多支血管病变及术后eGFR对急性心肌梗死患者1年预后的影响
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摘要
背景
急性心肌梗死(AMI)的预后,与治疗是否及时、梗死范围的大小以及是否有侧枝循环的建立等因素有关。AMI患者绝大多数有一支以上的冠状动脉严重受累,一定数量的患者三支主要血管均存在有临床意义的狭窄。梗死相关血管(IRA)斑块破裂和继发血栓形成是导致AMI的主要机制,虽然非梗死相关血管不作为发病的主要原因,但合并存在其他非梗死相关血管是否会增加患者的死亡率或不良事件的发生率尚不完全确定。本文就以冠脉造影结果出发,探讨病变血管数量对AMI患者预后的影响。
方法
选取浙江大学附属邵逸夫医院2009年1月至2011年11月所有行冠脉造影检查的AMI患者。收集患者住院期间资料并通过门诊或电话两种方式随访1年(12±3月)。随访联合终点为主要心脑血管不良事件(MACCE)。根据病变血管数量将所有患者分为冠脉造影阴性组、单支病变组、两支病变组和三支病变组。通过Kaplan-Meier法描述1年随访无MACCE发生率曲线,Cox回归模型分析患者1年预后的独立预测因子。
结果
493名患者中累及左主干(LM)的有39人(7.9%),累及左冠状动脉前降支(LAD)的有421人(85.4%),累及左冠状动脉回旋支(CX)的有270人(54.8%),累及右冠状动脉(RCA)的有305人(61.9%)。所有患者中有279人(56.6%)患高血压,132人(26.8%)患糖尿病。多支病变比单支病变：年龄(64.1vs.59.2,P=0.000)、高血压(59.9%vs.48.9%,P=0.031)、糖尿病(30.6%vs.17.3%,P=0.003)、既往卒中病史(8.1%vs.1.4%,P=0.006)、糖化血红蛋白(6.6vs.6.2,P=0.044)、低密度脂蛋白(2.00vs.1.83,P=0.044)。1年中72人(16.5%)发生MACCE事件。多支病变vs.单支病变：1年累积MACCE发生率(19.5%vs.10.1%,P=0.013)、再次血运重建(11.8%vs.5.8%, P=0.049). COX多因素回归提示以下三个变量对1年预后有阳性预测意义：多支病变(HR:2.445,95%CI:1.028-5.815, P=0.043)、术后eGFR<60ml·min-1·1.73m-2(HR:4.245,95%CI:1.405-12.827, P=0.010)、既往卒中史(HR:3.250,95%CI:1.202-8.787, P=0.020)
肾功能方面术后eGFR<60ml·min-1·1.73m-2的患者比术后eGFR≥60ml·min-1·1.73m2的患者：1年MACCE发生率(37.9%vs.13.4%,P=0.000)、1年全因死亡(25.9%vs.2.2%,P=0.000)、致死性心梗(19.0%vs.1.6%,P=0.000)。
结论
1)56.6%的AMI患者合并高血压,26.8%患者合并糖尿病。各支血管中前降支最易受累,其次为右冠、回旋支和左主干。
2)多支病变的患者年龄较大、有较多的心血管危险因素及既往卒中病史、糖化血红蛋白高、低密度脂蛋白高。
3)多支血管病变和术后eGFR水平为AMI患者1年随访MACCE的独立预测因子。
4)冠造阳性患者1年MACCE发生率为16.5%,多支病变患者1年累积MACCE发生率更高,更多的患者需要再次血运重建。
5)术后eGFR<60ml·min-1·1.73m-2的患者1年MACCE发生率更高,1年全因死亡率尤其是发生致死性心梗的比例高。
Background
The prognosis of AMI depends on the time of reperfusion therapy, the size of infarct area and the establishment of collateral circulation. The overwhelming majorities of AMI patients present at least one-vessel disease while certain quantities of patients have clinically significant stenosis in all three vessels. The main initiating mechanism of AMI is plaque rupture or erosion with overlying thrombosis in infarct related artery (IRA). Though non-IRA is not considered to be the main cause of AMI, we are not sure whether it will increase the mortality and major adverse events in AMI patients. We aim to clarify this impact on1-year outcome of acute myocardial infarction from the aspect of the number of vessel diseased.
