非ST段抬高型急性冠状动脉综合征中血运重建与低死亡率的关联：来自GUSTO IV-ACS的报告

Association of revascularisation with low mortality in non-ST elevation acute coronary syndrome, a report from GUSTO IV-ACS.

作者信息

Ottervanger J P, Armstrong P, Barnathan E S, Boersma E, Cooper J S, Ohman E M, James S, Wallentin L, Simoons M L

机构信息

Erasmus Medical Center, University Hospital Rotterdam, Room H 560, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.

出版信息

Eur Heart J. 2004 Sep;25(17):1494-501. doi: 10.1016/j.ehj.2004.07.004.

DOI:10.1016/j.ehj.2004.07.004

PMID:15342168

Abstract

BACKGROUND

Immediate, as well as early, revascularisation is of benefit in patients with acute coronary syndromes (ACS) presenting with ST elevation. However, trials comparing invasive versus medical treatment in patients with an acute coronary syndrome without ST elevation do not consistently show improvement in survival after revascularisation. Accordingly, additional data are warranted.

METHODS

The effect of revascularisation within 30 days on one-year survival in the GUSTO IV ACS trial was investigated. A total of 7800 patients were included with an acute coronary syndrome without ST elevation, documented by either elevated cardiac troponin or transient or persistent ST-segment depression. In this trial, comparing abciximab versus placebo as initial medical therapy, coronary angiography within 60 h after randomisation was discouraged. In 30-day survivors, those who underwent revascularisation were compared with 30-day survivors without revascularisation. Adjustments were made for patient characteristics, and for a propensity score that was adjusted for covariates associated with the likelihood of early revascularisation.

FINDINGS

Of the 7496 patients who survived at least 30 days, 2265 (30%) underwent coronary revascularisation within 30 days: 789 patients CABG, 1450 PCI and 26 both CABG and PCI. Procedure-related mortality was low at 1.8%. Patients with revascularisation had a lower one-year mortality compared to medically treated patients (2.3% vs. 5.6%, p < 0.001). After multivariable analyses, patients with revascularisation had a relative risk of subsequent mortality within 1 year of 0.53 (95% CI 0.37-0.77) compared to patients without revascularisation.

CONCLUSIONS

Revascularisation within 30 days is associated with an improved prognosis in ACS without ST-segment elevation. The relative high mortality in medically treated patients may be related in part to patient selection, but warrants further studies to improve outcome of these patients.

摘要

背景

对于ST段抬高型急性冠脉综合征（ACS）患者，即刻以及早期血运重建均有益处。然而，比较非ST段抬高型急性冠脉综合征患者侵入性治疗与药物治疗的试验并未一致显示血运重建后生存率有所改善。因此，需要更多数据。

方法

在GUSTO IV ACS试验中，研究了30天内血运重建对1年生存率的影响。共纳入7800例非ST段抬高型急性冠脉综合征患者，其通过心肌肌钙蛋白升高或短暂或持续性ST段压低得以记录。在该试验中，比较阿昔单抗与安慰剂作为初始药物治疗，不鼓励随机分组后60小时内进行冠状动脉造影。在30天存活者中，将接受血运重建的患者与未接受血运重建的30天存活者进行比较。对患者特征以及针对与早期血运重建可能性相关的协变量进行调整的倾向评分进行了校正。

结果

在至少存活30天的7496例患者中，2265例（30%）在30天内接受了冠状动脉血运重建：789例行冠状动脉旁路移植术（CABG），1450例行经皮冠状动脉介入治疗（PCI），26例同时行CABG和PCI。与手术相关的死亡率较低，为1.8%。与接受药物治疗的患者相比，接受血运重建的患者1年死亡率较低（2.3%对5.6%，p<0.001）。多变量分析后，与未接受血运重建的患者相比，接受血运重建的患者1年内后续死亡的相对风险为0.53（95%CI 0.37-0.77）。