不同完全血运重建策略对急性ST段抬高型心肌梗死多支病变患者预后影响

Impact of different strategies of complete percutaneous revascularization on prognosis of patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease

目的探讨不同完全血运重建策略对急性ST段抬高型心肌梗死(STEMI)多支病变患者预后的影响。方法选取自2009年1月至2014年6月空军军医大学附属西京医院收治的发病时间在12 h以内行完全血运重建的131例STEMI多支病变患者为研究对象。根据完全血运重建时机(非梗死相关血管重建时机)将研究对象进一步分为急诊经皮冠状动脉介入术(PCI)干预梗死相关血管后同台干预非梗死相关血管组(MV-PCI,n=21)、7 d内择期干预非梗死相关血管组(7 d stagedPCI,n=82)以及8~60 d择期干预非梗死相关血管组(60 d staged-PCI,n=28)。比较3组的主要研究终点,包括首次或二次PCI术后3年内主要不良心血管事件(MACE),定义为包括心源性死亡、再发心肌梗死、缺血驱动血运重建及心力衰竭的复合终点;次要研究终点,包括主要终点中各独立组份以及全因死亡、顽固性心绞痛及全部出血事件(BARC 1~5型)。结果所有患者均获得3年的随访,MV-PCI组、7 d staged-PCI组与60 d staged-PCI组MACE的发生率比较,差异无统计学意义(P>0.05),但60 d staged-PCI组的MACE(7.1%比19.0%、20.7%)、缺血驱动血运重建(7.1%比19.0%、15.9%)及全部出血事件(BARC 1~5型)(0比4.8%、4.9%)的发生率在数值上显著低于MV-PCI组和7 d staged-PCI组,且60 d staged-PCI组MACE出现的时间明显晚于其他两组。结论对STEMI多支病变患者在急诊PCI开通梗死相关血管后8~60 d干预非梗死相关血管的完全血运重建策略有使MACE、缺血驱动血运重建及出血事件的发生风险下降的趋势。

Objective To investigate the impact of different strategies of complete percutaneous revascularization on prognosis in patients presented with ST-segment elevation myocardial infarction（ STEMI） and multivessel disease（ MVD）. Methods A retrospective study was performed on 131 cases of patients with STEMI and MVD who were admitted and underwent complete percutaneous revascularization（ CPR） from January 2009 to June 2014. According to the timing of CPR（ timing of non-infarction related vascular reconstruction）,patients were divided into groups in which patients received non-culprit arteries revascularization during the same procedure as the primary PCI（ MV-PCI group,n = 21）,underwent revascularization of the non-culprit arteries at 1-7 days（ 7 days staged-PCI group,n = 82） and 8-60 days（ 60 days staged-PCI group,n = 28） after the primary PCI according to the timing of PCI for the non-culprit arteries. The primary endpoint was a composite of cardiac death,recurrent myocardial infarction,ischemia-driven revascularization and heart failure within 3 years. Other endpoints included the components of the primary endpoints,all-cause death,refractory angina and all bleedings（ BARC 1-5） at 3 years follow-up. Results All the patients were followed up for 3 years. The comparison of MV-PCI,7 days staged-PCI and 60 days staged-PCI groups had no statistically significant difference in the prespecified endpoints（ P〉0. 05）. The rates of MACE（ 7. 1% versus 19. 0%,20. 7%）,ischemia-driven revascularization（ 7. 1% versus 19. 0%,15. 9%） and all bleedings（ BARC1-5）（ 0 versus 4. 8%,4. 9%） of 60 days staged-PCI group were significantly lower than those in the other two groups. The MACE of 60 days staged-PCI group occurred later than that in the other two groups. Conclusion The strategy of 60 days staged-PCI tends to reduce the rates of MACE,ischemia-driven revascularization or all bleedings（ BARC 1-5） for patients with STEMI and MVD.