【作者】 贾辛未；

【导师】 傅向华；

【作者基本信息】 河北医科大学 ， 内科学， 2010， 博士

【摘要】 经皮冠状动脉介入治疗是冠心病治疗的重大进展,每年有大量的冠心病患者从中获益。和世界各国一样,我国的冠心病介入治疗病例逐年增多,据统计,我国2002年的经皮冠状动脉介入治疗例数为3万例,2005年为7万5千例,到2009年,我国的冠心病介入治疗例数已经突破24万例,目前还在快速上升期。冠状动脉介入治疗后缓复流(无复流)现象和急性对比剂肾损伤是影响经皮冠状动脉介入治疗近远期效果的主要因素。虽然目前其发病机制尚未明确,但是,微循环功能障碍、炎症以及氧化应激反应等被认为是发生无复流和对比剂肾病的共同病理基础。他汀类药物和山莨菪碱均具有改善微循环、抗炎、抗氧化应激、改善血管内皮功能等作用。已有研究表明,常规剂量的他汀类药物可显著改善心肌灌注,降低对比剂肾病的发生,我们以前的研究也已经证明了山莨菪碱对冠脉无复流的防治作用。目前,关于强化剂量的他汀类药物能否进一步改善冠脉灌注、山莨菪碱对急性对比剂肾损伤的防治作用以及二者联合使用的效果等尚无研究。本研究在既往工作的基础上,进一步探索强化辛伐他汀治疗以及辛伐他汀联合山莨菪碱对冠脉介入治疗中心肌灌注的影响以及对急性肾损伤的保护作用并探讨起可能机制。本研究分为以下五部分:第一部分强化降脂治疗对急性冠脉综合征患者经皮冠状动脉介入治疗中心肌灌注的保护作用目的:探讨强化他汀治疗对急性冠脉综合征患者经皮冠状动脉介入治疗过程中心肌灌注的保护作用,并探讨其可能机制。方法:行择期PCI的急性冠脉综合征患者228例,随机分为标准他汀组(n=115)和强化他汀组(n=113)。于PCI术前7天,纪录PCI后的TIMI血流、纠正的TIMI计桢数(CTFC)以及TIMI心肌灌注分级(TMPG)等。于PCI前后测量肌酸磷酸激酶(CPK)、CPK同工酶MB(CPK-MB)、肌钙蛋白(ITnI)、高敏C反应蛋白(hs-CRP)、P选择素和细胞间粘附分子(ICAM)水平。结果:强化他汀组支架植入后TIMI血流0-1级显著少于标准他汀组,3级显著多于标准他汀组(P<0.05)。强化他汀组无复流发生率显著低于标准他汀组(P<0.001)。CTFC在强化他汀组显著低于标准他汀组(P<0.001)。强化他汀组的TMPG也显著优于标准他汀组(P=0.001)。PCI术后24小时,CPK-MB和TnI在强化他汀组显著低于标准他汀组(CPK-MB:18.74±8.41对21.78±10.64 P=0.018;TnI:0.99±1.07对1.47±1.54 P=0.006)。标准治疗组CK-MB升高者占27.8% (32/115),强化他汀组则只有15.9%(18/113)(P=0.030)。标准他汀组TnI升高者显著多于强化他汀组[36.5% (42/115)对19.5%(22/113),P=0.04],其中,标准他汀组的心肌坏死发生率为13%(15/115),而在强化他汀组仅为4.4%(5/113)(P=0.021)。PCI术后24小时,强化他汀组的hs-CRP、P选择素及ICAM-1水平均显著低于标准他汀组(P<0.001)。结论:PCI术前使用强化他汀治疗比标准他汀治疗能更有效改善急性冠脉综合征患者的心肌灌注、减轻心肌损伤。同时伴有hs-CRP、P选择素和ICAM-1水平的显著降低。第二部分辛伐他汀联合山莨菪碱治疗对约克猪冠状动脉介入治疗后心肌灌注的保护作用目的:缓复流/无复流不但增加冠脉介入治疗过程中的手术风险,还严重影响术后患者的长期预后。研究无复流的发生机制、寻找有效的预防和治疗的手段,是目前冠心病介入治疗领域的研究热点之一。山莨菪碱具有改善微循环,抗氧化、保护心肌细胞的良好作用。他汀类药物具有改善血管内皮细胞功能、抗凝、抗血小板、抗氧化、抗炎、改善血流动力学效应等多重效应。目前尚未发现有二者联合使用改善冠脉介入治疗中心肌灌注效果的研究报告。为此,我们在既往实验性微型猪冠脉介入治疗后无复流模型的基础上,进一步评价了强化的辛伐他汀联合山莨菪碱对冠脉介入治疗过程中心肌微循环灌注的保护作用。并通过测定炎症因子高敏C反应蛋白(hs-CRP)、超氧化物歧化酶(SOD)、丙二醛(MDA)和一氧化氮(NO)的水平,探讨其可能机制。方法:健康约克猪16头,体重30-40kg,被随机分为山莨菪碱组和辛伐他汀+山莨菪碱治疗组。联合治疗组预先饲喂辛伐他汀1mg/kg,山莨菪碱组则给予安慰剂,7天后开始实验。利用微导管超选择LAD,将多普勒导丝置于LAD中段,纪录LAD中段血流速度的变化,并监测LCA开口处压力。于LAD中段注射PMBS混悬液,5ml/次,每十分钟一次,共四次,每次注射PMBS前2分钟LAD内注射山莨菪碱5000ug,PMBS注射后5分钟行冠脉造影,纪录LAD的TIMI血流、TMPG和CTFC,评价心肌灌注情况。于试验结束时处死动物,取坏死和正常交界处缺血心肌分别测定超氧化物歧化酶(SOD)、丙二醛(MDA)、一氧化氮(NO),并行病理学检查。于实验前、实验后采静脉血测定CKMB、TnI以及血清C反应蛋白(CRP)水平。利用染色法计算梗死心肌占左室重量之百分比。结果:联合治疗组的TIMI血流显著优于山莨菪碱组,TFCs显著低于山莨菪碱组(均P<0.05)。早期LAD内注射PMBS后两组心率均较基础值显著上升(P<0.05),但两组之间无显著差别(P=0.47,P=0.85)。以后山莨菪碱组的心率进一步显著升高(P=0.005),而联合治疗组则仍保持原水平。早期LAD内给与PMBS注射后两组的冠脉灌注压均显著上升(P<0.01)。以后山莨菪碱组的冠脉灌注压开始降低(P<0.05),联合治疗组则仍维持较高的冠脉灌注压力(P=0.042)。晚期联合治疗组冠脉灌注压力仍维持无显著降低,而山莨菪碱组则显著降低。早期冠脉注射PMBS后,两组的bAPV均有增高,但山莨菪碱组更明显;hAPV在山莨菪碱组降低,而在联合治疗组则维持高水平(P=0.000)。第三次PMBS注射后hAPV两组均较基础值显著降低(P<0.01),但联合治疗组仍显著高于山莨菪碱组(P=0.000)。至第四次PMBS注射后,两组的hAPV进一步降低,两组比较无显著差别。在第一、二次冠脉注射PMBS后,联合治疗组CFR无显著降低,而山莨菪碱组的CFR则持续显著降低(P=0.006)。第三、四次注射PMBS后两组的CFR均连续显著降低(P<0.05),但联合治疗组始终优于山莨菪碱组(P=0.025)。第一、二次注射PMBS后山莨菪碱组的h-MR均显著增高(P=0.032),而联合治疗组则无显著增高。在第三次冠脉LAD内注射PMBS后,两组的h-MR均显著增高(P=0.030),两组间比较联合治疗组的h-MR仍显著低于山莨菪碱组(P=0.010)。在第四次冠脉LAD内注射PMBS后,两组的h-MR进一步显著增高(P=0.024),两组间比较h-MR已无显著差别。试验前山莨菪碱组血清总胆固醇水平为4.44±0.47mmol/L,联合治疗组的血清胆固醇水平为3.93±0.53mmol/L(P=0.063)。实验后60分钟,肌酸激酶同工酶MB、TnI、hs-CRP、MDA均显著增高,但山莨菪碱组显著高于联合治疗组;NO水平均显著增高(P=0.000),但联合治疗组的NO水平显著高于山莨菪碱组(P=0.006)。SOD水平显著降低(P=0.000),但联合治疗组的SOD水平高于山莨菪碱组(P=0.000)。山莨菪碱组心肌坏死平均坏质量占左心室总质量的18.5±3.1%,联合治疗组为11.3±2.9%。(P<0.05)。光镜下改变联合治疗组的心肌坏死显著轻于山莨菪碱组。结论:联合应用山莨菪碱和辛伐他汀治疗可显著改善冠脉介入治疗中的冠脉血流,增加心肌灌注,保护心肌。改善冠脉血流动力学、抗炎、抗氧化可能是其潜在机制。第三部分强化他汀治疗对经皮冠状动脉介入治疗后肾损伤的保护作用目的:研究强化他汀治疗对PCI后肾功能的保护作用和预防对比剂肾病的效果,探讨其可能机制。方法:228例接受择期PCI的急性冠脉综合征,随机分为标准他汀治疗组(SSG n=115)和强化他汀治疗组(ISG n=113)。于PCI术前7天开始,SSG组患者口服20mg/天辛伐他汀,ISG组患者则口服80mg/天辛伐他汀。于PCI术前、术后24、48小时分别测定血清肌酐水平,按Cochcroft-Gault公式计算肌酐清除率。于PCI术前、术后24小时分别测定血清高敏C反应蛋白(hs-CRP)、P选择素和细胞间粘附分子1(ICAM-1)水平。结果:PCI后血肌酐水平显著升高,并于术后24小时达高峰,然后逐渐下降。PCI术后48小时,ISG组血肌酐水平显著回降(和术后24小时比P<0.001)并恢复到术前水平(和术前比P=0.94),而SSG组PCI术后48小时血肌酐水平未显著回降(和术后24小时比,P=0.11)。PCI术后24、48小时,ISG组的血肌酐水平均显著低于SSG组(术后24小时,P<0.05;术后48小时P<0.001)。PCI术后,两组肌酐清除率均显著降低,最低值出现在术后24小时,然后逐渐回升。术后48小时,SSG组肌酐清除率显著回升(和术后24小时相比,P=0.03),但仍低于术前水平(和术前相比,P<0.001),而ISG组术后48小时显著回升(和术后24小时相比,P<0.001)并恢复到术前水平(和术前相比,P=0.87),在术后24、48小时,ISG组肌酐清除率的回升程度均显著高于SSG组(均P<0.001)。虽然PCI术后血清hs-CRP、P选择素和ICAM-1水平均显著升高(均P<0.001),但ISG组低于SSG组(均P<0.001)。结论:和标准剂量他汀治疗相比,PCI前使用强化剂量他汀治疗可进一步保护PCI术后肾脏功能,降低CIN的发生率。这种益处伴随有血清hs-CRP、P选择素和ICAM-1水平的显著降低。