正电子发射断层扫描显示的心肌缺血程度与早期血运重建的生存获益。
Extent of Myocardial Ischemia on Positron Emission Tomography and Survival Benefit With Early Revascularization.
机构信息
University of Missouri-Kansas City, Kansas City, Missouri; Saint Luke's Mid America Heart Institute, Kansas City, Missouri.
University of Missouri-Kansas City, Kansas City, Missouri; Saint Luke's Mid America Heart Institute, Kansas City, Missouri.
出版信息
J Am Coll Cardiol. 2019 Oct 1;74(13):1645-1654. doi: 10.1016/j.jacc.2019.07.055.
BACKGROUND
Prior studies with single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) have shown a survival benefit with early revascularization in patients with >10% to 12.5% ischemic myocardium. The relationship among positron emission tomography (PET)-derived extent of ischemia, early revascularization, and survival is unknown.
OBJECTIVES
The purpose of this study was to evaluate the association among percent ischemia on PET MPI, revascularization, and survival.
METHODS
A total of 16,029 unique consecutive patients who were undergoing Rubidium-82 rest-stress PET MPI from 2010 to 2016 were included. Patients with known cardiomyopathy and nondiagnostic perfusion results were excluded. Percent ischemic myocardium was estimated from a 17-segment model. Propensity scoring was used to account for nonrandomized referral to early revascularization (90 days of PET). A Cox model was developed, adjusting for propensity scores for early revascularization and percent ischemia, and an interaction between ischemia and early revascularization was tested.
RESULTS
Median follow-up was 3.7 years. Overall, 1,277 (8%) patients underwent early revascularization and 2,493 (15.6%) died (738 cardiac). Nearly 37% of patients (n = 5,902) had ischemia, with 13.5% (n = 2,160) having ≥10%. In propensity-adjusted analyses, there was a significant interaction between ischemia and early revascularization (p < 0.001 for all-cause and cardiac death), such that patients with greater ischemia had improved survival with early revascularization, with a potential ischemia threshold at 5% (upper limit 95% confidence interval at 10%). There was no differential association between ischemia and early revascularization on death based on history of known coronary artery disease (interaction p = 0.72).
CONCLUSIONS
In a contemporary cohort of patients undergoing PET MPI, patients with greater ischemia had a survival benefit from early revascularization. On exploratory analyses, this threshold was lower than that previously reported for SPECT. These findings require future validation in prospective cohorts or trials.
背景
先前使用单光子发射计算机断层扫描（SPECT）心肌灌注成像（MPI）的研究表明，对于缺血心肌>10%至 12.5%的患者，早期血运重建具有生存获益。但是，正电子发射断层扫描（PET）检测到的缺血范围、早期血运重建和生存之间的关系尚不清楚。
目的
本研究旨在评估 PET MPI 心肌缺血程度、血运重建与生存之间的关系。
方法
共纳入 2010 年至 2016 年间行放射性铷-82 静息-负荷 PET MPI 的 16029 例患者。排除已知有心肌病和不可诊断的灌注结果的患者。通过 17 节段模型来估计缺血心肌的百分比。采用倾向评分法来解释早期血运重建（PET 后 90 天）的非随机转诊。开发 Cox 模型，校正早期血运重建和缺血百分比的倾向评分，并检验缺血和早期血运重建之间的交互作用。
结果
中位随访时间为 3.7 年。总体而言，1277 例（8%）患者进行了早期血运重建，2493 例（15.6%）死亡（738 例为心源性）。将近 37%的患者（n=5902）有缺血，其中 13.5%（n=2160）有≥10%的缺血。在经过倾向评分校正的分析中，缺血和早期血运重建之间存在显著的交互作用（所有原因和心源性死亡的 p 值均<0.001），即缺血程度较高的患者进行早期血运重建可提高生存率，且存在 5%（上限为 95%置信区间为 10%）的潜在缺血阈值。在基于已知冠状动脉疾病史的死亡方面，缺血和早期血运重建之间的关联没有差异（交互作用 p=0.72）。
结论
在接受 PET MPI 的当代患者队列中，缺血程度较高的患者从早期血运重建中获益。通过探索性分析，该阈值低于之前 SPECT 报道的阈值。这些发现需要在未来的前瞻性队列或试验中进行验证。
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