合并结缔组织病的冠心病患者冠状动脉病变特点及冠状动脉介入治疗术预后分析

目的探讨合并结缔组织病(CTD)的冠状动脉性心脏病(CAD)患者的冠状动脉病变特点,以及接受经皮冠状动脉介入治疗术(PCI)的长期预后。方法收集106例自2009年1月至2012年12月在北京友谊医院接受PCI治疗CTD患者的临床资料,回顾性分析CTD患者的临床表现和冠状动脉病变特点等,并对CTD患者进行长期随访。结果 106例患者中有92例(86.8%)具有≥1个传统冠心病危险因素。78例(73.6%)的患者冠状动脉为多支血管病变,以前降支受累为主(65.1%)。共植入5枚金属裸支架和202枚药物涂层支架。对CTD患者进行了平均时间长达3年的随访,期间共发生主要不良心血管事件(MACE)24例(22.6%),其中心源性死亡13例(12.3%)、支架内血栓形成(ST)10例(9.4%)、靶血管再次血运重建(TVR)15例(14.2%)。结论合并CTD的CAD患者冠状动脉病变以多支病变为主。此类患者接受PCI术后不良事件以ST及TVR多见。     

强化他汀治疗对经皮冠状动脉介入治疗后患者肾损伤的保护作用

目的研究强化他汀治疗对经皮冠状动脉介入治疗(PCI)后肾功能的保护作用和预防对比剂肾病(CIN)的效果,探讨其可能机制。方法 228例接受择期PCI的急性冠脉综合征(ACS)患者,随机分为标准他汀治疗组(SSG,n=115)和强化他汀治疗组(ISG,n=113)。于PCI术前7d开始,SSG组患者口服20mg/d辛伐他汀,ISG组患者则口服80mg/d辛伐他汀。于PCI术前、术后24、48h分别测定血清肌酐水平,按Cochcroft-Gault公式计算肌酐清除率。于PCI术前、术后24h分别测定血清高敏C反应蛋白(hs-CRP)、P选择素和细胞间黏附分子1(ICAM-1)水平。结果 PCI后血肌酐水平显著升高,并于术后24h达高峰,然后逐渐下降,术后48hISG组血肌酐水平显著回降(与术后24h比较P0.001)至术前水平(P=0.94),而SSG组血肌酐水平未显著回降(与术后24h比,P=0.11)。PCI术后24、48h,ISG组的血肌酐水平均显著低于SSG组(术后24h,P0.05;术后48hP0.001)。PCI术后,两组肌酐清除率均显著降低,最低值出现在术后24h,然后逐渐回升。术后48h,SSG组肌酐清除率显著回升(与术后24h相比,P=0.03),但仍低于术前水平(P0.001),而ISG组术后48h显著回升(与术后24h相比,P0.001)并恢复到术前水平(P=0.87),在术后24、48h,ISG组肌酐清除率的回升程度均显著高于SSG组(均P0.001)。虽然PCI术后血清hs-CRP、P选择素和ICAM-1水平均显著升高(均P0.001),但ISG组低于SSG组(均P0.001)。结论与标准剂量他汀治疗相比,PCI前使用强化剂量他汀治疗可进一步保护PCI术后肾脏功能,降低CIN的发生率。这种益处伴随有血清hs-CRP、P选择素和ICAM-1水平的显著降低。     

急性冠状动脉综合征患者经皮冠状动脉介入术后血浆过氧化物酶5水平及其与预后的关系

目的 探究急性冠状动脉综合征(ACS)患者经皮冠状动脉介入术(PCI)后血浆过氧化物酶5(Prx5)水平及与预后的关系.方法 选取2016年5月-2017年8月接受救治的148例ACS患者作为研究对象,平均随访时间为21.97(8～24)个月.以Prx5评价ACS患者预后的最佳截断点(44.12 μg/L)为界,将患者...     