第四部分急性对比剂肾损伤动物模型的建立目的:随着血管内使用对比剂日益增多,对比剂急性肾脏损伤已经成为当前医院内获得性急性肾损伤的第三位原因。急性对比剂肾损伤的发生机制及预防措施,是当前心血管介入领域研究的焦点问题。但是迄今为止,还没有研究急性对比剂肾损伤的动物模型。本研究的目的是探讨利用大鼠复制急性对比剂肾损伤动物模型的效果。方法:健康SD大鼠24只,随机分为A组(实验组)和B组(安慰剂对照组)。A、B两组再分别随机分为12小时组和24小时组。大鼠正常饲养7天,待适应环境后开始模型制作。禁水三天后,A组经舌下静脉注射复方泛影葡胺8ml/Kg,B组则注射等量生理盐水,然后给予自然饮水至试验结束,A、B两组分别于注射对比剂后12小时、24小时处死动物。分别于试验前、禁水三天后、注射对比剂后3小时、6小时、12小时、24小时(B组)行肾脏超声检查,观察肾脏形态结构变化。并测量左侧肾脏长径、宽径和厚径以及左侧肾动脉直径、收缩期峰值血流速度(PSV)、舒张期峰值血流速度(EDV)、收缩/舒张期血流速度比值(S/D)、阻力指数(RI)、左肾血流量积分指数(VTI)容量及心率。于实验前、禁水三天后、术后12小时(A组)、24小时(B组)采血测量血肌酐水平。分别于术后12小时(A组)、24小时(B组)处死大鼠,取肾脏进行光镜和透射电镜检查。结果:试验前、禁水三天后两组肾脏大小无显著差别,术后3小时、6小时、12小时和24小时实验组的肾脏体积逐渐增大,回声均匀减低,但未见集合系统分离现象,此种表现在6-12小时最为明显,到术后24小时仍未恢复正常。肾动脉直径两组之间无显著差异。但收缩期峰值血流速度(PSV)、舒张期峰值血流速度(EDV)、收缩/舒张期血流速度比值(S/D)、左肾血流量积分指数(VTI)容量在术后6小时最低,以后逐渐恢复,至术后24小时基本恢复到术前水平;阻力指数(RI)术后逐渐升高,在术后6小时最低,到术后24小时恢复到术前水平,禁水三天后心率显著增快,但术后心率无显著改变。禁水三天后术后血清肌酐水平显著升高,以术后12小时为最高,至术后24小时随有明显恢复,当仍未恢复到术前水平。光镜检查发现使用对比剂后12小时肾髓质区可见片状肾小管结构消失,广泛充血、淤血,可见肾小管上皮细胞高度退变,并有较多的成纤维细胞增生及单核细胞浸润。24小时仍可见肾髓质区呈局灶性肾小管结构消失,充血、淤血,有少量成纤维细胞增生及数个单核细胞浸润,但均较12小时明显减轻。光镜下未见显著的肾小球病理学改变。电镜检查发现,使用对比剂后肾小管上皮细胞微绒毛脱落、稀疏,线粒体嵴合膜融合、消失,部分线粒体肿胀、破碎,质膜内褶消失,部分阻塞小管腔,基底膜水肿等改变。另外也可见肾小球毛细血管上皮细胞肿胀、吞噬现象,基底膜及组织间隙水肿,以术后12小时最明显。结论:结合脱水和对比剂静脉注射可造成的显著的急性肾功能损害,其肾脏组织形态学、血流动力学以及肾功能改变均符合人类对比剂肾病的特点。因此,本模型是研究人类对比剂肾病的理想模型。第五部分辛伐他汀联合山莨菪碱对大鼠急性对比剂肾损伤的保护作用目的:随着血管内使用对比剂日益增多,急性对比剂肾损伤发病率急剧增加,研究急性对比剂肾损伤的发生机制及预防措施,是当前心血管介入领域研究的焦点问题。他汀类药物具有独立于降脂作用以外的多重肾脏保护作用,山莨菪碱也具有抗休克、改善组织微循环灌注、抗自由基等的良好作用。但是,目前尚没有关于山莨菪碱对冠脉介入治疗后急性对比剂肾损伤的防治作用的研究,也缺乏关于他汀类药物和山莨菪碱联合使用对使用对比剂后肾脏保护方面的研究。本研究利用大鼠急性对比剂肾损伤动物模型,研究辛伐他汀、山莨菪碱及其联合使用对急性对比剂肾损伤的保护作用,并探讨其可能机制。方法:健康SD大鼠48只,随机分为对照组(C,n=12只)、山莨菪碱组(A,n=12只)、辛伐他汀组(S,n=12只)、辛伐他汀联合山莨菪碱组(A+S,n=12只)。四组再分别随机分为12小时组和24小时组,每组各6只。辛伐他汀组及联合治疗组大鼠给予辛伐他汀灌胃(0.1mg/100g)。对照组和山莨菪碱组则以等量生理盐水灌饲,连续7天。于给药的第四天开始禁水,连续三天后,静脉注射对比剂(0.8ml/100g),然后给予自然饮水。于注射对比剂前15分钟,山莨菪碱组和联合治疗组分别给予山莨菪碱100ug/100g腹腔注射,对照组和辛伐他汀组则给予等量生理盐水腹腔注射。山莨菪碱组和联合治疗组于注射对比剂后4小时内每小时腹腔注射山莨菪碱100ug/100g一次,至第4-12小时每4小时重复腹腔注射山莨菪碱100ug/100g,而对照组和辛伐他汀组则于相应时间腹腔注射等量生理盐水。别于试验前、禁水三天后、注射对比剂后3小时、6小时分别行肾脏超声检查,观察肾脏形态结构变化。并测量左侧肾脏长径、宽径和厚径以及左侧肾动脉直径、收缩期峰值血流速度(PSV)、舒张期峰值血流速度(EDV)、阻力指数(RI)、左肾血流量积分指数(VTI)容量及心率。分别于试验前、禁水三天后、注射对比剂后12(12小时组)、24小时(24小时组)取血测定血肌酐、高敏C反应蛋白水平。于术后第12小时和24小时处死动物,分离左侧肾脏,做光镜和电镜检查。并取肾脏组织测定抗氧化指标超氧化物岐化酶、丙二醛、一氧化氮合成酶、一氧化氮、谷胱苷肽氧化酶水平。结果:注射对比剂后6小时起对照组肾脏的各径线均显著增大,而联合治疗组的肾脏各径线则均无显著变化。山莨菪碱组和辛伐他汀组则部分肾脏径线出现显著增大。对照组皮质髓质回声较3小时均匀减低,山莨菪碱组和辛伐他汀组回声仅有轻微减低,而联合治疗组则未见明显回声减低表现,各组均未见集合系统分离现象。术后3小时,联合治疗组的收缩期峰值血流速度(PSV)、舒张期峰值血流速度(EDV)、左肾血流量积分指数(VTI)均显著高于其它各组同期水平,并且不低于甚至高于术前水平。而对照组上述指标则显著低于其它各组,并且低于术前水平。山莨菪碱组和辛伐他汀组则无显著差别。在术后6小时,联合治疗组的收缩期峰值血流速度(PSV)、舒张期峰值血流速度(EDV)、左肾血流量积分指数(VTI)仍然显著高于其它各组同期水平,并且均比3小时显著增高。对照组上述指标则仍显著低于其它各组,并未恢复到术前水平,甚至进一步减低。而辛伐他汀组显著高于山莨菪碱组。术前S/D联合治疗组显著低于其它三组,对照组显著高于其它三组,辛伐他汀组和山莨菪碱组无显著差别。术后3、6小时,在继续保持这种差异的同时,S/D总体趋于恢复到基线水平,但联合治疗组在术后6小时已经和基线时无显著差别,而对照组仍显著高于基线水平。在术后3、6小时,联合治疗组的阻力指数显著低于对照组,而辛伐他汀组和山莨菪碱组则无显著差别。禁水三天后心率显著增快(284±25次/分),但术后3小时和6小时山莨菪碱组和联合治疗组的心率均显著高于对照组和辛伐他汀组,辛伐他汀组3、6小时无差别,而山莨菪碱组6小时的心率高于3小时。血清肌酐水平在禁水三天后、术后12小时及24小时显著升高,以术后12小时为最高,至术后24小时虽有明显恢复,但只有联合治疗组和辛伐他汀组恢复到术前水平,而山莨菪碱组和对照组均未恢复到术前水平,其中对照组恢复最慢。从肌酐升高的水平来看,术后12小时对照组最高,而联合治疗组最低,山莨菪碱组和辛伐他汀组位列第二和第三,四组均有显著性差异。使用对比剂后12小时光镜观察发现:对照组在肾髓质区可见片状肾小管结构消失,广泛充血、淤血,可见多个高度退变的肾小管样上皮细胞残留,有较多的成纤维细胞增生及单核细胞浸润。山莨菪碱组肾髓质区可见局灶性区域肾小管结构消失,广泛充血、淤血,有数个散在的肾小管上皮残留,并可见少量成纤维细胞增生及数个单核细胞浸润。辛伐他汀组肾髓质区可见局灶性区域肾小管结构消失,广泛充血、淤血,可见少量成纤维细胞增生及数个单核细胞浸润。联合治疗组肾髓质区可见点状肾小管结构紊乱,有极少量成纤维细胞和数个单核细胞浸润,轻度充血。术后24小时,对照组仍可见肾髓质区呈局灶性肾小管结构消失,充血、淤血,可见有少量成纤维细胞增生及数个单核细胞浸润,山莨菪碱组也可发现上述改变,但均较12小时时明显减轻,而辛伐他汀组和联合治疗组的肾脏结构基本恢复正常。光镜下12小时和24小时均未见显著的肾小球病理学改变。电镜检查发现,使用对比剂后肾小管上皮细胞微绒毛脱落、稀疏,线粒体嵴合膜融合、消失,部分线粒体肿胀、破碎,质膜内褶消失,部分阻塞小管腔,并有基底膜及组织间隙水肿等改变,另外也可见肾小球毛细血管上皮细胞肿胀、吞噬现象,基底膜及组织间隙水肿,以术后12小时最明显。四组比较以对照组最明显,而联合治疗组最轻。四组动物的高敏C反应蛋白(hs-CRP)术前则显著增高,但联合治疗组和辛伐他汀组显著低于其它两组。术后12小时,hs-CRP水平达到最高水平,四组之间均有显著差别,其中联合治疗组最低,对照组最高,辛伐他汀组低于山莨菪碱组。至术后24小时,四组的hs-CRP水平均比12小时显著降低,但仍均显著高于术前水平。其中仍以联合治疗组最低,对照组最高,辛伐他汀组显著低于山莨菪碱组。术后12小时,四组的SOD水平均显著降低,其中对照组SOD降低最显著,而联合治疗组最高,山莨菪碱组和辛伐他汀组无显著差别,但均显著高于对照组。术后24小时,对照组和山莨菪碱组的SOD水平进一步显著降低,而辛伐他汀组和联合治疗组则显著回升,其中联合治疗组已经恢复到基础水平。术后12小时四组MDA水平均显著增高,其中对照组最高,联合治疗组最低,虽然山莨菪碱组和辛伐他汀组显著低于对照组,但辛伐他汀组显著低于山莨菪碱组。术后24小时的MDA水平在四组均显著降低,其中联合治疗组的MDA水平已经接近术前水平,而其它三组仍显著高于术前水平。术后12小时,GSH-Px水平以对照组为最低,联合治疗组最高,山莨菪碱组和辛伐他汀组均显著高于对照组,辛伐他汀组高于山莨菪碱组。术后24小时,四组的GSH-Px水平较12小时均显著回升,其中联合治疗组已经恢复到术前水平,而其它三组仍低于术前水平。术后12小时,对照组和山莨菪碱组的NOS水平显著降低,而辛伐他汀组则无显著改变,而联合治疗组则显著升高。术后24小时,对照组的NOS水平进一步降低,山莨菪碱组无显著差别,而辛伐他汀组和联合治疗组则进一步升高,其中联合治疗组升高最明显,后二者均显著高于基础水平。术后12小时,iNOS水平显著增高(P<0.01),其中以对照组最高,显著高于其它三组(P<0.05),而山莨菪碱组、辛伐他汀组和联合治疗组无显著差别。术后24小时,仍以对照组为最高,联合治疗组最低,山莨菪碱组和辛伐他汀组无显著差别。和12小时比较,术后24小时iNOS水平在对照组、山莨菪碱组和辛伐他汀组均无显著差别,但联合治疗组的iNOS水平则显著低于术后12小时。在对照组,术后12小时NO水平较低,24小时有轻微但显著上升;山莨菪碱组12小时NO较高,但术后24小时的显著降低;辛伐他汀组术后12小时的NO含量比较高,术后24小时则继续上升;联合治疗组在术后12小时的NO最高,虽在术后24小时有所下降,但仍呈显著升高状态。结论:山莨菪碱和辛伐他汀的联合治疗可有效预防对比剂急性肾损伤的发生,其可能机制涉及改善肾脏的血流动力学、抗炎、抗氧化等。更多还原

