude of diseases. To date, however, there has not been a study correlating socioeconomic details from nationwide databases on the prevalence of advanced coronary artery disease. We seek to identify whether socioeconomic factors contribute to advanced coronary artery disease prevalence in the United States.

Methods and Findings

State specific prevalence data was queried form the United States Nationwide Inpatient Sample for 2009. Patients undergoing percutaneous coronary angioplasty and coronary artery bypass graft were identified as principal procedures. Non-cardiac related procedures, lung lobectomy and hip replacement (partial and total) were identified and used as control groups. Information regarding prevalence was then merged with data from the Behavioral Risk Factor Surveillance System, the largest, on-going telephone health survey system tracking health conditions and risk behaviors in the United States. Pearson''s correlation coefficient was calculated for individual socioeconomic variables including employment status, level of education, and household income. Household income and education level were inversely correlated with the prevalence of percutaneous coronary angioplasty (−0.717; −0.787) and coronary artery bypass graft surgery (−0.541; −0.618). This phenomenon was not seen in the non-cardiac procedure control groups. In multiple linear regression analysis, socioeconomic factors were significant predictors of coronary artery bypass graft and percutaneous transluminal coronary angioplasty (p<0.001 and p = 0.005, respectively).

Conclusions

Socioeconomic status is related to the prevalence of advanced coronary artery disease as measured by the prevalence of percutaneous coronary angioplasty and coronary artery bypass graft surgery.     

川崎病患儿肠道菌群构成及分布与其冠状动脉病变的相关性分析

摘要 目的：分析川崎病患儿肠道菌群构成及分布与其冠状动脉病变的相关性。方法：选择我院自2020年1月至2023年2月接诊的86例川崎病患儿作为研究对象,根据是否出现冠状动脉病变,分为冠状动脉病变组（35例）和非冠状动脉病变组（51例）。检测所有患儿的肠道菌群多样性[肠道菌群丰度（Ace指数）、肠道菌群多样性（Shannon指数）]、肠道菌群构成比例[门水平（变形菌门、厚壁菌门、拟杆菌门）、属水平（乳杆菌属、拟杆菌属、韦荣球菌属）],使用多因素Logistic回归分析肠道菌群构成及分布与冠状动脉病变的关系。结果：冠状动脉病变组Ace指数大于非冠状动脉病变组（P＜0.05）;冠状动脉病变组与非冠状动脉病变组的Shannon指数比较无差异（P＞0.05）;冠状动脉病变组肠道厚壁菌门占比低于非冠状动脉病变组,拟杆菌门占比高于非冠状动脉病变组（P＜0.05）;冠状动脉病变组与非冠状动脉病变组的肠道变形菌门占比比较无差异（P＞0.05）;冠状动脉病变组肠道乳杆菌属占比、韦荣球菌属占比均低于非冠状动脉病变组（P＜0.05）;冠状动脉病变组与非冠状动脉病变组的肠道拟杆菌属占比比较无差异（P＞0.05）;经多因素Logistic回归分析,肠道Ace指数、厚壁菌门、拟杆菌门、乳杆菌属、韦荣球菌属均是川崎病患儿发生冠状动脉病变的独立影响因素（P＜0.05）。结论：川崎病患儿肠道菌群构成及分布与其冠状动脉病变密切相关,为改善肠道菌群失调、增加患儿的临床获益提供依据,应引起临床重视。     

