Alderman Edwin L, Kip Kevin E, Whitlow Patrick L, Bashore Thomas, Fortin Donald, Bourassa Martial G, Lesperance Jacques, Schwartz Leonard, Stadius Michael
Cardiovascular Division, Stanford University, Stanford, California, USA.
J Am Coll Cardiol. 2004 Aug 18;44(4):766-74. doi: 10.1016/j.jacc.2004.05.041.
Coronary angiograms obtained five years following revascularization were examined to assess the extent of compromise in myocardial perfusion due to failure of revascularization versus progression of native disease.
The Bypass Angioplasty Revascularization Investigation (BARI) randomized revascularization candidates between bypass surgery and angioplasty. Entry and five-year angiograms from 407 of 519 (78%) patients at four centers were analyzed.
Analysis of the distribution of coronary vessels and stenoses provided a measure of myocardial jeopardy that correlates with presence of angina. The extent to which initial benefits of revascularization were undone by failed revascularization versus native disease progression was assessed.
Myocardial jeopardy fell following initial revascularization, from 60% to 17% for percutaneous coronary intervention (PCI)-treated patients compared with 60% to 7% for coronary artery bypass graft (CABG) surgery patients (p < 0.001), rebounding at five years to 25% for PCI and 20% for surgery patients (p = 0.01). Correspondingly, angina prevalence was higher at five years in PCI-treated patients than in surgery-treated patients (28% vs. 18%; p = 0.03). However, myocardial jeopardy at five years, and not initial treatment (PCI vs. surgery), was independently associated with late angina. Increased myocardial jeopardy from entry to five-year angiogram occurred in 42% of PCI-treated patients and 51% of CABG-treated patients (p = 0.06). Among the increases in myocardial jeopardy, two-thirds occurred in previously untreated arteries.
Native coronary disease progression occurred more often than failed revascularization in both PCI- and CABG-treated patients as a cause of jeopardized myocardium and angina recurrence. These results support intensive postrevascularization risk-factor modification.
检查血运重建术后五年获得的冠状动脉造影，以评估因血运重建失败与原发病进展导致的心肌灌注受损程度。
旁路血管成形血运重建术研究（BARI）将血运重建候选者随机分为接受旁路手术和血管成形术两组。对四个中心519例患者中的407例（78%）患者的入院时及五年时的血管造影进行了分析。
分析冠状动脉血管和狭窄的分布情况，以衡量与心绞痛存在相关的心肌危险程度。评估了血运重建失败与原发病进展相比，使血运重建的初始益处丧失的程度。
初始血运重建后心肌危险程度降低，经皮冠状动脉介入治疗（PCI）患者从60%降至17%，冠状动脉旁路移植术（CABG）患者从60%降至7%（p<0.001），五年时反弹，PCI患者升至25%，手术患者升至20%（p = 0.01）。相应地，PCI治疗患者五年时心绞痛患病率高于手术治疗患者（28%对18%；p = 0.03）。然而，五年时的心肌危险程度而非初始治疗（PCI与手术）与晚期心绞痛独立相关。42%的PCI治疗患者和51%的CABG治疗患者从入院到五年血管造影时心肌危险程度增加（p = 0.06）。在心肌危险程度增加的患者中，三分之二发生在先前未治疗的动脉。
在PCI和CABG治疗的患者中，作为心肌危险和心绞痛复发的原因，原冠状动脉疾病进展比血运重建失败更常见。这些结果支持强化血运重建术后危险因素的调整。
