伴发慢性完全闭塞病变的急性 ST 段抬高型心肌梗死患者行直接经皮冠状动脉介入治疗时侧支循环对预后的影响

Impact of Collateral Circulation on Survival in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention With a Concomitant Chronic Total Occlusion.

机构信息

Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.

出版信息

JACC Cardiovasc Interv. 2017 May 8;10(9):906-914. doi: 10.1016/j.jcin.2017.01.026.

DOI:10.1016/j.jcin.2017.01.026

PMID:28473112

Abstract

OBJECTIVES

This study sought to compare long-term clinical outcome in ST-segment elevation myocardial infarction (STEMI) patients with a concomitant chronic total occlusion (CTO) with well-developed versus poorly developed collaterals toward the CTO.

BACKGROUND

In STEMI patients, presence of a CTO is associated with increased morbidity and mortality. CTOs are often (partially) perfused by collateral vessels. Therefore, when the infarct-related artery (IRA) is the main donor vessel for the collateral blood supply of the CTO, infarct size may increase significantly. Well-developed collaterals to the infarct related vessel have been associated with improved clinical outcome after STEMI. However, the impact of well-developed collaterals toward a concomitant CTO in STEMI patients is unknown.

METHODS

Consecutive STEMI patients with a CTO in a non-IRA presenting for primary percutaneous coronary intervention (PCI) were divided according to the presence of angiographic, well-developed (grade 2 to 3) or poorly developed collaterals (grade 0 to 1).

RESULTS

Between 2000 and 2012 we included 413 STEMI patients with a single concomitant CTO. Well-developed collaterals to the CTO were present in 53%. Associated with poorly developed collaterals to the CTO were cardiogenic shock (hazard ratio [HR]: 1.8; 95% confidence interval [CI]: 1.11 to 3.07; p = 0.02), CTO located in the left circumflex artery (HR: 1.9; 95% CI: 1.00 to 3.43; p = 0.05), CTO diameter ≤2.5 mm (HR: 2.1; 95% CI: 1.07 to 4.12; p = 0.03), and CTO tapering (HR: 1.9; 95% CI: 1.21 to 2.85; p < 0.001). Patients with well-developed collaterals to the CTO had a better 5-year survival compared to those with poorly developed collaterals (74% vs. 63%; p = 0.01). The presence of well-developed collaterals to the CTO was independently associated with improved survival (HR: 1.5; 95% CI: 1.03 to 2.10; p = 0.04).

CONCLUSIONS

In STEMI patients with a CTO in a non-IRA, the presence of well-developed collaterals to the CTO is associated with improved survival.

摘要

目的

本研究旨在比较伴有慢性完全闭塞（CTO）的 ST 段抬高型心肌梗死（STEMI）患者中，向 CTO 侧侧支循环良好与不良的患者的长期临床预后。

背景

在 STEMI 患者中，CTO 的存在与发病率和死亡率的增加相关。CTO 通常（部分）由侧支血管供血。因此，当梗死相关动脉（IRA）是 CTO 侧支血供的主要供体血管时，梗死面积可能会显著增加。向 IRA 侧支循环良好的侧支循环与 STEMI 后临床预后改善相关。然而，STEMI 患者向伴发 CTO 的侧支循环良好的影响尚不清楚。

方法

连续纳入 2000 年至 2012 年间因首次经皮冠状动脉介入治疗（PCI）就诊的 IRA 非罪犯病变的 CTO 相关 STEMI 患者，根据是否存在血管造影显示的侧支循环良好（分级 2 至 3 级）或不良（分级 0 至 1 级）进行分组。

结果

共纳入 413 例伴有单一 CTO 的 STEMI 患者，其中 53%存在向 CTO 侧支循环良好。与向 CTO 侧支循环不良相关的因素包括心源性休克（危险比[HR]：1.8；95%置信区间[CI]：1.11 至 3.07；p=0.02）、CTO 位于左回旋支（HR：1.9；95%CI：1.00 至 3.43；p=0.05）、CTO 直径≤2.5mm（HR：2.1；95%CI：1.07 至 4.12；p=0.03）和 CTO 逐渐变细（HR：1.9；95%CI：1.21 至 2.85；p<0.001）。与向 CTO 侧支循环不良的患者相比，向 CTO 侧支循环良好的患者 5 年生存率更高（74% vs. 63%；p=0.01）。向 CTO 侧支循环良好与生存率提高独立相关（HR：1.5；95%CI：1.03 至 2.10；p=0.04）。