Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France.
Université Paris-Descartes, Sorbonne Paris Cité, Paris Cardiovascular Research Center (PARCC), INSERM UMRS 970, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.
J Am Coll Cardiol. 2019 Oct 15;74(15):1868-1878. doi: 10.1016/j.jacc.2019.08.1002.
The long-term evolution of premature coronary artery disease (CAD) is unknown.
The objective of this study was to describe the evolution of coronary atherosclerosis in young patients and identify the risk factors of poor outcomes.
Participants age ≤45 years with acute or stable obstructive CAD were prospectively enrolled and followed. The primary endpoint was all-cause death, myocardial infarction (MI), refractory angina requiring coronary revascularization, and ischemic stroke.
Eight hundred-eighty patients with premature CAD were included. They were age 40.1 ± 5.7 years, mainly men, smokers, with a family history of CAD or hypercholesterolemia. At baseline presentation, 91.2% underwent coronary revascularization, predominantly for acute MI (78.8%). Over a follow-up of 20 years, one-third (n = 264) of patients presented with a total of 399 ischemic events, and 36% had at least a second recurrent event. MI was the most frequent first recurrent event (n = 131 of 264), mostly related to new coronary lesions (17.3% vs. 7.8%; p = 0.01; hazard ratio [HR]:1.45; 95% confidence interval [CI]: 1.09 to 1.93 for new vs. initial culprit lesion). All-cause death (n = 55; 6.3%) occurred at 8.4 years (median time). Ethnic origin (sub-Saharan African vs. Caucasian, adjusted hazard ratio [adjHR]: 1.95; 95% CI: 1.13 to 3.35; p = 0.02), inflammatory disease (adjHR: 1.58; 95% CI: 1.05 to 2.36; p = 0.03), and persistent smoking (adjHR: 2.32; 95% CI: 1.63 to 3.28; p < 0.01) were the strongest correlates of a first recurrent event. When considering all recurrent events, the same factors and Asian ethnicity predicted poor outcome, but persistent smoking had the greatest impact on prognosis.
Premature CAD is an aggressive disease despite the currently recommended prevention measures, with high rates of recurrent events and mortality. Ethnicity and concomitant inflammatory disease are associated with poor prognoses, along with insufficient control of risk factors.
早发性冠心病（CAD）的长期演变尚不清楚。
本研究旨在描述年轻患者冠状动脉粥样硬化的演变，并确定不良结局的危险因素。
前瞻性纳入年龄≤45 岁的急性或稳定型阻塞性 CAD 患者，并进行随访。主要终点是全因死亡、心肌梗死（MI）、需要冠状动脉血运重建的难治性心绞痛和缺血性卒中。
共纳入 880 例早发性 CAD 患者，平均年龄为 40.1±5.7 岁，主要为男性、吸烟者，有 CAD 或高胆固醇血症家族史。基线时，91.2%的患者行冠状动脉血运重建术，主要用于急性 MI（78.8%）。经过 20 年的随访，三分之一（n=264）的患者共发生 399 次缺血事件，36%至少发生了第二次复发事件。MI 是最常见的首发复发事件（n=264 例中有 131 例），主要与新的冠状动脉病变有关（17.3%比 7.8%；p=0.01；危险比[HR]：1.45；95%置信区间[CI]：1.09 至 1.93，新病变与初始罪犯病变相比）。全因死亡（n=55；6.3%）发生在 8.4 年（中位时间）。种族（撒哈拉以南非洲裔与白人，校正危险比[adjHR]：1.95；95%CI：1.13 至 3.35；p=0.02）、炎症性疾病（adjHR：1.58；95%CI：1.05 至 2.36；p=0.03）和持续吸烟（adjHR：2.32；95%CI：1.63 至 3.28；p<0.01）是首发复发事件的最强相关因素。考虑所有复发事件时，相同的因素和亚洲种族与不良结局相关，但持续吸烟对预后的影响最大。
尽管目前推荐了预防措施，但早发性 CAD 仍然是一种侵袭性疾病，其复发事件和死亡率均较高。种族和伴随的炎症性疾病与不良预后相关，同时危险因素的控制也不充分。
