Impact of large periprocedural myocardial infarction on mortality after percutaneous coronary intervention and coronary artery bypass grafting for left main disease: an analysis from the EXCEL trial
Impact of large periprocedural myocardial infarction on mortality after percutaneous coronary intervention and coronary artery bypass grafting for left main disease: an analysis from the EXCEL trial
复制标题
DOI：
10.1093/eurheartj/ehz113
复制
发表时间：
2019-06-21
影响因子：
39.3
通讯作者：
Stone, Gregg W.
中科院分区：
文献类型：
--
作者：
Ben-Yehuda, Ori;Chen, Shmuel;Stone, Gregg W.
目的经皮冠状动脉介入治疗（PCI）和冠状动脉旁路移植术（CABG）后围手术期心肌梗死（PMI）的预后意义仍存在争议。在大规模、多中心、前瞻性、随机EXCEL试验中，我们检查了接受左主干冠状动脉介入治疗的PMI和非PMI患者的3年死亡率，这些患者随机接受依维莫司洗脱支架PCI和CABG。使用PCI和CABG的相同阈值定义PMI [术后72小时内肌酐激酶-MB（CK-MB）升高> 10倍参考上限（URL）]。手术，或> 5x URL伴新Q波、血管造影血管闭塞或成像心肌丢失]。控制年龄、性别、高血压、糖尿病、左心室射血分数、SYNTAX评分和慢性阻塞性肺疾病（COPD），进行考克斯比例风险模型。共有1858例患者按照随机分配接受治疗。PCI组34/935（3.6%）例患者和CABG组56/923（6.1%）例患者发生围手术期MI [比值比0.61，95%置信区间（CI）0.40 - 0.93; P = 0.02]。围手术期心肌梗死与SYNTAX评分、COPD、阻断时间和总手术时间相关，且不使用顺行停搏液。通过多变量分析，PMI与3年时的心血管死亡和全因死亡相关[分别为校正的风险比（HR）2.63，95% CI 1.19 - 5.81; P = 0.02和校正的HR 2.28，95% CI 1.22 - 4.29; P = 0.01]。PMI对PCI和CABG的心血管死亡（P-相互作用= 0.56）和全因死亡（P-相互作用= 0.59）的影响是一致的。峰值术后CK-MB>= 10 × URL强烈预测死亡率，而较小程度的肌坏死与预后无关。结论在EXCEL试验中，PMI是更常见的CABG后比PCI，并与增加3年死亡率后，控制潜在的混杂因素。只有广泛的肌坏死（CK-MB>= 10 × URL）具有重要的病理意义。
Aims The prognostic implications of periprocedural myocardial infarction (PMI) after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) remain controversial. We examined the 3-year rates of mortality among patients with and without PMI undergoing left main coronary artery intervention randomized to PCI with everolimus-eluting stents vs. CABG in the large-scale, multicentre, prospective, randomized EXCEL trial.Methods and results By protocol, PMI was defined using an identical threshold for PCI and CABG [creatinine kinase-MB (CK-MB) elevation >10x the upper reference limit (URL) within 72h post-procedure, or >5x URL with new Q-waves, angiographic vessel occlusion, or loss of myocardium on imaging]. Cox proportional hazards modelling was performed controlling for age, sex, hypertension, diabetes mellitus, left ventricular ejection fraction, SYNTAX score, and chronic obstructive pulmonary disease (COPD). A total of 1858 patients were treated as assigned by randomization. Periprocedural MI occurred in 34/935 (3.6%) of patients in the PCI group and 56/923 (6.1%) of patients in the CABG group [odds ratio 0.61, 95% confidence interval (CI) 0.40-0.93; P=0.02]. Periprocedural MI was associated with SYNTAX score, COPD, cross-clamp duration and total procedure duration, and not using antegrade cardioplegia. By multivariable analysis, PMI was associated with cardiovascular death and all-cause death at 3years [adjusted hazard ratio (HR) 2.63, 95% CI 1.19-5.81; P=0.02 and adjusted HR 2.28, 95% CI 1.22-4.29; P=0.01, respectively]. The effect of PMI was consistent for PCI and CABG for cardiovascular death (P-interaction = 0.56) and all-cause death (P-interaction = 0.59). Peak post-procedure CK-MB >= 10x URL strongly predicted mortality, whereas lesser degrees of myonecrosis were not associated with prognosis.Conclusion In the EXCEL trial, PMI was more common after CABG than PCI, and was strongly associated with increased 3-year mortality after controlling for potential confounders. Only extensive myonecrosis (CK-MB >= 10x URL) was prognostically important.