术后即刻基于计算流体力学的造影血流储备分数对冠心病患者临床结局的影响

The prognosis value of angiography-derived fractional flow reserve on the cardiovascular risk of patients who have underwent the percutaneous intervention

目的探讨经皮冠状动脉介入治疗(PCI)术后即刻基于计算流体力学的造影血流储备分数(post-PCI caFFR)对冠心病患者临床预后意义。方法回顾性入选CAF研究队列中2013年8月至2020年12月在北京大学第一医院完成冠状动脉CT血管造影检查后行PCI的冠心病患者729例。采集患者人群基线信息,测量post-PCI caFFR,并采集随访信息。以主要不良心血管事件(MACE,包括心原性死亡、非致死性心肌梗死和缺血驱动的血运重建)为主要研究终点。次要研究终点为全因死亡、任何原因的血运重建。通过时间依赖的受试者工作特征(ROC)曲线计算预测MACE风险最佳post-PCI caFFR值,根据该值进行分组。绘制不同组别MACE的Kaplan-Meier曲线。使用Cox比例风险模型分析post-PCI caFFR与临床各结局指标的关系。结果729例患者中,男性517例(70.92%),平均年龄(64.40±10.31)岁。平均随访(4.29±2.11)年中,共14例(1.92%)患者失访。ROC曲线分析显示post-PCI caFFR最佳界值为0.86,424例患者post-PCI caFFR>0.86。Post-PCI caFFR>0.86的患者发生MACE风险显著低于post-PCI caFFR≤0.86的患者(7.00%比14.62%,P=0.001),其中缺血驱动的血运重建风险降低为主要驱动因素(6.52%比11.63%,P=0.017)。此外,post-PCI caFFR>0.86的患者发生任何原因的血运重建的风险也显著低于post-PCI caFFR≤0.86的患者(13.53%比19.60%,P=0.029)。通过Cox比例风险模型post-PCI caFFR≤0.86对临床结局的影响进行单因素和多因素回归分析,结果提示post-PCI caFFR≤0.86是临床结局的独立影响因素。经多因素调整后post-PCI caFFR≤0.86的患者MACE发生风险升高1.33倍(HR 2.33,95%CI 1.44~3.77,P=0.001),非致死性心肌梗死的发生风险升高2.06倍(HR 3.06,95%CI 1.06~8.80,P=0.038),任何原因的血运重建的发生风险升高0.54倍(HR 1.54,95%CI 1.06~2.24,P=0.023)。结论post-PCI caFFR≤0.86的患者MACE风险显著增加,主要由缺血驱动的血运重建导致,提示post-PCI caFFR对预后的预测价值。

Objective The aim of the study is to investigate the prognosis value of angiographyderived fractional fl ow reserve on the cardiovascular risk of patients who have underwent the percutaneous coronary intervention(PCI).Methods This study retrospectively enrolled 729 patients from CAF(CT-derived and angiography-derived fractional fl ow reserve in guiding revascularization in patients with coronary artery disease)study cohort who underwent coronary angiography and PCI in Peking University First Hospital within 30 days after coronary CT angiography from August 2013 to December 2020.Baseline characteristics of patients and target vessel,information of medication,revascularization and followup were collected.The original images of coronary angiography were desensitized.The analysis of caFFR(computational pressure-flow dynamics derived angiography fractional flow reserve)were performed independently in the core laboratory.The primary endpoint of the study was major adverse cardiovascular events(MACE),including cardiac death,nonfatal myocardial infarction(MI)and ischemia-driven revascularization.The second endpoint was all-cause mortality and revascularization from any cause.The cutoff value of post-PCI caFFR for MACE was analyzed using ROC curve.Patients were then classifi ed by caFFR cutoff value.Kaplan-meier curves of MACE in the two groups were drawn and Cox proportional risk model was used to analyze the relationship between caFFR immediately post-PCI and each clinical outcome indicator.Results We included 729 patients with coronary artery disease who underwent PCI,with an average age of(64.40±10.31)years and 517 male patients(70.92%).14(1.92%)patients were lost to follow-up.Our study found that the optimal caFFR value immediately post-PCI for predicting MACE was 0.86.The incidence of MACE in patients with post-PCI caFFR≤0.86 was signifi cantly higher than that in patients with post-PCI caFFR>0.86(14.62%vs.7.00%,P=0.001),mainly driven by ischemic-driven revascularization.In addition,the risk of revascularization for any cause was signifi cantly increased in the post-PCI caFFR≤0.86 group than post-PCI caFFR>0.86 group(19.60%vs.13.53%,P=0.029).Τhe result of Cox proportional risk model showed that post-PCI caFFR≤0.86 was an independent risk factor of clinical outcome.As compared with post-PCI caFFR>0.86,post-PCI caFFR≤0.86 was associated with an increased risk of MACE(HR 2.33,95%CI 1.44–3.77,P=0.001),nonfatal MI(HR 3.06,95%CI 1.06–8.80,P=0.038)and revascularization from any cause(HR 1.54,95%CI 1.06–2.24,P=0.023).Conclusions Patients with post-PCI caFFR≤0.86 had a signifi cantly higher risk of MACE,suggesting the predictive value of post-PCI caFFR for prognosis in clinical practice.