急性心肌梗死急诊冠状动脉介入治疗后非梗死相关血管病变的处理策略

Strategy for non -infarction related artery post primary percutaneous coronary intervention in acute myocardial infarction

目的：对急性心肌梗死（ AMI）合并冠状动脉多支血管病变（ MVD）患者，评估非梗死相关血管（ non-IRA）的干预策略。方法本研究为前瞻性随机对照研究，选择2009-01～2011-06成功行急诊冠状动脉介入治疗（ PCI）的302例符合入选标准AMI合并MVD患者，随机分为A组：近期（ AMI后7～10 d） PCI干预non-IRA病变和B组：根据缺血证据行non-IRA PCI治疗。强调两组患者均根据指南施行最优化药物治疗。主要终点事件为再发心肌梗死、靶血管重建（ TVR）和心因性死亡，次要终点事件为心因性再住院、心绞痛、心力衰竭、缺血相关的PCI治疗。结果共计288例患者完成24个月随访，A组145例，B组143例。其中A组和B组分别有12例和15例患者发生了主要终点事件（ P＝0．519），次要终点事件B组明显高于A组。在处理non-IRA过程中，两组均无围术期死亡发生。结论优化药物治疗基础上，AMI合并MVD患者近期干预non-IRA是安全的，能够明显降低心绞痛再发、心因性再住院和PCI的风险。但不能降低再梗死、靶血管重建、心因性死亡和心力衰竭的风险。

Objective To evaluate short -term percutaneous coronary intervention （PCI） for non-infarction related artery （ IRA） compared with ischemia related PCI accompanied with optimized medical therapy in acute myocardial infarction （ AMI） and multivessel disease .Methods From January 2009 to June 2011 , a total of 302 patients with AMI and mutivessel disease were enrolled in this retrospective study .These patients underwent primary PCI and were randomly assigned to group A （ staged PCI for non-IRA within 7-10 days after AMI ） and group B （ no staged PCI group ） .In group B, subsequent PCI for non -IRA was recommended only for ischemia evidence .Optimized medical therapy was administrated for all of patients according to clinical guideline .The primary outcome was recurrence of myocardial infarction , target vessel revascularization （ TVR） and death from cardiac causes in 24 months follow -up.The secondary outcomes were PCI for ischemia , heart failure, angina and rehospitalization from cardiac causes .Results After 24 months follow-up visit, 288 patients finished the experiment in group A （145 patients） and group B （143 patients）.The primary outcome occurred in 12 patients in group A and in 15 patients in group B （P=0.519）.There was no patient dead in the PCI operation for non-IRA in two groups .But the secondary outcomes were obviously higher in group B than those in group A , inclusive revascularization , heart failure , refractory angina and rehospitalization . Conclusion In patients with AMI and multivessel coronary artery disease undergoing primary PCI , staged PCI within 7-10 days for non-IRA is safe and decrease the risk of revascularization , angina and rehospitalization .But staged PCI dose not reduce the risk of death from cardiac causes , myocardial infarction and heart failure .