Method
The AMI patients who received coronary angiography from January2009to November2011in Sir Run Run Shaw hospital were enrolled and followed up for1year. Patients were evaluated at baseline for clinical characteristics and the treatment strategies during the hospitalization. Follow-up data were collected at the time of3 month (3±1months) and1year (12±3months) following discharge. The combining endpoint was the occurrence of major adverse cardiac and cerebrovascular events (MACCE), which was a composite of fatal MI, fatal stroke, other cardiovascular death, non-fatal MI, non-fatal stroke and hospitalization for revascularization. According to the number of vessel diseased, all patients were divided into4groups:negative, single-vessel, double-vessel and triple-vessel. In the survival analysis, cumulative MACCE-free survival rates over1-year follow-up period were estimated using the Kaplan-Meier method. The independent risk factors of MACCE were assessed using a multivariate Cox proportional hazards model.
Results
A total of493patients were assessed, among whom39(7.9%) were involved in left main (LM),421(85.4%) were involved in left anterior descending (LAD),270(54.8%) were involved in circumflex (CX),305(61.9%) were involved in right coronary artery (RCA).279(56.6%) had hypertension and132(26.8%) had diabetes mellitus. Multi-vessel vs. single-vessel:age (64.1vs.59.2, P=0.000), hypertension (59.9%vs.48.9%, P=0.031), diabetes mellitus (30.6%vs.17.3%, P=0.003), history of stoke (8.1%vs.1.4%, P=0.006), HbAlc (6.6vs.6.2, P=0.044), LDL-C (2.00vs.1.83, P=0.044).
At1-year follow up,72(16.5%) patients had MACCE. Multi-vessel vs. single-vessel:1-year cumulative rate of MACCE (19.5%vs.10.1%, P=0.013), revascularization (11.8%vs.5.8%, P=0.049). COX regression (multivariate analysis): multivessel lesions (HR:2.445,95%CI:1.028-5.815, P=0.043), post-PCI eGFR<60ml·min-1·1.73m-2(HR:4.245,95%CI:1.405-12.827, P=0.010), history of stroke (HR:3.250,95%CI:1.202-8.787, P=0.020). Post-PCI eGFR<60ml·min-1.73m-2vs. post-PCI eGFR≥60ml·min-1·1.73m2:1-year cumulative rate of MACCE (37.9%vs. 13.4%, P=0.000),1-year all cause mortality (25.9%vs.2.2%, P=0.000), fatal MI (19.0%vs.1.6%,P=0.000).
Conclusion
1) For the entire patient group,56.6%of patients had hypertension,26.8%had diabetes mellitus, LAD was involved in most of the patients, then RCA, CX and LM.
2) In the comparison of subgroups, patients with multi-vessel disease tended to be older and have more concomitant disease, including diabetes, hypertension, and previous history of stoke.
3) The multi-vessel disease and post-PCI eGFR were both risk factors for1-year outcome of AMI and predicted poor prognosis in Chinese patients.
4) At1-year follow up, the cumulative incidence of MACCE was16.5%. The1-year incidence of MACCE was significantly higher in patients with multi-vessel disease than single-vessel disease, especially the revascularization rate.
5) Comparatively, post-PCI eGFR<60ml·min-1·1.73m-2had a higher rate of1-year MACCE and all cause mortality, which was largely due to fatal MI.
