Fractional flow reserve-guided percutaneous coronary intervention is not a valid concept.
Fractional flow reserve-guided percutaneous coronary intervention is not a valid concept.
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DOI：
10.1161/circulationaha.113.003583
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发表时间：
2014-05-06
期刊：
影响因子：
37.8
通讯作者：
Arbab-Zadeh A
中科院分区：
文献类型：
--
作者：
Arbab-Zadeh A
1872年循环2014年5月6日结果，在比较血管造影和心肌灌注数据的旧文献中通常不考虑。13-16在使用冠状动脉钙扫描（提供冠状动脉粥样硬化斑块负荷的估计值）和负荷试验对同一患者进行的研究中，尽管通过单光子发射计算机断层扫描17或正电子发射断层扫描进行了正常的负荷灌注研究，但钙化的冠状动脉粥样硬化斑块的存在表明后续心脏事件的风险增加。18与荟萃分析的数据一致，荟萃分析表明，在高危人群中，单光子发射计算机断层扫描结果正常的情况下，心脏死亡和心肌梗死的年发生率为1.8%，12这些结果证明，尽管负荷心肌灌注结果正常，但严重冠状动脉钙化患者的心脏事件风险较高（超过2%/年）（图1）。相反，在血管造影没有冠状动脉粥样硬化性疾病证据的患者中，心肌梗死和死亡的风险极低（< 0.2%/年）。19，20值得注意的是，即使在可激发试验中存在心肌缺血，无显著冠状动脉疾病的患者发生不良事件的风险仍然很低。20妇女缺血综合征评估（WISE）研究，具有讽刺意味的是，经常被引用来支持相反的观点，在有心肌缺血证据但冠状动脉造影没有阻塞性冠状动脉疾病的有症状的妇女中，经过3年的随访，心肌梗死或死亡的风险没有增加（尽管更多的重复住院）。21上述结果与心肌梗死/死亡风险最一致的标志物是冠状动脉粥样硬化疾病的存在和程度的范式一致。在> 25 000例患者中显示的冠状动脉钙的存在/程度与死亡率之间的关系令人印象深刻地说明了这一点。22这种关联并没有揭示心肌缺血的“阈值”效应，但（钙化）冠状动脉粥样硬化疾病负担与死亡风险之间存在近乎线性的关系（图2）。利用血运重建和积极药物评价（COURAGE）的临床结局和其他随机试验未证明接受血运重建的慢性心绞痛患者的心肌梗死和死亡减少，从而降低了负荷试验的缺血负荷。[23-25]对COUmont试验的初步亚组分析表明，与无残余缺血负荷的患者相比，残余缺血负荷较大的患者预后较差;然而，在风险调整后，这些结果失去了统计学意义。26随后的报告显示，在COUNUS人群或旁路血管成形术血运重建研究（巴里）研究中，基线负荷试验的缺血程度不能预测不良事件或治疗有效性。27，28最近的研究发现，在高危人群中识别可诱发的缺血并不能指导血运重建。29，30在一项罕见的直接比较中，动脉粥样硬化疾病负担和心肌缺血预测冠心病患者的心肌梗死和死亡，疾病负担的影响一致，但心肌缺血的影响不一致。31最后，一项荟萃分析并未显示，与接受药物治疗的患者相比，在入组时有记录的可诱发心肌缺血的患者接受PCI的死亡或心肌梗死减少。32国际比较健康效果研究与...
1872 Circulation May 6, 2014 outcome, is commonly not considered in older literature comparing angiographic and myocardial perfusion data. 13–16 In studies using coronary calcium scanning–-providing an estimate for the coronary atherosclerotic plaque burden–-and stress testing in the same patients, the presence of calcified coronary atherosclerotic plaque conveys increased risk for subsequent cardiac events despite normal stress perfusion studies by single-photon emission computed tomography17 or positron emission tomography. 18 Consistent with data from meta-analyses demonstrating an annual cardiac death and myocardial infarction rate of 1.8% with normal single-photon emission computed tomography results in at-risk populations, 12 these results document high risk (exceeding 2%/y) for cardiac events in patients with severe coronary calcification despite normal stress myocardial perfusion results (Figure 1). Conversely, the risk of myocardial infarction and death is exceedingly low (< 0.2%/y) in patients without evidence of coronary atherosclerotic disease on angiography. 19, 20 It is important to note that the risk of adverse events remains low in patients without significant coronary artery disease even in the presence of myocardial ischemia on provokable testing. 20 The Women’s Ischemia Syndrome Evaluation (WISE) study, ironically often cited to support the opposite, reported no increased risk of myocardial infarction or death (albeit more repeat hospitalizations) after 3 years of follow-up among symptomatic women who had evidence of myocardial ischemia but no obstructive coronary artery disease by coronary angiography. 21 The aforementioned results are consistent with the paradigm that the most consistent marker of myocardial infarction/death risk is the presence and extent of the coronary atherosclerotic disease. This is impressively illustrated by the relationship between the presence/extent of coronary artery calcium and mortality shown in> 25 000 patients. 22 This association does not reveal a “threshold” effect for myocardial ischemia but a nearly linear relationship between (calcified) coronary atherosclerotic disease burden and mortality risk (Figure 2). The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) and other randomized trials have not demonstrated a reduction in myocardial infarction and death in patients with chronic angina who underwent revascularization with resultant decreased ischemic burden on stress testing. 23–25 A preliminary subanalysis of the COURAGE trial suggested worse outcomes in patients with large residual ischemic burden compared with those without; however, these results lost statistical significance after risk adjustments. 26 Subsequent reports revealed that the extent of ischemia on stress testing at baseline did not predict adverse events or treatment effectiveness in the COURAGE population or in the Bypass Angioplasty Revascularization Investigation (BARI) study. 27, 28 Recent studies found no benefit of identifying provokable ischemia for guiding revascularization in high-risk groups. 29, 30 In a rare direct comparison of atherosclerotic disease burden and myocardial ischemia for predicting myocardial infarction and death in patients with coronary artery disease, there was a consistent effect for disease burden but not for myocardial ischemia. 31 Finally, a meta-analysis did not reveal a reduction in death or myocardial infarction in patients with documented provokable myocardial ischemia at the time of enrollment who underwent PCI compared with medically treated patients. 32 The International Study of Comparative Health Effectiveness With …