住院期间完全血运重建与仅罪犯血管血运重建对ST段抬高型心肌梗死合并多支血管病变患者远期预后的影响

Long-term Effect of the In-hospital Complete Revascularization Versus Infarct-related Artery Treatment Only PCI for ST-elevation Myocardial Infarction With Multivessel Disease

目的:比较住院期间经皮冠状动脉介入治疗(PCI)部分血运重建(IRA-only)和完全血运重建(CR)治疗急性ST段抬高型心肌梗死(STEMI)合并多支冠状动脉病变患者的远期预后。方法:回顾性分析2008年1月至2011年7月发病12 h内到达北京朝阳医院心脏中心并接受急诊PCI的592例合并多支冠状动脉病变的STEMI患者,在住院期间择期干预非罪犯血管为CR组(n=341),择期PCI平均延迟(5.2±2.2)天;未干预非罪犯病变的患者为IRA-only组(n=251)。所有患者置入药物洗脱支架。比较两组患者远期预后,其中主要不良心脑血管事件(MACCE)包括全因死亡、再发心肌梗死、脑卒中以及再次冠状动脉血运重建。结果:两组临床基线特征相似,具备可比性。随访7～10年,平均随访(105.0±13.6)个月期间,CR组MACCE发生率与IRA-only组无显著差异(21.2%vs 26.0%,P=0.26),两组死亡、脑卒中及再发心肌梗死无显著差异,IRAonly组仅再次血运重建率显著高于CR组(21.5%vs 14.8%,OR=1.48,95%CI:1.01～2.18,P=0.04),主要表现在非罪犯血管再次血运重建率较高(14.6%vs 5.7%, OR=2.69,95%CI:1.54～4.69,P<0.001)。结论:对于已经接受急诊PCI合并多支血管病变的STEMI患者,住院期间择期干预非罪犯病变血管未降低远期MACCE。

Objectives: To compare the long-term results of the in-hospital complete revascularization(CR)or the infarct-related artery(IRA) treatment only for patients with ST segment elevation myocardial infarction(STEMI) and multivessel disease.Methods: Clinical data from 592 STEMI with multivesel disease who received emergent PCI between January 2008 and July 2011 in our hospital were retrospectively analyzed. Patients were divided into complete revascularization(CR) group(n=341) and IRA-only group(n=251). Complete revascularization in non-culprit coronary arteries was performed in a separate procedure with an average delay of(5.2±2.2) days before discharge. All cases in the two groups were deployed with drugeluting stent(DES). Patients were followed up for 7 to 10 years. The primary endpoint was major adverse cardiovascular and cerebral events(MACCE) including all-cause death, recurrent myocardial infarction(MI), stroke and revascularization.Results: Baseline characteristics of patients in the two groups were comparable. During a mean of(105.0±13.6) months follow-up, MACCE occurred in 21.2% patients of the CR group versus 26.0% in the IRA-only revascularization group(P=0.26).No significant differences were found in all-cause death, recurrent myocardial infarction(MI) and stroke between the two groups. A higher rate of revascularization was evidenced in IRA-only group(21.5% vs 14.8%, OR=1.48, 95%CI: 1.01-2.18,P=0.04). Subgroup analysis showed that revascularization mainly involved the non-culprit arteries(14.6% vs 5.7%, OR=2.69,95% CI: 1.54-4.69, P<0.001)but not in culprit arteries(6.1% vs 8.2%,OR=0.73, 95% CI:0.38-1.38,P=0.35).Conclusions: Complete revascularization before discharge does not supply additional benefit on long time MACCE as compared with IRA-only intervention strategy in patients presenting with STEMI for primary PCI with multivessel disease.