Iwasaki Kohichiro
Kohichiro Iwasaki, Department of Cardiology, Okayama Kyokuto Hospital, Okayama 703-8265, Japan.
World J Cardiol. 2014 Apr 26;6(4):130-9. doi: 10.4330/wjc.v6.i4.130.
Previous studies demonstrated that coronary revascularization, especially percutaneous coronary intervention (PCI), does not significantly decrease the incidence of cardiac death or myocardial infarction in patients with stable coronary artery disease. Many studies using myocardial perfusion imaging (MPI) showed that, for patients with moderate to severe ischemia, revascularization is the preferred therapy for survival benefit, whereas for patients with no to mild ischemia, medical therapy is the main choice, and revascularization is associated with increased mortality. There is some evidence that revascularization in patients with no or mild ischemia is likely to result in worsened ischemia, which is associated with increased mortality. Studies using fractional flow reserve (FFR) demonstrate that ischemia-guided PCI is superior to angiography-guided PCI, and the presence of ischemia is the key to decision-making for PCI. Complementary use of noninvasive MPI and invasive FFR would be important to compensate for each method's limitations. Recent studies of appropriateness criteria showed that, although PCI in the acute setting and coronary bypass surgery are properly performed in most patients, PCI in the non-acute setting is often inappropriate, and stress testing to identify myocardial ischemia is performed in less than half of patients. Also, some studies suggested that revascularization in an inappropriate setting is not associated with improved prognosis. Taken together, the presence and the extent of myocardial ischemia is a key factor in the management of patients with stable coronary artery disease, and coronary revascularization in the absence of myocardial ischemia is associated with worsened prognosis.
以往研究表明,冠状动脉血运重建,尤其是经皮冠状动脉介入治疗(PCI),并不能显著降低稳定型冠状动脉疾病患者的心源性死亡或心肌梗死发生率。许多使用心肌灌注成像(MPI)的研究表明,对于中重度缺血患者,血运重建是获得生存益处的首选治疗方法,而对于无缺血或轻度缺血患者,药物治疗是主要选择,血运重建与死亡率增加相关。有证据表明,无缺血或轻度缺血患者进行血运重建可能会导致缺血加重,这与死亡率增加有关。使用血流储备分数(FFR)的研究表明,缺血指导下的PCI优于血管造影指导下的PCI,缺血的存在是PCI决策的关键。无创MPI和有创FFR的互补使用对于弥补每种方法的局限性很重要。近期关于适当性标准的研究表明,虽然大多数患者在急性情况下进行PCI和冠状动脉搭桥手术是恰当的,但在非急性情况下进行PCI往往不恰当,并且不到一半的患者进行了用于识别心肌缺血的负荷试验。此外,一些研究表明,在不适当的情况下进行血运重建与预后改善无关。综上所述,心肌缺血的存在和程度是稳定型冠状动脉疾病患者管理的关键因素,在无心肌缺血的情况下进行冠状动脉血运重建与预后恶化相关。