经皮冠状动脉介入治疗的隐静脉桥。
Percutaneous Coronary Intervention of Saphenous Vein Graft.
机构信息
From the Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., P.G., T.M., X.H., A.M., G.W., R.M., A.J.K., G.W.S.); Center for Interventional Vascular Therapy, Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center (J.D., A.M., G.W., A.J.K., G.W.S.); Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (P.G.); Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Quebec, Canada (P.G.); Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau, Germany (B.W.); Els & Charles Bendheim Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel (G.W.); and The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M.).
出版信息
Circ Cardiovasc Interv. 2017 May;10(5). doi: 10.1161/CIRCINTERVENTIONS.117.004953.
BACKGROUND
Percutaneous coronary intervention (PCI) of saphenous vein grafts (SVGs) has historically been associated with a high risk of adverse ischemic events, but there is a paucity of contemporary data on the second-generation drug-eluting stent use within SVG, and the relative importance of high platelet reactivity (HPR) in SVG PCI versus native lesion PCI is unknown. We studied ischemic and bleeding events after SVG PCI and their association with HPR.
METHODS AND RESULTS
Subjects in the prospective, multicenter ADAPT-DES study (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) were stratified according to whether they had PCI of an SVG or a non-SVG lesion. Two-year outcomes were compared between groups using univariate and multivariable Cox proportional hazards models. HPR was defined as on-clopidogrel P2Y12 platelet reaction units >208 as measured by the VerifyNow assay; major adverse cardiac events were defined as the composite of cardiac death, myocardial infarction, or stent thrombosis. Among 8582 subjects in ADAPT-DES, 405 (4.7%) had SVG PCI. SVG PCI was independently associated with a higher 2-year risk of major adverse cardiac events (adjusted hazard ratio, 2.34; 95% confidence interval, 1.69-3.23; <0.0001), ischemia-driven target vessel revascularization (adjusted hazard ratio, 1.82; 95% confidence interval, 1.37-2.42; <0.0001), and stent thrombosis (adjusted hazard ratio, 2.26; 95% confidence interval, 1.42-3.59; =0.0006), but not of bleeding (adjusted hazard ratio, 0.99; 95% confidence interval, 0.68-1.46; =0.97). There was no statistical interaction between HPR and SVG PCI in regard to major adverse cardiac events (adjusted =0.99).
CONCLUSIONS
SVG PCI is associated with a considerably higher risk of 2-year adverse ischemic events, with HPR conferring similar risk in SVG and non-SVG PCI. More potent and longer antiplatelet therapy may be beneficial for patients undergoing SVG PCI.
CLINICAL TRIAL REGISTRATION
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00638794.
背景
经皮冠状动脉介入治疗（PCI）的隐静脉移植物（SVG）与不良缺血事件的高风险相关，但目前缺乏关于 SVG 中第二代药物洗脱支架应用的当代数据，以及高血小板反应性（HPR）在 SVG PCI 与原生病变 PCI 中的相对重要性尚不清楚。我们研究了 SVG PCI 后的缺血和出血事件及其与 HPR 的关系。
方法和结果
前瞻性、多中心 ADAPT-DES 研究（药物洗脱支架双联抗血小板治疗评估）中的受试者根据他们是否进行了 SVG 或非 SVG 病变的 PCI 进行分层。使用单变量和多变量 Cox 比例风险模型比较两组的两年结局。HPR 的定义是使用 VerifyNow 测定法测定的氯吡格雷 P2Y12 血小板反应单位 >208；主要不良心脏事件定义为心脏死亡、心肌梗死或支架血栓形成的复合事件。在 ADAPT-DES 中的 8582 名受试者中，有 405 名（4.7%）进行了 SVG PCI。SVG PCI 与较高的 2 年主要不良心脏事件风险独立相关（调整后的危险比，2.34；95%置信区间，1.69-3.23；<0.0001）、缺血驱动的靶血管血运重建（调整后的危险比，1.82；95%置信区间，1.37-2.42；<0.0001）和支架血栓形成（调整后的危险比，2.26；95%置信区间，1.42-3.59；=0.0006），但与出血无关（调整后的危险比，0.99；95%置信区间，0.68-1.46；=0.97）。在主要不良心脏事件方面，HPR 与 SVG PCI 之间没有统计学上的相互作用（调整后=0.99）。
结论
SVG PCI 与 2 年不良缺血事件的风险显著增加相关，而 HPR 在 SVG 和非 SVG PCI 中具有相似的风险。更强效和更长时间的抗血小板治疗可能对接受 SVG PCI 的患者有益。
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