【Abstract】 More and more patients of coronary artery disease have benefit from percutaneous coronary intervention (PCI). About 30 000 cases of PCI were performed in 2002 in China. It rises to 75 000 in 2005. By the end of 2009, the PCI cases has been over 240 000. Now, the number is still increasing.No/slow reflow phenomenon and contrast induced nephropathy are the main complications that limited the short and long-term efficacy of PCI. Although the exact mechanism remains uncertain, it was accepted that dysfunction of microcirculation, inflamation and oxidant stress were among the common pathophysiological basis.Both statins and anisodamine possess these characteristics such as anti-inflammation, antioxidation, improving the function of the endothelium. It has been confirmed that common dose statins improve myocardial perfusion and prevent the incidence of CIN. Data in our laboratory also support the use of anisodamine in the setting of NRP. So far, the effect of intensive statin dose on myocardial perfusion, the preventive effect of anisodamine on CIN and the effect of their combination have not been carried out. Based on our previous work, this study was designed to evaluate the effect of intensive simvastatin, anisodamine and their combination on myocardila perfusion and CIN. The possible mechanisms were also probed.Part I Intensive cholesterol lowering with simvastatin improves the outcomes of percutaneous coronary intervention in patients with acute coronary syndromeObjective: The incidence of no reflow penomenon limits the clinical outcomes of percutaneous coronary intervention (PCI). We designed a randomized controlled study to evaluate the immediate protective effects of intensive statin pretreatment on myocardial perfusion and myocardial ischemic injury during PCI.Methods: A total of 228 acute coronary syndrome (ACS) patients were randomly divided into standard statin group (SSG, n=115) and intensive statin group (ISG, n=113). Patients in SSG received 20 mg simvastatin and patients in ISG received 80 mg simvastatin for 7 days before PCI. TIMI grade flow (TGF), corrected TIMI frame count (CTFC) and TIMI myocardial perfusion grade (TMPG) of the intervened vessel were recorded before and after stent deployment. CPK isoenzyme MB, troponin I and plasma level of hs-CRP, P-selectin and ICAM were measured before and 24 hours after the procedure.Results: The TFG after stent deployment was significantly improved with less TIMI 0-1 patients and more TIMI 3 blood flow in ISG than in SSG (all p<0.05). Patients with no reflow phenomenon were less in ISG (P<0.001). The CTFC was lower in ISG than SSG (P<0.001). TMPG was also improved in ISG than SSG (P=0.001). Twenty-four hours after the procedure, although PCI caused significantly increase in CK-MB, the elevated CK-MB value was lower in ISG than SSG (18.74±8.41 vs 21.78±10.64 P=0.018). Similar changes were also found with regard to Troponin I (0.99±1.07 in ISG vs 1.47±1.54 in SSG P=0.006). CK-MB elevation occurred in 27.8% (32/115) in SSG versus 15.9% (18/113) in ISG (P=0.030). Among them, myocardial necrosis was detected in 4.4% (5/115) of the patients in SSG, whereas 0.9% (1/113) in ISG (P=0.341). No myocardial infarction was found. Similarly, the patients with increased troponin I were much more in SSG (36.5% 42/115) than ISG (19.5% 22/113) (P=0.04). Among them, myocardial necrosis was detected in 13% (15/115) of the patients in SSG, while 4.4% (5/113) in ISG (P=0.021). Myocardial infarction was found in 4.4% (5/115) in the patients in SSG and 0.9% (1/113) in ISG (P=0.213).Conclusion: Intensive