不稳定型心绞痛的治疗进展
作者：李晓春 刘东岳
单位：222042 江苏省连云港市，解放军149医院心内科
关键词：
中国煤炭工业医学杂志000707
不稳定型心绞痛(UAP)是一种病情较重、预后介于稳定性心绞痛(SAP)与急性心肌梗死(AMl)或猝死之间的一组冠脉综合征。治疗UAP的目的是缓解心绞痛症，降低心脏事件的发生率，改善疾病预后，提高生活质量。
1溶栓疗法
UAP的溶栓治疗仍有许多值得进一步研究的问题，首先是病例选择，再则是溶栓剂剂量，溶栓方式及抗血小板和抗凝血酶药物的配合使用。Rakov等[1]对65例常规治疗无效的UAP患者进行溶栓治疗，发现其能缓解UAP病症及改善预后。hoh等[2]的研究显示：UAP患者冠脉内溶栓(ICT)的效果与冠脉造影的形态学改变有关。ICT后3种冠状血管造影指标(TIMI血流分级，直径狭窄%和最小管径)在AC型组(急性闭塞和[或]充盈缺损形明显改善(P<0.01，P<0.01和P<0.05).而在TA型组(管径变细)均无改善。TA型组ICT后住院心脏事件(紧急冠脉成形术或旁路手术，非致命性MI或心脏死亡)发生率比AC型组明显增高(76%vs48%，P<0.05)。AC型组，ICT成功的OR为7.9(P<0.01)。近年的研究显示，肌钙蛋白是提示UAP高危患者的最好指标。有研究显示[3]：30%～40%的静息性心绞痛患者肌钙蛋白T和肌钙蛋白I增高。可否将肌钙蛋白增高作为对UAP患者进行改良溶栓治疗的指标，有待进一步探讨。
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2抗凝和抗血小板
随着UAP病理生理学研究的进展，对抗凝和抗血小板治疗更为重视，新型抗凝和抗血小板制剂的不断出现，以期得到更好的临床疗效。
2.1血小板膜Ⅱb/Ⅲa(GPⅡb/Ⅲa)受体抑制剂或拮抗剂包括Eptifibatid，lamiflban，可从根本上抑制血小板的聚集。PURSUIT试验显示[4]，Eptifibatide80mg/kg静推后2mg/(kg·min)静滴≤72h(在对10948例UAP或非Q波心梗的研究中)可减少30d内死亡或非致命性心梗的危险1.5%(14.2%vsl5.7%对照组；P<0.05).且持续6个月.PARAGON试验显示[5]：lamifiban减少心血管事件远超过阿斯匹林+肝素治疗。小剂量lamifiban(0.1mg/min)+肝素更为有利。(全文见PDF)……
参考文献：
, 百拇医药 [1]Rakov Al.,Ian'shin VL.Makarenko AS.et al. Role of thrombolytic therapy in the treatment of patients with unstable angina.Kiln Meal Mosk,1998.76:27～29.
[2]Itoh T.Nonogi H,Miyazaki S.et al. Does coronary artery morphology predict tavorable result of intracoronary thrombolysis in patients with unstable angina pectoris Jpn Circ J. t999.63:13～18.
[3]Hamm CW. Progress in the diagnsis of unstable angina and perspectives for treatment Eur Heart J, 1998.19:45～50.
, http://www.100md.com
[4]Goa KL,Noble s. Eptifibatide:a review of its use in paticnts with acute coronary syndromes and/or undergoing percutaneous coronary intervention. Drugs. 1999.57:439～462.
[5]International.randomized,controlled trial of tamifiban (a platelet glycoprotein Ⅱ b Ⅲ a inhibitor) .heparin. or both in unstable angina, The PARAGON Investigators, platelet Ⅱ b/ Ⅲ a Antagonism for the Reduction of Acute coronary Syndrome events in a Global organization Network circulation. 1998.97:2386～2395.
, 百拇医药
[6]Kauw FH, Cleophas. TJ. Kalmansohn RB. I.ow molecular weight heparins better than unfractionated heparin in unstblc coronary artery disease? unstable angina pectoris/non-Q wave infaetion a partly outpatient clinic condition? Imt J clin pharmacol Thet.1998.36:392～397.
