Abdelmeguid A E, Whitlow P L, Sapp S K, Ellis S G, Topol E J
Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA.
Circulation. 1995 Jun 1;91(11):2733-41. doi: 10.1161/01.cir.91.11.2733.
Successful reversal of abrupt vessel closure without resultant major ischemic complications (death, Q-wave myocardial infarction, or coronary artery bypass graft surgery) is achieved in nearly half of all cases of abrupt vessel closure. The long-term outcome of these patients has not been previously addressed, and it is not clear whether they have a different prognosis than that of patients who have a successful procedure not associated with transient vessel closure.
We examined 4863 consecutive patients who underwent successful percutaneous transluminal coronary angioplasty (PTCA) or directional coronary atherectomy (DCA). Eighty-eight patients had an uncomplicated, successfully reversed transient in-laboratory vessel closure (group 2) and were compared with 4775 patients who had a successful procedure not associated with transient in-laboratory closure (group 1). Clinical follow-up was available in 4839 patients (99.5%), with a mean duration of 41 +/- 23 months (range, 1 to 104 months). Survival analysis showed that successfully treated, uncomplicated transient vessel closure per se does not have an adverse effect on long-term prognosis (death, myocardial infarction, or coronary interventions). However, when the procedure (PTCA or DCA) was associated with an increase in creatine kinase-MB (CK-MB), there was a significant adverse effect on long-term outcome. By multivariate logistic regression, an increase in postprocedure CK-MB was the most significant correlate for cardiac death (risk ratio, 1.25; P < .0001). An increase in CK-MB was also the most important correlate for major ischemic complications (death, infarction, or coronary interventions) on follow-up (risk ratio, 1.08; P = .0005).
Transient, uncomplicated in-laboratory vessel closure per se does not have an adverse long-term effect. However, a concomitant elevation of postprocedure cardiac enzymes has an important and significant adverse effect on long-term outcome. This study suggests that periprocedural creatine kinase isoenzyme determination in patients experiencing in-laboratory coronary closure has important prognostic implications.
在几乎一半的血管突然闭塞病例中，能成功逆转血管突然闭塞且无重大缺血性并发症（死亡、Q波心肌梗死或冠状动脉搭桥手术）发生。这些患者的长期预后此前尚未得到探讨，且不清楚他们与未发生短暂血管闭塞而手术成功的患者相比，预后是否不同。
我们研究了连续4863例行成功的经皮腔内冠状动脉成形术（PTCA）或定向冠状动脉斑块旋切术（DCA）的患者。88例患者发生了无并发症、成功逆转的术中短暂血管闭塞（2组），并与4775例未发生术中短暂血管闭塞而手术成功的患者（1组）进行比较。4839例患者（99.5%）有临床随访资料，平均随访时间为41±23个月（范围1至104个月）。生存分析显示，成功治疗的无并发症短暂血管闭塞本身对长期预后（死亡、心肌梗死或冠状动脉介入治疗）无不良影响。然而，当手术（PTCA或DCA）与肌酸激酶-MB（CK-MB）升高相关时，对长期预后有显著不良影响。通过多因素逻辑回归分析，术后CK-MB升高是心脏死亡的最显著相关因素（风险比，1.25；P<.0001）。CK-MB升高也是随访时重大缺血性并发症（死亡、梗死或冠状动脉介入治疗）的最重要相关因素（风险比，1.08；P=.0005）。
术中短暂、无并发症的血管闭塞本身对长期预后无不良影响。然而，术后心肌酶的同时升高对长期预后有重要且显著的不良影响。本研究提示，对于发生术中冠状动脉闭塞的患者，围手术期测定肌酸激酶同工酶具有重要的预后意义。
