非 ST 段抬高型心肌梗死和非阻塞性冠状动脉疾病患者的预后：来自急性血管成形术和紧急介入治疗分诊策略试验的倾向匹配分析。
Prognosis of patients with non-ST-segment-elevation myocardial infarction and nonobstructive coronary artery disease: propensity-matched analysis from the Acute Catheterization and Urgent Intervention Triage Strategy trial.
机构信息
From the Hadassah-Hebrew University Medical Center, Jerusalem, Israel (D.P.); Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); Cardiovascular Research Foundation, New York, NY (R.M., K.X., G.W.S.); Duke University Medical Center, Durham, NC (E.M.O.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and Columbia University Medical Center, New York, NY (J.D.N., G.W.S.).
出版信息
Circ Cardiovasc Interv. 2014 Jun;7(3):285-93. doi: 10.1161/CIRCINTERVENTIONS.113.000606. Epub 2014 May 20.
BACKGROUND
Troponin elevation is a risk factor for mortality in patients with non-ST-segment-elevation acute coronary syndromes. However, the prognosis of patients with troponin elevation and nonobstructive coronary artery disease (CAD) is unknown. Our objective was therefore to evaluate the impact of nonobstructive CAD in patients with non-ST-segment-elevation acute coronary syndromes and troponin elevation enrolled in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial.
METHODS AND RESULTS
In the ACUITY trial, 3-vessel quantitative coronary angiography was performed in a formal substudy of 6921 patients presenting with non-ST-segment-elevation acute coronary syndromes. Patients with elevated admission troponin levels were stratified by the presence or absence of obstructive CAD (any lesion with quantitative diameter stenosis >50%). Propensity score matching was performed to adjust for baseline characteristics. Of 2442 patients with elevated troponin, 197 (8.8%) had nonobstructive CAD. Maximum diameter stenosis was 87.4 (73.2, 100.0) versus 22.6 (19.2, 25.7; P<0.0001) in patients with versus without obstructive CAD, respectively. Propensity matching yielded 117 patients with nonobstructive CAD and 331 patients with obstructive CAD, with no significant baseline differences between groups. In the matched cohort, overall 1-year mortality was significantly higher in patients with nonobstructive CAD (5.2% versus 1.6%; hazard ratio [95% confidence interval]=3.44 [1.05, 11.28]; P=0.04), driven by greater noncardiac mortality. Conversely, recurrent myocardial infarction and unplanned revascularization rates were significantly higher in patients with obstructive CAD.
CONCLUSIONS
Patients with non-ST-segment-elevation acute coronary syndromes and elevated troponin levels but without obstructive CAD, while having low rates of subsequent myocardial infarction and unplanned revascularization, are still at considerable risk for 1-year mortality from noncardiac causes.
CLINICAL TRIAL REGISTRATION URL
http://www.clinicaltrials.gov. Unique identifier: NCT00093158.
背景
肌钙蛋白升高是伴有非 ST 段抬高急性冠状动脉综合征患者死亡的一个危险因素。然而，伴有肌钙蛋白升高和非阻塞性冠状动脉疾病（CAD）患者的预后尚不清楚。因此，我们的目的是评估在伴有非 ST 段抬高急性冠状动脉综合征和肌钙蛋白升高的患者中，非阻塞性 CAD 对接受急性经皮冠状动脉介入治疗的影响（ACUITY）试验。
方法和结果
在 ACUITY 试验中，对 6921 例非 ST 段抬高急性冠状动脉综合征患者进行了 3 支血管定量冠状动脉造影的正式亚组研究。根据是否存在阻塞性 CAD（任何定量直径狭窄>50%的病变）对入院时肌钙蛋白水平升高的患者进行分层。采用倾向评分匹配来调整基线特征。在 2442 例肌钙蛋白升高的患者中，有 197 例（8.8%）患有非阻塞性 CAD。最大直径狭窄程度分别为 87.4（73.2，100.0）和 22.6（19.2，25.7；P<0.0001）。倾向评分匹配后，非阻塞性 CAD 患者 117 例，阻塞性 CAD 患者 331 例，两组间无显著的基线差异。在匹配队列中，非阻塞性 CAD 患者的 1 年总死亡率明显更高（5.2%比 1.6%；风险比[95%置信区间]=3.44[1.05，11.28]；P=0.04），这主要是由于非心脏原因所致死亡率较高。相反，阻塞性 CAD 患者的复发性心肌梗死和计划外血运重建率明显更高。
结论
伴有非 ST 段抬高急性冠状动脉综合征和肌钙蛋白升高但无阻塞性 CAD 的患者，虽然随后心肌梗死和计划外血运重建的发生率较低，但仍存在非心脏原因导致 1 年死亡率的较大风险。
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