SYNTAX-Ⅱ评分对慢性完全闭塞病变PCI术后患者远期预后的预测价值

Predictive value of SYNTAX-Ⅱscore on prognosis of patients with chronic total occlusion undergoing percutaneous coronary intervention

目的探讨SYNTAX-Ⅱ评分对接受经皮冠状动脉介入治疗(PCI)的冠状动脉慢性完全闭塞(CTO)病变患者的远期预后的预测价值。方法本研究为回顾性研究。入选2010年1月至2013年12月于中国医学科学院阜外医院接受PCI治疗且存在至少1处CTO病变的患者。计算纳入患者的SYNTAX-Ⅱ评分,依据SYNTAX-Ⅱ评分采用三分位数法将纳入患者分为3组,即SYNTAX-Ⅱ≤20、20<SYNTAX-Ⅱ≤27和SYNTAX-Ⅱ>27组。主要终点为主要不良心脑血管事件(MACCE),定义为包括全因死亡、心肌梗死、卒中和血运重建的复合事件。次要终点包括支架内血栓、心力衰竭和靶病变失败(TLF)。分别于术后1、6个月,1年对纳入患者进行门诊或电话随访,此后每年进行1次直至术后5年。比较3组PCI术后5年终点事件的发生率,使用多因素Cox回归模型分析CTO病变患者在PCI术后全因死亡的独立危险因素,绘制受试者工作特征(ROC)曲线,计算曲线下面积(AUC),比较SYNTAX评分与SYNTAX-Ⅱ评分对全因死亡的预测能力。结果共纳入2391例接受PCI治疗的CTO病变患者,年龄(57.0±10.5)岁,其中男性1994例(83.40%)。SYNTAX-Ⅱ≤20组802例,20<SYNTAX-Ⅱ≤27组798例,SYNTAX-Ⅱ>27组791例。5年随访结束时3组的失访率分别为9.10%(73/802)、10.78%(86/798)和8.85%(70/791)。在全因死亡[1.78%(13/729)比3.65%(26/712)比9.02%(65/721),P<0.001]、心原性死亡[1.37%(10/729)比2.11%(15/712)比4.85%(35/721),P<0.001]、靶血管心肌梗死[4.25%(31/729)比4.49%(32/712)比7.07%(51/721),P=0.03]、可能的支架内血栓[1.51%(11/729)比2.81%(20/712)比3.61%(26/721),P=0.04]、心力衰竭[1.78%(13/729)比1.97%(14/712)比5.41%(39/721),P<0.001]发生率方面,3组间比较差异均有统计学意义。多因素Cox回归分析结果显示,女性(HR=2.05,95%CI 1.12~3.73,P=0.01)、左心室射血分数(HR=0.97,95%CI 0.95~1.00,P=0.05)和SYNTAXⅡ评分(HR=1.07,95%CI 1.02~1.11,P=0.01)是冠状动脉CTO病变患者PCI术后5年全因死亡事件的独立影响因素。ROC曲线显示SYNTAX-Ⅱ评分对CTO病变患者PCI术后全因死亡的预测能力高于SYNTAX评分(AUC:0.71比0.60,P=0.003)。结论在接受PCI治疗的CTO病变患者中,SYNTAX-Ⅱ评分是PCI术后5年全因死亡的独立危险因素,对PCI术后全因死亡风险具有一定预测价值。

Objective To investigate the predictive value of SYNTAX-Ⅱscore on long term prognosis of patients diagnosed with chronic total occlusion(CTO)and received percutaneous coronary intervention(PCI).Methods Patients undergoing CTO-PCI in Fuwai hospital from January 2010 to December 2013 were enrolled in this retrospective analysis.The SYNTAX-Ⅱscore of the patients was calculated.According to SYNTAX-Ⅱscore tertiles,patients were stratified as follows:SYNTAX-Ⅱ≤20,20<SYNTAX-Ⅱ≤27,SYNTAX-Ⅱ>27.Primary endpoint was major adverse cardiac events(MACCE),including all-cause death,myocardial infarction,stroke and any revascularization.Secondary endpoints included stent thrombosis,heart failure and target lesion failure(TLF).Patients were followed up by outpatient visit or telephone call at 1 month,6 months and 1 year after PCI,and annually up to 5 years.Multivariate Cox regression model was used to analyze the independent risk factors of all-cause death in patients undergoing CTO-PCI.The predictive value of SYNTAX score with SYNTAX-Ⅱscore for all-cause death was evaluated by the receiver operating characteristic(ROC)curve and the area under the curve(AUC).Results A total of 2391 patients with CTO and received PCI were enrolled in this study.The mean age was(57.0±10.5)years,1994(83.40%)patients were male.There were 802 patients in lower tertile group(SYNTAX-Ⅱ≤20),798 patients in intermediate group(20<SYNTAX-Ⅱ≤27)and 791 patients in upper tertile group(SYNTAX-Ⅱ>27).At the end of 5-year follow-up,the loss to follow-up rate of the three groups was 9.10%(73/802),10.78%(86/798)and 8.85%(70/791),respectively.The rate of all-cause mortality(1.78%(13/729)vs.3.65%(26/712)vs.9.02%(65/721),P<0.001),cardiac death(1.37%(10/729)vs.2.11%(15/712)vs.4.85%(35/721),P<0.001),target vessel myocardial infarctions(4.25%(31/729)vs.4.49%(32/712)vs.7.07%(51/721),P=0.03),probable stent thrombosis(1.51%(11/729)vs.2.81%(20/712)vs.3.61%(26/721),P=0.04)and heart failure(1.78%(13/729)vs.1.97%(14/712)vs.5.41%(39/721),P<0.001)increased in proportion to increasing SYNTAX-Ⅱscore(all P<0.05).Multivariable Cox regression analysis indicated that female(HR=2.05,95%CI 1.12-3.73,P=0.01),left ventricular ejection fraction(HR=0.97,95%CI 0.95-1.00,P=0.05)and SYNTAX-Ⅱscore(HR=1.07,95%CI 1.02-1.11,P=0.01)were independent predictors for all-cause mortality in patients undergoing CTO-PCI.The predicted value of the SYNTAX-Ⅱscore for all-cause death was significantly higher than the SYNTAX score(AUC 0.71 vs.0.60,P=0.003).Conclusion For CTO patients who underwent percutaneous coronary intervention,SYNTAX-Ⅱscore is an independent predictor for 5-year all-cause death,and SYNTAX-Ⅱserves as an important predictor for all-cause death in these patients.