Goldstein J A, Demetriou D, Grines C L, Pica M, Shoukfeh M, O'Neill W W
Division of Cardiology, William Beaumont Hospital, Royal Oak, Mich 48073-6769, USA.
N Engl J Med. 2000 Sep 28;343(13):915-22. doi: 10.1056/NEJM200009283431303.
Acute myocardial infarction is believed to be caused by rupture of an unstable coronary-artery plaque that appears as a single lesion on angiography. However, plaque instability might be caused by pathophysiologic processes, such as inflammation, that exert adverse effects throughout the coronary vasculature and that therefore result in multiple unstable lesions.
To document the presence of multiple unstable plaques in patients with acute myocardial infarction and determine their influence on outcome, we analyzed angiograms from 253 patients for complex coronary plaques characterized by thrombus, ulceration, plaque irregularity, and impaired flow.
Single complex coronary plaques were identified in 153 patients (60.5 percent) and multiple complex plaques in the other 100 patients (39.5 percent). As compared with patients with single complex plaques, those with multiple complex plaques were less likely to undergo primary angioplasty (86.0 percent vs. 94.8 percent, P = 0.03) and more commonly required urgent bypass surgery (27.0 percent vs. 5.2 percent, P < or = 0.001). During the year after myocardial infarction, the presence of multiple complex plaques was associated with an increased incidence of recurrent acute coronary syndromes (19.0 percent vs. 2.6 percent, P < or = 0.001); repeated angioplasty (32.0 percent vs. 12.4 percent, P < or = 0.001), particularly of non-infarct-related lesions (17.0 percent vs. 4.6 percent, P < or = 0.001); and coronary-artery bypass graft surgery (35.0 percent vs. 11.1 percent, P < or = 0.001).
Patients with acute myocardial infarction may harbor multiple complex coronary plaques that are associated with adverse clinical outcomes. Plaque instability may be due to a widespread process throughout the coronary vessels, which may have implications for the management of acute ischemic heart disease.
急性心肌梗死被认为是由不稳定冠状动脉斑块破裂所致，这种斑块在血管造影时表现为单个病变。然而，斑块不稳定可能是由诸如炎症等病理生理过程引起的，这些过程会对整个冠状动脉血管系统产生不利影响，从而导致多个不稳定病变。
为了证实急性心肌梗死患者中存在多个不稳定斑块并确定其对预后的影响，我们分析了253例患者的血管造影照片，以寻找具有血栓、溃疡、斑块不规则和血流受损特征的复杂冠状动脉斑块。
153例患者（60.5%）发现单个复杂冠状动脉斑块，另外100例患者（39.5%）发现多个复杂斑块。与单个复杂斑块患者相比，多个复杂斑块患者接受直接血管成形术的可能性较小（86.0%对94.8%，P = 0.03），且更常需要紧急搭桥手术（27.0%对5.2%，P≤0.001）。在心肌梗死后的一年中，多个复杂斑块的存在与复发性急性冠状动脉综合征的发生率增加相关（19.0%对2.6%，P≤0.001）；再次血管成形术（32.0%对12.4%，P≤0.001），尤其是非梗死相关病变（17.0%对4.6%，P≤0.001）；以及冠状动脉搭桥手术（35.0%对11.1%，P≤0.001）。
急性心肌梗死患者可能存在多个与不良临床预后相关的复杂冠状动脉斑块。斑块不稳定可能是由于冠状动脉广泛存在的病变过程，这可能对急性缺血性心脏病的治疗有重要意义。
