Revascularization in "no option" patients with refractory angina: Frequency, etiology and outcomes
Revascularization in "no option" patients with refractory angina: Frequency, etiology and outcomes
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DOI：
10.1002/ccd.27707
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发表时间：
2018-12-01
影响因子：
2.3
通讯作者：
Henry, Timothy D.
中科院分区：
文献类型：
--
作者：
Sharma, Rahul;Tradewell, Michael;Henry, Timothy D.
背景：很大一部分复杂的晚期冠状动脉疾病患者尽管接受了最大限度的药物治疗，但仍存在难治性心绞痛（RA），并且被认为是血管重建术的次理想候选者。这些患者通常被称为“别无选择”的患者。然而，尽管如此，许多患者随后接受了冠状动脉血管重建术。我们试图确定“无选择”患者血运重建术的发生率、病因和结果。方法和结果我们检查了一个全面的前瞻性RA数据库，以确定1363例（25.1%）患者中的342例，这些患者在“无选择”诊断后的中位间隔为2.2年之后接受了血运重建术。经皮冠状动脉介入治疗（PCI） （n = 274, 20.1%）、冠状动脉搭桥手术（n = 44, 3.2%）或两者兼用（n = 24, 1.8%）实现冠状动脉血运重建术。在中位5.1年的随访期间，接受血运重建术的患者的年死亡率较低（2%对4.4%,P < 0.001）。181例合并302个病变的PCI患者可获得详细的配对血管造影记录。在这些干预措施中，48%针对新病变，31%针对现有病变，21%针对再狭窄。77%的患者为原生血管，23%的患者为旁路移植。结论“无选择”或不可血运重建的认定通常是基于单一时间点的血管造影。然而，冠状动脉疾病是一个渐进和动态的过程，在这类患者中经常出现新的病变。考虑到血运重建术与更好的生存率之间的关系，对于以前被归类为“无选择”的难治性心绞痛患者，应慎重考虑重复血运重建术。
Background A significant proportion of patients with complex, advanced coronary artery disease have refractory angina (RA) despite maximal pharmacological therapy and are deemed suboptimal candidates for revascularization. These patients are frequently termed "no-option" patients. However, despite this designation, many subsequently undergo coronary revascularization. We sought to determine the incidence, etiology and outcome of revascularization in "no-option" patients. Methods and Results We examined a comprehensive, prospective RA database to identify 342 of 1363 (25.1%) patients who subsequently underwent revascularization after a median interval of 2.2 years from the "no-option" diagnosis. Coronary revascularization was achieved by percutaneous coronary intervention (PCI) (n = 274, 20.1%), coronary bypass graft surgery (n = 44, 3.2%) or both (n = 24, 1.8%). During a median follow-up of 5.1 years, patients who underwent revascularization had lower annual mortality (2% vs. 4.4%, P < .001). Detailed paired angiographic records were available for 181 PCI patients with a combined 302 lesions. Of these interventions, 48% were for a new lesion, 31% for an existing lesion and 21% for restenosis. The location was a native vessel in 77% and a bypass graft in 23%. Conclusions The "no-option" or non-revascularizable designation is frequently based on angiography at a single time-point. However, coronary artery disease is a progressive and dynamic process and new lesions often develop in such patients. Given the association between revascularization and better survival, careful consideration should be given to repeat revascularization in patients with refractory angina previously classified as "no-option".