statin pretreatment for 7 days before PCI can further improve myocardial blood perfusion, protect myocardium from ischemic injury. This benefit is associated with the lowering of hs-CRP, P-selectin and ICAM level.Part II Protective effect of simvastatin in combined with anisodamine on myocardial perfusion in swine no reflow model. Objectives: Slow reflow or no reflow phenomenon not only increase the risk during percutaneous coronary intervention, but also limit the long prognosis of this therapy. Study of its mechanism and find out the prevention measures remain the main focus of this field. Anisodamine can improve the state of mircrocirculation, antioxidant and protect the myocardium from ischemic injury, while statins posses the ability of improving the function of endothelium, anticoagulation, antiplatelet, antioxidation, antiinflammation and improving blood hemodynamics. So far, data on the combination of the two drugs on the prevention of SRP/NRP is absent. So, based on our previous study of experimental SRP/NRP model on minipig, we evaluated the preventive effect of their combination. We also probed the possible mechanism by measuring the level of hs-CRP, SOD, MDA and NO.Method: Totally 16 minipin of 30-40 Kg were randomly divided into anisodamine groups (A, n=8) and anisodamine plus simvastatin group (A+S, n=8). Pigs of A+S group were prtreated with oral simvastatin (1 mg/Kg) for 7 days, while pigs in S groups were given oral placebo.Seven days later, after coronary angiography were performed, a minicatheter was superselected into middle LAD,and the dopper wire was placed at the midle LAD, 3 cm far from the catheter in order to record the changes of blood velocity. The pressure of aorta was monitored all the time. PMBS was injected (5ml each time) for 4 times with an interval of 10 minutes. Anisodamine (5000u) was injected into the LAD 2 minutes before PBMS was injected. CAG was reperformed 5 minutes after the PMBS was injected to record the TIMI blood flow, TMPG and CTFC to evaluate the myocardial perfusion. Then the animal was killed and the smple of myocardium was take at the joint area of ischemic and normal myocardium in order to measure the tissue level of SOD,MDA and NO and to perform pathological examination.Blood sample was take before and after the expeiment to measure the level of CK-MB,InI and hs-CRP. The percent of necrostic myocardium was calculated by myocardium stain method.Results: The TIMI blood flow was better in S group and TFCs was lower in A group (P<0.05). At the early stage of PMBS injection, the heart rate was increased in both the groups than their baseline (P<0.05). There was no difference between the two groups. There after, the HR was further increased in A group, while the HR in A+S group remain unchanged.The Pa was increased in both the two groups after PMBS injection at the early stage (P<0.01). Then it begain to decrease in A group (P<0.05), while it remain its high level in A+S group (P=0.042). In the late stage, the Pa did not decrease in A+S group, however, it was further decreased in A group.In the early stage after PMBS injection, the bAPV was increased in both groups, which was more obvious in the S group.The hAPV was decreased in S group while it remain its high level in A+S group (P=0.000). After the third injection of PMBS, comparing with the baseline, the hAPV was sinificantly decreased in both groups (P<0.01), but it was still higher than that in S groups (P=0.000). After the forth injection, the hAPV was further decreased with no difference between the two groups.After the first and second injection of PMBS, the CFR in A+S group was not changed, while it was decreased continously in S group (P=0.006).The CFR was continously deceased after the third and the fourth injection (p<0.05), but it was higher in A+S group (P=0.025).The h-MR in S group was elevated in S group after the first and the second injection of PMBS (P=0.032), while it not changed in A+S group.After the third injection, the h-MR increased in both group (P=0.030) with the higher level in A+S group (P=0.010). After the fourth injection, the h-MR was