载脂蛋白亚型与糖尿病合并冠心病的相关性研究

目的:探讨载脂蛋白亚型与糖尿病合并冠脉病变严重程度相关性,为预防及治疗糖尿病伴发的动脉粥样硬化性疾病提供新的依据。方法:选取440名心内科患者,根据冠脉造影有无冠脉狭窄及是否合并糖尿病分为四组:冠脉内膜光滑组94人(A组);单纯冠脉狭窄组108人(B组);糖尿病合并冠脉狭窄组共184人(C组);糖尿病冠脉无狭窄组44人(D组),记录患者空腹血糖、餐后血糖、传统血脂脂谱、载脂蛋白A(apoA)、载脂蛋白B(apoB)及两者的比值(apoB/apoA);采用Gensini评分比较传统血脂、apoA、apoB及与Gensini积分值的相关性。结果:与正常对照组比较,糖尿病冠脉无狭窄组apoB、apoB/apoA、LDL和TG升高,apoA和HDL降低,B组和C组apoA与Gensini积分值存在负相关(P=0.01570.05);apoB;apoB/apoA与Gensini积分值存在正相关(P0.0001);两组中,apoB与Gensini积分值相关系数最大(r=0.85795,0.85941),且apoB与Gensini积分值的相关性都强于LDL与积分值的相关性。结论:在糖尿病患者预测心血管风险上,apoB,apoA,apoB/apoA的测定可能优于传统的血脂指标。     

Cocaine: its use in otolaryngology

A review of 120 patients who had a discharge diagnosis of intermediate coronary syndrome showed 12 patients with documented transient ST elevation during spontaneous rest pain consistent with Prinzmetal''s angina. Coronary arteriography showed severe proximal occlusive coronary atherosclerosis in nine of the patients, and normal or minimal disease in the other three patients. In two of these three, there was documented coronary arterial spasm with reproduction of symptoms during arteriography. Although a shorter history of chest pain, presence of an old myocardial infarction and a positive finding on electrocardiogram treadmill test tended to predict the patients with severe occlusive coronary artery disease, these methods were inadequate to select candidates for arteriography. All patients responded well to nitroglycerine while in the hospital. Five of the nine patients with coronary artery disease had coronary bypass operations, with two excellent, two fair and one poor result. One of the three patients with normal findings on coronary arteriograms died with refractory ventricular arrhythmia six months after study. The other two have had good-to-moderate relief of symptoms on long-acting vasodilators and propranolol. Current concepts of the syndrome of Prinzmetal''s angina and ST elevation are reviewed. It appears that this syndrome has a wide spectrum of clinical presentations and coronary arteriographic anatomies.     

Preoperative prediction of significant coronary artery disease in patients with valvular heart disease.

A prognostic index for predicting significant coronary artery disease was established using multiple logistic regression analysis of clinical data from 643 patients with valvular heart disease who had undergone routine coronary arteriography before valve replacement. The index or equation obtained incorporated the presence of angina, a family history of ischaemic heart disease, age, cigarette smoking habits, mitral valve disease, sex, and electrocardiographic evidence of myocardial infarction. The equation was validated using prospective data from 387 patients with valvular disease and shown to enable almost a third of routine coronary arteriograms to be omitted while maintaining 95% sensitivity for patients with coronary artery disease. Similar analysis of the more detailed prospective data produced a second discriminant function incorporating diastolic blood pressure, total cigarettes smoked in life, the severity of angina, family history of ischaemic heart disease, age, current cigarette smoking habits, and the ratio of total to high density lipoprotein cholesterol. This method improved the discrimination between patients with and without coronary artery disease, allowing omission of 30% of routine coronary arteriograms with 100% sensitivity for patients with coronary disease and omission of 41% with a 96% sensitivity level.     

The Treatment of Multiple Coronary Occlusions by Internal Mammary Artery Implantation and Omental Graft: Report on Two Human Cases

The importance of triple coronary artery disease was evident in 125 patients undergoing internal mammary artery implantation, when some patients died from right coronary artery occlusion. This occurred even when the internal mammary artery was patent and revascularizing the left ventricle.In 1961 the free omental graft operation was developed to revascularize both right and left ventricles. In animals this operation has proved most effective in preventing death after application of Ameroid constrictors to all three coronary arteries. Arteriolar or larger-sized vessels rapidly formed between the aorta and omentum and the pericardium and omentum and the heart and omentum.Two patients with triple coronary artery disease underwent internal mammary artery implantation and free omental graft early in December 1962. Postoperative convalescence was uneventful. They have returned home and appear to be improved. Wrapping the entire heart with the free omental graft has produced little reaction, suggesting that, as in the animal, the grafts are surviving.     