静息心率与经皮冠状动脉介入术后短期预后的关系研究

目的：探讨经皮冠状动脉介入（PCI）术前的静息心率(HR)与术后30d内预后的关系。方法：选择3720例行PCI术患者,均有明确术前静息HR记录及住院和术后30d的随访临床结果。用五分位数分析静息HR和结果,再用二分法将HR＜70次/min或≥70次/min的结果进行分析。结果：所有患者的平均静息HR为(70.9±14.7)次/min。五个百分位数的平均静息HR分别为：(54.8±5.3)、(63.7±1.6)、(69.9±1.5)、(77.1±2.5)、(93.4±13.1)次/min。出院后30d内临床随访结果提示：5组患者之间,总死亡率、再发心肌梗死、靶病变血运重建、靶血管血运重建、主要不良心血管事件（MACE）和再入院治疗患者比例比较,差异有统计学意义（均P＜0.05）。在HR＜70次/min和≥70次/min的患者中,总死亡率、再发心肌梗死、靶病变血运重建、靶血管血运重建、MACE、再入院治疗患者比例比较,差异有统计学意义（均P＜0.05）。按HR五分位数计算的患者中,随着HR升高,住院期间和出院后30d内MACE发生率明显升高（P＜0.01)。在HR≥70次/min的患者中,住院期间和出院后30d内MACE发生率明显高于HR＜70次/min的患者（P＜0.05)。结论：PCI术前的静息HR在预测患者住院和短期心血管结局的风险方面具有重要作用,较高的静息HR预示着冠心病患者的预后较差。     

冠状动脉介入术后强化他汀类药物治疗的意义

<正>冠状动脉介入术(PCI)围手术期缺血综合征及术后并发症严重影响了患者的预后,甚至增加死亡风险,因此需要寻找一种全身的治疗方案、调整引发急性冠状动脉综合征(ACS)靶点的生物特性及如何改善PCI术后患者围手术期     

冠状动脉造影评估的靶病变钙化程度对接受经皮冠状动脉介入治疗患者手术即刻成功率和长期预后的影响

目的：分析冠状动脉造影评估的靶病变钙化程度对接受经皮冠状动脉介入治疗（PCI）患者手术即刻成功率与长期预后的影响。方法：连续选取2017年1月至2018年12月在中国医学科学院阜外医院行PCI的前瞻性队列中有冠状动脉造影评估靶病变钙化病变程度的26 712例患者数据进行分析,按靶病变钙化病变程度将患者分为4组,包括无钙化组（n=14 387）、轻度钙化组（n=8 231）、中度钙化组（n=3 208）和重度钙化组（n=886）。主要术后即刻终点为PCI成功,定义为术后残余狭窄<50%且无主要操作并发症（包括冠状动脉穿孔、冠状动脉夹层、术中支架内血栓形成、介入器械穿入失败）。主要长期临床终点事件为3年主要不良心血管事件（MACE）,包括全因死亡、心肌梗死（MI）及再次血运重建在内的复合终点事件。结果：重度钙化组较无钙化组、轻度钙化组、中度钙化组具有更低的PCI即刻成功率（80.59%vs. 94.23%vs. 94.29%vs. 91.49%）,更高的术后残余狭窄≥50%发生率（17.72%vs. 5.03%vs. 4.84%vs. 7.29%）、冠状动脉夹层发生率（1.81%vs...     

基线外周血循环单核细胞水平对冠心病患者经皮冠状动脉介入治疗后长期死亡风险的影响

目的 探讨基线外周血循环单核细胞(MO)水平对冠心病(CHD)患者经皮冠状动脉介入治疗(PCI)术后长期死亡风险的影响。方法 对PCI术的6 045例CHD患者进行回顾性分析。根据基线外周血循环单核细胞水平将患者分为3组并对其进行随访:Ⅰ组:MO＜0.40×10⁹ L－1(n＝1 943);Ⅱ组:0.40×10⁹ L－1≤MO≤0.56×10⁹ L－1(n＝2 072);Ⅲ组:MO＞0.56×10⁹ L－1(n＝2 030)。随访终点包括:全因死亡(ACM)、心脏死亡(CM)、主要不良心血管事件(MACE)和主要不良心脑血管事件(MACCE)。平均随访时间为(35.9±22.6)个月。结果 309例患者发生ACM,其中Ⅰ组73例(3.8%),Ⅱ组98例(4.7%),Ⅲ组138例(6.8%);251例患者发生CM,其中Ⅰ组58例(3.0%),Ⅱ组80例(3.9%),Ⅲ组113例(5.6%);785例患者发生MACE,其中Ⅰ组226例(11.6%),Ⅱ组248例(12.0%),Ⅲ组311例(15.3%);862例患者发生MACCE,其中Ⅰ组250例(12.9%),Ⅱ组269例(13.0%),Ⅲ组343例(16.9%)。3组发生ACM、CM、MACE、MACCE的差异有统计学意义(P≤0.001)。ACM和CM在3组的Kaplan-Meier曲线分析显示,随着基线外周血循环单核细胞水平上升,患者的预后越差(P＜0.05)。COX回归分析显示,基线外周血循环单核细胞水平上升与ACM(Ⅲ组比I组,HR=1.418,95%CI:1.056～1.905,P＝0.020)、CM(Ⅲ组比I组,HR=1.425,95%CI:1.023～1.983,P＝0.036)的发生独立相关。结论 高水平的基线外周血循环单核细胞是CHD患者PCI术后长期死亡风险的一个独立预测指标。     

