Cui Kong-Yong, Yuan Fei, Liu Hong, Xu Feng, Zhang Min, Wang Wei, Zhang Ming-Duo, Wang Yun-Lu, Zhang Dong-Feng, Zhang Xiao, Tian Jin-Fan, Lyu Shu-Zheng
Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.
Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
J Geriatr Cardiol. 2020 Jan;17(1):16-25. doi: 10.11909/j.issn.1671-5411.2020.01.010.
In patients with acute ST-segment elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI), approximately 10% are concomitant with a chronic total occlusion (CTO) in a non-culprit vessel. However, the impact of staged CTO recanalization on prognosis in this cohort remains disputable. This study aimed to compare the long-term outcomes of staged CTO recanalization versus medical therapy in patients with STEMI after primary PCI.
Between January 2005 and December 2016, a total of 287 patients were treated with staged CTO-PCI ( = 91) or medical therapy ( = 196) after primary PCI in our center. The primary endpoint was major adverse cardiovascular and cerebrovascular event (MACCE), defined as a composite of all-cause death, nonfatal myocardial infarction (MI), stroke or unplanned revascularization. After propensity-score matching, 77 pairs of well-balanced patients were identified.
The mean follow-up period was 6.06 years. Overall, the incidence of the primary endpoint of MACCE was significantly lower in staged CTO-PCI group than that in medical therapy group in both overall population (22.0% . 46.9%; hazard ratio (HR) = 0.48, 95% CI: 0.29-0.77) and propensity-matched cohorts (22.1% . 42.9%; HR: 0.48, 95% CI: 0.27-0.86). In addition, staged CTO-PCI was also associated with reduced risk of the composite of cardiac death, nonfatal MI or stroke compared with medical therapy in both overall population (9.9% . 26.5%; hazard ratio (HR) = 0.39, 95% CI: 0.19-0.79) and propensity-matched cohorts (9.1% . 22.1%; HR: 0.40, 95% CI: 0.16-0.96). After correction of the possible confounders, staged CTO-PCI was independently associated with reduced risks of MACCE (adjusted HR: 0.46, 95% CI: 0.28-0.75), the composite of cardiac death, nonfatal MI or stroke (adjusted HR: 0.45, 95% CI: 0.22-0.94) and all-cause mortality (adjusted HR: 0.32, 95% CI: 0.13-0.83). Moreover, the results of sensitivity analysis were almost concordant with the overall analysis.
In patients with STEMI and a concurrent CTO who undergo primary PCI, successful staged recanalization of CTO in the non-culprit vessels is associated with better clinical outcomes during long-term follow-up.
在接受直接经皮冠状动脉介入治疗（PCI）的急性ST段抬高型心肌梗死（STEMI）患者中，约10%在非罪犯血管中合并慢性完全闭塞（CTO）。然而，分期CTO再通对此类患者预后的影响仍存在争议。本研究旨在比较STEMI患者直接PCI后分期CTO再通与药物治疗的长期结局。
2005年1月至2016年12月期间，我院中心共有287例患者在直接PCI后接受了分期CTO-PCI（n = 91）或药物治疗（n = 196）。主要终点为主要不良心血管和脑血管事件（MACCE），定义为全因死亡、非致命性心肌梗死（MI）、中风或非计划血运重建的复合终点。在倾向评分匹配后，确定了77对均衡的患者。
平均随访期为6.06年。总体而言，在总体人群（22.0%对46.9%；风险比（HR）= 0.48，95%置信区间：0.29 - 0.77）和倾向评分匹配队列（22.1%对42.9%；HR：0.48，95%置信区间：0.27 - 0.86）中，分期CTO-PCI组的MACCE主要终点发生率均显著低于药物治疗组。此外，在总体人群（9.9%对26.5%；风险比（HR）= 0.39，95%置信区间：0.19 - 0.79）和倾向评分匹配队列（9.1%对22.1%；HR：0.40，95%置信区间：0.16 - 0.96）中，与药物治疗相比，分期CTO-PCI还与心脏死亡、非致命性MI或中风的复合风险降低相关。在校正可能的混杂因素后，分期CTO-PCI与MACCE风险降低（调整后HR：0.46，95%置信区间：0.28 - 0.75）、心脏死亡、非致命性MI或中风的复合风险降低（调整后HR：0.45，95%置信区间：0.22 - 0.94）和全因死亡率降低（调整后HR：0.32，95%置信区间：0.13 - 0.83）独立相关。此外，敏感性分析结果与总体分析基本一致。
在接受直接PCI且合并CTO的STEMI患者中，非罪犯血管CTO的成功分期再通与长期随访期间更好的临床结局相关。
