Relationship Between Infarct Size and Outcomes Following Primary PCI Patient-Level Analysis From 10 Randomized Trials
Relationship Between Infarct Size and Outcomes Following Primary PCI Patient-Level Analysis From 10 Randomized Trials
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DOI：
10.1016/j.jacc.2016.01.069
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发表时间：
2016-04-12
影响因子：
24
通讯作者：
Ben-Yehuda, Ori
中科院分区：
文献类型：
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作者：
Stone, Gregg W.;Selker, Harry P.;Ben-Yehuda, Ori
背景：ST段抬高型心肌梗死(STEMI)患者的即刻再通可缩小梗塞面积，提高存活率。本研究试图确定STEMI患者行直接经皮冠状动脉介入治疗(PCI)后早期评估的梗塞范围与随后的全因死亡率、再梗塞和因心力衰竭住院的关系的强度。方法我们对10个随机的初次经皮冠状动脉介入治疗试验(共2,632例患者)进行了合并患者水平分析，在随机分组后1个月内通过心脏磁共振(CMR)成像或~(99m)氚-99m双光子发射计算机断层扫描(SPECT)对梗塞范围进行了评估，并对其进行了临床随访。结果1,889例患者(71.8%)行CMR检查，743例患者(28.2%)行SPECT检查。测量梗塞面积的中位时间(第25、75百分位数)为STEMI后4天(3、10天)。中位心肌梗死面积(%)为17.9%(8.0%，29.8%)，中位临床随访时间为352天(185,371天)。Kaplan-Meier估计全原因死亡率、再梗死率和心力衰竭住院率分别为2.2%、2.5%和2.6%。在心肌梗死面积(每增加5%)和随后的死亡率(COX调整后的风险比：1.19[95%可信区间：1.18到1.2]；p<；0.0001)和心力衰竭住院(调整后的风险比：1.2[95%可信区间：1.19到1.21]；p<；独立于年龄、性别、糖尿病、高血压、高脂血症、当前吸烟、左前降支与非左前降支梗塞血管、症状至首次介入治疗的时间和基线心肌梗死溶栓血流0/1与2/3。梗塞面积与随后的再梗塞无明显关系。结论首次经皮冠状动脉介入治疗术后1个月内的心肌梗死面积与全因死亡率及1年内因心力衰竭住院的患者密切相关。因此，当STEMI患者接受治疗时，梗死面积可作为临床试验的终点和重要的预后指标。(C)2016年，由美国心脏病学院基金会提供。
BACKGROUND Prompt reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) reduces infarct size and improves survival. However, the intuitive link between infarct size and prognosis has not been convincingly demonstrated in the contemporary era.OBJECTIVES This study sought to determine the strength of the relationship between infarct size assessed early after primary percutaneous coronary intervention (PCI) in STEMI and subsequent all-cause mortality, reinfarction, and hospitalization for heart failure.METHODS We performed a pooled patient-level analysis from 10 randomized primary PCI trials (total 2,632 patients) in which infarct size was assessed within 1 month after randomization by either cardiac magnetic resonance (CMR) imaging or technetium-99m sestamibi single-photon emission computed tomography (SPECT), with clinical follow-up for >= 6 months.RESULTS Infarct size was assessed by CMR in 1,889 patients (71.8%) and by SPECT in 743 patients (28.2%). Median (25th, 75th percentile) time to infarct size measurement was 4 days (3, 10 days) after STEMI. Median infarct size (% left ventricular myocardial mass) was 17.9% (8.0%, 29.8%), and median duration of clinical follow-up was 352 days (185, 371 days). The Kaplan-Meier estimated 1-year rates of all-cause mortality, reinfarction, and HF hospitalization were 2.2%, 2.5%, and 2.6%, respectively. A strong graded response was present between infarct size (per 5% increase) and subsequent mortality (Cox-adjusted hazard ratio: 1.19 [95% confidence interval: 1.18 to 1.20]; p < 0.0001) and hospitalization for heart failure (adjusted hazard ratio: 1.20 [95% confidence interval: 1.19 to 1.21]; p < 0.0001), independent of age, sex, diabetes, hypertension, hyperlipidemia, current smoking, left anterior descending versus non-left anterior descending infarct vessel, symptom-to-first device time, and baseline TIMI (Thrombolysis In Myocardial Infarction) flow 0/1 versus 2/3. Infarct size was not significantly related to subsequent reinfarction.CONCLUSIONS Infarct size, measured by CMR or technetium-99m sestamibi SPECT within 1 month after primary PCI, is strongly associated with all-cause mortality and hospitalization for HF within 1 year. Infarct size may, therefore, be useful as an endpoint in clinical trials and as an important prognostic measure when caring for patients with STEMI. (C) 2016 by the American College of Cardiology Foundation.