Wang Tom Kai Ming, Kerr Andrew, Kasargod Chethan, Chan Daniel, Cicovic Sergej, Dimalapang Eliazar, Webster Mark, Somaratne Jithendra
Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand; Department of Cardiology, Middlemore Hospital, Auckland, New Zealand.
Department of Cardiology, Middlemore Hospital, Auckland, New Zealand; Department of Medicine, University of Auckland, Auckland, New Zealand.
Cardiovasc Revasc Med. 2020 May;21(5):573-579. doi: 10.1016/j.carrev.2019.08.016. Epub 2019 Aug 23.
Approximately 5% of coronary angiographies detect LMS disease >50%. Recent randomized trials showed PCI has comparable outcomes to coronary artery bypass grafting (CABG) in low or intermediate risk candidates. In clinical practice, PCI is frequently utilized in those with prohibitive surgical risk. We reviewed contemporary national results of percutaneous coronary intervention (PCI) for left main coronary disease (LMS) disease in New Zealand.
All patients undergoing PCI for LMS disease from 01/09/2014-24/09/2017 were extracted from the All New Zealand Acute Coronary Syndrome-Quality Improvement registry with national dataset linkage, analyzing characteristics and in-hospital outcomes.
The cohort included 469 patients, mean age 70.8 ± 10.7 years, male 331 (71%), and the majority 339 (72%) were unprotected LMS. Indications include ST-elevation myocardial infarction (STEMI) 83 (18%) and NSTEMI or unstable angina 229 (49%). Compared with protected LMS, unprotected LMS were more likely to present with an acute coronary syndrome (73% versus 48%, P < 0.001), and to die in-hospital (9.4% versus 3.9%, P = 0.045). In those with unprotected LMS, in-hospital mortality after acute STEMI PCI was higher than for other indications (21.1% versus 6.1%, P < 0.001). Independent predictors of in-hospital death and major adverse cardiovascular events included STEMI, femoral access and worse renal function.
Our LMS PCI cohort had high mortality rates, especially those presenting with STEMI and an unprotected LMS. This reflects the contemporary real-world practice of LMS PCI being predominantly performed in high risk patients which differs from randomized trial populations, and this should be considered before comparing with CABG outcomes.
约5%的冠状动脉造影检查发现左主干病变>50%。近期随机试验表明，在低危或中危患者中，经皮冠状动脉介入治疗（PCI）与冠状动脉旁路移植术（CABG）的疗效相当。在临床实践中，PCI常用于手术风险极高的患者。我们回顾了新西兰当代全国性经皮冠状动脉介入治疗（PCI）治疗左主干冠状动脉疾病（LMS）的结果。
从全新西兰急性冠状动脉综合征-质量改进登记处提取2014年9月1日至2017年9月24日期间所有接受LMS疾病PCI治疗的患者，并与全国数据集进行关联，分析其特征和住院期间的结局。
该队列包括469例患者，平均年龄70.8±10.7岁，男性331例（71%），大多数339例（72%）为无保护左主干。适应证包括ST段抬高型心肌梗死（STEMI）83例（18%）和非ST段抬高型心肌梗死或不稳定型心绞痛229例（49%）。与有保护左主干相比，无保护左主干更易出现急性冠状动脉综合征（73%对48%，P<0.001），且住院死亡风险更高（9.4%对3.9%，P=0.045）。在无保护左主干患者中，急性STEMI PCI术后的住院死亡率高于其他适应证（21.1%对6.1%，P<0.001）。住院死亡和主要不良心血管事件的独立预测因素包括STEMI、股动脉入路和肾功能较差。
我们的LMS PCI队列死亡率较高，尤其是那些表现为STEMI和无保护左主干的患者。这反映了LMS PCI在当代现实世界中的实践主要在高危患者中进行，这与随机试验人群不同，在与CABG疗效进行比较之前应予以考虑。
