Cardiology Department, CHU Clermont-Ferrand, ISIT-CAVITI, UMR 6284, UdA-CNRS, 63000 Clermont-Ferrand, France; Cardiology Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France.
Cardiology Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France.
Arch Cardiovasc Dis. 2018 Nov;111(11):666-677. doi: 10.1016/j.acvd.2017.10.006. Epub 2018 Jun 20.
A two-step strategy of invasive management without stenting, guided by optical coherence tomography (OCT), in selected patients with acute coronary syndrome (ACS), might avoid systematic stent implantation and allow medical therapy alone.
To assess the feasibility and safety of such a procedure, and to define coronary imaging characteristics in a specific population.
This single-centre proof-of-concept study included all patients with ACS who benefited from a two-step revascularization procedure with optimal reperfusion during primary percutaneous coronary intervention followed by delayed angiography and OCT. OCT imaging determined medical therapy treatment alone without stenting in case of absence of vulnerable plaque rupture and <70% stenosis. Follow-up consisted of screening for major adverse cardiac events (MACE) at 12months.
Forty-six patients were included, mainly men (86.9%) and smokers (65.2%), with a mean age of 47.1years. Most cases (80.4%) were large thrombus burden lesions. Delayed angiography and OCT were performed in a median period of 6 [3-10] days. No adverse events occurred between the initial and second angiograms. Plaque rupture was detected in 39.1% of patients, plaque erosion in 54.3% and calcified nodule in 6.5%. Twenty-three patients benefited from systematic delayed OCT over a median period of 171days, showing an increase in minimal lumen area. At 12months, two patients (4.3%) presented MACE and were stented. No sudden death or myocardial infarction recurrence occurred.
Analysing ACS mechanisms by OCT might facilitate treatment decisions in patients with ST-segment elevation myocardial infarction managed by a two-step procedure. Conservative treatment with antithrombotic therapy without stenting seems to be a reliable option in a selected population.
在急性冠状动脉综合征（ACS）患者中，采用两步策略进行血管内治疗（无支架），并结合光学相干断层扫描（OCT）指导，可能避免系统支架植入，并仅采用药物治疗。
评估这种方法的可行性和安全性，并确定特定人群的冠状动脉成像特征。
这项单中心概念验证研究纳入了所有接受经皮冠状动脉介入治疗（primary percutaneous coronary intervention，pPCI）后行两步再血管化治疗的 ACS 患者，pPCI 时实现了最佳再灌注，随后进行延迟血管造影和 OCT 检查。OCT 成像在无易损斑块破裂和＜70%狭窄的情况下决定单独进行药物治疗，而不进行支架植入。随访包括在 12 个月时筛查主要不良心脏事件（major adverse cardiac events，MACE）。
共纳入 46 例患者，主要为男性（86.9%）和吸烟者（65.2%），平均年龄为 47.1 岁。大多数病例（80.4%）为大血栓负荷病变。延迟血管造影和 OCT 检查分别在中位时间 6[3-10]天内进行。初始和第二次血管造影之间未发生不良事件。39.1%的患者存在斑块破裂，54.3%的患者存在斑块侵蚀，6.5%的患者存在钙化结节。23 例患者在中位时间 171 天内接受了系统的延迟 OCT 检查，显示最小管腔面积增加。12 个月时，2 例患者（4.3%）发生 MACE 并进行了支架植入。无猝死或心肌梗死复发。
通过 OCT 分析 ACS 机制可能有助于 ST 段抬高型心肌梗死患者进行两步治疗的决策。在选择的人群中，采用抗血栓治疗的保守治疗（无支架）似乎是一种可靠的选择。
