不完全纠正心肌缺血对接受血管重建术患者长期预后的影响

Impact for Incomplete Correction of Myocardial Ischemia on Long-term Prognosis in Patients With Revascularization

目的:冠心病患者是否针对心肌灌注显像(MPI)心肌缺血节段所对应的冠状动脉病变均接受了血管重建术(RVS),比较其预后的不同,与根据冠状动脉造影(CAG)显示的冠状动脉病变是否得到完全血管化治疗的预后进行对比研究,探讨两种不同影像技术对指导RVS治疗方案制定的临床价值。方法:对2007-10至2010-12期间在阜外医院行MPI提示有心肌缺血,并在3个月内在我院接受RVS的患者进行回顾性随访。共202例患者入选,根据CAG标准将患者分为完全血管化组(CAG_(CR)组,n=99)和不完全血管化组(CAG_(IR)组,n=103)。根据MPI心肌缺血节段所对应的冠状动脉病变是否均接受RVS,分为心肌缺血完全纠正组(MPI_(CR)组,n=112)和心肌缺血不完全纠正组(MPI_(IR)组,n=90)。死亡为第一随访终点,主要不良心血管事件(MACE,包括死亡、急性心肌梗死或再次RVS)为第二随访终点。随访时间为(46±21)个月。结果:CAG_(CR)组的死亡率低于CAG_(IR)组[4.0%(4/99) vs 11.7%(12/103),P=0.025],CAG_(CR)组与CAG_(IR)组的MACE发生率的差异无统计学意义[15.4%(15/99) vs 18.5%(19/103),P=0.28]。MPICR组的死亡率[3.6%(4/112) vs 13.3%(12/90),P=0.005]和MACE发生率[12.6%(14/112) vs 22.6%(20/90),P=0.004]均明显低于MPI_(IR)组。Cox多因素回归分析显示MPI指导下的心肌缺血纠正不完全是预测死亡的独立危险因子[危险比(HR)=4.02,95%可信区间(CI):1.13~12.55,P=0.017]和预测MACE的唯一独立危险因子(HR=2.67,95%CI:1.31~5.40,P=0.006)。结论:对有心肌缺血接受RVS的冠心病患者,应该重视针对心肌缺血节段所对应的"罪犯血管"早期进行完全血管化治疗,达到完全纠正和改善心肌缺血,从而改善患者的长期预后。

Objective： To compare the prognosis between complete and incomplete revasculaization（RVS） based on myocardial perfusion imaging（MPI） and coronary angiography（CAG） in patients with coronary artery disease（CAD）.Methods： A total of 202 patients with MPI confirmed myocardial ischemia and received RVS within 3 months of diagnosis in our hospital from 2007-10 to 2010-12 were retrospectively studied. Based on CAG and MPI examinations, the patients were divided into 2 sets of groups：（1）CAG_（CR） group, n=99 patients with complete revasculaizationand CAGIRgroup, n=103 patients with incomplete revasculaization;（2） MPI_（CR） group, n=112 and MPI_（IR） group, n=90. The mean follow-up time was（46±21） months and the 1^（st） end point event was death, the 2^（nd） was the occurrence rate of MACE including death, acute myocardial infarction（AMI） or re-RVS.Results： The mortality in CAG_（CR） group was lower than CAG_（IR） group, 4.0%（4/99） vs 11.7%（12/103）, P=0.025; while the occurrence rate of MACE was similar between 2 groups, 15.4% vs 18.5%, P=0.28. Compared with MPI_（IR） group, MPI_（CR） group had decreased mortality 3.6%（4/112） vs 13.3%（12/90）, P=0.005 and reduces occurrence rate of MACE 12.6% vs 22.6%, P=0.004. Multivariate Cox hazard regression analysis indicated that incomplete correction of myocardial ischemia by MPI was an independent predictor for death（HR=4.02, 95% CI1.13-12.55, P=0.017） and for MACE（HR=2.67, 95% CI 1.31-5.40, P=0.006）.Conclusion：It is important to identify theculprit vessel in relevant myocardial segment and perform complete RVS at the early stage, therefore, improve myocardial ischemia and prognosis in CAD patients for RVS.