| Objective:In ischemic heart disease(IHD),the myocardial tissue of ischemic infarction is replaced by scar tissue and loses its effective relaxation and contraction Heart failure,ventricular arrhythmia,sudden death,atrial fibrillation and stroke caused by structural and electrical remodeling are the main reasons for its high death and disability rate.Extracorporeal cardiac shock wave therapy system(CSWT)is a new type of therapy for promoting myocardial angiogenesis.At present,the research on its mechanism is mainly focused on promoting angiogenesis,anti-inflammatory response and inhibition of apoptosis.But how does the local stimulation of ischemic myocardium by CSWT promote the morphogenesis of local capillaries?It's not clear yet.Stromal cell-derived factor-1(SDF-1),also known as chemokine CXCL12,has a strong chemotactic effect on many types of adult cells,such as hematopoietic stem cells,endothelial progenitor cells(EPCs).EPCs is the precursor of vascular endothelial cells,which has the characteristics of self-renewal,continuous proliferation,differentiation,lacunar migration and so on.It plays an important role in the repair of endothelial injury and promoting angiogenesis.This study will explore the correlation between the improvement of cardiac function in patients with IHD after CSWT and SDF-1 and EPCs,and then reveal the mechanism of CSWT in improving cardiac function in patients with IHD.Methods:A total of 20 patients(18 males and 2 females)with old myocardial infarction(OMI)diagnosed and treated in the department of cardiology or cardiac surgery of the first affiliated hospital of Kunming Medical University from April 201 8 to December 2019 were prospectively collected.Moderate and severe coronary artery stenosis was revealed by coronary angiography(CAG)or coronary CT angiography(CCTA).After regular medication or percutaneous coronary intervention(PCI)or coronary artery bypass grafting(CABG),There are still clinical manifestations of refractory angina pectoris,such as chest tightness,chest pain,shortness of breath,poor exercise endurance and so on.While receiving standard medical treatment,extracorporeal cardiac shock wave therapy(CSWT),was performed 9 times a month,and real-time ECG,blood pressure and blood oxygen saturation were monitored during treatment.Before treatment,1 month and 6 months after treatment,all patients underwent echocardiographic evaluation of cardiac structure,function and global longitudinal strain of myocardium(GLS);99Tcm-methoxyisobutyl isonitrile myocardial perfusion imaging(MPI)identified viable myocardium and located myocardial ischemic segments,which were expressed by 17-segment method.New York heart association(NYHA),Canadian cardiovascular society(CCS)angina pectoris grade,Seattle angina questionnaire(SAQ),Minnesota heart failure score,SF-36 health survey summary scale score,6 minute walk test(6MWT)and nitroglycerin dosage were recorded,and stromal cell-derived factor-1(SDF-1)and endothelial progenitor cells(EPCs)were detected.Results:1.A total of 43 myocardial ischemic segments in 20 patients were treated with cardiac shock wave for 9 times and were followed up successfully.During the treatment,the hemodynamics was stable and no adverse events occurred.During the follow-up period,2 patients were re-admitted for special reasons(1 for gouty arthritis and 1 for digestive tract malignant tumor).Admission had nothing to do with shock wave therapy.2.Imaging evaluation:the inner diameters of LVEDD measured by echocardiography at 0,1 and 6 months were(53.10±17.05mm,53.05±13.55mm and 52.50 ± 15.75mm),respectively,but there was no significant difference between them(p>0.05);LVEF was(53.25 ± 18.48,52.90 ± 14.41 and 52.70±16.47)respectively,there was no significant difference among these three groups,(p>0.05);The GLS were(-17.03±3.75%,-18.15±4.13%and-23.78±3.20%),(after treatment,the absolute value of 1 month was 1.12%higher than that of 0 month,p<0.01;the absolute value of 6 months was 6.75%higher than that of 0 month,p<0.01;the absolute value of 6 months was 5.63%higher than that of 1 month,p<0.01);MPI score at month 0 and 