急性心肌梗死(AMI)的预后,与治疗是否及时、梗死范围的大小以及是否有侧枝循环的建立等因素有关。AMI患者绝大多数有一支以上的冠状动脉严重受累,一定数量的患者三支主要血管均存在有临床意义的狭窄。梗死相关血管(IRA)斑块破裂和继发血栓形成是导致AMI的主要机制,虽然非梗死相关血管不作为发病的主要原因,但合并存在其他非梗死相关血管是否会增加患者的死亡率或不良事件的发生率尚不完全确定。本文就以冠脉造影结果出发,探讨病变血管数量对AMI患者预后的影响。
方法
选取浙江大学附属邵逸夫医院2009年1月至2011年11月所有行冠脉造影检查的AMI患者。收集患者住院期间资料并通过门诊或电话两种方式随访1年(12±3月)。随访联合终点为主要心脑血管不良事件(MACCE)。根据病变血管数量将所有患者分为冠脉造影阴性组、单支病变组、两支病变组和三支病变组。通过Kaplan-Meier法描述1年随访无MACCE发生率曲线,Cox回归模型分析患者1年预后的独立预测因子。
结果
493名患者中累及左主干(LM)的有39人(7.9%),累及左冠状动脉前降支(LAD)的有421人(85.4%),累及左冠状动脉回旋支(CX)的有270人(54.8%),累及右冠状动脉(RCA)的有305人(61.9%)。所有患者中有279人(56.6%)患高血压,132人(26.8%)患糖尿病。多支病变比单支病变：年龄(64.1vs.59.2,P=0.000)、高血压(59.9%vs.48.9%,P=0.031)、糖尿病(30.6%vs.17.3%,P=0.003)、既往卒中病史(8.1%vs.1.4%,P=0.006)、糖化血红蛋白(6.6vs.6.2,P=0.044)、低密度脂蛋白(2.00vs.1.83,P=0.044)。1年中72人(16.5%)发生MACCE事件。多支病变vs.单支病变：1年累积MACCE发生率(19.5%vs.10.1%,P=0.013)、再次血运重建(11.8%vs.5.8%, P=0.049). COX多因素回归提示以下三个变量对1年预后有阳性预测意义：多支病变(HR:2.445,95%CI:1.028-5.815, P=0.043)、术后eGFR<60ml·min-1·1.73m-2(HR:4.245,95%CI:1.405-12.827, P=0.010)、既往卒中史(HR:3.250,95%CI:1.202-8.787, P=0.020)
肾功能方面术后eGFR<60ml·min-1·1.73m-2的患者比术后eGFR≥60ml·min-1·1.73m2的患者：1年MACCE发生率(37.9%vs.13.4%,P=0.000)、1年全因死亡(25.9%vs.2.2%,P=0.000)、致死性心梗(19.0%vs.1.6%,P=0.000)。
结论
1)56.6%的AMI患者合并高血压,26.8%患者合并糖尿病。各支血管中前降支最易受累,其次为右冠、回旋支和左主干。
2)多支病变的患者年龄较大、有较多的心血管危险因素及既往卒中病史、糖化血红蛋白高、低密度脂蛋白高。
3)多支血管病变和术后eGFR水平为AMI患者1年随访MACCE的独立预测因子。
4)冠造阳性患者1年MACCE发生率为16.5%,多支病变患者1年累积MACCE发生率更高,更多的患者需要再次血运重建。
5)术后eGFR<60ml·min-1·1.73m-2的患者1年MACCE发生率更高,1年全因死亡率尤其是发生致死性心梗的比例高。
Background
The prognosis of AMI depends on the time of reperfusion therapy, the size of infarct area and the establishment of collateral circulation. The overwhelming majorities of AMI patients present at least one-vessel disease while certain quantities of patients have clinically significant stenosis in all three vessels. The main initiating mechanism of AMI is plaque rupture or erosion with overlying thrombosis in infarct related artery (IRA). Though non-IRA is not considered to be the main cause of AMI, we are not sure whether it will increase the mortality and major adverse events in AMI patients. We aim to clarify this impact on1-year outcome of acute myocardial infarction from the aspect of the number of vessel diseased.
Method
The AMI patients who received coronary angiography from January2009to November2011in Sir Run Run Shaw hospital were enrolled and followed up for1year. Patients were evaluated at baseline for clinical characteristics and the treatment strategies during the hospitalization. Follow-up data were collected at the time of3 month (3±1months) and1year (12±3months) following discharge. The combining endpoint was the occurrence of major adverse cardiac and cerebrovascular events (MACCE), which was a composite of fatal MI, fatal stroke, other cardiovascular death, non-fatal MI, non-fatal stroke and hospitalization for revascularization. According to the number of vessel diseased, all patients were divided into4groups:negative, single-vessel, double-vessel and triple-vessel. In the survival analysis, cumulative MACCE-free survival rates over1-year follow-up period were estimated using the Kaplan-Meier method. The independent risk factors of MACCE were assessed using a multivariate Cox proportional hazards model.
