Rambam Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel.
Institut Lorrain du Coeur et des Vaisseaux, Vandoeuvre-les-Nancy, France; Université de Lorraine, Nancy, France.
JACC Cardiovasc Interv. 2017 Mar 27;10(6):548-556. doi: 10.1016/j.jcin.2016.12.028.
This study sought to compare the outcomes of patients undergoing drug-eluting stent implantation according to lesion location within or outside the proximal left anterior descending (LAD) artery.
Proximal LAD artery involvement is considered uniquely in revascularization guidelines. The impact of LAD lesion location on long-term outcomes after revascularization is poorly understood in context of current percutaneous coronary intervention and medical therapy.
Among 8,709 patients enrolled in PROTECT (Patient Related Outcomes with Endeavor Versus Cypher Stenting Trial), a multicenter percutaneous coronary intervention trial, we compared the outcomes of 2,534 patients (29.1%) (3,871 lesions [31.5%]) with stents implanted in the proximal LAD to 6,172 patients (70.9%) (8,419 lesions [68.5%]) with stents implanted outside the proximal LAD.
At the 4-year follow-up, death rates were the same (5.8% vs. 5.8%; p > 0.999), but more myocardial infarctions occurred in the proximal LAD group (6.2% vs. 4.9%; p = 0.015). The rate of clinically driven target vessel failure (TVF) (14.8% vs. 13.5%; p = 0.109), major adverse cardiac event(s) (MACE) (15.0% vs. 13.7%; hazard ratio: 1.1; 95% confidence interval: 0.97 to 1.31; p = 0.139), and stent thrombosis (2.1% vs. 2.0%; p = 0.800) were similar. Drug-eluting stent type had no interaction with MACE or TVF. In multivariate analysis, the proximal LAD was a predictor of myocardial infarction (p = 0.038) but not of TVF (p = 0.149) or MACE (p = 0.069).
In this study of contemporary percutaneous coronary intervention, proximal LAD location was associated with higher rates of myocardial infarction during the long-term follow-up, but there were no differences in stent thrombosis, death, TVF, or overall MACE. This finding may suggest that, in the drug-eluting stent era, proximal LAD no longer confers a different prognosis than other lesion sites. (Randomized Study Comparing Endeavor With Cypher Stents [PROTECT]; NCT00476957).
本研究旨在比较药物洗脱支架植入患者的治疗结果，根据病变位于左前降支（LAD）近端内或外的情况进行分组。
在再血管化指南中，近端 LAD 动脉受累被认为是独特的。在当前经皮冠状动脉介入治疗和药物治疗的背景下，LAD 病变位置对再血管化后长期预后的影响尚不清楚。
在 PROTECT（ Endeavor 与 Cypher 支架试验的患者相关结局研究）多中心经皮冠状动脉介入治疗试验中，我们比较了 8709 例患者中的 2534 例（29.1%）（3871 处病变[31.5%]）与支架植入在 LAD 近端的患者的结局，与 6172 例（70.9%）（8419 处病变[68.5%]）支架植入 LAD 外的患者进行比较。
在 4 年随访时，死亡率相同（5.8% vs. 5.8%；p > 0.999），但 LAD 近端组心肌梗死发生率更高（6.2% vs. 4.9%；p = 0.015）。临床驱动的靶血管失败（TVF）发生率（14.8% vs. 13.5%；p = 0.109）、主要不良心脏事件（MACE）（15.0% vs. 13.7%；风险比：1.1；95%置信区间：0.97 至 1.31；p = 0.139）和支架血栓形成（2.1% vs. 2.0%；p = 0.800）相似。药物洗脱支架类型与 MACE 或 TVF 无交互作用。多变量分析显示，LAD 近端是心肌梗死的预测因素（p = 0.038），但不是 TVF（p = 0.149）或 MACE（p = 0.069）的预测因素。
在这项当代经皮冠状动脉介入治疗的研究中，LAD 近端的位置与长期随访期间更高的心肌梗死发生率相关，但支架血栓形成、死亡、TVF 或总体 MACE 无差异。这一发现可能表明，在药物洗脱支架时代，LAD 近端不再比其他病变部位具有不同的预后。（随机比较 Endeavor 与 Cypher 支架的研究 [PROTECT]；NCT00476957）。
