IVUS指导DES置入在ACS患者中的长期预后评价:ULTIMATE研究ACS亚组分析

Long-term outcomes of intravascular ultrasound-guided drug-eluting stents implantation in patients with acute coronary syndrome:ULTIMATE ACS subgroup

目的评估血管内超声(IVUS)指导药物洗脱支架(DES)置入对急性冠脉综合征(ACS)患者长期临床结局的影响。方法研究对象来源于ULTIMATE研究,该研究是一项前瞻性、多中心、随机对照研究,于2014年8月—2017年5月在国内8家医院入选1448例置入DES的冠心病患者。本研究为ULTIMATE研究的亚组分析,将冠心病患者分为ACS组和非ACS组,2组患者均在IVUS或冠状动脉造影指导下置入DES。主要终点是术后3年靶血管失败(TVF)率,包含心原性死亡、靶血管心肌梗死和临床驱动的靶血管血运重建。结果1448例冠心病患者中,ACS组1136例(78.5%),1423例(98.3%)患者完成术后3年随访。ACS组患者术后3年的TVF发生率为9.6%(109/1136),高于非ACS组的4.5%(14/312),log-rankP=0.005。ACS组中IVUS指导下置入DES者的TVF发生率低于冠状动脉造影指导下置入DES架者[7.6%(43/569)比11.6%(66/567),log-rankP=0.019]。ACS组中IVUS指导下DES置入达标组患者术后3年的TVF发生率为5.4%(16/296),低于IVUS未达标组的9.9%(27/273),log-rankP=0.041。结论ACS患者置入DES后3年的TVF事件率高于无ACS患者;相比于冠状动脉造影,IVUS指导DES置入可以降低ACS患者术后3年的TVF事件,尤其是IVUS指导下DES置入达标的患者获益更明显。

Objective To explore the long-term effects of intravascular ultrasound(IVUS)guidance on patients with acute coronary syndrome(ACS)undergoing drug-eluting stents(DES)implantation.Methods Data used in this study derived from ULTIMATE trial,which was a prospective,multicenter,randomized study.A total of 1448 all-comer patients were enrolled between 2014 August and 2017 May.Primary endpoint of this study was target vessel failure(TVF)at 3 years,including cardiac death,target-vessel-related myocardial infarction,and clinically-driven target vessel revascularization.Results ACS was present in 1136(78.5%)patients,and 3-year clinical follow-up was available in 1423 patients(98.3%).TVF in the ACS group was 9.6%(109/1136),which was significantly higher than 4.5%(14/312)in the non-ACS group(log-rank P=0.005).There were 109 TVFs in the ACS patients,with 7.6%(43/569)TVFs in the IVUS group and 11.6%(66/567)TVFs in the angiography group(log-rank P=0.019).Moreover,patients with optimal IVUS guidance were associated with a lower risk of 3-year TVF compared to those with suboptimal IVUS results(5.4%(16/296)vs.9.9%(27/273),log-rank P=0.041).Conclusions This ULTIMATE-ACS subgroup analysis showed that ACS patients undergoing DES implantation were associated with a higher risk of 3-year TVF.More importantly,the risk of TVF could be significantly decreased through IVUS guidance in patients with ACS,especially in those who had an IVUS-defined optimal procedure.