老年冠状动脉多支病变患者完全和不完全血运重建远期预后的比较研究
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摘要
目的:比较老年冠状动脉多支病变患者中完全和不完全血运重建策略对远期预后的影响。方法:入选2013年1月至2013年12月中国医学科学院阜外医院行经皮冠状动脉介入治疗(PCI)的1 152例≥60岁冠状动脉多支病变患者,按年龄分为60～64岁组(n=465)、65～69岁组(n=315)、70～74岁(n=223)和≥75岁(n=149)4个年龄组,采用多因素Cox回归分析方法比较完全和不完全血运重建患者的2年预后差异。主要终点包括全因死亡、心肌梗死、再次血运重建、脑卒中和支架内血栓。结果:535例(46.4%)患者接受完全血运重建。完全血运重建患者中有9.5%发生主要不良心脑血管事件(MACCE),而不完全血运重建患者中有14.7%发生MACCE(P=0.007)。多因素Cox生存分析显示,与不完全血运重建患者相比,完全血运重建患者MACCE发生风险显著降低(HR=0.697,95%CI:0.493～0.986,P=0.041);亚组分析显示,急性冠状动脉综合征(ACS)患者(HR=0.647,95%CI:0.419～0.998,P=0.049)和双支病变患者(HR=0.386,95%CI:0.158～0.946,P=0.037)在完全血运重建中获益更大,稳定性冠心病患者在完全血运重建中并无明显获益(HR=0.774,95%CI:0.434～1.379,P=0.384)。结论:60岁以上老年冠状动脉多支病变患者行完全血运重建的预后优于不完全血运重建,但仅见于ACS患者。
Objectives:To compare the impact of complete or incomplete revascularization strategies on long-term prognosis in elderly patients with multi-vessel coronary artery disease. Methods: Clinical data of 1 152 consecutive patients aged 60 and above, who underwent PCI from 2013 January to December in Fuwai Hospital with multi-vessel coronary artery disease, were evaluated. Patients were grouped according to ages: 60-64 years old group(n=465 cases), 65-69 years old group(n=315 cases), 70-74 years old group(n=223 cases) and ≥75 years old group(n=149 cases). Multivariable Cox regression method was used for survival analysis. The primary endpoints were defined as all-cause death, myocardial infarction, revascularization, stroke, and stent thrombosis. Results:535(46.4%) patients underwent complete revascularization. 9.5% of patients with complete revascularization had major adverse cardiovascular and cerebrovascular events(MACCE), and 14.7% of patients with incomplete revascularization had MACCE events. Multivariate Cox survival analysis showed that MACCE was significantly lower in the complete revascularization group than that in the incomplete revascularization group(HR=0.697, 95%CI: 0.493-0.986, P=0.041). Subgroup analysis showed that patients in ACS group(HR=0.647, 95%CI:0.419-0.998, P=0.049) and doublevessel coronary disease group(HR=0.386, 95%CI:0.158-0.946, P=0.037) benefited more from complete revascularization strategy. However, patients in stable coronary heart disease group did not benefit from complete revascularization(HR=0.774, 95%CI:0.434-1.379, P=0.384). Conclusions:Complete revascularization is superior to incomplete revascularization in elderly patients(>60 years) with multi-vessel coronary artery disease. ACS patients benefit more from complete revascularization, while stable coronary heart disease patients do not benefit from complete revascularization in this patient cohort.
