Division of Cardiovascular Medicine, Cardiothoracic Department, University of Pisa, Pisa, Italy.
Am J Cardiovasc Drugs. 2010;10 Suppl 1:27-32. doi: 10.2165/1153643-S0-000000000-00000.
Percutaneous coronary intervention (PCI) has not been shown to reduce mortality in patients with stable coronary artery disease (CAD). The long-term clinical success of PCI is defined as the persistent relief of signs and symptoms of myocardial ischemia for more than 6 months after the index procedure. Data from large trials investigating the use of PCI in patients with stable CAD show that angina is still experienced in a large number of patients one year after the procedure and that this proportion increases over time. These data are, however, largely from post-hoc analyses of studies powered to measure other end points. We conducted the first prospective study investigating the incidence of persistent angina and inducible ischemia in patients with stable CAD undergoing PCI rated as 'successful' by the interventional cardiologist, and present an interim analysis of data from 220 patients. The mean age of our patients was 65 years; they were mostly male, mildly obese, hypertensive and dyslipidemic. Most patients had single-vessel disease affecting the left anterior descending artery and received a drug-eluting stent, and all patients had a positive stress test before PCI. At the follow-up visit, which was performed within 4 weeks of the index procedure, 52% of patients still had a positive stress test. Before PCI, 66% of patients reported experiencing angina on exertion. At the follow-up visit, one-third of those patients were still experiencing angina. Patients experiencing persistent angina (21% of the study population) graded their symptoms as improved (66%), unchanged (33%) or worsened (1%) after the procedure. We hypothesize that coronary microvascular dysfunction is a possible cause of persistent angina in this highly select group of patients. Risk factors for microvascular dysfunction include dyslipidemia, smoking and diabetes. It is currently difficult to dissect the relative contributions of coronary artery stenosis and microvascular dysfunction in precipitating myocardial ischemia. A better understanding of these mechanisms could reduce the number of unnecessary PCI procedures. Moreover, treatment options in patients who continue to experience angina despite 'optimal' medical therapy and 'successful' PCI are urgently required.
经皮冠状动脉介入治疗（PCI）并未降低稳定性冠状动脉疾病（CAD）患者的死亡率。PCI 的长期临床成功定义为在指数手术后 6 个月以上持续缓解心肌缺血的症状和体征。来自大型试验的数据调查了 PCI 在稳定性 CAD 患者中的应用，结果表明，在手术后一年，仍有大量患者经历心绞痛，而且这种比例随着时间的推移而增加。然而，这些数据主要来自旨在测量其他终点的研究的事后分析。我们进行了第一项前瞻性研究，调查了在介入心脏病学家评定为“成功”的 PCI 后，稳定性 CAD 患者持续心绞痛和可诱导缺血的发生率，并报告了 220 例患者数据的中期分析。我们患者的平均年龄为 65 岁；他们主要是男性，轻度肥胖，高血压和血脂异常。大多数患者患有影响左前降支的单支血管疾病，并接受了药物洗脱支架治疗，所有患者在 PCI 前都进行了阳性应激试验。在指数手术后 4 周内进行的随访中，52%的患者仍有阳性应激试验。在 PCI 之前，66%的患者报告在用力时出现心绞痛。在随访时，三分之一的患者仍有胸痛。经历持续心绞痛的患者（研究人群的 21%）在手术后将其症状评为改善（66%）、不变（33%）或恶化（1%）。我们假设，在这个高度选择的患者群体中，冠状动脉微血管功能障碍是持续心绞痛的一个可能原因。微血管功能障碍的危险因素包括血脂异常、吸烟和糖尿病。目前，很难区分冠状动脉狭窄和微血管功能障碍在引发心肌缺血方面的相对贡献。更好地了解这些机制可以减少不必要的 PCI 手术数量。此外，对于尽管接受了“最佳”药物治疗和“成功”PCI 但仍持续出现心绞痛的患者，迫切需要治疗选择。