further increased (P=0.024), with no difference between two groups.The level of serum cholesterol 7 days later was 4.44±0.47mmol/L and 3.93±0.53mmol/L in S group and A+S group (P=0.063). The CK-MB, TnI, hs-CRP and MDA were increased 60 minutes after the experiment, but they were higher in S group. Level of NO was also increased (P=0.000), with the higher level in A+S group (P=0.006). SOD was decreased (P=0.000) in both groups, but it was lower in A group (P=0.000).The infarcted myocardium in S grous was 18.5±3.1%, while it was 11.3±2.9% in A+S group (P<0.05).Conclusion: Simvastatin combined with anisodamine treatment can significantly improves myocardial blood perfusion and porotect the myocardium against ischemic injury during percutaneous coronary intervention. The possible mechanism involves improving of coronary hemodynamics, antiinflammation and antioxidation.Part III Protective effects of intensive statin pretreatment on renal function in patients with acute coronary syndrome undergoing percutaneous interventionObjectives: To evaluate the protective effects of higher dose statin on renal function and the incidence of CIN and to probe its possible mechanisms.Methods: Two hundreds and twenty eight patients with acute coronary syndrome undergoing delayed percutaneous coronary intervention were randomly divided into standard statin group (SSG n=115) and intensive statin group (ISG n=113). Patients in SSG group were given simvastatin 20 mg/day and patients in ISG were given simvastatin 80 mg/day for at least 7 days befor PCI, Serum creatinine was measured at admission, 24 hours and 48 hours after PCI. Creatinine clearance was calculated by Cochcroft-Gault formula. The changes of high sensitive C reaction protein (hs-CRP), intercellular cell adhesion molecule 1 (ICAM-1) and P-selectin level before and after the procedure were also measured.Results: Serum creatinine underwent significant increase after PCI, the peak value occurred at 24 hours, and then began to decrease. At 48 hours after PCI, the creatinine level significantly decreased (P<0.001 compared with the level at 24 hours) to baseline level (P=0.94 compared with the level at baseline) in ISG, whereas in SSG the creatinine level failed to decrease significantly (P=0.11) at 48 hours. Serum creatinine at admission was not significantly different between the two groups. But at 24 and 48 hours after PCI, it was lower in ISG than SSG (P<0.05 at 24 hours and P<0.001 at 48 hours). The creatinine clearance significantly decreased after PCI, the lowest value occurred at 24 hours, and then it began to increase. In SSG, the creatinine clearance increased significantly (P=0.03 compared with the level at 24 hours) at 48 hours, but still significantly lower than baseline level (P<0.001 compared with the level at baseline). In ISG, the creatinine clearance increased significantly (P<0.001 compared with level at 24 hours) at 48 hours and recover to the level at baseline (P=0.87 compared with level of baseline). Creatinine clearance improved much more in ISG at 24 and 48 hours than that in SSG (P<0.001 at 24 hours and at 48 hours). After PCI, the serum level of hs-CRP, P-selectin and ICAM-1in ISG were significantly lower than SSG (all P<0.001). Although procedure caused significant increase in hs-CRP, P-selectin and ICAM-1 (P<0.001), the increase in ISG was smaller than SSG (P<0.001).Conclusion: Pretreatment with intensive statin dosage before PCI can further decrease the occurrence of postprocedural contrast induced nephropathy compared with standand statin therapy. This benefit is associated with the lowering of hs-CRP, P-selectin and ICAM levels.Part IV: Establishment of contrast induced nephropathy model in ratsObjectives: with the widespread application of intravascular contrast, contrast induced nephropathy (CIN) has became to the third rank cause of intra-hospital-attained acute kidney injury. Study of the mechanism and its prevention has become the hot research point in the field of interventional cardiology. So far, the accepted animal model of CIN has not been established.The purpose of this stuy was to establish an rat