接受经皮冠状动脉介入治疗的冠心病患者术后体力恢复影响因素

目的 分析经皮冠状动脉介入治疗(PCI)的冠心病患者术后体力恢复的影响因素.方法 96例成功接受PCI的冠心病患者,依据术后1周体力活动能力评分(以全部患者得分的中位数为截点)分为低分组(48例)和高分组(48例),采用单因素及多因素Logistic回归分析法分析患者术后体力恢复的影响因素.结果 两组年龄、婚姻状况、心...     

不同性别患者经皮冠状动脉介入治疗术后免疫功能及预后差异性分析

目的 探讨不同性别患者经皮冠状动脉介入(PCI)后免疫功能及预后的差异性。方法 选择322例行PCI患者,分为女性组(n=98)和男性组(n=224);两组均进行炎性指标和免疫指标检测,同时进行心功能、肾功能指标监测和中文版健康状况问卷(SF-36)调查。依据检测监测指标及SF-36评分,评估术后1个月不同性别患者健康相关生活质量(HRQOL)水平及预后。结果 (1)炎性指标:白细胞(WBC)、肿瘤坏死因子(TNF)-α、白细胞介素(IL)-6、超敏C反应蛋白(hs-CRP)女性组均高于男性组,差异具有统计学意义(P<0.05);(2)免疫指标:免疫球蛋白(Ig) G水平女性组高于男性组,差异具有统计学意义(P<0.05);两组IgM未见统计学差异(P>0.05);(3)心功能指标:左室射血分数(LVEF)女性组低于男性组,左心室收缩末期容积指数(LVESVI)、左心室舒张末期容积指数(LVEDVI)女性组高于男性组,差异均有统计学意义(P<0.05);(4)肾功能指标:血肌酐(Scr)、血尿素氮(BUN)女性组均高于男性组,差异有统计学意义(P<0.05...     

冠心病患者经皮冠状动脉介入治疗后心肌灌注情况及其与近期预后的关系

目的 观察冠心病患者经皮冠状动脉介入治疗（PCI）前后的心肌灌注情况,并探讨其与近期预后的关系。方法 选取经冠脉造影检查确诊的冠心病患者102例,均行PCI手术。患者分别于术前及术后3个月,应用PHILIPS EPIQ 7C超声诊断仪进行实时心肌超声造影（RTMCE）检查评价心肌灌注情况,记录前壁、下壁、侧壁曲线上升平台期的平均斜率（β）、心肌显峰强度（A）、局部心肌血流量（MBF）。记录患者PCI术后6个月心血管不良事件（MACE）发生情况,采用Logistic多因素回归分析术后3个月RTMCE参数对冠心病患者PCI术后6个月发生MACE的影响,绘制其预测冠心病患者PCI术后6个月发生MACE的受试者工作特征（ROC）曲线,比较其预测价值。结果 患者PCI术后3个月前壁、下壁、侧壁的β、A、MBF均较术前升高（P均<0.05）。102例冠心病患者PCI术后6个月发生MACE 15例（14.7%）。发生MACE者术后3个月前壁、下壁、侧壁的β、A、MBF均低于未发生MACE者（P均<0.05）。Logistic回归分析结果显示,术后3个月β、A、MBF降低均是冠心病患者PC...     

Operator Experience and Outcomes After Left Main Percutaneous Coronary Intervention

Purpose of Review

This review was performed with the goal of summarizing the role of operator experience in the treatment of severe left main stenosis by percutaneous intervention techniques.

