冠状动脉慢性完全闭塞性病变治疗策略选择的相关影响因素

目的从临床基线资料、病变影像学特征等方面,对影响冠状动脉慢性完全闭塞性(CTO)病变治疗策略选择的相关因素进行探讨。方法 2004年1月—2008年12月在复旦大学附属中山医院经冠状动脉造影检查发现的完全闭塞性病变患者1485例,其中638例确诊为CTO病变,平均年龄为(64.1±11.0)岁。依据首选经皮冠状动脉介入治疗(PCI)、行冠状动脉旁路移植术(CABG)或因无法耐受手术而接受单纯药物治疗将患者分为PCI组(447例)和非PCI组(191例),比较两组间临床基线资料及病变特点等方面的差异。结果 PCI组患者的平均年龄为(63.4±10.4)岁,显著小于非PCI组的(65.7±12.0)岁(P<0.05);中位胸痛时间为160(24,262)周,显著短于非PCI组的242(40,382)周(P<0.05);两组间性别构成及高血压、高血脂、心肌梗死、糖尿病患者的构成比的差异均无统计学意义(P值均>0.05)。PCI组患者的总胆固醇及低密度脂蛋白胆固醇水平分别为(4.18±1.1)和(2.28±1.00)mmol/L,均显著低于非PCI组的(4.39±1.19)及(2.55±1.08)mmol/L(P值分别<0.05、0.01);两组间血清葡萄糖、三酰甘油、高密度脂蛋白胆固醇、肌钙蛋白T、肌酸激酶同工酶和氨基末端脑钠素前体水平的差异均无统计学意义(P值均>0.05)。PCI组冠状动脉造影检查示近段血管严重迂曲、病变钙化、靶血管开口闭塞,以及合并三支病变、左主干病变及靶血管外闭塞的发生率均显著低于非PCI组(P值均<0.01);而闭塞端缺如的发生率显著高于非PCI组(P<0.01)。多元逐步Logistic回归分析结果显示,胸痛时间>3年(OR=0.998,95%CI0.997～1.000,P=0.004)、合并三支病变(OR=0.288,95%CI0.172～0.482,P=0.000)及靶血管开口闭塞(OR=0.288,95%CI0.172～0.482,P=0.000)为CTO病变行PCI的独立负性预测因素。结论胸痛时间>3年、靶血管开口闭塞、合并三支病变为CTO病变行PCI的独立负性预测因素,应权衡患者的临床因素及病变特点选择个体化的治疗策略。

Factors influecing selection of different treatment strategies for patients with chronic total occlusion in coronary artery

Objective To evaluate the influencing factors concerning clinic data and lesion imaging features for the choice of different treatments in patients with chronic totally occlusion(CTO) in coronary artery.Methods We identified 1 485 patients with totally occluded coronary arteries by arteriography from January 2004 to December 2008.Of them,638 patients with an average age of(64.1±11.0) years were affirmed as CTO.The patients were divided into percutaneous coronary intervention(PCI) group(n=447) and non-PCI group(n=191,coronary artery bypass grafting or drug treatment) according to the primary treatment strategy.The clinical baseline data and characteristics of target lesions were compared between the two groups.Results Compared with those with CABG or drug treatment,the patients treated by PCI were much younger(63.4±10.4] years vs.65.7±12.0] years,P<0.05),suffered from less angina(160 24,262] weeks vs.242 40,382] weeks,P<0.05),and had lower levels of total cholesterol and low density lipoprotein cholesterol(4.18±1.1] mmol/L vs.4.39±1.19] mmol/L,P<0.05;2.28±1.00] mmol/L vs.2.55±1.08] mmo/L,P<0.01).There were no significant differences in constituent ratios of gender and other diseases(hypertension,hyperlipemia,myocardial infarction and diabetes mellitus) and the results of laboratory examination(serum glucose,triacylglycerol,high density lipoprotein cholesterol,troponin T,creatine kinase isozyme and N terminal brain natriuretic peptide prosoma) between the two groups(P>0.05).Arteriography showed that the incidence rates of severe tortuosity of proximal vessel,calcification,ostial occlusion of target vessel,multivessel disease,left main coronary artery disease and exterior occlusion of target vessel in PCI group were significantly lower than those in non-PCI group(P<0.01),but the incidence rate of occlusion absence in PCI group was significantly higher than that in non-PCI group(P<0.01).Logistic regression analysis revealed that angina lasting more than 3 years(OR=0.998,95%CI 0.997-1.000,P=0.004),complicated with multivessel disease(OR=0.288,95%CI 0.172-0.482,P=0.000) and ostial occlusion of target vessel(OR=0.288,95%CI 0.172-0.482,P=0.000) were the independent negative predictors of PCI for CTO.Conclusion Angina lasting more than 3 years,ostial occlusion of target vessel and presence of multivessel disease are independent negative predictors of PCI for CTO.Appropriate strategy should be made on the basis of clinical features and characteristics of target lesions.