Objectives:To compare the impact of complete or incomplete revascularization strategies on long-term prognosis in elderly patients with multi-vessel coronary artery disease. Methods: Clinical data of 1 152 consecutive patients aged 60 and above, who underwent PCI from 2013 January to December in Fuwai Hospital with multi-vessel coronary artery disease, were evaluated. Patients were grouped according to ages: 60-64 years old group(n=465 cases), 65-69 years old group(n=315 cases), 70-74 years old group(n=223 cases) and ≥75 years old group(n=149 cases). Multivariable Cox regression method was used for survival analysis. The primary endpoints were defined as all-cause death, myocardial infarction, revascularization, stroke, and stent thrombosis. Results:535(46.4%) patients underwent complete revascularization. 9.5% of patients with complete revascularization had major adverse cardiovascular and cerebrovascular events(MACCE), and 14.7% of patients with incomplete revascularization had MACCE events. Multivariate Cox survival analysis showed that MACCE was significantly lower in the complete revascularization group than that in the incomplete revascularization group(HR=0.697, 95%CI: 0.493-0.986, P=0.041). Subgroup analysis showed that patients in ACS group(HR=0.647, 95%CI:0.419-0.998, P=0.049) and doublevessel coronary disease group(HR=0.386, 95%CI:0.158-0.946, P=0.037) benefited more from complete revascularization strategy. However, patients in stable coronary heart disease group did not benefit from complete revascularization(HR=0.774, 95%CI:0.434-1.379, P=0.384). Conclusions:Complete revascularization is superior to incomplete revascularization in elderly patients(>60 years) with multi-vessel coronary artery disease. ACS patients benefit more from complete revascularization, while stable coronary heart disease patients do not benefit from complete revascularization in this patient cohort.
引文
[1]王玉珏,高展,杨进刚,等.75岁及以上老年患者经皮冠状动脉介入治疗术后远期预后的性别差异[J].中国循环杂志,2015, 30(5):438-441. DOI:10. 3969/j. issn. 1000-3614. 2015. 05. 007.
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[4] Task Force M, Montalescot G, Sechtem U, et al. 2013 ESC guidelines on the management of stable coronary artery disease:the Task Force on the management of stable coronary artery disease of the European Society of Cardiology[J]. Eur Heart J, 2013, 34(38):2949-3003. DOI:10. 1093/eurheartj/eht296.
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[6] Mehran R, Rao S V, Bhatt D L, et al. Standardized bleeding definitions for cardiovascular clinical trials:a consensus report from the Bleeding Academic Research Consortium[J]. Circulation, 2011, 123(23):2736-2747. DOI:10. 1161/CIRCULATIONAHA. 110. 009449. DOI:10.3969/j. issn. 1000-3614. 2010. 05. 008.
[7]陈杰,白静,王禹,等.75岁以上老年冠心病患者介入治疗近期疗效分析[J].中国循环杂志,2010,25(5):344-347.DOI:10.3969/j.issn. 1000-3614. 2010. 05. 008.
[8] Wang TY, Mccoy LA, Bhatt DL, et al. Multivessel vs culprit-only percutaneous coronary intervention among patients 65 years or older with acute myocardial infarction[J]. Am Heart J, 2016, 172:9-18.DOI:10. 1016/j. ahj. 2015. 10. 017.
[9] Harada M, Miura T, Kobayashi T, et al. Clinical impact of complete revascularization in elderly patients with multi-vessel coronary artery disease undergoing percutaneous coronary intervention:A subanalysis of the SHINANO registry[J]. Int J Cardiol, 2017, 230:413-419. DOI:10. 1016/j. ijcard. 2016. 12. 093.
[10] Tegn N, Abdelnoor M, Aaberge L, et al. Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris(After Eighty study):an open-label randomised controlled trial[J]. Lancet, 2016,387(10023):1057-1065. DOI:10. 1016/S0140-6736(15)01166-6.
[11] Peiyuan H, Jingang Y, Haiyan X, et al. The comparison of the outcomes between primary PCI, fibrinolysis, and no reperfusion in patients> 75 years old with ST-segment elevation myocardial infarction:results from the Chinese Acute Myocardial Infarction(CAMI)registry[J]. PLoS One, 2016, 11(11):e0165672. DOI:10.1371/journal. pone. 0165672.
[12] Arroyo-Espliguero R, Avanzas P, Cosin-Sales J, et al. C-reactive protein elevation and disease activity in patients with coronary artery disease[J].Eur Heart J, 2004, 25(5):401-408. DOI:10. 1016/j. ehj. 2003. 12. 017.