Recent Findings

The Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial demonstrated that percutaneous coronary intervention and coronary artery bypass grafting had similar clinical outcomes for severe left main disease. However, PCI of the left main coronary stenosis is considered to be a high-risk intervention because of the large area of myocardium at jeopardy that can quickly cause hemodynamic compromise. Operator experience and familiarity with the use of hemodynamic support devices, plaque modification techniques, and intravascular imaging tools is associated with better clinical outcomes.

Summary

In patients with severe left main stenosis undergoing percutaneous coronary intervention by high-volume operators, the clinical outcomes are superior.

     

Ischemic Burden Reduction and Long-Term Clinical Outcomes After Chronic Total Occlusion Percutaneous Coronary Intervention

ObjectivesThe authors sought to evaluate the impact of ischemic burden reduction after chronic total occlusion (CTO) percutaneous coronary intervention (PCI) on long-term prognosis and cardiac symptom relief.BackgroundThe clinical benefit of CTO PCI is questioned.MethodsIn a high-volume CTO PCI center, 212 patients prospectively underwent quantitative [¹⁵O]H₂O positron emission tomography perfusion imaging before and three months after successful CTO PCI between 2013-2019. Perfusion defects (PD) (in segments) and hyperemic myocardial blood flow (hMBF) (in ml · min^?1 · g^?1) allocated to CTO areas were related to prognostic outcomes using unadjusted (Kaplan-Meier curves, log-rank test) and risk-adjusted (multivariable Cox regression) analyses. The prognostic endpoint was a composite of all-cause death and nonfatal myocardial infarction.ResultsAfter a median [interquartile range] of 2.8 years [1.8 to 4.3 years], event-free survival was superior in patients with ≥3 versus <3 segment PD reduction (p < 0.01; risk-adjusted p = 0.04; hazard ratio [HR]: 0.34 [95% confidence interval (CI): 0.13 to 0.93]) and with hMBF increase above (Δ≥1.11 ml · min^?1 · g^?1) versus below the population median (p < 0.01; risk-adjusted p < 0.01; HR: 0.16 [95% CI: 0.05 to 0.54]) after CTO PCI. Furthermore, event-free survival was superior in patients without versus any residual PD (p < 0.01; risk-adjusted p = 0.02; HR: 0.22 [95% CI: 0.06 to 0.76]) or with a residual hMBF level >2.3 versus ≤2.3 ml · min^?1 · g^?1 (p < 0.01; risk-adjusted p = 0.03; HR: 0.25 [95% CI: 0.07 to 0.91]) at follow-up positron emission tomography. Patients with residual hMBF >2.3 ml · min^?1 · g^?1 were more frequently free of angina and dyspnea on exertion at long-term follow-up (p = 0.04).ConclusionsPatients with extensive ischemic burden reduction and no residual ischemia after CTO PCI had lower rates of all-cause death and nonfatal myocardial infarction. Long-term cardiac symptom relief was associated with normalization of hMBF levels after CTO PCI.     

Percutaneous Coronary Intervention: Relationship Between Procedural Volume and Outcomes

Percutaneous coronary intervention (PCI) is an integral treatment modality for acute coronary syndromes (ACS) as well as chronic stable coronary artery disease (CAD) not responsive to optimal medical therapy. This coupled with studies on the feasibility and safety of performing PCI in centers without on-site surgical backup led to widespread growth of PCI centers. However, this has been accompanied by a recent steep decline in the volume of PCIs at both the operator and hospital level, which raises concerns regarding minimal procedural volumes required to maintain necessary skills and favorable clinical outcomes. The 2011 ACC/AHA/SCAI competency statement required PCI be performed by operators with a minimal procedural volume of >75 PCIs annually at high-volume centers with >400 PCIs per year, a number which was relaxed in the 2013 ACC/AHA/SCAI update to >50 PCIs/operator/year in hospitals with >200 PCIs annually to coincide with reduction in national PCI volume. Recent data suggests that many hospitals do not meet these thresholds. We review data on the importance of volume as a vital quality metric at both an operator and hospital level in determining procedural outcomes following PCI.     