Results
A total of493patients were assessed, among whom39(7.9%) were involved in left main (LM),421(85.4%) were involved in left anterior descending (LAD),270(54.8%) were involved in circumflex (CX),305(61.9%) were involved in right coronary artery (RCA).279(56.6%) had hypertension and132(26.8%) had diabetes mellitus. Multi-vessel vs. single-vessel:age (64.1vs.59.2, P=0.000), hypertension (59.9%vs.48.9%, P=0.031), diabetes mellitus (30.6%vs.17.3%, P=0.003), history of stoke (8.1%vs.1.4%, P=0.006), HbAlc (6.6vs.6.2, P=0.044), LDL-C (2.00vs.1.83, P=0.044).
At1-year follow up,72(16.5%) patients had MACCE. Multi-vessel vs. single-vessel:1-year cumulative rate of MACCE (19.5%vs.10.1%, P=0.013), revascularization (11.8%vs.5.8%, P=0.049). COX regression (multivariate analysis): multivessel lesions (HR:2.445,95%CI:1.028-5.815, P=0.043), post-PCI eGFR<60ml·min-1·1.73m-2(HR:4.245,95%CI:1.405-12.827, P=0.010), history of stroke (HR:3.250,95%CI:1.202-8.787, P=0.020). Post-PCI eGFR<60ml·min-1.73m-2vs. post-PCI eGFR≥60ml·min-1·1.73m2:1-year cumulative rate of MACCE (37.9%vs. 13.4%, P=0.000),1-year all cause mortality (25.9%vs.2.2%, P=0.000), fatal MI (19.0%vs.1.6%,P=0.000).
Conclusion
1) For the entire patient group,56.6%of patients had hypertension,26.8%had diabetes mellitus, LAD was involved in most of the patients, then RCA, CX and LM.
2) In the comparison of subgroups, patients with multi-vessel disease tended to be older and have more concomitant disease, including diabetes, hypertension, and previous history of stoke.
3) The multi-vessel disease and post-PCI eGFR were both risk factors for1-year outcome of AMI and predicted poor prognosis in Chinese patients.
4) At1-year follow up, the cumulative incidence of MACCE was16.5%. The1-year incidence of MACCE was significantly higher in patients with multi-vessel disease than single-vessel disease, especially the revascularization rate.
5) Comparatively, post-PCI eGFR<60ml·min-1·1.73m-2had a higher rate of1-year MACCE and all cause mortality, which was largely due to fatal MI.
引文
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[14]Vasu S, Gruberg L, Brown DL. The Impact of advanced chronic kidney disease on in-hospital mortality following percutaneous coronary intervention for acute myocardial infarction. Cathet Cardiovasc Interv 2007; 70:701-705.
[15]Osten MD., Ivanov J, Eichhofer J et al. Impact of renal insufficiency on angiographic, procedural, and in-hospital outcomes following percutaneous coronary intervention. Am J Cardiol 2008; 101:780-785.
[16]Yamaguchi J, Kasanuki H, Ishii Y et al Prognostic significance of serum creatinine concentration for in-hospital mortality in patients with acute myocardial infarction who underwent successful primary percutaneous coronary intervention (from the Heart Institute of Japan Acute Myocardial Infarction [HIJAMI] Registry). Am J Cardiol 2004; 93:1526-1528.
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[1]Sarnak MJ, Levey AS, Schoolwerth AC et al.; American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Kidney disease as a risk factor for development of cardiovascular disease:A statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Circulation 2003; 108:2154-2169.
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[15]Osten MD., Ivanov J, Eichhofer J et al. Impact of renal insufficiency on angiographic, procedural, and in-hospital outcomes following percutaneous coronary intervention. Am J Cardiol 2008; 101:780-785.