[13] Kubo T, Imanishi T, Kashiwagi M, et al. Multiple coronary lesion instability in patients with acute myocardial infarction as determined by optical coherence tomography[J]. Am J Cardiol, 2010, 105(3):318-322. DOI:10. 1016/j. amjcard. 2009. 09. 032.
[2] Smith SC, Jr., Dove JT, Jacobs AK, et al. ACC/AHA guidelinesfor percutaneous coronary intervention(revision of the 1993 PTC A guidelines)-executive summary:a report of the American College of Cardiology/American Heart Association task force on practice guidelines(Committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty)endorsed by the Society for Cardiac Angiography and Interventions[J]. Circulation, 2001,103(24):3019-3041.
[3] Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction[J]. J Am Coll Cardiol, 2012, 60(16):1581-1598. DOI:10. 1016/j.jacc. 2012.08.001.
[4] Task Force M, Montalescot G, Sechtem U, et al. 2013 ESC guidelines on the management of stable coronary artery disease:the Task Force on the management of stable coronary artery disease of the European Society of Cardiology[J]. Eur Heart J, 2013, 34(38):2949-3003. DOI:10. 1093/eurheartj/eht296.
[5] Cutlip DE, Windecker S, Mehran R, et al. Clinical end points in coronary stent trials:a case for standardized definitions[J].Circulation, 2007, 115(17):2344-2351. DOI:10. 1161/CIRCULATIONAHA. 106. 685313.
[6] Mehran R, Rao S V, Bhatt D L, et al. Standardized bleeding definitions for cardiovascular clinical trials:a consensus report from the Bleeding Academic Research Consortium[J]. Circulation, 2011, 123(23):2736-2747. DOI:10. 1161/CIRCULATIONAHA. 110. 009449. DOI:10.3969/j. issn. 1000-3614. 2010. 05. 008.
[7]陈杰,白静,王禹,等.75岁以上老年冠心病患者介入治疗近期疗效分析[J].中国循环杂志,2010,25(5):344-347.DOI:10.3969/j.issn. 1000-3614. 2010. 05. 008.
[8] Wang TY, Mccoy LA, Bhatt DL, et al. Multivessel vs culprit-only percutaneous coronary intervention among patients 65 years or older with acute myocardial infarction[J]. Am Heart J, 2016, 172:9-18.DOI:10. 1016/j. ahj. 2015. 10. 017.
[9] Harada M, Miura T, Kobayashi T, et al. Clinical impact of complete revascularization in elderly patients with multi-vessel coronary artery disease undergoing percutaneous coronary intervention:A subanalysis of the SHINANO registry[J]. Int J Cardiol, 2017, 230:413-419. DOI:10. 1016/j. ijcard. 2016. 12. 093.
[10] Tegn N, Abdelnoor M, Aaberge L, et al. Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris(After Eighty study):an open-label randomised controlled trial[J]. Lancet, 2016,387(10023):1057-1065. DOI:10. 1016/S0140-6736(15)01166-6.
[11] Peiyuan H, Jingang Y, Haiyan X, et al. The comparison of the outcomes between primary PCI, fibrinolysis, and no reperfusion in patients> 75 years old with ST-segment elevation myocardial infarction:results from the Chinese Acute Myocardial Infarction(CAMI)registry[J]. PLoS One, 2016, 11(11):e0165672. DOI:10.1371/journal. pone. 0165672.
[12] Arroyo-Espliguero R, Avanzas P, Cosin-Sales J, et al. C-reactive protein elevation and disease activity in patients with coronary artery disease[J].Eur Heart J, 2004, 25(5):401-408. DOI:10. 1016/j. ehj. 2003. 12. 017.
[13] Kubo T, Imanishi T, Kashiwagi M, et al. Multiple coronary lesion instability in patients with acute myocardial infarction as determined by optical coherence tomography[J]. Am J Cardiol, 2010, 105(3):318-322. DOI:10. 1016/j. amjcard. 2009. 09. 032.