model of CIN and to evaluate its efficacy.Methods: Totally 24 SD rats of 250-270 grams were randomly allocated into experimental group (group A, n=12) and control group (group B, n=12). Rats in the two groups were further divided into group of 12 hours and group of 24 hours. All the rats were normally raised for 7 days in order to accommodate to the new environment.After dehydration of three days, rats in group A were given intravenous Meglumine Diatrizoate and Diatrizoate Sodium (MDDS), while rats in group B were given intraveous normal saline (NS). Then, all rats get normal water-drinking to the end of this study. Animals were killed at 12 hours (group of 12 hours) and 24 hours (group of 24 hours).Renal ultrasonic examination was performed before this study, after dehydration and 3, 6, 12 and 24 hours after contrast media injection to observe the morphologic changes and the changes of renal dimensions (length,width and thickness), diameters of renal artery, peak systolic velocity (PSV), end diastolic velocity (EDV), ratio of PSV/EDV (S/D) and velocity-time index of left kidney. The heart rate was also recorded at the corresponding time points.Blood samples were taken before the study, after dehydration and 12 hours (Group A) , 24 hours (Group B) to meseaure the level of serum creatinine. Animals were killed at 12 hours (group A) and 24 hours (group B) and the tissue of kidney were incised for microscope and electron microscope study.Results: The dimensions of the two groups before and after dehydration were not different. It gradually enlarged at 3, 6, 12 and 24 hours after CM injection. These changes were the most obvious at 6 and 12 hours, which did not recover at 24 hours.The renal diameters of the two groups were not different. The PSV, EDV, S/D and VTI were lowerest at 6 hours and then recover to normal level at 24 hours. RI was increased after CN injection, the lowest occurred at 6 hours, and recover to normal level at 24 hours. The heart rate was obviously increased after hehydration, but it remained unchanged during the following time period. Serum creatinine was signicicantly elevated after dehydration, the highest level occurred at 12 hours and then begain to recover at 24 hours.Microscope examination to renal sample at 12 hours found patch disapperence of tubular structure, widely congestion at medullar area. High degeneration of the tubular endothelium, infiltration of fibromyocyte and mononuclear cells were also found. At 24 hours, the obove changes were still present, but become much mild. No pathological glomerular changes were found under microscope. Electron microscope examination found desquamation, sparseness of microvillous of tubular endothelium, membrane confusion, disapperence, swelling, fragmentation of the MIT, with obstrcted tubular lumen and basal membrane sweling. Swelling, licking up, edema of basal membrane and interstitium of the endothelium of glomerular capillary were also found. It was most obvious a 12 hours. Conclusion: Combined with dehydration, intravenous injection of contrast lead to obvious acute kidney injury, with the changes of kidney tissue pathology, hemodynamics and kidney functions much similar to the characteristics of contrast induced nephropathy in humanbings. Thus, we established an eligible animl model of contrast induced nephropathy which mimiced the time course of contrast induced nephropathy in humanbeings.Part V: Renal protective effects of intensive statin in combined with anisodamine against contrast induced nephropathy.Objectives: With the widespread use of intravascular contrast, acute kidney injury was more and more found in clinical practice. Study on its mechanism and prevention has aroused great interest in the field of interventional cardiology. Statins possess pleiotrophic effects against renal injury, which are independent of its cholesterol lowering effects. Also, anisodamine have benefit features again renal injury such as antishock, improving microcirculation and antioxidation. But study of anisodamine in the prevention of CIN after percutaneous coronary intervention has not been carried out. Also, data