直接血运重建治疗急性 ST 段抬高型心肌梗死伴多支血管病变患者的疗效：来自 ORBI 注册研究的结果。

Immediate complete revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease treated by primary percutaneous coronary intervention: Insights from the ORBI registry.

机构信息

CIC-IT 804, service de cardiologie et maladies vasculaires, CHU Pontchaillou, 35000 Rennes, France; Inserm U1099, laboratoire de traitement du signal et de l'image, université de Rennes 1, 35000 Rennes, France.

出版信息

Arch Cardiovasc Dis. 2018 Nov;111(11):656-665. doi: 10.1016/j.acvd.2017.08.005. Epub 2017 Dec 8.

DOI:10.1016/j.acvd.2017.08.005

PMID:29229216

Abstract

BACKGROUND

Recent studies demonstrated the superiority of complete revascularization (CR) in patients treated by primary percutaneous coronary intervention (pPCI) in ST-elevation myocardial infarction (STEMI).

AIM

To evaluate whether immediate CR improves in-hospital outcomes in patients with STEMI with multivessel disease.

METHODS

Data from a prospective multicentre registry including 9365 patients with STEMI were analysed. Patients with multivessel disease and treated with pPCI (n=3412) were included and separated into two groups according to whether immediate CR was performed during the index procedure. The primary endpoint was in-hospital major adverse cardiovascular events (MACE), defined as a composite of all-cause death, non-fatal myocardial infarction, stroke and definite stent thrombosis. Secondary endpoints were individual components of MACE and major bleeding. Multivariable Cox regression and propensity-score adjustment were performed to account for confounders.

RESULTS

Immediate CR was performed in 98 patients (2.9%), whereas 3314 patients (97.1%) were incompletely revascularized. The prevalence of severe heart failure (Killip class III or IV) and significant lesions of the left main coronary artery were higher in the immediate CR group (21.6% vs. 13.5% and 24.5% vs. 6.7%, respectively; P<0.001 for both). After adjustment, immediate CR was not associated with reduced rates of MACE (hazard ratio [HR] 0.64, 95% confidence interval [CI]: 0.31-1.35; P=0.24) or all-cause death (HR: 0.52, 95% CI: 0.23-1.16; P=0.11), but with increased risks of definite stent thrombosis (HR: 3.93, 95% CI: 1.12-13.75; P=0.03) and major bleeding (HR: 17.46, 95% CI: 2.29-133.17; P=0.006).

CONCLUSION

Immediate CR did not improve in-hospital outcomes of patients with STEMI with multivessel disease in this analysis. Randomized studies are warranted to elucidate the optimal timing of CR in patients with STEMI.

摘要

背景

最近的研究表明，在接受直接经皮冠状动脉介入治疗（pPCI）的 ST 段抬高型心肌梗死（STEMI）患者中，完全血运重建（CR）具有优势。

目的

评估在多支血管病变的 STEMI 患者中，即刻 CR 是否改善住院期间的结局。

方法

对一项包括 9365 例 STEMI 患者的前瞻性多中心登记研究的数据进行分析。纳入多支血管病变且接受 pPCI 治疗的患者（n=3412），并根据指数操作期间是否进行即刻 CR 将其分为两组。主要终点是住院期间的主要不良心血管事件（MACE），定义为全因死亡、非致死性心肌梗死、卒中和明确的支架血栓形成的复合终点。次要终点是 MACE 和大出血的各个组成部分。采用多变量 Cox 回归和倾向评分调整来考虑混杂因素。

结果

98 例（2.9%）患者进行了即刻 CR，而 3314 例（97.1%）患者未完全血运重建。即刻 CR 组的严重心力衰竭（Killip 分级 III 或 IV 级）和左主干冠状动脉严重病变的发生率更高（分别为 21.6% vs. 13.5%和 24.5% vs. 6.7%；均 P<0.001）。调整后，即刻 CR 与降低 MACE 发生率无关（风险比 [HR] 0.64，95%置信区间 [CI]：0.31-1.35；P=0.24）或全因死亡（HR：0.52，95% CI：0.23-1.16；P=0.11）相关，但与明确的支架血栓形成（HR：3.93，95% CI：1.12-13.75；P=0.03）和大出血（HR：17.46，95% CI：2.29-133.17；P=0.006）风险增加相关。