UCP-866G/A和ADIPQ+45T/G基因多态性的交互作用与2型糖尿病 合并冠心病发病风险的关系

目的：探讨UCP2-866G/A 和ADIPOQ+45T/G 基因多态性的交互作用与2型糖尿病合并冠心病发病风险的关系。方法：随机 选取2014 年10 月至2015 年5 月在佳木斯大学附属第一医院就诊的130 例单纯2 型糖尿病患者和128 例2 型糖尿病合并冠心 病患者进行病例对照研究。分别采用聚合酶链反应- 限制性片段长度多态性（PCR-RFLP）方法和聚合酶链反应- 高分辨率溶解曲 线（PCR-HRM）方法检测UCP2-866G/A 和ADIPOQ+45T/G 的基因多态性,并用非条件Logistic 回归分析两基因间的交互作用。 结果：在两组间分别进行UCP2-866G/A 和ADIPOQ+45T/G 基因多态性的单独关联分析,两变异位点的基因型和等位基因的频率 在两组间的分布及遗传模型关联分析均无统计学差异（P>0.05）。两变异位点联合分析发现,UCP2-866 G/A 的GG、GA 分别和 ADIPOQ+45T/G 的TG 在2 型糖尿病合并冠心病中存在正向交互作用（P=0.000,ORI=ORAB/(ORA× ORB)=30.533/(0.549× 0.116) >1;P=0.007,ORI= ORAB/(ORA× ORB)=13.914/(0.525× 0.116)>1。结论：该研究显示： UCP-866G/A 和ADIPOQ+ 45T/G 单一基因的 多态性与2 型糖尿病合并冠心病患病风险无关,而两者之间的交互作用可能增加2 型糖尿病合并冠心病的发病风险。     

血清同型半胱氨酸、高敏C反应蛋白及肱踝脉搏波传导速度与冠心病患者冠脉病变程度的相关性研究

目的:探讨血清同型半胱氨酸(Hcy)、高敏C反应蛋白(hs-CRP)及肱踝脉搏波传导速度(baPWV)与冠心病患者冠脉病变程度的相关性。方法:选取2015年6月-2017年10月期间承德医学院附属医院收治的疑似冠心病的患者324例为研究对象,根据冠状动脉造影结果分为冠心病组213例与非冠心病组111例,根据不同冠脉病变程度将冠心病组分为单支病变组87例,双支病变组74例,多支病变组52例,检测并对比所有患者血清Hcy、hs-CRP水平及baPWV值,分析Hcy、hs-CRP水平及baPWV值与冠心病患者冠脉病变程度相关性。结果:冠心病组患者血清Hcy、hs-CRP水平及baPWV值较非冠心病组升高(P0.05)。冠心病组不同冠脉病变程度患者血清Hcy、hs-CRP水平及baPWV值整体比较差异有统计学意义(P0.05),多支病变组与双支病变组患者血清Hcy、hs-CRP水平及baPWV值高于单支病变组,且多支病变组高于双支病变组,差异有统计学意义(P0.05)。经Pearson相关性分析显示,Hcy、hs-CRP及baPWV均与冠心病患者冠脉病变程度呈正相关(P0.05)。结论:冠心病患者血清Hcy、hs-CRP水平及baPWV值高于非冠心病者,且血清Hcy、hs-CRP水平及baPWV值随着冠心病患者冠脉病变程度的加重而升高,与冠脉病变程度呈正相关。     

