Quebec Heart-Lung Institute, Department of Cardiology, Quebec, Quebec, Canada.
Am J Cardiol. 2013 Jul 15;112(2):194-9. doi: 10.1016/j.amjcard.2013.03.010. Epub 2013 Apr 18.
Chronic total occlusion (CTO) in a non-infarct-related artery and chronic kidney failure (CKD) are associated with worse outcomes after primary percutaneous coronary intervention (PCI). The aim of this study was to investigate the interaction of CTO and CKD in patients who underwent primary PCI for acute ST-segment elevation myocardial infarction (STEMI). Patients with STEMIs with or without CKD, defined as an estimated glomerular filtration rate <60 ml/min/1.73 m(2), were categorized into those with single-vessel disease and those with multivessel disease with or without CTO. The primary outcomes were the incidence of 30-day and 1-year mortality. Among 1,873 consecutive patients with STEMIs included between 2006 and 2011, 336 (18%) had CKD. The prevalence of CTO in a non-infarct-related artery was 13% in patients with CKD compared with 7% in those without CKD (p = 0.0003). There was a significant interaction between CKD and CTO on 30-day mortality (p = 0.018) and 1-year mortality (p = 0.013). Independent predictors of late mortality in patients with CKD were previous myocardial infarction (hazard ratio [HR] 1.71, 95% confidence interval [CI] 1.01 to 2.79), age >75 years (HR 1.86, 95% CI 1.19 to 2.95), a left ventricular ejection fraction after primary PCI <40% (HR 2.20, 95% CI 1.36 to 3.63), left main culprit artery (HR 4.46, 95% CI 1.64 to 10.25), and shock (HR 7.44, 95% CI 4.56 to 12.31), but multivessel disease with CTO was not a predictor. In contrast, multivessel disease with CTO was an independent predictor of mortality in patients without CKD (HR 3.30, 95% CI 1.70 to 6.17). In conclusion, in patients with STEMIs who underwent primary PCI, with preexisting CKD, the prevalence of CTO in a non-infarct-related artery was twice as great. In these patients, the clinical impact of CTO seems to be overshadowed by the presence of CKD.
非梗死相关动脉的慢性完全闭塞（CTO）和慢性肾脏衰竭（CKD）与经皮冠状动脉介入治疗（PCI）后的主要不良结局相关。本研究旨在探讨在接受急性 ST 段抬高型心肌梗死（STEMI）患者行 PCI 治疗的患者中，CTO 和 CKD 的相互作用。STEMI 患者，无论是否存在 CKD，定义为估算肾小球滤过率 <60 ml/min/1.73 m(2)，分为单支血管病变和多支血管病变伴或不伴 CTO。主要结局是 30 天和 1 年死亡率。在 2006 年至 2011 年期间连续纳入的 1873 例 STEMI 患者中，336 例（18%）患有 CKD。与无 CKD 的患者相比，CKD 患者非梗死相关动脉 CTO 的患病率为 13%，而无 CKD 的患者为 7%（p=0.0003）。CKD 和 CTO 对 30 天死亡率（p=0.018）和 1 年死亡率（p=0.013）均有显著交互作用。在 CKD 患者中，晚期死亡率的独立预测因素是既往心肌梗死（HR 1.71，95%置信区间 [CI] 1.01 至 2.79）、年龄>75 岁（HR 1.86，95% CI 1.19 至 2.95）、首次 PCI 后左心室射血分数<40%（HR 2.20，95% CI 1.36 至 3.63）、左主干罪犯动脉（HR 4.46，95% CI 1.64 至 10.25）和休克（HR 7.44，95% CI 4.56 至 12.31），但多支血管病变伴 CTO 不是预测因素。相比之下，多支血管病变伴 CTO 是无 CKD 患者死亡率的独立预测因素（HR 3.30，95% CI 1.70 至 6.17）。总之，在接受 PCI 治疗的 STEMI 患者中，预先存在 CKD 的患者，非梗死相关动脉 CTO 的患病率是两倍。在这些患者中，CTO 的临床影响似乎被 CKD 的存在所掩盖。
