Evolving Management Paradigm for Stable Ischemic Heart Disease Patients: JACC Review Topic of the Week.
Evolving Management Paradigm for Stable Ischemic Heart Disease Patients: JACC Review Topic of the Week.
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DOI：
10.1016/j.jacc.2022.08.814
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发表时间：
2023-02-07
影响因子：
24
通讯作者：
Kaski, Juan Carlos
中科院分区：
文献类型：
--
作者：
Boden, William E;Marzilli, Mario;Kaski, Juan Carlos
稳定型冠状动脉疾病（CAD）的治疗基于这样的假设：血流限制性动脉粥样硬化性阻塞是大多数患者心绞痛和心肌缺血的直接原因，并且是血运重建的重要目标。然而，血运重建在减少这些患者长期心脏事件方面的作用主要限于患有左主干疾病、糖尿病三支血管疾病或射血分数降低的患者。越来越多的证据表明，心绞痛和缺血的非心外膜冠状动脉原因，包括冠状动脉微血管功能障碍、血管痉挛疾病和心肌代谢紊乱，比血流限制性狭窄更常见，这引起了人们的担忧，即心外膜 CAD 之外的许多重要原因既没有得到考虑，也没有得到诊断探讨。需要一种更具包容性的管理范式，以解开心外膜CAD和血运重建之间的单一关联，并更好地调整诊断方法，根据当代临床实践中心绞痛和缺血的潜在机制和诱因调整治疗。
Management of stable coronary artery disease (CAD) has been based on the assumption that flow-limiting atherosclerotic obstructions are the proximate cause of angina and myocardial ischemia in most patients and represent an important target for revascularization. However, the role of revascularization in reducing long-term cardiac events in these patients has been limited mainly to those with left main disease, 3-vessel disease with diabetes, or decreased ejection fraction. Mounting evidence indicates that nonepicardial coronary causes of angina and ischemia, including coronary microvascular dysfunction, vasospastic disorders, and derangements of myocardial metabolism, are more prevalent than flow-limiting stenoses, raising concerns that many important causes other than epicardial CAD are neither considered nor probed diagnostically. There is a need for a more inclusive management paradigm that uncouples the singular association between epicardialCAD and revascularization and better aligns diagnostic approaches that tailor treatment to the underlying mechanisms and precipitants of angina and ischemia in contemporary clinical practice.