IVUS-VH在罪犯病变为临界病变的急性冠脉综合征患者中的应用

Application of intravascular ultrasound-virtual histology in patients with acute coronary syndrome with culprit lesion as critical lesion

目的当冠状动脉(冠脉)造影显示罪犯病变为临界病变时,探讨急性冠脉综合征(ACS)患者斑块的血管内超声-虚拟组织学(IVUS-VH)特点及IVUS-VH对ACS患者是否介入治疗的指导意义。方法ACS并行冠脉造影检查提示罪犯病变为临界病变(管腔狭窄50%~70%)且完成IVUS-VH检查的患者102例(ACS组),诊断稳定型心绞痛(SA)、罪犯病变为临界病变并完成IVUS-VH的患者30例(SA组)。测量患者罪犯病变处最小管腔面积(MLA)、外弹力膜面积(EEM-CSA)、面积狭窄率(%AS),利用虚拟组织学分析斑块特点,测量坏死核心成分比例;在ACS组中根据IVUS MLA检查结果决定是否介入干预,并观察不同治疗策略组心绞痛复发、急性心肌梗死、靶病变血运重建、心源性死亡等主要心血管事件的发生率。结果SA、ACS患者MLA无统计学差异,ACS患者EEM-CSA、%AS、正性重构比例明显高于SA组,差异有统计学意义(P<0.05);且ACS组中斑块存在较普遍的不稳定情况,虚拟组织学分析显示,ACS组中斑块坏死组织大于10%的比例明显高于SA组,差异均有统计学意义(P<0.05);在ACS组中有54例患者予介入治疗,48例予以单纯药物治疗,随访半年,两组不同治疗策略的患者间心血管事件发生率无统计学差异(P>0.05)。结论当冠脉造影显示罪犯病变为临界病变时,ACS患者相比SA患者的病变处的外弹力膜面积、面积狭窄率、正性重构比例明显增高,斑块不稳定检出率增加,IVUS-VH可识别斑块的不稳定性,为临床治疗策略的制定提供参考依据。

Objective To investigate the characteristics of intravascular ultrasound-virtual histology(IVUS-VH)of plaques in patients with acute coronary syndrome(ACS),and discuss the guiding significance of IVUS-VH to ACS patients receiving or not receiving PCI when coronary angiography showed that culprit lesion became critical lesion.Methods ACS patients(n=102)were given examinations of coronary angiography(CAG)indicated that culprit lesion became critical lesion(luminal stenosis from 50%to70%)and IVUS-VH(ACS group).The patients(n=30)diagnosed as stable angina(SA)were given CAG examination indicated that culprit lesion became critical lesion and IVUS-VH(SA group).The minimal lumen area(MLA),external elastic membrane cross-sectional area(EEM-CSA)and area stenosis rate(%AS)were detected in culprit lesion position,plaque features were analyzed by using virtual histology,and component proportion of necrotic core(NC)was detected.In ACS group,PCI was determined by the results of IVUS and MLA.The incidence rates of angina recurrence,acute myocardial infarction(AMI),target lesion revascularization,cardiac death and other major cardiovascular events were observed in patients with different therapeutic strategies.Results MLA had no statistical difference between SA group and ACS group,and EEM-CSA,%AS and positive remodeling ratio were significantly higher in ACS group than those in SA group(P<0.05),and unstable plaques were generally observed in ACS group.The results of virtual histology analysis showed that the percentage of plaque necrotic tissue>10%was significantly higher in ACS group than that in SA group(P<0.05).There were 54 patients undergone PCI and 48 patients treated with drugs only in ACS group.After followed up for half year,the incidence rate of cardiovascular events had no statistical difference in patients with different therapeutic strategies(P>0.05).Conclusion When CAG results show that culprit lesion become critical lesion,EEM-CSA,%AS and percentage of positive remodeling ratio increase significantly,and detection rate of unstable plaques increased in ACS patients compared with SA patients.IVUS-VH can identify instability of plaque and provide reference for the formulation of clinical treatment strategies.