Nicolau J C, Nogueira P R, Pinto M A, Serrano C V, Garzon S A
Heart Institute, Faculty of Medicine, University of São Paulo, Brazil.
Am J Cardiol. 1999 Jan 1;83(1):21-6. doi: 10.1016/s0002-9149(98)00776-0.
It is known that acutely developed collaterals can prevent the onset of acute myocardial infarction (AMI) in the presence of a total coronary occlusion. However, there still is controversy concerning long-term follow-up of coronary collateral circulation to the infarct-related artery. In this study we analyze the prognostic role of collateral flow (degrees 0 to 3) as well as anterograde flow (degrees 0 to 3) in patients with AMI treated with thrombolytic therapy. Four hundred twenty-two patients (median age 57 years, 355 men) with AMI were treated with intravenous streptokinase and followed prospectively for up to 8 years. At the end of the study period, patients with collateral coronary flow 3 (n = 30) and those with flow <3 (n = 392) at in-hospital coronary arteriography had survival rates of 66% and 85%, respectively (p <0.12). Meanwhile, patients with coronary anterograde flow 3 (n = 189) and those with flow <3 (n = 233) had survival rates of 89% and 80%, respectively (p <0.04). By censored regression analysis, a negative correlation was found between coronary collateral flow degree and survival (p = 0.0498) and, inversely, a positive correlation was found between coronary anterograde flow degree and survival (p = 0.0053). By Cox multivariate analysis, the following variables showed significant correlations with long-term survival: global left ventricular ejection fraction (p = 0.0003), anterograde flow degree (p = 0.0006), collateral flow degree (negative correlation, p = 0.0179), and medical treatment (negative correlation, p = 0.0464). Thus, patients treated with intravenous streptokinase during AMI and with adequate coronary collateral circulation had a worse prognosis than those who developed adequate anterograde flow, probably because of residual myocardial ischemia. Such patients may benefit from coronary revascularization (angioplasty or surgery) to restore anterograde blood flow and minimize myocardium at risk.
众所周知，在冠状动脉完全闭塞的情况下，急性形成的侧支循环可预防急性心肌梗死（AMI）的发生。然而，关于梗死相关动脉冠状动脉侧支循环的长期随访仍存在争议。在本研究中，我们分析了接受溶栓治疗的AMI患者侧支血流（0至3级）以及顺行血流（0至3级）的预后作用。422例AMI患者（中位年龄57岁，男性355例）接受了静脉链激酶治疗，并进行了长达8年的前瞻性随访。在研究期末，住院期间冠状动脉造影显示侧支血流为3级的患者（n = 30）和血流<3级的患者（n = 392）的生存率分别为66%和85%（p <0.12）。同时，冠状动脉顺行血流为3级的患者（n = 189）和血流<3级的患者（n = 233）的生存率分别为89%和80%（p <0.04）。通过截尾回归分析，发现冠状动脉侧支血流程度与生存率呈负相关（p = 0.0498），相反，冠状动脉顺行血流程度与生存率呈正相关（p = 0.0053）。通过Cox多因素分析，以下变量与长期生存显示出显著相关性：整体左心室射血分数（p = 0.0003）、顺行血流程度（p = 0.0006）、侧支血流程度（负相关，p = 0.0179）和药物治疗（负相关，p = 0.0464）。因此，AMI期间接受静脉链激酶治疗且冠状动脉侧支循环良好的患者预后比形成良好顺行血流的患者更差，可能是由于残余心肌缺血。这类患者可能从冠状动脉血运重建（血管成形术或手术）中获益，以恢复顺行血流并使危险心肌最小化。
