急性ST段抬高型心肌梗死多支病变患者血运重建策略

急性ST段抬高型心肌梗死（ST-segment elevation myocardial infarction,STEMI）是一种发病率逐年上升的心血管急重症之一,致残、致死率高。40%~65%的STEMI患者存在冠状动脉多支病变（multi-vessel disease,MVD）,与单支病变相比,并发MVD的STEMI患者心血管不良事件的发生率明显增加。目前,在不考虑外科干预的情况下,针对STEMI多支病变患者的治疗策略主要有3种:即仅对梗死相关血管（infarct-related artery,IRA）即罪犯血管（culprit vessel）行急诊经皮冠状动脉介入（Percutaneous Coronary Intervention,PCI）治疗（culprit-PCI）、同时对IRA及至少1支非梗死相关血管（non-infarct-related artery,non-IRA）行急诊PCI（MV-PCI）、对IRA行急诊PCI后择期对至少1支non-IRA行PCI（staged-PCI）。由于STEMI多支病变患者non-IRA病理生理状态相对特殊,因此,国内外对non-IRA的处理策略及处理时机存在争议。同时,随着临床新技术及新型口服药物不断发展,STEMI多支病变处理策略也不断完善。本文就STEMI多支病变患者血运重建策略研究进展进行综述。     

合并多支血管病变的ST段抬高型心肌梗死血运重建策略研究

目的探索不同策略的急诊经皮冠状动脉介入治疗(PCI)对合并多支血管病变的ST段抬高型心肌梗死(STEMI)短期及长期预后的影响。方法回顾性分析行急诊PCI且经冠状动脉造影证实为伴有多支血管病变的STEMI病人90例,按住院期间不同急诊PCI策略将其分为不完全血运重建组(IR组)、择期完全血运重建组(SCR组)、一次性完全血运重建组(OCR组)。比较病人住院期间及随访12个月时主要不良心脑血管事件(MACCE)发生率。结果 3组病人住院期间发热情况比较差异有统计学意义(P<0.05),MACCE及消化道出血发生情况比较差异无统计学意义(P>0.05)。术后12个月3组病人再发心绞痛比例IR组>OCR组>SCR组,差异有统计学意义(P<0.05)。结论对于合并多支血管病变的STEMI病人,不同的血运重建方式对于病人预后没有明显差别,但是完全血运重建可以使病人再发心绞痛比例减少。     

不同血运重建策略对老年非ST段抬高型急性冠脉综合征合并多支血管病变患者预后的影响

目的比较一次与分次经皮冠状动脉介入(PCI)治疗完全血运重建对高龄非ST段抬高型急性冠脉综合征(NSTE-ACS)合并多支血管病变(MVD)患者预后的影响。方法回顾性分析陕西省第四人民医院心血管内科2016年6月至2017年1月住院治疗的高龄NSTE-ACS合并MVD患者110例,其中男性67例,女性43例,年龄(63.1±8.5)岁。根据完全血运重建策略不同分为一次PCI组(n=48)和分次PCI组(n=62),比较两组患者PCI治疗、住院期间主要并发症和院内主要不良心血管事件(MACEs)发生率。术后对患者随访6个月,比较两组心功能、心绞痛症状改善情况和MACEs发生率。采用SPSS 19.0统计软件对数据进行分析。组间比较采用t检验或x~2检验。结果患者术前左室射血分数(LVEF)和院内全球急性冠状动脉事件注册(GRACE)评分差异无统计学意义(P0.05)。分次PCI组单次造影剂用量明显低于一次PCI组[(180.0±60.0)vs(230.0±70.0)ml,P=0.04],院内MACEs和住院期间主要并发症较一次次PCI组显著降低[1.6%(1/62)vs 10.4%(5/48),P=0.04;4.8%(3/62)vs 18.8%(9/48),P=0.02]。随访6个月结果表明分次PCI组较一次PCI组MACEs发生率降低[4.9%(3/61》)vs 17.4%(8/46),P=0.03]。结论分次PCI完全血运重建安全有效,可能是高龄NSTE-ACS合并MVD患者优先选用的介入治疗策略。     

ST段抬高型心肌梗死非罪犯病变血运重建的指导策略：现状与研究进展

ST段抬高型心肌梗死（STEMI）合并多支血管病变（MVD）是冠心病的高危类型。早期开通梗死相关动脉,恢复心肌组织的血液灌注,可显著降低急性期死亡率。然而,非梗死相关动脉上存在的非罪犯病变仍存在风险,对患者远期预后具有很重要的影响。采用何种手段精准评估此类病变的临床意义和预后价值,并优化非罪犯病变的血运重建策略目前尚有争议。本文拟对STEMI合并MVD患者的非罪犯病变血运重建指导策略的研究现状及进展进行综述。     

