Stolker Joshua M, Cohen David J, Kennedy Kevin F, Pencina Michael J, Arnold Suzanne V, Kleiman Neal S, Spertus John A
Mercy Heart and Vascular, Washington, MO, United States; Saint Louis University, St. Louis, MO, United States.
Saint Luke's Mid America Heart Institute, Kansas City, MO, United States; University of Missouri-Kansas City, Kansas City, MO, United States.
Cardiovasc Revasc Med. 2017 Apr-May;18(3):169-176. doi: 10.1016/j.carrev.2016.12.014. Epub 2016 Dec 18.
Drug-eluting stents (DES) reduce restenosis but require prolonged antiplatelet therapy, when compared with bare metal stents. Ideally, the patient should be involved in this risk:benefit assessment prior to selecting DES, to maximize the benefits and cost-effectiveness of care, and to improve medication adherence. However, accurate estimation of restenosis risk may require angiographic factors identified at cardiac catheterization.
In a large PCI registry, we used logistic regression to identify clinical and angiographic predictors of clinically-driven target lesion revascularization (TLR) over the first year after stent placement. Discrimination c-statistic and integrated discrimination improvement (IDI) were used to calculate the incremental utility of angiographic variables when added to clinical predictors.
Of 8501 PCI patients, TLR occurred in 4.5%. After adjusting for DES use, clinical TLR predictors were younger age, female sex, diabetes, prior PCI, and prior bypass surgery (model c-statistic 0.630). Angiographic predictors were vein graft PCI, in-stent restenosis lesion, longer stent length, and smaller stent diameter (c-statistic 0.650). After adding angiographic factors to the clinical model, c-statistic improved to 0.680 and the average separation in TLR risk among patients with and without TLR improved by 1% (IDI=0.010, 95% CI 0.009-0.014), primarily driven by those experiencing TLR (from 5.9% to 6.9% absolute risk).
Among unselected PCI patients, the incidence of clinically-indicated TLR is <5% at 1-year, and standard clinical variables only moderately discriminate who will and will not experience TLR. Angiographic variables significantly improve TLR risk assessment, suggesting that stent selection may be best performed after coronary anatomy has been delineated.
SHORT SUMMARY (FOR ANNOTATED TABLE OF CONTENTS): Although several recent studies have challenged traditional expectations regarding the duration of dual antiplatelet therapy, current guidelines recommend at least 6 to 12months of treatment after implantation of a drug eluting stent, with a shorter course for bare metal stents. Stent selection ideally should involve input from the patient receiving these stents, but multiple studies have suggested that angiographic factors - obtained after the patient has received sedation during the diagnostic catheterization - are important predictors of repeat revascularization. In this analysis from a large registry of patients receiving coronary stents, angiographic characteristics were found to significantly improve risk assessment for target lesion revascularization, when added to clinical variables alone.
与裸金属支架相比，药物洗脱支架（DES）可降低再狭窄风险，但需要延长抗血小板治疗时间。理想情况下，患者应在选择DES之前参与这种风险效益评估，以最大化护理的效益和成本效益，并提高用药依从性。然而，准确估计再狭窄风险可能需要在心脏导管插入术时确定的血管造影因素。
在一个大型经皮冠状动脉介入治疗（PCI）注册研究中，我们使用逻辑回归来确定支架置入后第一年临床驱动的靶病变血运重建（TLR）的临床和血管造影预测因素。使用鉴别c统计量和综合鉴别改善（IDI）来计算血管造影变量添加到临床预测因素时的增量效用。
在8501例PCI患者中，TLR发生率为4.5%。在调整DES使用情况后，临床TLR预测因素为年轻、女性、糖尿病、既往PCI和既往搭桥手术（模型c统计量为0.630）。血管造影预测因素为静脉桥PCI、支架内再狭窄病变、较长的支架长度和较小的支架直径（c统计量为0.650）。将血管造影因素添加到临床模型后，c统计量提高到0.680，有和没有TLR的患者之间TLR风险的平均差异提高了1%（IDI=0.010，95%CI 0.009-0.014），主要由发生TLR的患者驱动（绝对风险从5.9%升至6.9%）。
在未选择的PCI患者中，临床指征性TLR的发生率在1年时<5%，标准临床变量对谁会和谁不会发生TLR的鉴别能力一般。血管造影变量显著改善了TLR风险评估，表明在明确冠状动脉解剖结构后进行支架选择可能最为合适。
简短总结（用于带注释的目录）：尽管最近的几项研究对关于双联抗血小板治疗持续时间的传统预期提出了挑战，但当前指南建议在药物洗脱支架植入后至少进行6至12个月的治疗，裸金属支架的疗程较短。理想情况下，支架选择应包括接受这些支架的患者的意见，但多项研究表明，在诊断性导管插入术期间患者接受镇静后获得的血管造影因素是再次血运重建的重要预测因素。在这项来自大型冠状动脉支架置入患者注册研究的分析中，发现血管造影特征在仅添加到临床变量时可显著改善靶病变血运重建的风险评估。
