血管内超声对急性冠状动脉综合征临界病变治疗决策的影响

Vulnerable plaque burden post pharmacological and interventional treatments in patients with acute coronary syndrome and borderline lesion： intravascular ultrasound follow up results

目的 在血管内超声指导下评价急性冠状动脉综合征（ACS）患者易损斑块介入治疗和单纯药物治疗的疗效和安全性。方法 入选ACS经冠状动脉造影显示狭窄程度在50％～70％的临界狭窄病变患者100例，采用完全随机方法分为介入治疗组和药物治疗组，每组各50例。其中男78例，女22例，年龄在43～74（60．4±14．1）岁。每组再根据血管内超声（IVUS）测定的罪犯病变最小血管腔面积（MLA）分为2个亚组，即MLA≥4mm＾2组和MLA≤4mm＾2组。对比分析在IVUS指导下临界病变易损斑块介入治疗和单纯药物治疗两组患者住院期间和随访10～12个月的疗效。结果 介入治疗组50例中40例在术后10～12个月进行了冠状动脉造影和IVUS复查，IVUS未发现局部支架内血栓征象，支架内增生内膜负荷量与术后即刻比较差异无统计学意义。随访时最小支架内管腔面积与术后即刻相比差异亦无统计学意义[（8．98±2．12）mm＾2比（10．12±1．15）mm^2，P〉0．05]。药物治疗组50例中有9例在随访期问行经皮冠状动脉介入治疗，35例在术后10～12个月进行了冠状动脉造影和IVUS复查，IVUS结果与治疗前比较，狭窄处的MLA较大[（7．32±1．42）mm^2比（4．98±0．89）mm^2，P〈0．01]，斑块面积较小[（7．70±2．09）mm^2比（10．01±2．55）mm^2，P〈0．05]，斑块负荷较低[（55．94±8．36）％比（67．97±9．36）％，P〈0．01]，斑块内低回声区面积较小[（2．27±0．79）mm^2比（4．08±0．80）mm^2，P〈0．01]。介入治疗组MLA≥4mm^2亚组中1例术后第2天前降支支架急性血栓形成。药物治疗组MLA＜4mm＾亚组中9例[37．5％（9／24）]患者仵临床随访期间仍反复发作心绞痛，行介入治疗后未再发心绞痛。结论 IVUS测定MLA≥4．0mm^2的ACS临界病变患者经严格药物治疗可延缓易损斑块进展，使斑块趋于稳定。

Objective To compare the efficacy and safety between the interventional and conservative treatment options for borderline vulnerable plaque lesion in acute coronary syndrome （ACS） patients by intravascular ultrasound（IVUS）. Methods A total of 100 ACS patients [78 male, age 43 - 74 （60. 4 ± 14. 1 ）years ] undergoing coronary angiography （CAG） with borderline lesion （coronary artery stenosis between 50% - 70% ） were enrolled in May 2007 to February 2009, who were randomly divided into PCI group （50 patients） and conservative therapy group （50 patients）. According to minimal lumen area （MLA） detected by IVUS, patients were further divided into MLA≥4. 0 mm^2 sub-group and MLA ≤4.0 mm^2 sub-groups. Outcomes during hospitalization and after 10 - 12 month follow-up were compared. Results IVUS was performed in 40 patients at 10 - 12 months post PCI, there was no in-stent thrombosis and the extent of stent neointimal hyperplasia was comparable as at the time of immediately post PCI. IVUS was performed in 35 patients at 10 - 12 months post conservative therapy, IVUS results showed that MLA increased significantly [ （7. 32 ± 1.42 ） mm^2 vs （4. 98 ±0. 89 ）mm^2, P 〈 0. 01 ], while plaque area [ （ 7.70 ± 2. 09） mm^2 vs. （ 10. 01± 2. 55 ） mm^2, P 〈 0. 05 ], plaque burden [ （ 55.94 ± 8.36 ） % vs. （ 67.97 ±9.36）% ] and low echo area [ （4. 08 ±0. 80）mm^2 vs. （2.27 ±0. 79）mm^2 ] were significantly decreased at follow up compared to those as baseline （all P 〈 0. 01 ）. There was one patient in PCI group with MLA ≥4.0 mm^2 developed acute in-stent thrombosis in left anterior descending artery two days after the procedure and 9 patients in conservative therapy and MLA 〈 4.0 mm^2 group received PCI due to recurrent angina pectoris during follow-up. Conclusions For the borderline lesion with MLA≥4. 0 mm^2 detected by IVUS, adequate medication could effectively attenuate and or reverse the plaque progression and stabilize plaque.