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《急性冠状动脉疾病（CORONARY HEART DISEASE, ACUTE） 主要PCI后心梗后心包炎率下降》

  • 来源专题：心血管疾病防治
  • 编译者： 张燕舞
  • 发布时间：2018-05-22

  • 心肌炎可能使急性心肌梗塞（MI）过程复杂化，可能在MI后不久发生。 尽管心肌梗塞后心包炎通常是短暂性和自限性的，但症状并不舒服，并可能与潜在的复发性心肌缺血相混淆。 心肌梗塞后心包炎的发生率在再灌注时期之前高达20％，纤维蛋白溶解治疗后降至约5％，但主要经皮冠状动脉介入治疗（PCI）发生心包炎的发生率不详。 在2000年至2013年期间的一组以ST段抬高MI（STEMI）为标准的以色列患者中（其中三分之二的患者接受了主要再灌注治疗，主要为PCI），仅有1.2％发生MI后心包炎。 除了降低死亡率和其他主要不良心脏事件外，直接PCI还可能降低MI后心包炎的发生率。

    There are scarce contemporary data regarding the incidence and prognosis of early postmyocardial infarction pericarditis (PMIP). Thus, we retrospectively analyzed 6,282 patients with ST-segment elevation myocardial infarction (STEMI) enrolled with known PMIP status in the Acute Coronary Syndrome Israeli Survey 2000 to 2013 registry. The primary outcome was the composite of all-cause mortality, nonfatal myocardial infarction, cerebrovascular event, stent thrombosis, or revascularization. The secondary outcomes were mortality and length of stay during the acute hospitalization. Overall, 76 patients with STEMI had PMIP (1.2%). PMIP incidence gradually decreased from 170 per 10,000 in 2000 to 110 per 10,000 in 2013, respectively (35% reduction, p for trend = 0.035). Patients with PMIP were younger (median 58.0 vs 61.0; p = 0.045), had less hypertension, higher cardiac biomarkers, and more frequently reduced left ventricular ejection fraction (87.0% vs 67.0%; p = 0.001). Patients with PMIP had longer time to reperfusion (225 minutes vs 183 minutes; p = 0.016) and length of stay (7.0 vs 5.0 days; p < 0.001). The composite end point occurred similarly inpatients with and without PMIP (10.5% vs 13.2%, respectively). There was no significant difference in 30-day, 1-year, and 5-year survival. In conclusion, PMIP is a relatively rare complication of STEMI in the coronary reperfusion era, portends worse short-term but not long-term outcomes, and is associated with bigger infarct size.

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  • 《PCI后冠状动脉病变与多支血管病变的CABG死亡率》
    • 来源专题：心血管疾病防治
    • 编译者：张燕舞
    • 发布时间：2018-05-22
    • 对于需要血运重建的稳定多支冠状动脉疾病（CAD）患者，经皮冠状动脉介入治疗（PCI）和冠状动脉搭桥手术（CABG）之间的选择可能很困难。 2018年对来自11项比较两种血运重建策略的随机试验的个体患者数据汇总分析显示，多支血管病患者的5年全因死亡率高于PCI。 然而，预先指定的亚组分析发现，没有糖尿病的患者和疾病较轻的患者的CABG没有显着的死亡率益处。 这项荟萃分析提高了我们的舒适度，提供PCI作为无糖尿病或复杂疾病患者的CABG替代方案。 BACKGROUND Numerous randomised trials have compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for patients with coronary artery disease. However, no studies have been powered to detect a difference in mortality between the revascularisation strategies. METHODS We did a systematic review up to July 19, 2017, to identify randomised clinical trials comparing CABG with PCI using stents. Eligible studies included patients with multivessel or left main coronary artery disease who did not present with acute myocardial infarction, did PCI with stents (bare-metal or drug-eluting), and had more than 1 year of follow-up for all-cause mortality. In a collaborative, pooled analysis of individual patient data from the identified trials, we estimated all-cause mortality up to 5 years using Kaplan-Meier analyses and compared PCI with CABG using a random-effects Cox proportional-hazards model stratified by trial. Consistency of treatment effect was explored in subgroup analyses, with subgroups defined according to baseline clinical and anatomical characteristics. FINDINGS We included 11 randomised trials involving 11?518 patients selected by heart teams who were assigned to PCI (n=5753) or to CABG (n=5765). 976 patients died over a mean follow-up of 3·8 years (SD 1·4). Mean Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score was 26·0 (SD 9·5), with 1798 (22·1%) of 8138 patients having a SYNTAX score of 33 or higher. 5 year all-cause mortality was 11·2% after PCI and 9·2% after CABG (hazard ratio [HR]1·20, 95% CI 1·06-1·37; p=0·0038). 5 year all-cause mortality was significantly different between the interventions in patients with multivessel disease (11·5% after PCI vs 8·9% after CABG; HR 1·28, 95% CI 1·09-1·49; p=0·0019), including in those with diabetes (15·5% vs 10·0%; 1·48, 1·19-1·84; p=0·0004), but not in those without diabetes (8·7% vs 8·0%; 1·08, 0·86-1·36; p=0·49). SYNTAX score had a significant effect on the difference between the interventions in multivessel disease. 5 year all-cause mortality was similar between the interventions in patients with left main disease (10·7% after PCI vs 10·5% after CABG; 1·07, 0·87-1·33; p=0·52), regardless of diabetes status and SYNTAX score. INTERPRETATION CABG had a mortality benefit over PCI in patients with multivessel disease, particularly those with diabetes and higher coronary complexity. No benefit for CABG over PCI was seen in patients with left main disease.Longer follow-up is needed to better define mortality differences between the revascularisation strategies.
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  • 《血清纤维蛋白原/白蛋白比值预测急性心肌梗死患者经皮冠状动脉介入治疗后住院期间新发房颤的风险:一项回顾性研究》
    • 来源专题：重大慢性病
    • 编译者：黄雅兰
    • 发布时间：2023-09-12
    • 背景:新发心房颤动(NOAF)是急性心肌梗死(AMI)患者经皮冠状动脉介入治疗(PCI)的常见不良后果，并与住院时间和预后密切相关。近年来，血清纤维蛋白原/白蛋白比(FAR)作为炎症和血栓形成的新生物标志物，已被用于预测冠状动脉疾病的严重程度和预后。我们的研究旨在调查AMI患者PCI术后住院期间FAR和NOAF的关系。 方法:回顾性分析670例急性心肌梗死患者PCI术后住院期间和随访期间NOAF的发生率。收集的数据包括患者年龄、性别、体重指数、病史、当前药物治疗、心力衰竭、实验室检查、罪犯血管、超声心动图特征和AMI类型。入选患者被分为NOAF组和非NOAF组。比较两组患者的基线特征，并使用logistic回归分析和受试者工作特征曲线评估FAR和NOAF之间的预测相关性。 结果:53名(7.9%)患者在住院期间发生NOAF。除了年龄较大、中性粒细胞计数较高、左心房较大、入院时Killip分级较差、体重指数较低、血小板计数较低、左心室射血分数较低和目标性左旋支动脉疾病外，NOAF的发生与FAR较高独立相关。FAR对住院期间NOAF的发生表现出更好的预测值(曲线下面积，0.732；95%置信区间，0.659-0.808)。 结论:FAR是预测急性心肌梗死患者PCI术后住院期间NOAF风险的可靠工具，比单独使用血清纤维蛋白和血清白蛋白水平具有更好的预测价值。
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