Da Costa A, Isaaz K, Faure E, Mourot S, Cerisier A, Lamaud M
Division of Cardiology, University Jean Monnet of Saint-Etienne, Saint-Etienne, France.
Eur Heart J. 2001 Aug;22(16):1459-65. doi: 10.1053/euhj.2000.2553.
The purpose of this study was to evaluate the clinical outcome of a large cohort of patients who suffered an acute myocardial infarction with absolutely normal epicardial coronary arteries at the post-myocardial infarction coronary angiogram. The aetiological and prognostic factors in this population were also analysed.
Few data exist concerning the outcome, and aetiological and prognostic factors, of patients with myocardial infarction and angiographically absolutely normal coronary arteries.
Ninety-one patients (34 females/57 males; mean age 50+/-13 years, range 24--78 years) admitted with an acute myocardial infarction had absolutely normal coronary arteries at the angiogram performed 6.2+/-4 days (range 1--15 days) after the myocardial infarction, defined by smooth contours and no focal reduction (NC). Of the 91 NC patients, 71 were evaluated prospectively, alongside a systematic search of all aetiological factors reported in the literature. The NC patients were matched for age, sex, and the same period of myocardial infarction onset with a group of 91 patients with coronary artery stenosis (>50% diameter stenosis) at the angiogram performed 7.3+/-4 days (range 1--15 days) after the myocardial infarction (SC).
The percent of smokers was similar between the two groups; higher prevalence rates of coronary heart disease family history, obesity, hypertension, hypercholesterolaemia and diabetes mellitus were found in SC (P=0.043 to 0.0001). In NC, coronary spasm was found in 15.5%, congenital coagulation disorders in 12.8%, collagen tissue disorders in 2.2%, embolization in 2.2%, and oral contraceptive use in 1.1%. Left ventricular ejection fraction at hospital discharge was higher in NC (60%+/-13%) than in SC (55%+/-13%, P=0.04). The mean follow-up was 35 months (range 1--100 months). Kaplan-Meier event-free survival, with the combined end-point defined as death, reinfarction, heart failure and stroke was 75% in NC vs 50% in SC (P<0.0001). Survival rate was 94.5% in NC compared to 92% in SC (ns). Univariate predictors of events in NC were left ventricular ejection fraction (P=0.03), age (P=0.02), diabetes (P=0.01), and smoking (P=0.03). Using Cox multivariate analysis, independent predictors of long-term outcome in NC patients were left ventricular ejection fraction (P=0.003) and diabetes (P=0.004).
Aetiological factors, predominantly coronary spasm and inherited coagulation disorder, can be detected in only one third of the patients with myocardial infarction and absolutely normal coronary angiograms despite a systematic search in a prospective population. Mortality rates are similar but morbidity is lower in myocardial infarction patients with absolutely normal coronary angiography compared with those with coronary artery stenosis. The only two independent factors predictive of poor outcome in myocardial infarction patients with normal coronary arteries are left ventricular function and diabetes.
本研究旨在评估一大群急性心肌梗死后冠状动脉造影显示心外膜冠状动脉完全正常的患者的临床结局。同时分析该人群的病因及预后因素。
关于心肌梗死且冠状动脉造影显示冠状动脉完全正常的患者的结局、病因及预后因素的数据较少。
91例急性心肌梗死患者（34例女性/57例男性；平均年龄50±13岁，范围24 - 78岁）在心肌梗死后6.2±4天（范围1 - 15天）进行的血管造影显示冠状动脉完全正常，其特征为轮廓光滑且无局灶性狭窄（NC）。在91例NC患者中，71例进行了前瞻性评估，并对文献中报道的所有病因因素进行了系统检索。将NC患者与91例心肌梗死后7.3±4天（范围1 - 15天）进行血管造影显示冠状动脉狭窄（直径狭窄>50%）的患者（SC）按年龄、性别及心肌梗死发病同期进行匹配。
两组吸烟者比例相似；SC组冠心病家族史、肥胖、高血压、高胆固醇血症和糖尿病的患病率更高（P = 0.043至0.0001）。在NC组中，发现冠状动脉痉挛的占15.5%，先天性凝血障碍占12.8%，胶原组织疾病占2.2%，栓塞占2.2%，口服避孕药使用者占1.1%。NC组出院时左心室射血分数（60%±13%）高于SC组（55%±13%，P = 0.04）。平均随访35个月（范围1 - 100个月）。将死亡、再梗死、心力衰竭和中风作为联合终点，NC组的Kaplan - Meier无事件生存率为75%，而SC组为50%（P<0.0001）。NC组生存率为94.5%，SC组为92%（无统计学差异）。NC组事件的单因素预测因素为左心室射血分数（P = 0.03）、年龄（P = 0.02）、糖尿病（P = 0.01）和吸烟（P = 0.03）。使用Cox多因素分析，NC患者长期结局的独立预测因素为左心室射血分数（P = 0.003）和糖尿病（P = 0.004）。
尽管对前瞻性人群进行了系统搜索，但在仅三分之一的心肌梗死且冠状动脉造影完全正常的患者中可检测到病因因素，主要是冠状动脉痉挛和遗传性凝血障碍。与冠状动脉狭窄患者相比，冠状动脉造影完全正常的心肌梗死患者死亡率相似但发病率较低。冠状动脉正常的心肌梗死患者预后不良的仅有的两个独立预测因素是左心室功能和糖尿病。
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