血管内超声对急性冠脉综合征患者长支架植入预后的预测价值

The predictive value of intravascular ultrasound on the prognosis of long stent for patients with acute coronary syndrome

目的既往关于支架扩张阈值预测预后的研究鲜有报道。文中探讨血管内超声(IVUS)对急性冠脉综合征(ACS)患者长支架植入预后的预测价值。方法回顾性选择本院收治的157例急性冠脉综合征(ACS)患者,均接受雷帕霉素洗脱支架(≥28 mm)植入治疗,随访术后18个月主要心血管不良事件(MACE)的发生情况。比较MACE组和非MACE组临床、病变和手术特征,分析干预后IVUS相关参数对MACE的预测价值。结果随访18个月期间,接受支架植入治疗的157例ACS患者中共有9例(5.7%)发生MACE。其中,2例心源性死亡,7例靶病变相关心肌梗死或靶病变血运重建。MACE组和非MACE组临床特征差异无统计学意义(P>0.05)。在干预后定量冠脉造影分析中,与MACE组相比,非MACE组最小管腔直径更大[(0.9±0.5)mm vs(0.9±0.4)mm,P<0.05],直径狭窄率更低[(20.5±4.7)%vs(38.9±15.4)%,P<0.05]。在干预后IVUS分析中,与MACE组相比,非MACE组MLA、MLA与远端参考段管腔面积比、MLA与平均参考段管腔面积比更大(P<0.05)。二分类Logistic回归分析显示,MACE的独立预测因子包括干预后MLA、MLA与远端参考段管腔面积比(P<0.05)。MLA、MLA与远端参考段管腔面积比预测MACE的ROC曲线下面积分别为0.825(95%CI:0.724~0.927,P=0.001)和0.800(95%CI:0.688~0.912,P=0.003)。当MLA、MLA与远端参考段管腔面积比分别取值5.520 mm 2和0.885时,约登指数最大(分别为0.601和0.531),敏感度分别为100.0%和88.9%,特异度分别为60.1%和64.2%。干预后IVUS测量的MLA与干预前冠脉造影测量的远端参考段管腔直径呈正相关(r=0.673,P<0.001)。干预后MLA/远端参考段管腔面积与干预前远端参考段管腔直径无相关性(r=-0.063,P=0.432)。结论干预后MLA、MLA与远端参考段管腔面积比是ACS患者长支架植入后发生MACE的独立预测因素。干预后IVUS测量的MLA与干预前远端参考段管腔直径有关。

Objective In literature,the prognosis predicted by the threshold of the expansion of stents is barely reported.This article aims to explore the predictive value of intravascular ultrasound(IVUS)on the prognosis of the long stents for patients with the acute coronary syndrome(ACS).Methods A retrospective study was conducted on 157 patients with ACS admitted to our hospital.The patients were treated with rapamycin-eluting stent(≥28 mm)implantation.Within 18 months after the operation,the occurrence of major cardiovascular adverse events(MACE)was followed up.The clinical,pathological and surgical characteristics of patients in the MACE group and non-MACE group were compared,and the predictive value of IVUS related parameters for MACE after intervention was analyzed.Results During the 18 months follow-up period,9(5.7%)of the 157 patients had MACE,including 2 cases of cardiogenic death,and 7 cases of target lesion-related myocardial infarction or target lesion revascularization.There was no significant difference in clinical characteristics between the MACE group and the non-MACE group(P>0.05).In the quantitative coronary angiography analysis after intervention,compared with the MACE group,the non-MACE group had a larger minimum lumen diameter and a lower diameter stenosis rate(P<0.05).In the post-intervention IVUS analysis,compared with the MACE group,the MLA,the ratio of MLA to the distal reference segment lumen area,and the ratio of MLA to the average reference segment lumen area in the non-MACE group were higher(P<0.05).The binary logistic regression analysis showed that the independent predictors of MACE included the MLA,and the ratio of MLA to distal reference segment lumen area after intervention(P<0.05).The area under the ROC curve predicted the MACE by the MLA and the ratio of MLA to distal reference segment lumen area were 0.825(95%CI:0.724~0.927,P=0.001)and 0.800(95%CI:0.688~0.912,P=0.003),respectively.When the MLA,and the ratio of MLA to distal reference segment lumen area were 5.520 mm 2 and 0.885,the Youden index were the largest(0.601 and 0.531),the sensitivities were 100.0%and 88.9%,and the specificities were 60.1%and 64.2%.The MLA measured by IVUS after the intervention was positively correlated with the lumen diameter of the distal reference segment measured by the coronary angiography before the intervention(r=0.673,P<0.001).There was no correlation between the lumen area of the MLA/distal reference segment after intervention and the diameter of the distal reference segment before intervention(r=-0.063,P=0.432).Conclusion The MLA,the ratio of MLA to distal reference segment lumen area after intervention are independent risk factors of the MACE caused by the implantation of long stents on patients with the acute coronary syndrome.The MLA measured by IVUS after the intervention is related to the lumen diameter of the distal reference segment before the intervention.