冠状动脉造影大致正常的胸痛患者临床分析

摘要 目的：探讨有胸痛症状的冠状动脉造影大致正常的患者的临床特点及病因。方法：回顾性分析2019年1月至2021年5月我院收治的有胸痛症状疑诊为冠状动脉粥样硬化性心脏病并行冠状动脉造影的1283例患者,纳入其中冠状动脉造影提示冠状动脉大致正常的患者,比较冠状动脉造影结果大致正常者与冠状动脉造影存在异常的患者的人口学资料、危险因素等,并统计冠状动脉造影结果大致正常者的确定诊断并进行分析。结果：最终纳入91例疑诊为冠心病的冠状动脉造影大致正常的患者。与冠状动脉造影存在异常的1192例患者的相比,冠脉造影大致正常组中无危险因素者占20.1%,单一高危因素者占50.5%,显著高于冠脉造影异常组,而多重高危因素者占28.6%,显著低于冠脉造影异常组（P＜0.05）。91例疑诊为冠心病的冠状动脉造影大致正常的患者中心脏神经官能症及心律失常分别占45例（49.5％）及12例(13.2％)。结论：临床上很多疑诊为冠心病的胸痛患者的冠状动脉造影大致正常,这部分患者与冠状动脉异常的患者相比冠心病的危险因素更少,胸痛由其他原因引起,所以对这部分患者应强调应用无创的检查手段。     

冠状动脉CTA联合血清HCY、Cys-C、ApoB/ApoA1比值对2型糖尿病患者合并冠状动脉病变的诊断价值

摘要 目的：探究冠状动脉CT血管造影（CTA）联合血清同型半胱氨酸（HCY）、胱抑素C（Cys-C）、载脂蛋白B/载脂蛋白A1（ApoB/ApoA1）比值对2型糖尿病（T2DM）患者合并冠状动脉病变的诊断价值。方法：回顾性选取2018年8月到2021年8月间我院收治的358例T2DM患者,均行常规生化指标、CTA检查、冠状动脉造影（CAG）检查,根据CAG检查结果为金标准将T2DM患者分为未合并冠脉病变组（190例）和合并冠脉病变组（168例）,比较两组血清HCY、Cys-C、ApoB/ApoA1比值,分析CTA与CAG诊断冠脉狭窄结果的一致性,应用受试者工作特征（ROC）曲线评估冠状动脉CTA联合血清HCY、Cys-C、ApoB/ApoA1比值对T2DM合并冠状动脉病变的诊断价值。结果：与未合并冠脉病变组比较,合并冠脉病变组血清HCY、Cys-C、ApoB、ApoB/ApoA1比值水平明显更高（P＜0.05）,ApoA1明显更低（P＜0.05）。以CAG为金标准,CTA诊断冠脉狭窄程度与CAG一致性较高（Kappa值0.748）。ROC曲线评估冠状动脉CTA诊断T2DM合并冠脉病变的AUC、灵敏度、特异度、准确度依次为0.802、74.40%、83.71%、79.11%。三项血清指标联合AUC、准确度显著优于单一指标（P＜0.05）。冠状动脉CTA联合血清HCY、Cys-C、ApoB/ApoA1比值诊断T2DM合并冠脉病变的价值显著优于各项指标单一诊断或三项血清指标联合诊断（P＜0.05）。结论：冠状动脉CTA联合血清HCY、Cys-C、ApoB/ApoA1比值诊断T2DM患者合并冠状动脉病变的价值较高,相较各项指标单一应用而言更具优势。     

智能期相联合SSF技术改善冠状动脉CTA图像运动伪影

目的:评价智能期相选择(Smart phase)和自动追踪冻结(Snap-Shot-Freeze, SSF)技术联合应用在前门控冠状动脉CT血管成像(Coronary CT angiography, CCTA)改善图像运动伪影中的价值。方法:94例疑似心血管疾病的患者行CCTA检查。所有患者图像均采用smart phase、SSF及smart phase+SSF两种技术联合进行后处理。将原始图像(A组)、smart phase图像(B组)、SSF图像(C组)和smart phase+SSF图像(D组)导入GE AW4.6工作站。对四组患者冠状动脉三大分支(右冠状动脉、左前降支及左旋支)图像质量进行主观评价(5分法)和测量每组图像主动脉根部及前胸壁肌肉CT值和标准差,并计算图像的噪声(Noise,N)、信噪比(Signal-to-noise ratio,SNR)和对比噪声比(Contrast-to-noise ratio,CNR)和比较。结果:经smart phase处理后,A组冠状动脉三大分支图像评分均得到了明显提高(P<0.05)。经SSF矫正的A组和B组冠状动脉三大分支图像质量评分均得到明显提高(P<0.05)。Smart Phase联合SSF技术得到的图像评分在所有组中评分最高,与其他组均存在显著差异(P<0.05)。结论:Smart phase联合SSF技术可明显改善前门控CCTA图像运动伪影,值得临床推广应用。     

