冠状动脉介入术对再发急性冠状动脉综合征介入治疗预后的影响分析

Impact of Previous Percutaneous Revascularization on Long-term Outcome of Repeat Coronary Intervention in Acute Coronary Syndrome Patients

目的探讨既往经皮冠状动脉介入治疗(Percutaneous Coronary Intervention,PCI)对再发急性冠脉综合征(Acute Coronary Syndrome,ACS)患者行再次介入治疗的有效性、安全性和对远期预后影响。方法连续纳入2013年1月至12月在阜外医院进行PCI治疗的ACS患者,分为既往PCI和非既往PCI两组,并进行倾向性评分匹配,并进行2年随访,记录死亡、心原性死亡、心肌梗死、再次血运重建、再发卒中、主要心脑血管不良事件(包括死亡、心肌梗死、再次血运重建及再发卒中)及支架内血栓的发生情况,对比两组的远期预后差别。结果共纳入6194例行PCI的ACS患者。既往PCI组共1256例,既往非PCI组共4938例。既往PCI组患者年龄更高,合并冠心病危险因素更多。2年随访结果显示,既往PCI组全因死亡率(2.3%vs.1.1%,p=0.001)、心原性死亡(1.7%vs.0.5%,p<0.001)、急性心肌梗死(2.7%vs.1.8%,p=0.040)及主要心脑血管不良事件(13.9%vs.11.8%,p=0.039)显著高于既往非PCI组,而血运重建、脑卒中及支架内血栓发生率没有显著差别。多因素COX回归分析发现:既往PCI、年龄、左室射血分数<40%及介入治疗不成功是全因死亡和心原性死亡的独立危险因素(p<0.05)。经过倾向性评分匹配后,两组在年龄、左室射血分数、介入治疗不成功等方面均无显著差异。多因素COX回归显示:年龄、左室射血分数低于40%及糖尿病史是全因死亡的独立危险因素(p<0.05),同时年龄、左室射血分数低于40%及介入治疗不成功是心原性死亡的独立危险因素(p<0.05),而既往PCI不再是全因死亡(HR=1.81,95%CI:0.99–3.28,p=0.051)和心原性死亡(HR=1.09,95%CI:1.04–1.14,p=0.062)的独立危险因素。结论在中国单中心大样本人群,对于有相同危险因素的患者,既往PCI不是再发ACS介入治疗远期预后不良的独立危险因素。

Objective To compare the long-term outcome in acute coronary syndrome（ACS） patients undergoing percutaneous coronary intervention（PCl） with or without previous PCI. Methods All consecutive ACS patients presenting for PCI between January, 2013 and December, 2013 in Fuwai hospital were included. We evaluated 2-years all-cause death, cardiac death, myocardial infarction, revascularization, stroke, major adverse cardiovascular and cercbrovascular events （including all-cause death, myocardial infarction, revascularization and stroke） and in-stent thrombosis following PCI and compared patients with previous PCI and without prcvious PCI. Results Of all 6194 consecutive patients, 1256（20.3% ） had previously undergone PCI, PCI patients were older and more often had clinical risk factors compared to patients without previous PCI. At 2-years follow-up, all-caused death（2.3% vs. 1.1%, p = 0.001）, cardiac death （1.7% vs. 0.5%, p 〈 0.001）, myocardial infarction（2.7% vs. 1.8%, p = 0.040）and major adverse cardiovascular and cerebrovascular events（MACCE） （13.9% vs. 11.8%, p = 0.039） rates were significantly higher in previous PCI patients than in patients without PCI. After multivariable COX analysis, age, left ventricular ejection 〈 40%, unsuccessful PCI and previous PCI were independent predictors of all-caused death and cardiac death（p 〈 0.05）. After propensity score matched analyses （2544 patients）, age, left ventricular ejection 〈 40% and diabetes mellitus were independent predictors of all-cause death（p 〈 0.05）, meanwhile age, left ventricular ejection 〈 40% and unsuccessful PCI were independent predictors of cardiac death（p 〈 0.05）. However, previous PCI use was no longer an independent predictor of all-caused death（HR = 1.81, 95%CI：0.99-3.28, p = 0.051）and cardiac death（HR = 1.09, 95%CI：1.04 -1.14, p = 0.062）. Conclusion Previous PCI was not an independent predictor for repcat coronary intervention in patients with acute coronary syndrome in the large single center og China.