目的 观察叶酸对合并高血压病、高同型半胱氨酸血症(HCY)冠状动脉粥样硬化患者冠状动脉狭窄程度、症状、运动耐力及不良心血管事件治疗效果.方法 自2013年5月选取冠状动脉CT检查提示冠状动脉狭窄25％～50％患者22例,分为常规治疗组、联合治疗组(常规用药+叶酸),每组各11例,对治疗前后冠状动脉最狭窄部位及其前正常部位直径进行测量,对治疗前后血管内皮功能、血HCY、血基质金属蛋白酶-2(MMP-2)、血脂水平、单核细胞计数进行测定及平板运动试验检查,并同时记录患者有无不良心血管事件发生等情况.结果 随访36个月,两组患者冠状动脉狭窄程度均减轻,联合治疗组减轻明显,差异有统计学意义(P<0.01);两组均无心肌梗塞、心绞痛、猝死等不良心血管事件发生;均无平板运动试验阳性患者.两组患者低密度脂蛋白、甘油三酯水平治疗后均较治疗前降低(P<0.01);但两组间比较差异无统计学意义(P>0.05).两组患者血管内皮功能、MMP-2较治疗前均有改善,且联合治疗组较常规治疗组改善明显(P<0.05).常规治疗组血HCY、血单核细胞计数无明显降低,联合治疗组较治疗前降低明显,两组比较差异有统计学意义(P<0.01).结论 降压治疗联合阿托伐他汀钙能抑制冠状动脉粥样硬化进展,叶酸联合常规用药对高HCY患者能进一步降低冠状动脉粥样硬化狭窄程度;通过降低HCY水平、降低单核细胞计数、改善血管内皮功能、降低MMP-2水平可能是其主要机制;对于高血压病合并高HCY血症的冠状动脉粥样硬化患者,联合降HCY治疗可能能进一步抑制冠状动脉粥样硬化进展,对患者长期预后有利.%Objectives To study the effect of the treatment of folic acid in coronary heart disease patients with hypertension and hyperhomocysteinemia. Methods 22 patients with coronary artery stenosis 25％～50％ according to coronary CT angiography were selected and separated into two groups randomly:conventional therapy group and combined therapy group. The patients in conventional therapy group were treated with atorvastatin and Enalapril Maleate Tablets;the patients in combined therapy group were treated with atorvastatin,Enalapril Maleate and Folic Acid Tablets.All the patients were followed up for 36 months.Before and after the treatment,the diameter of coronary artery stenosis were measured, the vascular endothelial function,the levels of homocysteine,blood lipid,matrix metalloprotease-2 and monocyte were determined,treadmill exercise test was done,and also the adverse cardiovascular events were recorded. Results After 36 months therapy,the stenosis of the coronary of the patients in two groups was improved and it was improved more in the combined treatment group than that in the conventional treatment group (P<0.01).There were no adverse cardiovascular events in two groups and no treadmill exercise test positive in two groups before and after treatment. The levels of low density lipoprotein cholesterol and triglyceride were decreased by treatment at the end in the two groups (All P<0.001), but with no statistically significant difference between the two groups (P=0.058 and P=0.673). The vascular endothelial function of patients in two groups were all improved and it was improved more in the combined treatment group than that in the conventional treatment group (P<0.05). The levels of homocysteine in the two groups were high and decreased at the end of treatment in the combined treatment group (P<0.001),but not decreased in the conventional treatment group(P=0.592).The levels of MMP-2 in the two groups were high but with no statistically significant difference between the two groups (P=0.789). The levels of MMP-2 in the conventional treatment group were not decreased at the end of treatment,but in the combined treatment group and there was a statistically significant difference between the two groups (P<0.05).There was no statistically significant difference of monocyte counts between the two groups before treatment (P=0.983) and no change in the conventional treatment group after treatment,but there was a significant decrease in the combined treatment group(P=0.001) and it was statistically significantly different between the two groups of the change of the monocyte counts after the treatment(P<0.05). Conclusions Antihypertensive treatment combined with atorvastatin can inhibit the progression of coronary atherosclerosis;conventional therapy combined with folic acid can reduce the degree of coronaryartery stenosis in patients with high homocysteine. The main mechanisms may reduce the level of Hcy and the count of monocytes,improve the function of vascular endothelium and decrease the level of MMP-2. For patients with coronary artery disease complicated with hypertension and hyperhomocysteinemia,folic acid combined with conventional treatment may further inhibit the progression of coronary atherosclerosis and provide a favorable long-term prognosis for patients.
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