Outcomes After Emergency Percutaneous Coronary Intervention in Patients With Unprotected Left Main Stem Occlusion: The BCIS National Audit of Percutaneous Coronary Intervention 6-Year Experience

ObjectivesThis study sought to evaluate in-hospital outcomes and 3-year mortality of patients presenting with unprotected left main stem occlusion (ULMSO) treated with primary percutaneous coronary intervention (PPCI).BackgroundLimited data exists about management and outcome following presentation with ULMSO.MethodsFrom January 1, 2007 to December 21, 2012, 446,257 PCI cases were recorded in the British Cardiovascular Intervention Society database of all PCI cases in England and Wales. Of those, 568 were patients having emergency PCI for ST-segment elevation infarction (0.6% of all PPCI) who presented with ULMSO (TIMI [Thrombolysis In Myocardial Infarction] flow grade 0/1 and stenosis >75%), and they were compared with 1,045 emergency patients treated with nonocclusive LMS disease. Follow-up was obtained through linkage with the Office of National Statistics.ResultsPresentation with ULMSO, compared with nonocclusive LMS disease, was associated with a doubling in the likelihood of periprocedural shock (57.9% vs. 27.9%; p < 0.001) and/or intra-aortic balloon pump support (52.5% vs. 27.2%; p < 0.001). In-hospital (43.3% vs. 20.6%; p < 0.001), 1-year (52.8% vs. 32.4%; p < 0.001), and 3-year mortality (73.9% vs 52.3%, p < 0.001) rates were higher in patients with ULMSO, compared with patients presenting with a patent LMS, and were significantly influenced by the presence of cardiogenic shock. ULMSO and cardiogenic shock were independent predictors of 30-day (hazard ratio [HR]: 1.61 [95% confidence interval (CI): 1.07 to 2.41], p = 0.02, and HR: 5.43 [95% CI: 3.23 to 9.12], p<0.001, respectively) and 3-year all-cause mortality (HR: 1.52 [95% CI: 1.06 to 2.17], p = 0.02, and HR: 2.98 [95% CI: 1.99 to 4.49], p < 0.001, respectively).ConclusionsIn patients undergoing PPCI for ULMSO, acute outcomes are poor and additional therapies are required to improve outcome. However, long-term outcomes for survivors of ULMSO are encouraging.     

Long-Term Outcomes of Complete Revascularization With Percutaneous Coronary Intervention in Acute Coronary Syndromes

ObjectivesThe aim of this study was to evaluate the long-term outcomes of patients with acute coronary syndromes (ACS) with multivessel disease undergoing percutaneous coronary intervention (PCI).BackgroundControversy exists regarding the benefit of multivessel PCI across the spectrum of ACS.MethodsA total of 9,094 patients with ACS and multivessel disease (≥70% stenosis in 2 or more major epicardial vessels) undergoing PCI from the Alberta COAPT (Contemporary Acute Coronary Syndrome Patients Invasive Treatment Strategies) registry (April 1, 2007, to March 31, 2013) were reviewed. Comparisons were made between patients who underwent complete revascularization and those with incomplete revascularization. Complete revascularization was defined as multivessel PCI with a residual angiographic jeopardy score ≤10%. Associations between revascularization status and all-cause death or new myocardial infarction (primary composite endpoint) and all-cause death, new myocardial infarction, or repeat revascularization (secondary composite endpoint) were evaluated.ResultsOf the study cohort, 66.0% underwent complete revascularization. Compared with incomplete revascularization, the primary composite endpoint occurred less frequently with complete revascularization (event rate within 5 years 15.4% vs. 22.2%; inverse probability-weighted hazard ratio [IPW-HR]: 0.78; 95% confidence interval [CI]: 0.73 to 0.84; p < 0.0001). The secondary composite endpoint was less likely to occur with complete revascularization (event rate within 5 years 23.3% vs. 37.5%; IPW-HR: 0.61; 95% CI: 0.58 to 0.65; p < 0.0001). Complete revascularization was associated with a reduction in all-cause death (IPW-HR: 0.79; 95% CI: 0.73 to 0.86; p = 0.0004), new myocardial infarction (IPW-HR: 0.76; 95% CI: 0.69 to 0.84; p < 0.0001), and repeat revascularization (IPW-HR: 0.53; 95% CI: 0.49 to 0.57; p < 0.0001).ConclusionsResults from this large contemporary registry of patients with ACS and PCI for multivessel disease suggest that complete revascularization occurs commonly and is associated with improved clinical outcomes (including survival) within 5 years.