非ST段抬高型急性冠脉综合征的侵入性策略与保守策略：来自葡萄牙单一中心的数据。

Invasive versus conservative strategy in non-sT elevation acute coronary syndromes: data from a single Portuguese center.

作者信息

Teixeira Rogério, Lourenço Carolina, Baptista Rui, Jorge Elisabete, António Natália, Monteiro Sílvia, Gonçalves Francisco, Monteiro Pedro, Freitas Mário, Providência Luís A

机构信息

Serviço de Cardiologia, Hospitais da Universidade de Coimbra, Coimbra, Portugal.

出版信息

Rev Port Cardiol. 2009 Apr;28(4):355-73.

PMID:19634494

Abstract

BACKGROUND

In addition to medical therapy, revascularization plays an important role in determining prognosis in the acute setting of unstable angina (UA) or non-ST elevation myocardial infarction (NSTEMI).

OBJECTIVE

To compare in-hospital and medium-term outcome of an invasive versus a conservative strategy in the setting of UA/ NSTEMI.

METHODS

We carried out a prospective study of 802 consecutive patients admitted to a single coronary unit between May 2004 and December 2006 with UA/NSTEMI. Patients were divided into two groups: A (n=418)--invasive strategy; B (n=384)--conservative strategy. All-cause mortality and major adverse cardiovascular events (MACE) were assessed at one year.

RESULTS

Group B patients were older (73.0 [29-93] vs. 64.0 [27-86] years, p < 0.001), more frequently female and diabetic (35.9 vs. 26.0%, p = 0.002), and were more likely to have a history of myocardial infarction and heart failure. They also presented with worse renal function, lower hemoglobin levels and lower left ventricular ejection fraction (53.0 [45-59] vs. 57.0% [50-60]%, p < 0.001). In hospital mortality was significantly higher for this group (5.7 vs. 1.9%, p = 0.004). Group A had more smokers, more frequent history of percutaneous coronary intervention, higher total and LDL cholesterol, lower Killip class on admission and lower TIMI scores. They were more frequently treated with anti-platelet therapy and at discharge were more often under beta-blocker and dual anti-platelet therapy. Female gender (adjusted OR 0.46; 95% CI 0.27-0.78) and older age (adjusted OR 0.55; 95% CI 0.31-0.99), were independent predictors for a conservative strategy during hospital stay. One-year survival was higher for the invasive strategy patients (95.9% vs. 86.2%, log rank p < 0.001), as was one-year MACE-free survival (88.3% vs. 75.7%, log rank p < 0.001). According to two multivariate Cox regression analyses, opting for an invasive strategy during hospital stay conferred a 57% reduction in relative risk of death (HR 0.43; 95% CI 0.20-0.94), and a 56% reduction in relative risk of MACE (HR 0.44; 95% CI 0.26-0.77) at one year.

CONCLUSIONS

Despite some imbalances between the groups, in our population an invasive strategy during hospital stay independently predicted a favorable one-year outcome.

摘要

背景

除药物治疗外，血运重建在不稳定型心绞痛（UA）或非ST段抬高型心肌梗死（NSTEMI）急性发作时的预后判定中起着重要作用。

目的

比较UA/NSTEMI患者采用侵入性策略与保守策略的住院期间及中期结局。

方法

我们对2004年5月至2006年12月期间连续入住单一冠心病单元的802例UA/NSTEMI患者进行了一项前瞻性研究。患者分为两组：A组（n = 418）——侵入性策略组；B组（n = 384）——保守策略组。在1年时评估全因死亡率和主要不良心血管事件（MACE）。

结果

B组患者年龄更大（73.0[29 - 93]岁 vs. 64.0[27 - 86]岁，p < 0.001），女性和糖尿病患者更常见（35.9% vs. 26.0%，p = 0.002），且更可能有心肌梗死和心力衰竭病史。他们还表现出肾功能更差、血红蛋白水平更低以及左心室射血分数更低（53.0[45 - 59]% vs. 57.0%[50 - 60]%，p < 0.001）。该组患者的住院死亡率显著更高（5.7% vs. 1.9%，p = 0.004）。A组吸烟者更多，经皮冠状动脉介入治疗史更常见，总胆固醇和低密度脂蛋白胆固醇更高，入院时Killip分级更低且TIMI评分更低。他们接受抗血小板治疗更频繁，出院时更常接受β受体阻滞剂和双联抗血小板治疗。女性（校正OR 0.46；95%CI 0.27 - 0.78）和高龄（校正OR 0.55；95%CI 0.31 - 0.99）是住院期间采用保守策略的独立预测因素。侵入性策略组患者的1年生存率更高（95.9% vs. 86.2%，对数秩检验p < 0.001），1年无MACE生存率也更高（88.3% vs. 75.7%，对数秩检验p < 0.001）。根据两项多变量Cox回归分析，住院期间选择侵入性策略可使1年时死亡相对风险降低57%（HR 0.43；95%CI 0.20 - 0.94），MACE相对风险降低56%（HR 0.44；95%CI 0.26 - 0.77）。