[7]Demers C. essence. Trial results: betaking new ground. Efficacy and safety of subcutaneous enoxaparin in Non-Q wave coronary events. Can J cardiol, 1998,14:15～19.
, 百拇医药
[8]Godoy I,Herrera C,Zapata C,et al. Comparison of low molecular weight heparin and unfractionated heprin in treatment of unstable angina. Rev Med Chil. 1998.126: 259～264.
[9]Turpie AG. Management of acute coronary syndromes with low molecular weight heparin:TIMI Ⅱ A and Ⅲ B. Can J cardiol.1998,14:20～23.
[10]Bittl JA,Strony J,Brinker JA.et al.Treatment with bivalirudin (Hirulog) as compared with heparin during coronary angioplasty for unstable or postinfaretion angina Hirulog Angioplasty study Investigators N Engl J Med. 1995,333: 764～769.
, http://www.100md.com
[11]Bittle JA. Comparative safety profiles of hirutog and heparin in patients undergoing coronary angioplasty. The Hirulog Angioplasty study Investigators. Am Heart J, 1995,130: 658～665.
[12]Byington RP,Jukema JW.Salonen JT,et al. Reduction in cardiovaseular events during pravastatin therapy, pooled analysis of clinical events of the pravastatin Atherosclerosis Intervention program cieulation, 1995,92: 2419～2425.
[13]Ambrose JA, Almeida OD, Sharma SK. et al. Angiographic evolution of intracoronary thrombus and dissection following percutaneous transluminal coronary angioplasty (The Thrombolysis and Angioplasty in unstably Angina [tausa] trial). Am J eardiol, 1997,79: 559～563.
[14]Wilensky RL,Pyles,JM, Fineberg N. Increased thrombin activity correlates with increased isehemic event rate after percutaneous transluminal coronary angioplasty:lack of efficacy of locally delivered urokinase. Am Heart J, 1999.138: 319～325.
收稿日期：2000-01-20, http://www.100md.com
单位：222042 江苏省连云港市，解放军149医院心内科
关键词：
中国煤炭工业医学杂志000707
不稳定型心绞痛(UAP)是一种病情较重、预后介于稳定性心绞痛(SAP)与急性心肌梗死(AMl)或猝死之间的一组冠脉综合征。治疗UAP的目的是缓解心绞痛症，降低心脏事件的发生率，改善疾病预后，提高生活质量。
1溶栓疗法
UAP的溶栓治疗仍有许多值得进一步研究的问题，首先是病例选择，再则是溶栓剂剂量，溶栓方式及抗血小板和抗凝血酶药物的配合使用。Rakov等[1]对65例常规治疗无效的UAP患者进行溶栓治疗，发现其能缓解UAP病症及改善预后。hoh等[2]的研究显示：UAP患者冠脉内溶栓(ICT)的效果与冠脉造影的形态学改变有关。ICT后3种冠状血管造影指标(TIMI血流分级，直径狭窄%和最小管径)在AC型组(急性闭塞和[或]充盈缺损形明显改善(P<0.01，P<0.01和P<0.05).而在TA型组(管径变细)均无改善。TA型组ICT后住院心脏事件(紧急冠脉成形术或旁路手术，非致命性MI或心脏死亡)发生率比AC型组明显增高(76%vs48%，P<0.05)。AC型组，ICT成功的OR为7.9(P<0.01)。近年的研究显示，肌钙蛋白是提示UAP高危患者的最好指标。有研究显示[3]：30%～40%的静息性心绞痛患者肌钙蛋白T和肌钙蛋白I增高。可否将肌钙蛋白增高作为对UAP患者进行改良溶栓治疗的指标，有待进一步探讨。
, http://www.100md.com
2抗凝和抗血小板
随着UAP病理生理学研究的进展，对抗凝和抗血小板治疗更为重视，新型抗凝和抗血小板制剂的不断出现，以期得到更好的临床疗效。
2.1血小板膜Ⅱb/Ⅲa(GPⅡb/Ⅲa)受体抑制剂或拮抗剂包括Eptifibatid，lamiflban，可从根本上抑制血小板的聚集。PURSUIT试验显示[4]，Eptifibatide80mg/kg静推后2mg/(kg·min)静滴≤72h(在对10948例UAP或非Q波心梗的研究中)可减少30d内死亡或非致命性心梗的危险1.5%(14.2%vsl5.7%对照组；P<0.05).且持续6个月.PARAGON试验显示[5]：lamifiban减少心血管事件远超过阿斯匹林+肝素治疗。小剂量lamifiban(0.1mg/min)+肝素更为有利。(全文见PDF)……
参考文献：
, 百拇医药 [1]Rakov Al.,Ian'shin VL.Makarenko AS.et al. Role of thrombolytic therapy in the treatment of patients with unstable angina.Kiln Meal Mosk,1998.76:27～29.
