New York-Presbyterian Hospital, Columbia University Medical Center, Cardiovascular Research Foundation, NY 10022, USA.
Circulation. 2012 May 29;125(21):2613-20. doi: 10.1161/CIRCULATIONAHA.111.069237. Epub 2012 May 1.
The clinical significance of incomplete coronary revascularization (ICR) after percutaneous coronary intervention in patients with acute coronary syndromes is unknown.
We performed quantitative angiography of the entire coronary tree in 2954 patients with acute coronary syndromes in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. ICR was variably defined if any lesion with diameter stenosis (DS) cutoffs ranging from ≥30% to ≥70% with reference vessel diameter ≥2.0 mm remained after percutaneous coronary intervention. The primary outcome was 1-year composite rate of major adverse cardiac events (death, myocardial infarction, or ischemia-driven unplanned revascularization). With the use of DS cutoffs ≥30%, ≥40%, ≥50%, ≥60%, and ≥70%, the prevalence of ICR after percutaneous coronary intervention was 75%, 55%, 37%, 25%, and 17%, respectively. The 1-year major adverse cardiac event rate was increased among patients with ICR using all of the DS cutoffs. ICR (≥50% DS) was associated with higher 1-year rates of myocardial infarction (12.0% versus 8.2%; hazard ratio, 1.50; 95% confidence interval, 1.18-1.89; P=0.0007) and ischemia-driven unplanned revascularization (15.7% versus 10.2%; hazard ratio, 1.58; 95% confidence interval, 1.28-1.96; P<0.0001), with a trend toward increased mortality (3.1% versus 2.2%; hazard ratio, 1.43; 95% confidence interval, 0.90-2.27; P=0.13). By multivariable analysis, ICR (≥50% DS) was an independent predictor of 1-year major adverse cardiac events (hazard ratio, 1.36; 95% confidence interval, 1.12-1.64; P=0.002). The impact of ICR on major adverse cardiac events was similar regardless of chronic total occlusion presence, but it was more pronounced with a greater number of nonrevascularized lesions.
Depending on the threshold of percent DS, ICR was present in 17% to 75% of patients with acute coronary syndromes after percutaneous coronary intervention. Regardless of the threshold, ICR was strongly associated with 1-year myocardial infarction, ischemia-driven unplanned revascularization, and major adverse cardiac events.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.
急性冠脉综合征患者经皮冠状动脉介入治疗后不完全血运重建（ICR）的临床意义尚不清楚。
我们对急性经皮冠状动脉介入治疗及紧急介入治疗（ACUITY）试验中的 2954 例急性冠脉综合征患者进行了整个冠状动脉树的定量血管造影。如果任何病变的直径狭窄（DS）程度介于 30%至 70%之间，而参考血管直径≥2.0mm，那么经皮冠状动脉介入治疗后仍存在病变，则定义为 ICR。主要终点为 1 年时主要不良心脏事件（死亡、心肌梗死或缺血驱动的计划性血运重建）的复合发生率。使用 DS 截断值≥30%、≥40%、≥50%、≥60%和≥70%，经皮冠状动脉介入治疗后 ICR 的发生率分别为 75%、55%、37%、25%和 17%。所有 DS 截断值中，ICR 患者的 1 年主要不良心脏事件发生率均升高。ICR（≥50%DS）与较高的 1 年心肌梗死发生率（12.0%比 8.2%；风险比，1.50；95%置信区间，1.18-1.89；P=0.0007）和缺血驱动的计划性血运重建（15.7%比 10.2%；风险比，1.58；95%置信区间，1.28-1.96；P<0.0001）相关，且死亡率呈上升趋势（3.1%比 2.2%；风险比，1.43；95%置信区间，0.90-2.27；P=0.13）。多变量分析显示，ICR（≥50%DS）是 1 年主要不良心脏事件的独立预测因素（风险比，1.36；95%置信区间，1.12-1.64；P=0.002）。ICR 对主要不良心脏事件的影响与慢性完全闭塞的存在无关，但与未血运重建病变的数量增加有关。
根据 DS 百分比的阈值，17%至 75%的急性冠脉综合征患者经皮冠状动脉介入治疗后存在 ICR。无论阈值如何，ICR 与 1 年心肌梗死、缺血驱动的计划性血运重建和主要不良心脏事件均有密切关联。
