早期侵入性策略可改善既往有冠状动脉旁路移植术的急性冠状动脉综合征患者的预后：TACTICS-TIMI 18研究报告

Early invasive strategy improves outcomes in patients with acute coronary syndrome with previous coronary artery bypass graft surgery: a report from TACTICS-TIMI 18.

作者信息

Kugelmass Aaron D, Sadanandan Saihari, Lakkis Nasser, Dibattiste Peter M, Robertson Debbie H, Demopoulos Laura A, Gibson C Michael, Weintraub William S, Murphy Sabina A, Cannon Christopher P

机构信息

Henry Ford Hospital, Detroit, Michigan 48202, USA.

出版信息

Crit Pathw Cardiol. 2006 Sep;5(3):167-72. doi: 10.1097/01.hpc.0000236218.07432.a6.

DOI:10.1097/01.hpc.0000236218.07432.a6

PMID:18340233

Abstract

BACKGROUND

Patients with previous coronary artery bypass graft surgery (CABG) have been classified as a high-risk subset of patients who experience non-ST elevation acute coronary syndrome (ACS). Recent studies suggest that an early invasive strategy is beneficial in moderate- and high-risk patients with non-ST elevation ACS. We hypothesized that an early invasive strategy is associated with improved outcomes in patients with non-ST elevation ACS with prior CABG.

METHODS AND RESULTS

In the Treat Angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction 18 trial (TACTICS-TIMI 18), 2220 patients with non-ST segment elevation ACS were randomized to an early invasive or conservative (selectively invasive) strategy. All patients were treated with aspirin, heparin, and tirofiban. Four hundred eighty-four (22%) of these patients had undergone CABG before enrollment. We analyzed whether patients with previous CABG had different 6-month outcomes and whether an early invasive strategy was associated with an improvement in long-term outcomes. Prior CABG was associated with a higher risk of adverse outcomes by 6 months, including a higher rate of readmission for ACS (17.4% vs 11.0%, P < 0.001) and a higher incidence of the composite end point of death, myocardial infarction, or rehospitalization for ACS (22.3% vs 16.4%, P = 0.002). There was a trend toward a higher incidence of myocardial infarction (7.1% vs 5.3%, P = 0.051). An early invasive strategy was associated with a reduction in the composite of death or myocardial infarction (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.31-1.0; P = 0.089) and a significant reduction in the incidence of myocardial infarction at 6 months (OR, 0.44; 95% CI, 0.21-0.93; P=0.032).

CONCLUSIONS

Patients with non-ST segment elevation ACS who have had previous CABG are a high-risk subset. An early invasive strategy reduces risk of myocardial infarction in this high-risk group.

摘要

背景

既往接受过冠状动脉旁路移植术（CABG）的患者被归类为非ST段抬高型急性冠状动脉综合征（ACS）的高危亚组患者。近期研究表明，早期侵入性策略对中度和高危非ST段抬高型ACS患者有益。我们假设，早期侵入性策略与既往接受过CABG的非ST段抬高型ACS患者的预后改善相关。

方法与结果

在替罗非班治疗心绞痛并确定侵入性或保守性策略治疗成本-心肌梗死溶栓治疗18试验（TACTICS-TIMI 18）中，2220例非ST段抬高型ACS患者被随机分配至早期侵入性或保守（选择性侵入）策略组。所有患者均接受阿司匹林、肝素和替罗非班治疗。其中484例（22%）患者在入组前接受过CABG。我们分析了既往接受过CABG的患者6个月的预后是否不同，以及早期侵入性策略是否与长期预后改善相关。既往CABG与6个月时不良预后风险较高相关，包括ACS再入院率较高（17.4%对11.0%，P<0.001）以及死亡、心肌梗死或ACS再住院复合终点发生率较高（22.3%对16.4%，P = 0.002）。心肌梗死发生率有升高趋势（7.1%对5.3%，P = 0.051）。早期侵入性策略与死亡或心肌梗死复合终点降低相关（优势比[OR]，0.58；95%置信区间[CI]，0.31 - 1.0；P = 0.089），且6个月时心肌梗死发生率显著降低（OR，0.44；95%CI，0.21 - 0.93；P = 0.032）。