Kawaguchi T, Myers J, Ribisl P M, Morris C K, Ueshima K, Liu J H, Froelicher V F
Palo Alto, VA Medical Center, CA 94304.
Am Heart J. 1994 Jan;127(1):39-48. doi: 10.1016/0002-8703(94)90507-x.
Forty-two patients with angiographically documented left main coronary artery (LM) disease (luminal occlusion > or = 50%) and 30 patients with left main equivalent (LMEQ) disease (> or = 70% luminal occlusion of both the proximal left anterior descending artery and proximal left circumflex artery) were studied to determine the role of right coronary artery (RCA) involvement on exercise test responses and survival. Significant (> or = 70%) RCA stenosis was present in 30 (72%) of the 42 LM patients and 16 (53%) of the 30 LMEQ patients. No significant differences were observed between LM and LMEQ patients in any clinical or exercise variables or survival. Thus both groups were combined for analysis of the influence of RCA involvement (i.e., LM/LMEQ with RCA versus LM/LMEQ without RCA disease). Greater ischemic responses were observed in the LM/LMEQ group with significant stenosis of the RCA. The presence of RCA stenosis was associated with significantly greater horizontal or downsloping ST-segment depression during exercise (2.4 +/- 1.2 mm vs 1.3 +/- 1.4 mm; p < 0.001), and prolonged recovery time until normalization of the ST segment (3.2 +/- 1.4 min vs 2.0 +/- 1.9 min; p < 0.01). The LM/LMEQ without RCA disease group behaved like the subgroup with two-vessel disease, and responses of the LM/LMEQ group with RCA disease were similar to the group with three-vessel disease. The annual survival in LM/LMEQ with RCA disease was worse than that in LM/LMEQ without RCA disease (average annual mortality rates = 7.5% vs 1.0%, respectively; p = 0.05). Infarct-free survival in LM/LMEQ with RCA disease was also lower than that in LM/LMEQ without RCA disease. Thus although patients with LM and LMEQ were similar in terms of survival and exercise responses, the presence of RCA stenosis was associated with significantly greater ST-segment depression, a prolonged recovery time until normalization of the ST segment, a fivefold increase in the death rate, and higher morbidity from myocardial infarction over a 5-year period of follow-up. Involvement of the RCA should be considered when making decisions concerning medical-surgical management of patients with severe coronary artery disease.
对42例经血管造影证实有左冠状动脉主干（LM）病变（管腔闭塞≥50%）的患者和30例有左主干等同病变（LMEQ）（左前降支近端和左旋支近端管腔闭塞≥70%）的患者进行了研究，以确定右冠状动脉（RCA）受累对运动试验反应和生存的影响。42例LM患者中有30例（72%）存在显著（≥70%）的RCA狭窄，30例LMEQ患者中有16例（53%）存在显著RCA狭窄。在任何临床、运动变量或生存率方面，LM患者和LMEQ患者之间均未观察到显著差异。因此，将两组合并以分析RCA受累的影响（即有RCA病变的LM/LMEQ与无RCA病变的LM/LMEQ）。在RCA有显著狭窄的LM/LMEQ组中观察到更大的缺血反应。RCA狭窄的存在与运动期间显著更大的水平或下斜型ST段压低相关（2.4±1.2 mm对1.3±1.4 mm；p<0.001），以及直到ST段恢复正常的恢复时间延长（3.2±1.4分钟对2.0±1.9分钟；p<0.01）。无RCA病变的LM/LMEQ组表现类似于双支血管病变亚组，有RCA病变的LM/LMEQ组的反应类似于三支血管病变组。有RCA病变的LM/LMEQ的年生存率低于无RCA病变的LM/LMEQ（平均年死亡率分别为7.5%对1.0%；p=0.05）。有RCA病变的LM/LMEQ的无梗死生存率也低于无RCA病变的LM/LMEQ。因此，尽管LM和LMEQ患者在生存和运动反应方面相似，但RCA狭窄的存在与显著更大的ST段压低、直到ST段恢复正常的恢复时间延长、死亡率增加五倍以及在5年随访期内心肌梗死发病率更高相关。在对严重冠状动脉疾病患者进行药物 - 手术治疗决策时，应考虑RCA受累情况。