about their combination for the prevention of CIN after percutaneous coronary intervention was absent. This study, based on the CIN rat model we established, was performed to evaluate the protective effect of simvastatin, anisodamine and their combination in the prevention of CIN and to probe the possible mechanism.Methods: Totally, 48 of SD rats were randomly divided into control group (control, C, n=12), anisodamine group (anisodamine, A, n=12), simvastatin group (simvastatin, S, n=12) and anisodamine+simvastatin, A+S group, n=12). Then, rats in the four group were futher divided into 12hrs subgroup and 24hrs subgroup (n=6 in each subgroup). Rats in S group and A+S group were given oral simvastatin 0.1mg/100g, while rats in group C and group A+S were given oral placebo for 7 days. After dehydration for 3 days, intravenous Meglumine Diatrizoate and Diatrizoate Sodium (MDDS) was given (0.8mg/100g), then normal water drinking was recovered.At 15 minutes before contrast injection, anisodamine (100ug/100g) was abdominally injected in group A and group A+S, while normal saline in the other two groups. During the 4 hours after contrast injection, anisodamine abdominal injection was performed every 1 hours in group A and group A+S, while normal saline was injected abdominally at the corresponding time point.During the time between 4 and 12 hours after contrast injection, anisodamine (100ug/100g) and normal saline was repeated every 4 fours as mentioned above.Kidney untrasound examination was performed at baseline, after dehydration, 3 hours, 6 hours after contrast injection to observe the mophorlogical changes, the renal dimensions and hemodynamic parameters such as diameter of renal artery, peak systolic velocity (PSV), end-diastolic velocity (EDV), resistant index (RI), velocity time index (VTI) and heart rate (HR). Serum creatinine, high sensitive C reactive protein (hs-CRP) were measured at baseline, after dehydration, 12 (12hrs subgroup), 24 (24hrs subgroup) hours after contrast injection. Animals were killed at 12 (12hrs subgroup) and 24 (24hrs subgroup) hours respectively. Renal samples were incised to measure level of superoxide dimutase (SOD), MDA, NOS, NO and GSH-Px.Results: All the dimensions in group C increased 6 hours afer contrast injection, but is remain unchanged in group A+S. Partial of the dimensions in group A and S increased. The echo decreased at 6 hours compared with 3 hous in group C, while it was abscent in group A+S. The echo changes in group A and S was mild. No dilation of collective system concentrating system was found in all the groups.At 3 hours, the PSV, EDV and VTI in group A+S were higher than the other groups, and were not less than that after dehydration. However, these parameters were much lower in group C, and lower that that after dehydration of the same group.These parameters was not changed in group A and S. At 6 hours, the PSV, EDV and VTI remain the highest among the four groups and were higher than that at 3 hours. However, these parameters in group C were still lower than the other groups and not recovered to the level after dehydration,Those parameters in group S were higher than that in group A.S/D was the lowest in group A+S and the higest in group C, while no difference was found between group S and A. At 3 and 6 hours after contrast injection, although these differences of S/D keep existed, it tends to recorver. At 6 hours, it has recovered to baseline in group A+S while it keeps higher in group C. The RI in group A+S at 3 and 6 hours was lower than that in group C, while there was no difference between group S and A. The HR increased in all groups after dehydration with the higher level in group A and A+S. The HR in group S was not different between 3 and 6 hours, while it was higher at 6 hours than 3 hours in group S.Serum creatinine increased after dehydration, 12 and 24 hours after contrast injection with the highest level occurred at 12 hours. Although it recovered significantly at 24 hours, only that in group A+S and S recovered to baseline level and group C remain the highest. At 12 hours, the higest level occurred in