超声在完全与不完全川崎病患儿冠状动脉病变评估中的应用价值

摘要 目的：探讨超声在完全与不完全川崎病（Kawasaki Disease,KD）患儿冠状动脉病变（Coronary artery lesions,CAL）评估中的应用价值。方法：2019年6月到2021年5月选择在西安医学院第二附属医院住院诊治的83例川崎病患儿,其中完全川崎病患儿43例（完全组）,不完全川崎病患儿40例（不完全组）。所有患儿都给予超声检查,评估两组的临床表现、血液学指标、冠状动脉病变情况以及超声的诊断价值。结果：完全组的球结膜充血、皮疹、口唇破裂、手足硬肿、颈部淋巴结肿大等发生率高于不完全组（P>0.05）。两组的白细胞计数、血红蛋白对比差异有统计学意义（P<0.05）,C反应蛋白、血小板、白蛋白对比差异无统计学意义（P>0.05）。完全组的冠状动脉病变发生率为60.5 %,高于不完全组的27.5 %（P<0.05）。在83例患儿中,超声诊断为完全川崎病42例,不完全川崎病41例,超声对完全与不完全川崎病患儿的鉴别诊断敏感性与特异性为97.7 %（42/43）和100.0 %（40/40）。结论：完全与不完全川崎病患儿在临床表现、冠状动脉病变与实验室检测指标上都存在一定的差异,超声能鉴别诊断完全与不完全川崎病患儿的敏感性与特异性都比较好。     

Myocardial perfusion imaging with thallium-201: correlation with coronary arteriography and electrocardiography

Myocardial perfusion imaging with thallium-201 and electrocardiography with the subject at rest and undergoing submaximal treadmill exercise were performed in 19 men and 3 women. Selective coronary arteriography and left ventriculography showed that 7 had normal coronary arteries and 15 had coronary artery disease.The 11 persons with electrocardiographic evidence of an old myocardial infarct (q waves) had a perfusion defect at rest in the area of the infarct and a segmental abnormality of wall motion apparent on the left ventriculogram corresponding to the perfusion defect.Myocardial perfusion imaging and electrocardiography were equally sensitive in detecting coronary artery disease in exercising individuals: perfusion defects were noted in 7 of the 15 persons with coronary artery disease, and diagnostic ST-segment depression was present in 8 of the 15. Combination of the results of the two tests with exercise permitted the identification of 11 of the 15 persons and improved the sensitivity. Combination of the results of rest and exercise imaging and electrocardiography permitted the identification of 94% of the patients with coronary artery disease.Myocardial perfusion imaging with ²⁰¹TI in the subject at rest is a sensitive indicator of previous myocardial infarction. Imaging after the subject has exercised is a useful adjunct to conventional exercise electrocardiography, especially in those whose exercise electrocardiogram is non-interpretable.     

