Charite Campus Virchow-Klinikum, Berlin, Germany.
Am J Cardiol. 2011 Dec 15;108(12):1697-703. doi: 10.1016/j.amjcard.2011.07.040. Epub 2011 Sep 8.
Small studies have suggested that direct stenting without balloon predilatation in ST-segment elevation myocardial infarction may reduce microcirculatory dysfunction. To examine the clinical benefits of direct stenting in a large cohort of patients who underwent primary percutaneous coronary intervention treated with contemporary pharmacotherapy, the 1-year outcomes from the multicenter, randomized Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial were analyzed. A total of 3,602 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention were enrolled. The present study cohort consisted of 2,528 patients in whom single lesions (excluding bypass grafts) were treated with stent implantation. At operator discretion, direct stenting was attempted in 698 patients (27.6%), and stenting was performed after predilatation in 1,830 patients (72.4%). Propensity-score matching was performed to reduce bias. Direct stenting was successful in 677 patients (97.0%). ST-segment resolution at 60 minutes after the procedure was improved in patients who underwent direct compared to conventional stenting (median 74.8% vs 68.9%, respectively, p = 0.01). At 1-year follow-up, direct compared to conventional stenting was associated with a significantly lower rate of all-cause death (1.6% vs 3.8%, p = 0.01) and stroke (0.3% vs 1.1%, p = 0.049), with nonsignificant differences in target lesion revascularization, myocardial infarction, stent thrombosis, and major bleeding. Death at 1 year remained significantly lower in the direct stenting group after multivariate adjustment (hazard ratio 0.42, 95% confidence interval 0.21 to 0.86, p = 0.02) and in a propensity score-based analysis (hazard ratio 0.92, 95% confidence interval 0.88 to 0.95, p = 0.02). In conclusion, compared to stent implantation after predilatation, direct stenting is safe and effective in appropriately selected lesions in patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention and may result in improved survival.
一些小型研究表明，在 ST 段抬高型心肌梗死患者中直接支架置入术而不进行球囊预扩张可能会减少微血管功能障碍。为了在接受当代药物治疗的行直接经皮冠状动脉介入治疗的大量患者中检验直接支架置入术的临床获益，对多中心、随机 Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction（HORIZONS-AMI）试验的 1 年结果进行了分析。共纳入 3602 例接受直接经皮冠状动脉介入治疗的 ST 段抬高型心肌梗死患者。本研究队列包括 2528 例接受支架置入术治疗的单支病变（不包括旁路移植术）患者。根据术者的判断，698 例（27.6%）患者尝试直接支架置入术，1830 例（72.4%）患者行球囊预扩张后置入支架。采用倾向评分匹配以减少偏倚。直接支架置入术成功 677 例（97.0%）。与常规支架置入术相比，直接支架置入术患者术后 60 分钟 ST 段回落得到改善（分别为 74.8%和 68.9%，p=0.01）。在 1 年随访期间，与常规支架置入术相比，直接支架置入术与全因死亡率（1.6%比 3.8%，p=0.01）和卒（0.3%比 1.1%，p=0.049）显著降低相关，而靶病变血运重建、心肌梗死、支架血栓形成和大出血发生率无显著差异。多变量调整后（风险比 0.42，95%置信区间 0.21 至 0.86，p=0.02）和基于倾向评分的分析（风险比 0.92，95%置信区间 0.88 至 0.95，p=0.02）均显示，1 年时直接支架置入术组死亡率仍显著降低。总之，在接受直接经皮冠状动脉介入治疗的 ST 段抬高型心肌梗死患者中，与球囊预扩张后置入支架相比，直接支架置入术在适当选择的病变中是安全且有效的，可能会提高生存率。
