Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.
Abbott Northwestern Hospital, Minneapolis Heart Institute, Minneapolis, Minnesota, USA.
JACC Cardiovasc Interv. 2021 May 24;14(10):1067-1078. doi: 10.1016/j.jcin.2021.02.021. Epub 2021 Apr 28.
The aim of this study was to compare in-hospital outcomes and long-term mortality of multivessel versus culprit vessel-only percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation myocardial infarction (NSTEMI), multivessel disease (MVD) and cardiogenic shock.
The clinical benefits of complete revascularization in patients with NSTEMI, MVD, and cardiogenic shock remain uncertain.
Among 25,324 patients included in the National Cardiovascular Data Registry CathPCI Registry from July 2009 to March 2018, the rates of in-hospital procedural outcomes were compared between those undergoing multivessel PCI and those undergoing culprit vessel-only PCI after 1:1 propensity score matching. Among patients aged ≥65 years matched to the Centers for Medicare and Medicaid Services database, long-term mortality was compared using proportional hazards analysis.
Multivessel PCI was performed in 9,791 patients (38.7%), which increased from 32.2% in 2010 to 44.2% in 2017 (p for trend <0.001). After 1:1 propensity matching (n = 7,864 in each group), those undergoing multivessel PCI had a 3.5% (95% confidence interval [CI]: 2.0% to 5.0%) lower absolute rate of in-hospital mortality (30.9% vs. 34.4%; p < 0.001; odds ratio [OR]: 0.85; 95% CI: 0.80 to 0.91), but a higher risk for bleeding (13.2% vs. 10.8%; p < 0.001; OR: 1.26; 95% CI: 1.15 to 1.40) and new requirement for dialysis (5.7% vs. 4.6%; p = 0.001; OR: 1.26; 95% CI: 1.10 to 1.46). Among those surviving to discharge, all-cause mortality was similar through 7 years (conditional hazard ratio: 0.95; 95% CI: 0.87 to 1.03; p = 0.20).
Nearly 40% of patients with NSTEMI with MVD and cardiogenic shock underwent multivessel PCI, which was associated with lower in-hospital mortality but greater peri-procedural complications. Among those surviving to discharge, multivessel PCI did not confer additional long-term mortality benefit.
本研究旨在比较非 ST 段抬高型心肌梗死（NSTEMI）、多支血管病变（MVD）和心源性休克患者行多支血管经皮冠状动脉介入治疗（PCI）与罪犯血管仅行 PCI 的住院期间结局和长期死亡率。
NSTEMI、MVD 和心源性休克患者完全血运重建的临床获益仍不确定。
在 2009 年 7 月至 2018 年 3 月期间纳入的 25324 例 National Cardiovascular Data Registry CathPCI 注册登记研究患者中，采用 1:1 倾向评分匹配比较行多支血管 PCI 与仅行罪犯血管 PCI 患者的住院期间手术结局。对年龄≥65 岁的患者与美国医疗保险和医疗补助服务中心数据库进行匹配，采用比例风险分析比较长期死亡率。
9791 例（38.7%）患者行多支血管 PCI，这一比例从 2010 年的 32.2%增加至 2017 年的 44.2%（趋势 p<0.001）。在 1:1 倾向评分匹配（每组 n=7864 例）后，行多支血管 PCI 的患者住院期间死亡率绝对下降 3.5%（95%置信区间：2.0%5.0%）（30.9% vs. 34.4%；p<0.001；比值比[OR]：0.85；95%置信区间：0.800.91），但出血风险更高（13.2% vs. 10.8%；p<0.001；OR：1.26；95%置信区间：1.151.40）和新需要透析（5.7% vs. 4.6%；p=0.001；OR：1.26；95%置信区间：1.101.46）。出院后存活的患者，7 年内全因死亡率相似（条件风险比：0.95；95%置信区间：0.87~1.03；p=0.20）。
近 40%的 NSTEMI 合并 MVD 和心源性休克患者行多支血管 PCI，这与较低的住院期间死亡率相关，但围术期并发症更多。出院后存活的患者中，多支血管 PCI 并未带来额外的长期死亡率获益。
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