group C and the lowest level at group A+S, group A ranked the second and group S ranked the third.Microscope examination to renal sample at 12 hours found that in group C, there were patch disapperence of tubular structure, widely congestion at medullar area. High degeneration of the tubular endothelium, infiltration of fibromyocyte and mononuclear cells were also found. In group A, local changes of above mentioned, scattered tubular endothelium and a few fibromyocyte and mononuclear cells were found. In group S, the changes were much similar to group A. In group A+S, there were only spotted changes of above mentioned, few fibromyocyte and mononuclear cells and mild congestion. At 24 hours, the obove changes were still present in group C and group A, but it become much mild in group S. It recovered completely to normal apperence in group A+S. No pathological glomerular changes were found under microscope.Electron microscope examination found desquamation, sparseness of microvillous of tubular endothelium, membrane confusion, disapperence, swelling, fragmentation of the MIT, with obstructed tubular lumen and basal membrane sweling. Swelling, licking up, edema of basal membrane and interstitium of the endothelium of glomerular capillary were also found. It was most obvious a 12 hours. Among the four groups, group C was the most obvious and group A+S was the mildest. Although the level of hs-CRP increased in all the groups after dehydration, it was lower in group A+S and S. At 12 hours, hs-CRP reached its highest level. Among the four groups, group A+S was the lowest and group C was the highest. At 24 hours, the hs-CRP was lower than that of 12 hours in all the groups, but still higer than that after dehydration, among which, the lowerest occurred in group A+S, the highest in group C. It was lower in group S than that in group A.At 12 hours, the level of SOD was decreased in all the four groups, among which, the lowest in group C,the highest in group A+S. Although there was no difference between group A and S, they were all higher than that in group C. AT 24 hours, SOD was further decreased in group C and A, while it increased in group S and A+S. It has recovered to baseline level in group A+S.At 12 hours, level of MDA increased significantly. The highest occurred in group C and the lowest in group A+S. The level of SOD ranked the second in group A and the third in group S. At 24 hours, MDA was further decreased in all the groups, among which, the MDA in group has recovered to baseline, however, it was still higher the other three groups.At 12 hours, level of GSH-Px was the lowest in group C, the higest in group A+S.Group S rank the second and group A the third. At 24 hours, GSH-Px began to increase in all the four groups, among which, group A+S has recovered to baseline level and the other three groups remained lower than baseline.At 12 hours, the NOS deceased in group C and A, while group A+S increased. Group S did not change. At 24 hours, NOS in group C further decreased, NOS in group S and A+S further increased. Group A did not change. The most increasing occurred in group A+S.At 12 hours, iNOS increased significantly, with the highest in group C. At 24 hours, group C remain the highest and group A+S the lowest. There was no different between group A and S. Compared with 12 hours, level of iNOS at 24 hours in group C,A and S were not different, while level of iNOS in group A+S decreased.In group C, level of NO was lower at 12 hours and elevated at 24 hours. In group A, NO level was slightly but significantly higher, but decreased at 24 hours. In group S, NO level was significantly higher among the four groups at 12 hours, and further increased at 24 hours. In group A+S, NO level was the highest among the four groups at 12 hours.Althought there was a slight decrease at 24 hours, it was still higher than that at 12 hours, and further increased at 24 hours.Conclusion: Anisodamine combined with simvastatin can effectively prevent the contrast induced acute kidney injury. Improvement of renal hemodynamics, antiinflammation and antioxidation are the underlying mechanism.更多还原