Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea2Duke Clinical Research Institute, Durham, North Carolina.
Duke Clinical Research Institute, Durham, North Carolina.
JAMA. 2014 Nov 19;312(19):2019-27. doi: 10.1001/jama.2014.15095.
Little information exists about the anatomical characteristics and clinical relevance of non-infarct-related artery (IRA) disease among patients with ST-segment elevation myocardial infarction (STEMI).
To investigate the incidence, extent, and location of obstructive non-IRA disease and compare 30-day mortality according to the presence of non-IRA disease in patients with STEMI.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of patients pooled from a convenience sample of 8 independent, international, randomized STEMI clinical trials published between 1993 and 2007. Follow-up varied from 1 month to 1 year. Among 68,765 patients enrolled in the trials, 28,282 patients with valid angiographic information were included in this analysis. Obstructive coronary artery disease was defined as stenosis of 50% or more of the diameter of a major epicardial artery. To assess the generalizability of trial-based results, external validation was performed using observational data for patients with STEMI from the Korea Acute Myocardial Infarction Registry (KAMIR) (between November 1, 2005, and December 31, 2013; n = 18,217) and the Duke Cardiovascular Databank (between January 1, 2005, and December 31, 2012; n = 1812).
Thirty-day mortality following STEMI.
Overall, 52.8% (14,929 patients) had obstructive non-IRA disease; 29.6% involved 1 vessel and 18.8% involved 2 vessels. There was no substantial difference in the extent and distribution of non-IRA disease according to the IRA territory. Unadjusted and adjusted rates of 30-day mortality were significantly higher in patients with non-IRA disease than in those without non-IRA disease (unadjusted, 4.3% vs 1.7%, respectively; risk difference, 2.7% [95% CI, 2.3% to 3.0%], P < .001; and adjusted, 3.3% vs 1.9%, respectively; risk difference, 1.4% [95% CI, 1.0% to 1.8%], P < .001). The overall prevalence and association of non-IRA disease with 30-day mortality was consistent with findings from the KAMIR registry (adjusted, 3.6% for patients with non-IRA disease vs 2.5% in those without it; risk difference, 1.1% [95% CI, 0.6% to 1.7%]; P < .001), but not with the Duke database (adjusted, 4.7% with non-IRA disease vs 4.3% without it; risk difference, 0.4% [95% CI, -1.4% to 2.2%], P = .65).
In a retrospective pooled analysis of 8 clinical trials, obstructive non-IRA disease was common among patients presenting with STEMI, and was associated with a modest statistically significant increase in 30-day mortality. These findings require confirmation in prospectively designed studies, but raise questions about the appropriateness and timing of non-IRA revascularization in patients with STEMI.
在 ST 段抬高型心肌梗死 (STEMI) 患者中，关于非梗死相关动脉 (IRA) 疾病的解剖学特征和临床相关性的信息很少。
研究阻塞性非 IRA 疾病的发生率、程度和部位，并比较 STEMI 患者中非 IRA 疾病的存在与 30 天死亡率的关系。
设计、地点和参与者：这是一项回顾性研究，研究对象来自于 1993 年至 2007 年期间发表的 8 项独立的国际随机 STEMI 临床试验中的便利样本。随访时间从 1 个月到 1 年不等。在纳入的 68765 例患者中，有 28282 例患者有有效的血管造影信息，这些患者被纳入了本分析。阻塞性冠状动脉疾病定义为主要心外膜动脉直径狭窄 50%或以上。为了评估基于试验的结果的普遍性，使用韩国急性心肌梗死注册研究（KAMIR）（2005 年 11 月 1 日至 2013 年 12 月 31 日；n=18217）和杜克心血管数据库（2005 年 1 月 1 日至 2012 年 12 月 31 日；n=1812）的 STEMI 患者的观察数据进行了外部验证。
STEMI 后 30 天的死亡率。
总的来说，52.8%（14929 例）患者有阻塞性非 IRA 疾病；29.6%累及 1 支血管，18.8%累及 2 支血管。IRA 区域的非 IRA 疾病的程度和分布没有明显差异。未经调整和调整后的 30 天死亡率在有非 IRA 疾病的患者中明显高于无非 IRA 疾病的患者（未经调整，4.3%比 1.7%；风险差异，2.7%[95%CI，2.3%至 3.0%]，P<0.001；调整后，3.3%比 1.9%；风险差异，1.4%[95%CI，1.0%至 1.8%]，P<0.001）。非 IRA 疾病与 30 天死亡率的总体相关性和相关性与 KAMIR 登记处的研究结果一致（调整后，非 IRA 疾病患者的死亡率为 3.6%，而非 IRA 疾病患者的死亡率为 2.5%；风险差异为 1.1%[95%CI，0.6%至 1.7%]；P<0.001），但与杜克数据库不一致（调整后，非 IRA 疾病患者的死亡率为 4.7%，而非 IRA 疾病患者的死亡率为 4.3%；风险差异为 0.4%[95%CI，-1.4%至 2.2%]，P=0.65）。
在对 8 项临床试验的回顾性汇总分析中，非 IRA 疾病在 STEMI 患者中很常见，与 30 天死亡率的适度统计学显著增加相关。这些发现需要在前瞻性设计的研究中得到证实，但提出了关于在 STEMI 患者中进行非 IRA 血运重建的适宜性和时机的问题。
