接受直接经皮冠状动脉介入治疗的ST段抬高型心肌梗死患者中高度房室传导阻滞的发生率、预测因素及预后（来自HORIZONS-AMI试验）
Incidence, Predictors, and Outcomes of High-Grade Atrioventricular Block in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention (from the HORIZONS-AMI Trial).
作者信息
Kosmidou Ioanna, Redfors Björn, Dordi Rushad, Dizon José M, McAndrew Thomas, Mehran Roxana, Ben-Yehuda Ori, Mintz Gary S, Stone Gregg W
机构信息
Cardiovascular Research Foundation, Clinical Trials Center, New York, New York; Department of Cardiology, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York.
Cardiovascular Research Foundation, Clinical Trials Center, New York, New York.
出版信息
Am J Cardiol. 2017 May 1;119(9):1295-1301. doi: 10.1016/j.amjcard.2017.01.019. Epub 2017 Feb 16.
High-grade atrioventricular block (HAVB) is historically considered a marker of worse outcomes in patients with ST-segment elevation myocardial infarction (STEMI). However, the predictors and prognostic impact of HAVB in the primary percutaneous coronary intervention (PCI) era remain poorly understood. We sought to describe the characteristics and predictors of HAVB in patients undergoing primary PCI in STEMI and to assess the prognostic significance of HAVB in the contemporary reperfusion era. The present analysis includes 3,115 patients presenting with STEMI from the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial who underwent primary PCI. Outcomes were examined according to the presence of HAVB on a presenting electrocardiogram, as interpreted by an independent electrocardiography core laboratory. HAVB (second-degree Mobitz II or third-degree atrioventricular block) was present at baseline in 46 patients (1.5%). Independent predictors of HAVB included increased age, diabetes mellitus, right coronary artery occlusion, sum of ST-segment deviation, and baseline Thrombolysis In Myocardial Infarction flow 0/1. Thrombolysis In Myocardial Infarction flow 3 was restored in 83.7% and 91.5% of patients with versus without baseline HAVB respectively (p = 0.06). Mortality rate was significantly higher in patients with versus without HAVB at 30-day, 1-, and 3-year follow-ups (unadjusted hazard ratio [HR] 3.83, 95% CI 1.40 to 10.48; unadjusted HR 4.37, 95% CI 2.09 to 9.38 and unadjusted HR 2.78, 95% CI 1.31 to 5.91, respectively). After covariate adjustment, mortality rate was significantly higher in patients with HAVB at 1 year (adjusted HR 2.45, 95% CI 1.09 to 5.50, p = 0.03) but not at 30 days (adjusted HR 1.70, 95% CI 0.58 to 5.01, p = 0.33) or 3 years (adjusted HR 0.71 to 3.41, p = 0.27). In conclusion, HAVB is a rare complication of STEMI but remains associated with increased mortality, even after primary PCI.
从历史上看，高级别房室传导阻滞（HAVB）被认为是ST段抬高型心肌梗死（STEMI）患者预后较差的一个标志。然而，在直接经皮冠状动脉介入治疗（PCI）时代，HAVB的预测因素及其对预后的影响仍知之甚少。我们试图描述STEMI患者接受直接PCI时HAVB的特征和预测因素，并评估HAVB在当代再灌注时代的预后意义。本分析纳入了急性心肌梗死血管重建和支架置入术结果协调试验中3115例STEMI患者，这些患者均接受了直接PCI。由独立的心电图核心实验室对患者就诊时的心电图进行解读，并根据是否存在HAVB来检查结果。46例（1.5%）患者基线时存在HAVB（二度莫氏Ⅱ型或三度房室传导阻滞）。HAVB的独立预测因素包括年龄增加、糖尿病、右冠状动脉闭塞、ST段偏移总和以及基线心肌梗死溶栓血流0/1级。基线时存在与不存在HAVB的患者，心肌梗死溶栓血流3级恢复率分别为83.7%和91.5%（p = 0.06）。在30天、1年和3年随访时，存在HAVB的患者死亡率显著高于不存在HAVB的患者（未调整风险比[HR]分别为3.83，95%CI 1.40至10.48；未调整HR 4.37，95%CI 2.09至9.38；未调整HR 2.78，95%CI 1.31至5.91）。经过协变量调整后，1年时存在HAVB的患者死亡率显著更高（调整后HR 2.45，95%CI 1.09至5.50，p = 0.03），但30天时无显著差异（调整后HR 1.70，95%CI 0.58至5.01，p = 0.33），3年时也无显著差异（调整后HR 0.71至3.41，p = 0.27）。总之，HAVB是STEMI的一种罕见并发症，但即使在直接PCI后，它仍与死亡率增加相关。
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