[2]Itoh T.Nonogi H,Miyazaki S.et al. Does coronary artery morphology predict tavorable result of intracoronary thrombolysis in patients with unstable angina pectoris Jpn Circ J. t999.63:13～18.
[3]Hamm CW. Progress in the diagnsis of unstable angina and perspectives for treatment Eur Heart J, 1998.19:45～50.
, http://www.100md.com
[4]Goa KL,Noble s. Eptifibatide:a review of its use in paticnts with acute coronary syndromes and/or undergoing percutaneous coronary intervention. Drugs. 1999.57:439～462.
[5]International.randomized,controlled trial of tamifiban (a platelet glycoprotein Ⅱ b Ⅲ a inhibitor) .heparin. or both in unstable angina, The PARAGON Investigators, platelet Ⅱ b/ Ⅲ a Antagonism for the Reduction of Acute coronary Syndrome events in a Global organization Network circulation. 1998.97:2386～2395.
, 百拇医药
[6]Kauw FH, Cleophas. TJ. Kalmansohn RB. I.ow molecular weight heparins better than unfractionated heparin in unstblc coronary artery disease? unstable angina pectoris/non-Q wave infaetion a partly outpatient clinic condition? Imt J clin pharmacol Thet.1998.36:392～397.
[7]Demers C. essence. Trial results: betaking new ground. Efficacy and safety of subcutaneous enoxaparin in Non-Q wave coronary events. Can J cardiol, 1998,14:15～19.
, 百拇医药
[8]Godoy I,Herrera C,Zapata C,et al. Comparison of low molecular weight heparin and unfractionated heprin in treatment of unstable angina. Rev Med Chil. 1998.126: 259～264.
[9]Turpie AG. Management of acute coronary syndromes with low molecular weight heparin:TIMI Ⅱ A and Ⅲ B. Can J cardiol.1998,14:20～23.
[10]Bittl JA,Strony J,Brinker JA.et al.Treatment with bivalirudin (Hirulog) as compared with heparin during coronary angioplasty for unstable or postinfaretion angina Hirulog Angioplasty study Investigators N Engl J Med. 1995,333: 764～769.
, http://www.100md.com
[11]Bittle JA. Comparative safety profiles of hirutog and heparin in patients undergoing coronary angioplasty. The Hirulog Angioplasty study Investigators. Am Heart J, 1995,130: 658～665.
[12]Byington RP,Jukema JW.Salonen JT,et al. Reduction in cardiovaseular events during pravastatin therapy, pooled analysis of clinical events of the pravastatin Atherosclerosis Intervention program cieulation, 1995,92: 2419～2425.
[13]Ambrose JA, Almeida OD, Sharma SK. et al. Angiographic evolution of intracoronary thrombus and dissection following percutaneous transluminal coronary angioplasty (The Thrombolysis and Angioplasty in unstably Angina [tausa] trial). Am J eardiol, 1997,79: 559～563.
[14]Wilensky RL,Pyles,JM, Fineberg N. Increased thrombin activity correlates with increased isehemic event rate after percutaneous transluminal coronary angioplasty:lack of efficacy of locally delivered urokinase. Am Heart J, 1999.138: 319～325.
收稿日期：2000-01-20, http://www.100md.com