不同类型急性冠脉综合征患者冠状动脉旋磨术后两年内不良心脑血管结局分析

Analysis of adverse cardiovascular and cerebrovascular outcomes within two years after coronary artery rotational atherectomy in patients with different types of acute coronary syndrome

摘要:

目的]分析行冠状动脉旋磨术(RA)的不同类型急性冠脉综合征(ACS)患者两年内主要不良心脑血管事件(MACCE)的发生情况。 [方法]回顾性纳入2011年11月—2022年12月期间在南京大学医学院附属鼓楼医院心血管内科行RA的ACS患者268例。根据是否发生ST段抬高型心肌梗死(STEMI),分为STEMI组25例和非ST段抬高型急性冠脉综合征(NSTE-ACS)组243例,NSTE-ACS组包括不稳定型心绞痛(UAP)和非ST段抬高型心肌梗死(NSTEMI)。收集两组患者的基本资料、经皮冠状动脉介入治疗(PCI)术中相关资料,并对患者行RA后两年内MACCE(包括心血管死亡、非致死性心肌梗死、心衰加重、缺血性脑卒中、靶血管血运重建的复合结局)的发生进行随访和分析。 [结果]与NSTE-ACS组相比,STEMI组在两年内的随访期间有着更高的MACCE发生率和心血管死亡率(10.3%和0.4%比28.0%和8.0%；P＜0.05)。两组间靶血管血运重建、非致死性心肌梗死、缺血性脑卒中及心衰加重的发生率差异无统计学意义(P＞0.05)。根据纳入时间进行亚组分析,结果显示,随着时间的推移(2011年—2017年比2018年—2022年),所有患者行RA后两年内MACCE的发生率呈下降趋势(18.97%比6.58%)。结合既往研究,将性别、高血压、糖尿病、肾功能不全、吸烟、左心室射血分数(LVEF)纳入Cox回归模型校正后,发现血管内超声(IVUS)的应用是降低ACS患者行RA后两年内MACCE发生率的独立影响因素(HR＝0.3,5%CI:0.153～0.723,P＜0.01)。Kaplan-Meier分析显示,行RA的ACS患者中,STEMI组患者MACCE累积事件发生率高于NSTE-ACS组患者(P＜0.05)。 [结论]STEMI患者相较于NSTE-ACS患者行RA后有更高的两年内MACCE发生率和心血管死亡率,RA术中IVUS的应用可以降低ACS患者行RA后MACCE的发生率。

Abstract:

Aim To analyze the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) in patients with different types of acute coronary syndrome (ACS) undergoing coronary artery rotational atherectomy (RA) within two years. Methods 268 patients with ACS who underwent RA in the Department of Cardiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School of Nanjing University, between November 2011 and December 2022 were retrospectively included. According to whether ST-segment elevation myocardial infarction (STEMI) occurred, they were divided into 25 cases in the ST-segment elevation myocardial infarction (STEMI) group and 243 cases in the non-ST-segment elevation acute coronary syndrome (NSTE-ACS) group. The NSTE-ACS group included unstable angina pectoris (UAP) and non-STEMI (NSTEMI). The basic information and intraoperative data related to percutaneous coronary intervention (PCI) in the two groups were collected, and the occurrence of MACCE (including cardiovascular death, non fatal myocardial infarction, worsening heart failure, ischemic stroke and target vessel revascularization) within two years after RA was followed up and analyzed. Results Compared with the NSTE-ACS group, the STEMI group had a higher incidence of MACCE and cardiovascular mortality during the two-year follow-up period (10.3% and 0.4% vs. 28.0% and 8.0%; P＜0.05). There was no statistical difference between the incidence of target vessel revascularization, nonfatal infarction, ischemic stroke and worsening heart failure between the two groups (P＞0.05). According to subgroup analysis based on enrollment periods, the results showed that over time (2011-2017 compared to 2018-2022), the incidence of MACCE in all patients within two years after RA showed a decreasing trend (18.97% vs. 6.58%). Combined with previous studies, gender, hypertension, diabetes, renal insufficiency, smoking and left ventricular ejection fraction (LVEF) were included in the Cox regression model. It was found that the use of intravascular ultrasound (IVUS) was an independent factor to reduce the incidence of MACCE in ACS patients within two years after RA (HR＝0.3,5%CI:0.153～0.723, P＜0.01). Kaplan-Meier analysis showed that among ACS patients undergoing RA, the cumulative incidence of MACCE events was higher in the STEMI group than that in the NSTE-ACS group (P＜0.05). Conclusion STEMI patients have a higher incidence of MACCE and cardiovascular mortality within two years after RA compared to NSTE-ACS patients, and the use of IVUS during RA surgery can reduce the incidence of MACCE in ACS patients after RA.