腹型肥胖对急性冠脉综合征患者冠状动脉病变严重程度的影响

目的:研究腹型肥胖对急性冠脉综合征(ACS)患者冠状动脉病变严重程度的影响。方法:选择2012年4月至2013年4月在我院接受治疗的ACS患者120例,根据腰围身高比(RWH)将患者分为无腹型肥胖者60例(对照组,RWH0.5)及腹型肥胖者60例(观察组,RWH0.5)。测量所有患者的基本参数,计算RWH,利用冠脉造影判断冠脉病变的支数和程度,根据Gensini评分法对冠脉造影结果进行评价,分析冠脉病变范围、Gensini积分和RWH的相关性。结果:观察组的收缩压(SBP)、空腹血糖(FPG)、总胆固醇(TC)、甘油三酯(TG)、低密度脂蛋白(LDL-C)及Gensini积分水平均显著高于对照组,差异均有统计学意义(均P0.05)。观察组的高密度脂蛋白(HDL-C)水平显著低于对照组,差异有统计学意义(P0.05)。双支病变的RWH及Gensini积分水平显著高于单支病变,三支病变的RWH及Gensini积分水平显著高于单支病变及双支病变,差异均有统计学意义(均P0.05)。根据Spearman法分析相关性可知,冠脉病变范围、Gensini积分和RWH均呈正相关(r=0.635,0.739;P=0.000,0.000)。结论:ACS患者RWH水平增高与冠脉病变的严重程度关系密切,有效控制腹型肥胖对于降低心血管类疾病发病率以及降低冠脉病变的程度具有重要意义。     

Duke Treadmill Score in prioritizing patients for coronary angiography: retrospective study of a Croatian regional hospital

Aim of the study was to determine the potential of Duke Treadmill Score (DTS) in prioritizing patients for coronary angiography in a transitional country clinical setting. We analyzed 114patients with suspected stable coronary artery disease who underwent exercise treadmill testing, and coronary angiography in Slavonski Brod General Hospital. DTS was calculated from treadmill test as: exercise time--(5 x ST deviation in mm)--(4 x exercise angina). Regarding the score, patients were grouped into three groups of risk for coronary artery disease: low risk, medium risk, and high risk patients. All patients underwent coronary angiography, and were grouped in accordance to the severity of the coronary artery disease into three groups: insignificant, significant, or severe coronary artery disease. All patients scored as high risk DTS had significant or severe coronary artery disease. Medium and low risk DTS patients had insignificant coronary artery disease in 50%, and 90% of cases, respectively. Medium risk patients with significant or severe coronary artery disease were significantly older, and had more frequent history of typical chest pain with higher number of episodes per week (P<0.05), whereas there were no differences regarding gender or presence of risk factors. There were no significant differences among medium risk patients regarding the severity of coronary artery disease in exercise time or ST deviation. However, the presence of limiting exercise angina in medium risk patients was significantly more related with significant and severe coronary artery disease (P<0.05). High risk DTS result showed great potential in stratifying patients for immediate coronary angiography. This scoring system may be used in prioritizing patients for coronary angiography in a transitional clinical setting.     

Human antimicrobial peptide LL-37 is present in atherosclerotic plaques and induces death of vascular smooth muscle cells: a laboratory study

Background

A diverse range of factors influence clinicians' decisions regarding the allocation of patients to different treatments for coronary artery disease in routine cardiology clinics. These include demographic measures, risk factors, co-morbidities, measures of objective cardiac disease, symptom reports and functional limitations. This study examined which of these factors differentiated patients receiving angioplasty from medication; bypass surgery from medication; and bypass surgery from angioplasty.

Methods

Univariate and multivariate logistic regression analyses were conducted on patient data from 214 coronary artery disease patients who at the time of recruitment had been received a clinical assessment and were reviewed by their cardiologist in order to determine the form of treatment they were to undergo: 70 would receive/continue medication, 71 were to undergo angioplasty and 73 were to undergo bypass surgery.

Results

Analyses differentiating patients receiving angioplasty from medication produced 9 significant univariate predictors, of which 5 were also multivariately significant (left anterior descending artery disease, previous coronary interventions, age, hypertension and frequency of angina). The analyses differentiating patients receiving surgery from angioplasty produced 12 significant univariate predictors, of which 4 were multivariately significant (limitations in mobility range, circumflex artery disease, previous coronary interventions and educational level). The analyses differentiating patients receiving surgery from medication produced 14 significant univariate predictors, of which 4 were multivariately significant (left anterior descending artery disease, previous cerebral events, limitations in mobility range and circumflex artery disease).