罪犯血管对行分期经皮冠状动脉介入治疗完全血运重建合并多支冠状动脉病变急性ST段抬高型心肌梗死患者预后的预测价值

目的 探讨罪犯血管对行分期经皮冠状动脉介入治疗(PCI)完全血运重建合并多支冠状动脉病变急性ST段抬高型心肌梗死(STEMI)患者预后的预测价值。方法 纳入行分期PCI完全血运重建合并多支冠状动脉病变急性STEMI患者163例,根据罪犯血管不同将其分为左冠状动脉前降支(LAD)组64例、左冠状动脉回旋支(LCX)组32例和右冠状动脉(RCA)组67例。比较3组患者的临床资料,随访其PCI后2年主要不良心脏事件(MACE)和支架内血栓的发生情况,主要研究终点为Kaplan-Meier估计的MACE,并进行组间比较。采用Cox回归模型分析MACE的预测因素。结果 3组患者左心室射血分数(LVEF)比较差异有统计学意义,其中LAD组低于RCA组(P<0.05)。3组患者2年预期MACE发生率比较差异有统计学意义(Log-rank P=0.049),其中LAD组患者2年预期MACE发生率高于RCA组(Log-rank P=0.020)。多因素Cox回归分析结果显示,罪犯血管、主动脉球囊反搏、LVEF及胸痛发作时间均为行分期PCI完全血运重建合并多支冠状动脉病变急性STEMI患者PCI后2...     

多支血管病变的功能性血运重建

<正>传统认为,冠状动脉多支血管病变的不完全血运重建(incomplete revascularization,IR)增加死亡、心肌梗死、心绞痛和再次血运重建的风险,解剖学上的完全血运重建(complete revascularization,CR)则能够改善长期的临床预后,从而成为心脏介入治疗追求的主要目标。然而,一项外科的注册研究发现,     

STEMI伴多支冠状动脉病变患者急诊PCI策略优选

ST段抬高型心肌梗死(STEMI)患者合并多支冠状动脉病变的概率高达40%～65%, 与不良预后密切相关。国内外指南虽有推荐针对该类患者的急诊经皮冠状动脉介入治疗(PCI)策略, 但在真实世界中依然需要准确把握。本综述在对比急诊PCI仅开通梗死相关冠状动脉、急诊PCI同时完全血运重建和急诊PCI后分次完全血运重建3种不同策略疗效优劣的基础上, 总结出急诊PCI后分次完全血运重建是安全有效的优选策略。     

不同血运重建策略对存在多支血管病变的非ST段抬高型心肌梗死患者预后影响的Meta分析

目的 系统评价不同血运重建策略对存在多支血管病变的非ST段抬高型心肌梗死(NSTEMI)患者预后的影响,以便为临床诊疗提供指导.方法 检索Pubmed、Embase、CNKI及万方数据库,收集与NSTEMI并发多支血管病变采用不同血运重建策略治疗的相关临床随机对照研究,评价纳入研究质量,提取有效数据后通过Revman ...     

多支血管病变患者的血运重建策略

多支血管病变患者的治疗策略选择,应充分考虑各种因素。与单支血管病变患者相比,多支血管病变患者往往合并糖尿病、肾功能不全、既往心肌梗死史和左室射血分数减低。多支血管病变患者的冠状动脉常为钙化、慢性完全闭塞、弥漫和小血管病变,而导致操作过程复杂。血运重建策略的选择应综合考虑所有这些临床、解剖和操作因素。     

Effects of patient characteristics on the efficacy of complete revascularization for treatment of ST-segment elevation myocardial infarction with multivessel disease: A meta-analysis

Background:Several randomized controlled trials (RCTs) have evaluated the efficacy of complete vs culprit-only revascularization for treatment of ST-segment elevation myocardial infarction (STEMI) with multivessel disease. However, the efficacy of complete revascularization vs culprit-only revascularization in some STEMI patient subgroups remains unclear.Methods:We searched PubMed and Embase for related RCTs from the start date of databases to January 3, 2020. The endpoint assessed in this meta-analysis was major adverse cardiac events (MACE). Random-effects meta-analysis was conducted stratified by each of the 5 factors of interest (i.e., sex, age, history of diabetes, ECG infarct location, and the number of arteries with stenosis) to estimate pooled hazard ratio and 95% confidence interval. Random-effects meta-regression was conducted to assess subgroup differences. We examined publication bias by drawing funnel plots and performing Egger test. This meta-analysis is reported according to the PRISMA statement.Results:Six RCTs were included for pooled analysis. Compared with culprit-only revascularization, complete revascularization significantly reduced the risk of MACE (hazard ratio 0.48, 95% confidence interval 0.42–0.55; I² = 0%; P for relative effect < .001). This significant reduction in the risk of MACE exhibited by complete revascularization was observed in most of the subgroups of interest. All of the subgroup effects based on the 5 factors of interest were not statistically significant (P_subgroup ranged from 0.198 to 0.556). Publication bias was not suggested by funnel plots and Egger test.Conclusions:Compared with culprit-only revascularization, complete revascularization significantly reduces the MACE risk in patients with STEMI and multivessel disease, which is independent of sex, age, history of diabetes, ECG infarct location, and the number of arteries with stenosis.     

