ST 段抬高型心肌梗死患者行直接经皮冠状动脉介入治疗后梗死动脉、心肌损伤与预后的关系。

Relationship Between Infarct Artery, Myocardial Injury, and Outcomes After Primary Percutaneous Coronary Intervention in ST-Segment-Elevation Myocardial Infarction.

机构信息

Heart Center Leipzig at the University of Leipzig Leipzig Germany.

University Heart Center Lübeck and the German Center for Cardiovascular Research Lübeck Germany.

出版信息

J Am Heart Assoc. 2024 Sep 17;13(18):e034748. doi: 10.1161/JAHA.123.034748. Epub 2024 Sep 9.

BACKGROUND

The extent to which infarct artery impacts the extent of myocardial injury and outcomes in patients with ST-segment-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention is uncertain.

METHODS AND RESULTS

We performed a pooled analysis using individual patient data from 7 randomized STEMI trials in which myocardial injury within 30 days after primary percutaneous coronary intervention was assessed in 1774 patients by cardiac magnetic resonance (n=1318) or technetium-99m sestamibi single-photon emission computed tomography (n=456). Clinical follow-up was performed at a median duration of 351 days (interquartile range, 184-368 days). Infarct size and outcomes were assessed in anterior (infarct vessel=left anterior descending) versus nonanterior (non-left anterior descending) STEMI. Median infarct size (percentage left ventricular myocardial mass) was larger in patients with anterior compared with nonanterior STEMI (19.7% [interquartile range, 9.4%-31.7%] versus 12.6% [interquartile range, 5.1%-20.5%]; <0.001). Patients with anterior compared with nonanterior STEMI were at higher risk for 1-year all-cause mortality (6.2% versus 3.6%; adjusted hazard ratio [HR], 1.66 [95% CI, 1.02-2.69]; =0.04) and heart failure hospitalization (4.4% versus 2.6%; adjusted HR, 1.96 [95% CI, 1.15-3.36]; =0.01). Infarct size was a predictor of subsequent all-cause mortality or heart failure hospitalization in anterior STEMI (adjusted HR per 1% increase, 1.05 [95% CI, 1.03-1.07]; <0.001), but not in nonanterior STEMI (adjusted HR, 1.02 [95% CI, 0.99-1.05]; =0.19). The value for this interaction was 0.04.

CONCLUSIONS

Anterior STEMI was associated with substantially greater myonecrosis after primary percutaneous coronary intervention compared with nonanterior STEMI, contributing in large part to the worse prognosis in patients with anterior infarction.

背景

ST 段抬高型心肌梗死（STEMI）患者行直接经皮冠状动脉介入治疗（pPCI）时，梗死相关动脉与心肌损伤程度和预后的关系尚不确定。

方法和结果

我们对 7 项 STEMI 随机临床试验的个体患者数据进行了汇总分析，共纳入 1774 例患者，其中 1318 例患者通过心脏磁共振（CMR）评估 pPCI 后 30 天内的心肌损伤，456 例患者通过锝-99m 甲氧基异丁基异腈单光子发射计算机断层扫描（SPECT）评估心肌损伤。中位临床随访时间为 351 天（四分位距，184368 天）。根据梗死部位（前壁梗死相关动脉=左前降支）和非前壁梗死相关动脉（非左前降支）将患者分为前壁 STEMI 和非前壁 STEMI。前壁 STEMI 患者的梗死面积（左心室心肌质量百分比中位数）大于非前壁 STEMI 患者（19.7%[四分位距，9.4%31.7%]比 12.6%[四分位距，5.1%~~20.5%]；<0.001）。与非前壁 STEMI 患者相比，前壁 STEMI 患者 1 年全因死亡率（6.2%比 3.6%；校正后危险比[HR]，1.66[95%可信区间，1.02~~2.69]；=0.04）和心力衰竭住院率（4.4%比 2.6%；校正 HR，1.96[95%可信区间，1.15~~3.36]；=0.01）更高。在接受 pPCI 治疗的前壁 STEMI 患者中，梗死面积是全因死亡或心力衰竭住院的预测因素（每增加 1%，校正后 HR 为 1.05[95%可信区间，1.03~~1.07]；<0.001），而非前壁 STEMI 患者则不然（校正 HR 为 1.02[95%可信区间，0.99~1.05]；=0.19）。交互检验的 P 值为 0.04。