冠心病长期他汀治疗的必要性(修改).pptVIP

士不可以不弘毅，任重而道远 ----论语 · 泰伯 谢 谢! * 各位同道，大家好！作为心内科医生，慢性稳定型冠心病患者是我们临床工作中最常接触的一类患者群。近年不断涌现的他汀循证证据推动了他汀治疗观念的不断更新，其中也包括慢性稳定型冠心病的他汀治疗观念的更新。今天我们通过回顾慢性稳定性冠心病的发病机制，通过梳理他汀治疗的循证证据，来深入探讨慢性稳定型冠心病长期他汀管理的策略。 * * * 门诊管理的慢性稳定型冠心病患者真的病如其名“稳定”吗？如果从单个斑块来看，慢性稳定型冠心病患者似乎是稳定的。但如果从患者整个冠脉血管床来看，动脉粥样硬化的发生、进展、斑块形成、破裂及修复时刻在进行。门诊管理的慢性稳定型冠心病患者，其实“不稳定”，这个斑块是稳定的，那个斑块可能是面临破裂风险的不稳定斑块。 * 研究显示，稳定型心绞痛患者的冠脉斑块常常存在多个不稳定斑块。 在该研究中，作者评价了稳定型心绞痛（SA）患者冠脉中有易损特征的斑块的发生率。该研究共入选67名SA患者（男性n=46，年龄55.9岁）；易损斑块定义为IVUS观察到阳性重构，和动脉造影时出现复杂病变。结果显示，在67个目标病变中，有44.8%为阳性重构，23.9%为复杂斑块；其中31.3%的患者存在多个复杂斑块。 正因为如此，作者在结论中指出：在稳定型心绞痛患者中，约1/3的患者冠脉中存在多个易损斑块。同时，易损斑块的出现具有累积效应，一个易损斑块的出现意味着可能会出现更多的易损斑块。如果对这些稳定型心绞痛患者的冠脉斑块不进行干预，这些不稳定斑块极有可能破裂，发生急性事件。 Background: Development of vulnerable lesion may take place simultaneously at many sites of coronary vasculature, therefore causing multisite instability. The prevalence of the phenomenon in stable angina (SA) patients remains unknown. The aim of our study was to assess, in patients with stable angina, the prevalence of coronary plaques with vulnerable characteristics and to ascertain whether the number of such lesions may accumulate. Methods: Vulnerable plaques are characterised by positive remodelling on intravascular ultrasound (IVUS) and with complex appearance on angiography. We performed preprocedural IVUS in target lesion of 67 patients with SA (46 males, age 55.9). Remodelling index (RI) defined as vessel area at the target lesion divided by that of average reference segments z1.05 was assumed as positive remodelling. Plaques of z30% stenosis on angiography were classified into complex or smooth groups. Results: Positive remodelling was found in 30 (44.8%) and complex plaque in 16 (23.9%) of 67 target lesions. Multiple complex plaques were present in 21 (31.3%) patients. Plaques with positive remodelling more often were complex on angiography (12/30 vs. 4/37, respectively; p=0.005) and were more often associated by complex plaques at other sites (35/30 vs. 23/37; p=0.04) than