6(resting:28.15±3.03,23.15±1.26);(load:20.93±2.85,17.63±2.01),took a significant decreasing tendency(p<0.05).3.Clinical evaluation:NYHA cardiac function score at 0,1 and 6 months(2.70=0.47,1.70±0.57,1.15±0.37),(1 month after treatment,1.0 grade lower than 0 month,p<0.01;6 months lower than 0 month,1.55 grade,p<0.01;6 months,0.55 grade lower than 1 month,p<0.01);CCS angina pectoris grade(1.85±0.67,1.35±0.49,1.05±0.22),month after treatment,0.5 grade lower than 0 month,p<0.01;6 months lower than 0 month,0.8 grade,p<0.01;6 months,0.3 grade lower than 1 month,p<0.01);Minnesota heart failure score(27.35±19.02,21.65 ± 15.84,14.70 ± 14.55),(1 month after treatment was 5.7 points lower than that of 0 month,p<0.01;6 months was 12.65 points lower than that of 0 months,p<0.01;6 months was 6.95 points lower than that of 1 month,p<0.01);the dosage of nitroglycerin(1.27±1.32 tablets/week,0.96=1.19 tablets/week,0.60±0.89 tablets/week),(1 month after treatment,it decreased 0.31 tablets/week compared with 0 month,p<0.01;6 months decreased 0.67 tablets/week,p<0.01;6 months decreased 0.36 tablets/week,p<0.01);SAQ score(69.60 ± 11.55,78.40 ± 10.48,82.65±10.30),(1 month after treatment increased 8.8 points compared with 0 month,p<0.05;6 months increased 13.05 points compared with 0 month,p<0.05;6 months increased 4.25 points compared with 1 month,p<0.05);the SF-36 scores were(62.00 ± 13.39,66.70 ± 17.57,74.45 ± 15.14),respectively.(the scores of 1 month after treatment were 4.7 points higher than those of 0 month,p<0.05;6 months were 12.45 points higher than that of 0 month,p<0.05;6 months were 7.75 points higher than that of 1 month,p<0.05);6MWT were(379.95± 19.91m,407.90 ± 18.83m,413.05m±19.00m,respectively),After treatment,increased by 27.95m,p<0.05;1 month after treatment,33.1m(p<0.05)in 6 months,and 5.15m(p<0.05)in June compared with January.4.Blood biochemical assessment:The contents of SDF-1 in peripheral blood in 0,1 and 6 months were(97.72±5.95ng/ml,162.50 ± 10.36ng/ml and 242.50±20.33ng/ml,respectively),(1 month after treatment,it increased 64.78ng/ml compared with month 0,p<0.01;6 months,compared with 0 month,increased 144.78ng/ml,p<0.01;6 months,compared with 1 month,increased 80ng/ml,p<0.01,respectively);The number of EPCs colonies(5.61±10.05%,8.67 ± 11.03%,13.31±12.00%),(1 month after treatment increased 3.06%compared with 0 month,p<0.01;6 months increased by 7.7%compared with 0 month,p<0.01;6 months increased by 4.64%compared with 1 month,p<0.01).5.Correlation analysis of SDF-1,EPCs and NYHA,SAQ and GLS in peripheral blood:At the three time points of October.January and June,There was no correlation between EPCs and peripheral blood SDF-1(r=0.06,p=0.62),SDF-1 was negatively correlated with NYHA cardiac function(r=-0.56,p=0.00),positively correlated with SAQ score(r=0.26,p=0.04),had no correlation with GLS(r=0.24,p=0.06),EPCs was negatively correlated with NYHA cardiac function(r=-0.26,p=0.04),positively correlated with SAQ(?)(r=0.39,p=0.00),and had no correlation with GLS(r=-0.11,p=0.38),NYHA cardiac function was negatively correlated with SAQ score(r=-0.17,p=0.00),but not correlated with GLS(r=-0.15,p=0.23),and SAQ score was not correlated with GLS(r=0.02,p=0.83).Conclusion:1.CSWT can improve the regional myocardial contractile function and improve the quality of life of patients with IHD,which may be related to its promotion of the high expression of SDF-1 and the proliferation of EPCs,thus stimulating the microvascular regeneration of ischemic target myocardium and promoting the establishment of collateral circulation.It is a new,non-invasive,safe and effective angiogenesis therapy,which is worth further studying and popularizing.2.Ultrasonic speckle tracking technique GLS and radionuclide MPI,have high consistency in locating ischemic segments,and the combination of them can efficiently and quickly identify ischemic myocardium in patients with IHD,while GLS can become the first choice for imaging localization of ischemic myocardium because of its advantages such as non-invasive,safety and high repeatability. |
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