Miller Robert Jh, Bednarski Bryan, Cui Yujie, Calsavara Vinicius, Patel Krishna, Rozanski Alan, Liang Joanna X, Builoff Valerie, Acampa Wanda, Bateman Timothy M, Di Carli Marcelo, Dorbala Sharmila, Einstein Andrew J, Fish Matthews B, Hauser M Timothy, Kaufmann Philipp A, Miller Edward J, Ruddy Terrence D, Sharir Tali, Sinusas Albert J, Dey Damini, Berman Daniel S, Slomka Piotr J
Department of Medicine (Division of Artificial Intelligence in Medicine), Biomedical Sciences, and Imaging, Cedars-Sinai Medical Center, Los Angeles, California, United States.
Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada.
JACC Adv. 2024 Dec 12;4(1):101440. doi: 10.1016/j.jacadv.2024.101440. eCollection 2025 Jan.
Observational data have suggested that patients with moderate to severe ischemia benefit from revascularization. However, this was not confirmed in a large, randomized trial.
Using a contemporary, multicenter registry, the authors evaluated differences in the association between quantitative ischemia, revascularization, and outcomes across important subgroups.
Patients who underwent myocardial perfusion imaging in 12 centers were included in this retrospective analysis. The population was divided into original (2009-2014) and recent (2014-2021) registry sites. Early revascularization was defined as any revascularization within 90 days of myocardial perfusion imaging. A propensity score was developed to adjust for nonrandomization. Propensity score-adjusted survival analyses were used to evaluate the associations between quantitative ischemia, early revascularization, and death or myocardial infarction (MI) to identify at what severity of ischemia the HR for early revascularization crosses 1 (threshold for potential benefit).
Overall, 40,449 patients were included with a median follow-up of 3.5 (IQR: 2.4-4.6) years, during which death or MI occurred in 2,797 (6.9%). Early revascularization was associated with reduced death or MI in patients with >9.0% myocardial ischemia (95% upper CI: 11.2%, interaction < 0.001). The threshold for ischemia, above which patients may benefit from revascularization, was higher in more recent patients (14.0% vs 6.5%), but similar in female (>10.0%) and male patients (>8.6%).
Early revascularization was associated with reduced risk in patients with a higher burden of quantitative ischemia in more recent populations. These findings suggest that methods integrating more factors than just ischemia are needed to improve patient selection for revascularization.
观察性数据表明，中重度缺血患者可从血运重建中获益。然而，这一点在一项大型随机试验中并未得到证实。
作者利用一个当代多中心注册数据库，评估了重要亚组中定量缺血、血运重建与预后之间关联的差异。
本回顾性分析纳入了在12个中心接受心肌灌注成像的患者。研究人群分为原注册中心（2009 - 2014年）和近期注册中心（2014 - 2021年）。早期血运重建定义为心肌灌注成像后90天内的任何血运重建。通过倾向评分来调整非随机化因素。采用倾向评分调整后的生存分析来评估定量缺血、早期血运重建与死亡或心肌梗死（MI）之间的关联，以确定早期血运重建的风险比（HR）在何种缺血严重程度时超过1（潜在获益阈值）。
总体而言，共纳入40449例患者，中位随访时间为3.5年（四分位间距：2.4 - 4.6年），在此期间2797例（6.9%）患者发生死亡或MI。在心肌缺血>9.0%的患者中，早期血运重建与死亡或MI风险降低相关（95%可信区间上限：11.2%，交互作用<0.001）。近期患者中，缺血程度超过此阈值患者可能从血运重建中获益的阈值更高（14.0%对6.5%），但女性（>10.0%）和男性患者（>8.6%）相似。
在近期人群中，早期血运重建与定量缺血负担较高患者的风险降低相关。这些发现表明，需要整合比单纯缺血更多因素的方法来改善血运重建的患者选择。
