Division of Cardiovascular Medicine, Brigham & Women's Hospital, Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA.
Curr Opin Cardiol. 2020 Nov;35(6):712-719. doi: 10.1097/HCO.0000000000000789.
Management of patients with coronary artery disease (CAD) has been based on identification of a coronary obstruction causing ischemia and performing a revascularization procedure to reduce that ischemia, with the goal of thereby preventing subsequent major adverse cardiac events (MACEs) in that vascular territory. Recent investigations demonstrate that preemptive percutaneous coronary intervention (PCI) of nonculprit coronary lesions (NCLs) that may not cause ischemia in patients with ST-segment elevation myocardial infarction (STEMI) reduces MACE. In this review, we focus on preemptive PCI, discuss its mechanistic benefits and speculate on its potential value for other coronary syndromes.
The COMPLETE trial in STEMI patients treated with primary PCI demonstrated that preemptive PCI of NCL obstructions, which may not cause ischemia, but often exhibit high-risk OCT plaque characteristics, reduced cardiovascular death or nonfatal myocardial infarction. Reduction in MACE from preemptive PCI of NCL was similar for lesions confirmed to cause ischemia (fractional flow reserve <0.80) and for lesions that were only visually assessed to have luminal obstruction at least 70%.The ISCHEMIA trial in patients with stable CAD and moderate/severe ischemia demonstrated that MACE risk increased progressively with more extensive atherosclerosis, but that performing PCI of ischemia-producing lesions did not reduce MACE. Adverse cardiac events likely originated in high-risk plaque areas not treated with PCI.
In STEMI patients, preemptive PCI of high-risk NCL that may not cause ischemia improves long-term MACE. In stable CAD patients, MACE increases as the atherosclerotic burden increases, but PCI of the ischemia-producing lesion itself does not improve outcomes compared with optimal medical therapy. Adverse events likely originate in high-risk plaque areas that are distinct from ischemia-producing obstructions. Identification of highest-risk atherosclerotic lesions responsible for future MACE may provide an opportunity for preemptive PCI in patients with a variety of coronary syndromes.
冠心病（CAD）患者的管理一直基于识别引起缺血的冠状动脉阻塞，并进行血运重建以减少缺血，从而预防该血管区域的后续主要不良心脏事件（MACE）。最近的研究表明，对ST 段抬高型心肌梗死（STEMI）患者中可能不会引起缺血的非罪犯冠状动脉病变（NCL）进行预防性经皮冠状动脉介入治疗（PCI）可减少 MACE。在本综述中，我们重点讨论了预防性 PCI，探讨了其机制益处，并推测了其对其他冠状动脉综合征的潜在价值。
在接受直接 PCI 治疗的 STEMI 患者中进行的 COMPLETE 试验表明，对可能不会引起缺血但通常表现出高风险 OCT 斑块特征的 NCL 阻塞进行预防性 PCI，可降低心血管死亡或非致死性心肌梗死的风险。从 NCL 的预防性 PCI 中减少 MACE 的效果在证实引起缺血（血流储备分数 <0.80）的病变和仅通过视觉评估确定至少有 70%管腔阻塞的病变中相似。在稳定型 CAD 且存在中度/重度缺血的患者中进行的 ISCHEMIA 试验表明，随着动脉粥样硬化程度的增加，MACE 风险逐渐增加，但对产生缺血的病变进行 PCI 并不能降低 MACE。不良心脏事件可能起源于未接受 PCI 治疗的高危斑块区域。
在 STEMI 患者中，对可能不会引起缺血的高危 NCL 进行预防性 PCI 可改善长期 MACE。在稳定型 CAD 患者中，随着动脉粥样硬化负担的增加，MACE 增加，但与最佳药物治疗相比，缺血性病变本身的 PCI 并不能改善结局。不良事件可能起源于与引起缺血的阻塞不同的高危斑块区域。识别导致未来 MACE 的最高危动脉粥样硬化病变可能为各种冠状动脉综合征患者提供预防性 PCI 的机会。