Culprit only versus multivessel coronary revascularization in patients presenting with acute ST elevation myocardial infarction: Unending debate

The optimal percutaneous interventional strategy for dealing with significant non-culprit lesions in patients with multivessel disease with acute myocardial infarction (AMI) at presentation remains to be controversial. For the time being, the current guidelines recommended that primary percutaneous coronary intervention (PCI) for non-culprit lesions should be limited to the infarct-related artery. We believe that decisions about PCI of the non-infarct vessel(s) should be individualized and guided by objective evidence of significant residual ischemia except in patients with multivessel disease showing hemodynamic compromise. Further large, randomized trials will help us solve this dilemma.     

Prevalence of acute cardiac disorders in patients with suspected ST-segment elevation myocardial infarction and non-significant coronary artery disease

Background and purpose

We aimed to study the prevalence of acute cardiac disorders in patients with suspected ST-segment elevation myocardial infarction (STEMI) and non-significant coronary artery disease (CAD).

Methods

From January to October 2012 we consecutively included patients admitted with suspected STEMI and non-significant CAD (coronary artery stenosis diameter < 50%). Patients were diagnosed with acute cardiac disorder in the presence of elevated cardiac biomarkers (troponin T > 50 ng/l or creatine kinase MB > 4 μg/l) or dynamic ECG changes (ST-segment changes or T-wave inversion).

Results

Of the 871 patients admitted with suspected STEMI, 11% (n = 95) had non-significant CAD. Of these, 67% (n = 64) had elevated cardiac biomarkers or dynamic ECG changes and were accordingly diagnosed with acute cardiac disorders. In the remaining 33% (n = 31) of patients, cardiac biomarkers were normal and ECG changes remained stationary.

Conclusions

Acute cardiac disorders were diagnosed in two thirds of patients with suspected STEMI and non-significant CAD.     

完全血运重建对老年急性NSTEMI合并多支血管病变患者长期预后的影响

目的探讨完全血运重建(CR)对老年急性非ST段抬高型心肌梗死(NSTEMI)合并多支血管病变(MVD)患者长期预后的影响。方法连续入选603例老年急性NSTEMI合并MVD患者,根据患者冠状动脉血管处理情况分为2组:(1)单纯处理罪犯血管(SR)组(n=260);(2) CR组(n=343)。研究终点设定为术后1年的全因死亡、心血管死亡、非致死性再发心肌梗死及非计划再次血运重建。通过COX回归分析探讨CR对老年急性NSTEMI合并MVD患者长期预后的影响。结果与SR组相比,CR组既往接受PCI治疗的比例更低,3支病变、术前血流TIMI 0或1级比例更高,植入支架个数更多,长度更长,替格瑞洛的使用比例更高,而硝酸酯类的使用比例更低。随访期内,整体全因死亡率为4.8%(SR组比CR组为6.2%比3.8%,P=0.179),心源性死亡率为4.1%(SR组比CR组为4.6%比3.8%,P=0.615),非致死性再发心肌梗死率为2.5%(SR组比CR组为1.2%比3.5%,P=0.067),非计划再次血运重建率为6.8%(SR组比CR组为9.6%比4.7%,P=0.017)。单因素COX回归分析显示,CR可以显著降低老年NSTEMI合并MVD患者的非计划再次血运重建率(HR 0. 471,95%CI 0. 251~0. 882,P=0.019);在校正了各项临床因素之后,多因素COX回归分析也得到了相同的结论(HR 0.438,95%CI 0.229~0.837,P=0.012)。但是,无论单因素分析,还是多因素分析,CR对老年NSTEMI合并MVD患者的全因死亡、心源性死亡及非致死性再发心肌梗死均无显著影响。围手术期并发症方面,2组的BARC 3或5级出血、造影剂肾病、卒中及急性支架内血栓等发生率无显著差异。结论对于老年NSTEMI合并MVD患者,CR可以显著降低术后非计划再次血运重建率,同时围手术期也是较为安全的。