冠状动脉疾病和免疫检查点抑制剂相关心肌炎的血运重建：国际注册研究的报告。
Coronary artery disease and revascularization associated with immune checkpoint blocker myocarditis: Report from an international registry.
机构信息
Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
Sorbonne Université, Department of Cardiology, INSERM UMRS_1166, Pitié Salpêtrière (AP-HP), Paris, France.
出版信息
Eur J Cancer. 2022 Dec;177:197-205. doi: 10.1016/j.ejca.2022.07.018. Epub 2022 Aug 24.
PURPOSE
Immune checkpoint blocker (ICB) associated myocarditis (ICB-myocarditis) may present similarly and/or overlap with other cardiac pathology including acute coronary syndrome presenting a challenge for prompt clinical diagnosis.
METHODS
An international registry was used to retrospectively identify cases of ICB-myocarditis. Presence of coronary artery disease (CAD) was defined as coronary artery stenosis >70% in patients undergoing coronary angiogram.
RESULTS
Among 261 patients with clinically suspected ICB-myocarditis who underwent a coronary angiography, CAD was present in 59/261 patients (22.6%). Coronary revascularization was performed during the index hospitalisation in 19/59 (32.2%) patients. Patients undergoing coronary revascularization less frequently received steroids administration within 24 h of admission compared to the other groups (p = 0.029). Myocarditis-related 90-day mortality was 9/17 (52.7%) in the revascularised cohort, compared to 5/31 (16.1%) in those not revascularized and 25/156 (16.0%) in those without CAD (p = 0.001). Immune-related adverse event-related 90-day mortality was 9/17 (52.7%) in the revascularized cohort, compared to 6/31 (19.4%) in those not revascularized and 31/156 (19.9%) in no CAD groups (p = 0.007). All-cause 90-day mortality was 11/17 (64.7%) in the revascularized cohort, compared to 13/31 (41.9%) in no revascularization and 60/158 (38.0%) in no CAD groups (p = 0.10). After adjustment of age and sex, coronary revascularization remained associated with ICB-myocarditis-related death at 90 days (hazard ratio [HR] = 4.03, 95% confidence interval [CI] 1.84-8.84, p < 0.001) and was marginally associated with all-cause death (HR = 1.88, 95% CI, 0.98-3.61, p = 0.057).
CONCLUSION
CAD may exist concomitantly with ICB-myocarditis and may portend a poorer outcome when revascularization is performed. This is potentially mediated through delayed diagnosis and treatment or more severe presentation of ICB-myocarditis.
目的
免疫检查点抑制剂（ICB）相关心肌炎（ICB-心肌炎）可能表现相似和/或与其他心脏病理学重叠，包括急性冠状动脉综合征，这对及时的临床诊断提出了挑战。
方法
使用国际注册中心回顾性确定 ICB-心肌炎病例。冠状动脉造影显示冠状动脉狭窄>70%定义为存在冠状动脉疾病（CAD）。
结果
在 261 例临床疑似 ICB-心肌炎患者中，261 例行冠状动脉造影术，59/261 例（22.6%）存在 CAD。19/59 例（32.2%）患者在指数住院期间行冠状动脉血运重建术。与其他组相比，接受冠状动脉血运重建术的患者在入院 24 小时内接受类固醇治疗的频率较低（p=0.029）。血运重建组的心肌炎相关 90 天死亡率为 17 例中的 9 例（52.7%），而非血运重建组的 31 例中的 5 例（16.1%），无 CAD 组的 156 例中的 25 例（16.0%）（p=0.001）。血运重建组与免疫相关不良事件相关的 90 天死亡率为 17 例中的 9 例（52.7%），而非血运重建组的 31 例中的 6 例（19.4%），无 CAD 组的 156 例中的 31 例（19.9%）（p=0.007）。血运重建组的全因 90 天死亡率为 17 例中的 11 例（64.7%），而非血运重建组的 31 例中的 13 例（41.9%），无 CAD 组的 158 例中的 60 例（38.0%）（p=0.10）。在校正年龄和性别后，冠状动脉血运重建术与 ICB-心肌炎相关 90 天死亡率仍相关（风险比[HR]为 4.03，95%置信区间[CI]为 1.84-8.84，p<0.001），与全因死亡相关（HR 为 1.88，95%CI，0.98-3.61，p=0.057）。
结论
CAD 可能与 ICB-心肌炎同时存在，并且当进行血运重建时可能预示着预后更差。这可能是通过延迟诊断和治疗或 ICB-心肌炎更严重的表现来介导的。
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