Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia; Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota.
Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia.
JACC Cardiovasc Interv. 2019 Aug 12;12(15):1497-1506. doi: 10.1016/j.jcin.2019.04.015.
The aim of this study was to assess temporal trends in the incidence of ischemic stroke among patients undergoing percutaneous coronary intervention (PCI), predictors of post-PCI ischemic stroke, and the impact of post-PCI ischemic stroke on in-hospital morbidity, mortality, length of stay, and cost.
Data on the incidence and outcomes of ischemic stroke in patients undergoing PCI in the contemporary era are limited.
The National Inpatient Sample was used to identify patients who underwent PCI between January 1, 2003, and December 31, 2016. The incidence of post-PCI ischemic stroke was calculated, and its predictors were assessed. In-hospital outcomes of patients with and those without post-PCI stroke were also compared.
The adjusted incidence of post-PCI ischemic stroke increased during the study period from 0.6% to 0.96% following PCI for ST-segment elevation myocardial infarction, from 0.5% to 0.6% following PCI for non-ST-segment elevation myocardial infarction, and from 0.3% to 0.72% following PCI for unstable angina or stable ischemic disease (p <0.001). Carotid disease, cardiogenic shock, atrial fibrillation, and older age were the strongest predictors of post-PCI ischemic stroke. Post-PCI stroke rates were lower at high-volume versus low- to intermediate-volume centers. Thrombolytics, cerebral angiography, and mechanical thrombectomy use increased over time but remained infrequent. After propensity score matching, in-hospital mortality was higher among patients with post-PCI stroke (23.5% vs. 11.0%, 9.5% vs. 2.8%, and 11.5% vs. 2.4% in the ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, and unstable angina or stable ischemic heart disease cohorts, respectively; p < 0.001). Post-PCI stroke was associated with a >2-fold increase in length of stay, a >3-fold increase in nonhome discharges, and a >60% increase in cost.
The incidence of post-PCI ischemic stroke increased significantly over the past decade, partially because of the increasing complexity of patients undergoing PCI over time. Further studies are needed to systematically assess contributors to this worrisome trend and to identify effective strategies for its mitigation.
本研究旨在评估行经皮冠状动脉介入治疗（PCI）患者中缺血性卒中的发生率变化趋势、缺血性卒中的预测因素，以及缺血性卒中对住院期间发病率、死亡率、住院时间和费用的影响。
目前关于当代 PCI 患者中缺血性卒中的发生率和结局的数据有限。
利用国家住院患者样本，确定 2003 年 1 月 1 日至 2016 年 12 月 31 日间接受 PCI 的患者。计算 PCI 后缺血性卒中的发生率，并评估其预测因素。还比较了发生和未发生 PCI 后卒中患者的住院结局。
在研究期间，与 ST 段抬高型心肌梗死患者相比，行 PCI 后缺血性卒中的调整发生率从 0.6%增至 0.96%（PCI 治疗 ST 段抬高型心肌梗死），与非 ST 段抬高型心肌梗死患者相比，从 0.5%增至 0.6%（PCI 治疗非 ST 段抬高型心肌梗死），与不稳定型心绞痛或稳定型缺血性心脏病患者相比，从 0.3%增至 0.72%（PCI 治疗不稳定型心绞痛或稳定型缺血性心脏病）（p<0.001）。颈动脉疾病、心源性休克、心房颤动和年龄较大是 PCI 后缺血性卒中的最强预测因素。与低-中容量中心相比，高容量中心的 PCI 后卒中发生率较低。溶栓治疗、脑血管造影和机械血栓切除术的应用随着时间的推移而增加，但仍较为少见。经倾向评分匹配后，在 ST 段抬高型心肌梗死、非 ST 段抬高型心肌梗死和不稳定型心绞痛或稳定型缺血性心脏病队列中，PCI 后发生卒中的患者住院死亡率更高（分别为 23.5%比 11.0%、9.5%比 2.8%和 11.5%比 2.4%；p<0.001）。PCI 后发生卒中与住院时间延长超过 2 倍、非家庭出院增加超过 3 倍和费用增加超过 60%相关。
在过去十年中，PCI 后缺血性卒中的发生率显著增加，部分原因是接受 PCI 的患者的病情复杂性随时间推移而增加。需要进一步研究以系统评估导致这一令人担忧趋势的因素，并确定减轻该趋势的有效策略。
