Bench Travis J, Parikh Puja B, Jeremias Allen, Brener Sorin J, Naidu Srihari S, Shlofmitz Richard A, Pappas Thomas, Marzo Kevin P, Gruberg Luis
Division of Cardiovascular Medicine, Stony Brook University Medical Center, Stony Brook, New York, USA.
J Invasive Cardiol. 2013 Apr;25(4):166-9.
While the impact of prior coronary artery bypass graft surgery (CABG) on in-hospital outcomes in patients with ST-elevation myocardial infarction (STEMI) has been described, data are limited on patients with prior percutaneous coronary intervention (PCI) undergoing primary PCI in the setting of an STEMI. The aim of the present study was to assess the effect of previous revascularization on in-hospital outcomes in STEMI patients undergoing primary PCI. Between January 2004 and December 2007, a total of 1649 patients underwent primary PCI for STEMI at four New York State hospitals. Baseline clinical and angiographic characteristics and in-hospital outcomes were prospectively collected as part of the New York State PCI Reporting System (PCIRS). Patients with prior surgical or percutaneous coronary revascularization were compared to those without prior coronary revascularization. Of the 1649 patients presenting with STEMI, a total of 93 (5.6%) had prior CABG, 258 (15.7%) had prior PCI, and 1298 (78.7%) had no history of prior coronary revascularization. Patients with prior CABG were significantly older and had higher rates of peripheral vascular disease, diabetes mellitus, congestive heart failure, and prior stroke. Additionally, compared with those patients with a history of prior PCI as well as those without prior coronary revascularization, patients with previous CABG had more left main interventions (24% vs 2% and 2%; P<.001), but were less often treated with drug-eluting stents (47% vs 61% and 72%; P<.001). Despite a low incidence of adverse in-hospital events, prior CABG was associated with higher all-cause in-hospital mortality (6.5% vs 2.2%; P=.012), and as a result, higher overall MACE (6.5% vs 2.7%; P=.039). By multivariate analysis, prior CABG (odds ratio, 3.40; 95% confidence interval, 1.15-10.00) was independently associated with in-hospital mortality. In contrast, patients with prior PCI had similar rates of MACE (4.3% vs 2.7%; P=.18) and in-hospital mortality (3.1% vs 2.2%; P=.4) when compared to the de novo population. Patients with a prior history of CABG, but not prior PCI, undergoing primary PCI in the setting of STEMI have significantly worse in-hospital outcomes when compared with patients who had no prior history of coronary artery revascularization. Thus, only prior surgical - and not percutaneous - revascularization should be considered a significant risk factor in the setting of primary PCI.
虽然已有研究描述了既往冠状动脉旁路移植术（CABG）对ST段抬高型心肌梗死（STEMI）患者住院结局的影响，但关于既往接受经皮冠状动脉介入治疗（PCI）的患者在STEMI情况下接受直接PCI的数据有限。本研究的目的是评估既往血运重建对接受直接PCI的STEMI患者住院结局的影响。2004年1月至2007年12月期间，纽约州四家医院共有1649例患者因STEMI接受了直接PCI。作为纽约州PCI报告系统（PCIRS）的一部分，前瞻性收集了基线临床和血管造影特征以及住院结局。将既往接受外科或经皮冠状动脉血运重建的患者与未接受过冠状动脉血运重建的患者进行比较。在1649例STEMI患者中，共有93例（5.6%）既往接受过CABG，258例（15.7%）既往接受过PCI，1298例（78.7%）无冠状动脉血运重建史。既往接受CABG的患者年龄显著更大，外周血管疾病、糖尿病、充血性心力衰竭和既往中风的发生率更高。此外，与既往有PCI史的患者以及无冠状动脉血运重建史的患者相比，既往接受CABG的患者左主干介入治疗更多（24%对2%和2%；P<0.001），但使用药物洗脱支架的频率更低（47%对61%和72%；P<0.001）。尽管住院不良事件发生率较低，但既往CABG与全因住院死亡率较高相关（6.5%对2.2%；P=0.012），因此，总体主要不良心血管事件（MACE）发生率更高（6.5%对2.7%；P=0.039）。通过多变量分析，既往CABG（比值比，3.40；95%置信区间，1.15 - 10.00）与住院死亡率独立相关。相比之下，与初发人群相比，既往有PCI史的患者MACE发生率（4.3%对2.7%；P=0.18）和住院死亡率（3.1%对2.2%；P=0.4）相似。与无冠状动脉血运重建史的患者相比，既往有CABG史但无PCI史的患者在STEMI情况下接受直接PCI时住院结局明显更差。因此，在直接PCI的情况下，只有既往外科血运重建而非经皮血运重建应被视为重要的危险因素。