[16]Yamaguchi J, Kasanuki H, Ishii Y et al Prognostic significance of serum creatinine concentration for in-hospital mortality in patients with acute myocardial infarction who underwent successful primary percutaneous coronary intervention (from the Heart Institute of Japan Acute Myocardial Infarction [HIJAMI] Registry). Am J Cardiol 2004; 93:1526-1528.
[17]Schiffrin EL, Lipman ML, Mann J. Chronic kidney disease:Effects on the cardiovascular system. Circulation 2007; 116:85-97.
[18]Koganei H, Kasanuki H, Ogawa H, Tsurumi Y. Association of glomerular filtration rate with unsuccessful primary percutaneous coronary intervention and subsequent mortality in patients with acute myocardial infarction. Circ J 2008; 72: 179-185.
[19]Eijkelkamp WB, de Graeff PA, van Veldhuisen DJ et al. Effect of first myocardial ischemic event on renal function. Am J Cardiol 2007; 100:7-12.
[20]Latchamsetty R, Fang J, Kline-Rogers E et al. Prognostic value of transient and sustained increase in in-hospital creatinine on outcomes of patients admitted with acute coronary syndrome. Am J Cardiol 2007; 99:939-942.
[21]Kowalczyk J, Lenarczyk R, Kowalski O et al. Risk stratification according to the type of impaired renal function in patients with acute myocardial infarction treated with percutaneous coronary intervention. Kardiol Pol 2007; 65:635-643.
[22]Marenzi G, Lauri G, Assanelli E et al. Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction. J Am Coll Cardiol 2004; 44:1780-1785.
[23]Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction:A quantitative review of 23 randomised trials. Lancet 2003; 361:13-20.
[24]Aspelin P, Aubry P, Fransson SG, Strasser R, Willenbrock R, Berg KJ. Nephrotoxic effects in high-risk patients undergoing angiography. N Engl J Med 2003; 348:491-499.
[25]Masuda M, Yamada T, Mine T et al. Comparison of usefulness of sodium bicarbonate versus sodium chloride to prevent contrast-induced nephropathy in patients undergoing an emergent coronary procedure. Am J Cardiol 2007; 100: 781-786.
[26]Briguori C, Colombo A, Airoldi F et al. Nephrotoxicity of low-osmolality versus iso-osmolality contrast agents:Impact of N-acetylcysteine. Kidney Intern 2005; 68:2250-2255.
[27]Nallamothu BK, Shojania KG, Saint S et al. Is acetylcysteine effective in preventing contrast-related nephropathy? A meta-analysis. Am J Med 2004; 117: 938-947
[28]Briguori C, Airoldi F, D'Andrea D et al. Renal insufficiency following contrast media administration trial. Circulation 2007; 115; 1211-1217.
[29]Kelly AM, Dwamena B, Cronin P, Bemstein SJ, Carlos RC. Meta-analysis: Effectiveness of drugs for preventing contrast-induced nephropathy. Ann Intern Med 2008; 148:284-294.
[30]Chyrchel M, Rakowski T, Rzeszutko L et al. Effects of high-dose statin administered prior to coronary angioplasty on the incidence of cardiac events in patients with acute coronary syndrome. Kardiol Pol 2006; 64:1357-1362.
[31]Patti G, Nusca A, Chello M et al. Usefulness of statin pretreatment to prevent contrast-induced nephropathy and to improve long-term outcome in patients undergoing percutaneous coronary intervention. Am J Cardiol 2008; 101: 279-285.
[32]Zhao JL, Yang YJ, Zhang YH, You SJ, Wu YJ, Gao RL. Effect of statins on contrast-induced nephropathy in patients with acute myocardial infarction treated with primary angioplasty. Int J Cardiol 2008; 126:435-436.
[33]Jo SH, Koo BK, Park JS et al. Prevention of radiocontrast medium-induced nephropathy using short-term high-dose simvastatin in patients with renal insufficiency undergoing coronary angiography (PROMISS) trial:A randomized controlled study. Am Heart J 2008; 155:499:el-e8.
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