Conclusion

Variables emphasised in clinical guidelines are clearly involved in coronary artery disease treatment decisions. However, variables beyond these may also be important factors when therapy decisions are undertaken thus their roles require further investigation.     

冠状动脉CTA结合动态心电图夜间ST段趋势图诊断冠状动脉硬化性心脏病的价值研究

摘要 目的：探讨冠状动脉CTA结合动态心电图夜间ST段趋势图对冠状动脉硬化性心脏病（冠心病）的诊断价值。方法：回顾性分析2022年1月-2023年2月在我院疑似冠心病的患者104例,所有患者均行冠状动脉造影、冠状动脉CTA、动态心电图及临床相关实验室检查。以冠状动脉造影结果作为诊断冠心病的金标准,分析比较冠状动脉CTA、动态心电图夜间ST段趋势图及两者联合诊断冠心病的诊断效能和一致性。结果：104例疑似冠心病的患者确诊93例（89.42%）。冠状动脉CTA诊断冠心病的敏感性为90.32%,特异性为72.73%,阳性预测值为96.55%,阴性预测值为47.06%,准确率为88.46%,与冠状动脉造影的Kappa值为0.813,一致性好。动态心电图夜间ST段趋势图诊断冠心病的敏感性为84.95%,特异性为63.64%,阳性预测值为95.18%,阴性预测值为33.33%,准确率为82.69%,与冠状动脉造影的Kappa值为0.724,一致性较好。有夜间ST段动态改变的冠心病检出率（84.95%,79/93）明显高于无夜间ST段动态改变的冠心病检出率（15.05%,14/93）,差异有统计学意义（P＜0.001）。冠状动脉CTA结合动态心电图夜间ST段趋势图诊断冠心病的敏感性为96.77%,特异性为90.91%,阳性预测值为98.90%,阴性预测值为76.92%,准确率为96.15%,与冠状动脉造影的Kappa值为0.923,一致性好。结论：冠状动脉CTA结合动态心电图夜间ST段趋势图诊断冠心病的临床价值优于冠状动脉CTA或动态心电图夜间ST段趋势图单独检查。     

Selection of Patients for Coronary Artery Bypass Operations

Bypass operations have proved to be an effective treatment for advanced coronary artery disease. Randomized clinical trials have now shown that compared with medical treatment, bypass operations enhance survival in patients who have three-vessel disease or left main coronary stenosis. The goals of both medical and surgical treatment should be to improve a patient''s quality of life, extend survival and reduce medical care costs. Preliminary data suggest that bypass operations may be less costly than medical treatment in patients with severe angina that requires repeated or prolonged stays in hospital.     

Early interventions in the management of acute uncomplicated myocardial infarction.

The demonstration that the vast majority of acute transmural myocardial infarctions are caused by an occlusive thrombus in the coronary artery, together with the concept that myocardium can be salvaged for a period of time after the onset of such occlusion, has heralded a new era of management of this disorder. This involves an aggressive interventional approach aimed at restoring coronary artery patency early while decreasing myocardial oxygen demands. Abundant data show that coronary flow can be reestablished using either intravenous chemical thrombolytic agents (tissue-type plasminogen activator and streptokinase), percutaneous transluminal coronary angioplasty, or coronary artery bypass grafting. Conjunctive aspirin or heparin therapy (or both) is effective in maintaining vessel patency once perfusion is restored. Myocardial oxygen demand can be reduced, where feasible, by pharmacotherapy and control of the patient''s associated pain and anxiety. The beta-adrenergic blockers and nitrates are particularly suitable in this regard, and angiotensin-converting enzyme inhibitors favorably affect infarct expansion and ventricular remodeling. With such an approach, infarct size can be reduced, leading to improved left ventricular function--the prime determinant of morbidity and mortality in patients with acute infarction. The in-hospital mortality has fallen from about 30% three decades ago to less than 8% in many coronary care units.