Rezende Paulo Cury, Ribas Fernando Faglioni, Serrano Carlos Vicente, Hueb Whady
Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
J Thorac Dis. 2019 Mar;11(3):1005-1015. doi: 10.21037/jtd.2019.02.85.
Myocardial ischemia is considered the cornerstone of the treatment of patients with coronary artery disease (CAD). Although the deleterious effects of myocardial infarction, the maximum expression of ischemia, have been extensively studied and described, the clinical effects of chronic, documented myocardial ischemia are not completely clarified. The first studies that compared therapies for coronary disease focused on the presence of anatomical features and assessed ischemia based on the interpretation of the findings of obstructive atherosclerotic lesions. They suggested that revascularization interventions did not confer any clinical advantage over medical therapy (MT), in terms of cardiac or overall death. Other retrospective studies that were dedicated to assessing the impact of documented stress-induced ischemia on cardiovascular outcomes have suggested a prognostic impact of chronic ischemia. However, this has been questioned in recent studies. Moreover, the previous understanding that chronic ischemia could lead to worsening of ventricular function was not confirmed in a recent study. Thus, the prognostic significance of stress-induced ischemia has been questioned. Regarding treatment options, although some previous analyses have suggested that interventional therapies would reduce cardiovascular events in CAD patients with documented ischemia, recent post-hoc studies and metanalysis have shown distinct results. In this review article, the authors discuss myocardial ischemia, the different responses of the myocardium to ischemic insults, ischemic preconditioning, and the main findings of recent studies about the clinical aspects and treatment of patients with chronic, documented myocardial ischemia.
心肌缺血被认为是冠状动脉疾病（CAD）患者治疗的基石。尽管心肌梗死（即缺血的最大表现）的有害影响已得到广泛研究和描述，但慢性、有记录的心肌缺血的临床影响尚未完全阐明。最早比较冠心病治疗方法的研究聚焦于解剖特征的存在，并根据对阻塞性动脉粥样硬化病变检查结果的解读来评估缺血情况。这些研究表明，就心脏死亡或全因死亡而言，血运重建干预措施相较于药物治疗（MT）并无任何临床优势。其他致力于评估有记录的应激性缺血对心血管结局影响的回顾性研究表明，慢性缺血具有预后影响。然而，近期的研究对此提出了质疑。此外，先前关于慢性缺血会导致心室功能恶化的认识在最近的一项研究中并未得到证实。因此，应激性缺血的预后意义受到了质疑。关于治疗选择，尽管先前的一些分析表明，介入治疗可减少有缺血记录的CAD患者的心血管事件，但近期的事后分析和荟萃分析得出了不同的结果。在这篇综述文章中，作者讨论了心肌缺血、心肌对缺血性损伤的不同反应、缺血预处理以及近期有关慢性、有记录的心肌缺血患者临床情况和治疗的主要研究发现。
