老年急性ST段抬高型心肌梗死合并多支病变患者的介入治疗策略研究  

Analysis of revascularization strategies for elderly patients with ST-segment elevation myocardial infarction and multivessel disease

作　　者：郎嘉淳 王琛[1,2] 王乐 丛洪良 刘寅[2,3] 张敬霞 王林[2] 胡越成 徐榕笛[1,2] Lang Jiachun;Wang Chen;Wang Le;Cong Hongliang;Liu Yin;Zhang Jingxia;Wang Lin;Hu Yuecheng;Xu Rongdi(Clinical School of Thoracic Medicine,Tianjin Medical University,Tianjin 300070,China;Department of Cardiology,Tianjin Chest Hospital,Tianjin 300222,China;Tianjin Cardiovascular Institute,Tianjin 300222,China)

机构地区：[1]天津医科大学胸科临床学院,天津300070 [2]天津市胸科医院心内科,天津300222 [3]天津市心血管病研究所,天津300222

出　　处：《中华老年医学杂志》2023年第3期303-309,共7页Chinese Journal of Geriatrics

基　　金：天津市医学重点学科(专科)建设项目(TJYXZDXK-055B)。

摘　　要：目的 比较急诊经皮冠状动脉介入治疗(PCI)后择期干预非靶血管的治疗(Staged-PCI)策略与急诊仅开通靶血管的PCI(Culprit-only PCI)策略对老年急性ST段抬高型心肌梗死(STEMI)合并多支病变患者临床预后的影响。方法 回顾性分析2014年1月至2019年9月天津市胸科医院收治的年龄≥70岁且发病在12 h内的老年STEMI合并多支病变患者389例。根据血运重建策略分为Culprit-only PCI组(79.18%,308例)和Staged-PCI组(20.82%,81例)。采用Kaplan-Meier分析及Cox比例风险回归模型比较两组患者主要不良心脑血管事件(MACCE)、全因死亡、心源性死亡、再发心肌梗死、脑卒中和缺血驱动的再次血运重建的发生率,评估不同血运重建策略对MACCE和全因死亡的影响,并进行亚组分析。结果 经平均56个月的临床随访,131例患者发生MACCE,死亡96例。与Culprit-only PCI组比较,Staged-PCI组患者发生MACCE(HR:0.404,95%CI:0.227~0.716,P=0.002)、全因死亡(HR:0.354,95%CI:0.171~0.730,P=0.005)、心源性死亡(HR:0.363,95%CI:0.157~0.838,P=0.018)和再发心肌梗死(HR:0.229,95%CI:0.055~0.953,P=0.043)的风险均降低。而两组脑卒中和缺血驱动的再次血运重建的发生率差异无统计学意义(均P>0.05)。Staged-PCI策略对MACCE和全因死亡风险的降低作用在各亚组中持续存在。多因素Cox回归分析结果显示,校正混杂因素后,Staged-PCI是MACCE(HR:0.440,95%CI:0.239~0.815,P=0.009)和全因死亡(HR:0.390,95%CI:0.177~0.862,P=0.020)的独立保护因素。结论 对年龄≥70岁发病在12 h内的老年STEMI合并多支病变患者,相比Culprit-only PCI治疗策略,Staged-PCI策略能够显著改善患者的远期预后。Objective To compare the effects of staged percutaneous coronary intervention(PCI)after emergency PCI and emergency culprit-only PCI on clinical outcomes of elderly patients with ST-segment elevation myocardial infarction(STEMI)and multivessel disease.Methods A retrospective analysis was performed on 389 elderly patients with STEMI and multivessel lesions,aged≥70 years and within 12 h of onset,admitted to the Clinical College of Thoracic Medicine,Tianjin Medical University,between January 2014 and September 2019.According to different revascularization strategies,enrolled patients were divided into the culprit-only PCI group(79.18%,308)and the staged PCI group(20.82%,81).Kaplan-Meier analysis and the Cox proportional hazards regression model were used to compare the incidences of major adverse cardiac and cerebrovascular events(MACCE),all-cause death,cardiac death,recurrent myocardial infarction,stroke and ischemia-driven revascularization between the two groups and to evaluate the effects of different revascularization strategies on MACCE and all-cause death.Then subgroup analysis was performed.Results During a 56-month follow-up,131 patients developed MACCE and 96 patients died.Compared with the culprit-only PCI group,the staged PCI group had a lower risk of MACCE(HR:0.404,95%CI:0.227-0.716,P=0.002),all-cause death(HR:0.354,95%CI:0.171-0.730,P=0.005),cardiac death(HR:0.363,95%CI:0.157-0.838,P=0.018),and recurrent myocardial infarction(HR:0.229,95%CI:0.055-0.953,P=0.043).There was no significant difference in the incidence of stroke or ischemia-driven revascularization between the two groups(P>0.05).The reduced risk with staged PCI for MACCE and for all-cause mortality persisted in all subgroups.Multivariate Cox proportional hazards regression revealed that,after adjusting for confounding factors,staged PCI was an independent protective factor for MACCE(HR:0.44,95%CI:0.239-0.815,P=0.009)and for all-cause death(HR:0.390,95%CI:0.90,P=0.020).Conclusion Compared with culprit-only PCI,staged PCI can significantly i

关 键 词：心肌梗死 冠状动脉疾病 血管成形术 经腔 经皮冠状动脉 心肌血管重建术 

分 类 号：R542.22[医药卫生—心血管疾病]