Columbia University Medical Center, New York, NY 10022, USA.
Circ Cardiovasc Interv. 2010 Aug;3(4):308-16. doi: 10.1161/CIRCINTERVENTIONS.109.887604. Epub 2010 Jul 20.
Contemporary adjunctive pharmacology and revascularization strategies have improved the prognosis of patients with acute coronary syndromes (ACSs). We sought to identify the clinical and angiographic predictors of cardiac ischemic events in patients with ACSs treated with an early invasive strategy.
Multivariable logistic regression was used to analyze the relation between baseline characteristics and 30-day and 1-year composite ischemia (death, myocardial infarction, or unplanned revascularization) among the 6921 ACS patients included in the prespecified angiographic substudy of the Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial. Of the 6921 patients, 3826 (55.3%) were treated with percutaneous coronary intervention, 755 (10.9%) with coronary artery bypass grafting, and 2340 (33.8%) with medical therapy. Composite ischemia occurred in 595 (8.6%) patients at 30 days and in 1153 (17.4%) at 1 year. Renal insufficiency, biomarker elevation, ST-segment deviation, nonuse of aspirin or thienopyridine, insulin-treated diabetes, older age, baseline lower hemoglobin value, history of percutaneous coronary intervention, and current smoking were independently associated with 30-day or 1-year ischemic events. Angiographic characteristics predicting ischemic events included number of diseased vessels, moderate/severe calcification, worst percent diameter stenosis, jeopardy score, lower left ventricular ejection fraction, lesion eccentricity, and thrombus. With use of receiver operating characteristic methodology, the c statistic improved for the predictive model by adding angiographic to clinical parameters for the 30-day composite ischemia (from 0.62 to 0.68) and myocardial infarction (from 0.64 to 0.71) and 1-year composite ischemia (from 0.61 to 0.65) and myocardial infarction (from 0.63 to 0.69) end points.
Among ACS patients managed with an early invasive strategy, baseline angiographic markers of disease burden, calcification, lesion severity, lower left ventricular ejection fraction, and morphological characteristics provided important added independent predictive value for 30-day and 1-year ischemic outcomes, beyond the well-recognized clinical risk factors. These findings emphasize the prognostic importance of the diagnostic angiogram in the risk stratification of patients presenting with ACSs.
URL: http://clinicaltrials.gov. Unique identifier: NCT00093158.
当代辅助药理学和血运重建策略改善了急性冠状动脉综合征（ACS）患者的预后。我们旨在确定接受早期侵入性策略治疗的 ACS 患者心脏缺血事件的临床和血管造影预测因素。
多变量逻辑回归用于分析急性导管插入术和紧急介入治疗策略（ACUITY）试验的预设血管造影亚研究中纳入的 6921 例 ACS 患者的基线特征与 30 天和 1 年复合缺血（死亡、心肌梗死或计划外血运重建）之间的关系。在 6921 例患者中，3826 例（55.3%）接受经皮冠状动脉介入治疗，755 例（10.9%）接受冠状动脉旁路移植术，2340 例（33.8%）接受药物治疗。复合缺血在 30 天内发生于 595 例（8.6%）患者，在 1 年时发生于 1153 例（17.4%）患者。肾功能不全、生物标志物升高、ST 段偏移、未使用阿司匹林或噻吩吡啶、胰岛素治疗的糖尿病、年龄较大、基线较低的血红蛋白值、经皮冠状动脉介入治疗史和当前吸烟与 30 天或 1 年缺血事件独立相关。预测缺血事件的血管造影特征包括病变血管数量、中度/重度钙化、最差百分比直径狭窄、罪犯评分、较低的左心室射血分数、病变偏心性和血栓。使用接受者操作特征曲线法，通过将血管造影参数添加到临床参数中，可提高预测模型对 30 天复合缺血（从 0.62 提高至 0.68）和心肌梗死（从 0.64 提高至 0.71）以及 1 年复合缺血（从 0.61 提高至 0.65）和心肌梗死（从 0.63 提高至 0.69）终点的预测能力。
在接受早期侵入性策略治疗的 ACS 患者中，基线疾病负担、钙化、病变严重程度、较低的左心室射血分数和形态学特征的血管造影标志物提供了重要的独立预测价值，超过了公认的临床危险因素。这些发现强调了诊断性血管造影在风险分层中的预后重要性。
