OUTCOME AFTER ACUTE MYOCARDIAL-INFARCTION IN PATIENTS WITH PRIOR CORONARY-ARTERY BYPASS-SURGERY
OUTCOME AFTER ACUTE MYOCARDIAL-INFARCTION IN PATIENTS WITH PRIOR CORONARY-ARTERY BYPASS-SURGERY
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DOI：
10.1016/0002-9149(93)90343-b
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发表时间：
1993-09-01
影响因子：
2.8
通讯作者：
ROSS, J
中科院分区：
文献类型：
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作者：
DITTRICH, HC;GILPIN, E;ROSS, J
关于既往冠状动脉旁路移植术（CABG）对急性心肌梗死（AMI）患者预后的影响知之甚少。因此，本研究评价了2,494例AMI患者，其中219例（8.8%）在指数AMI前平均7.1 +/- 3.7年有CABG病史。与所有其他患者相比，有冠状动脉旁路移植术史的患者既往AMI（153例[70%] vs 547例[24%]）、充血性心力衰竭（48例[22%] vs 236例[10%]）和心绞痛（165例[75%] vs 787例[35%]）的患病率增加，所有p < 0.001。年龄无差异，但既往接受过CABG的患者多为男性（192例[88%] vs 1，702例[75%]，p < 0.001）。在AMI住院期间，既往CABG患者有更多的复发性缺血性疼痛（100 [46%] vs 732 [32%，p < 0.001]），更频繁地发生非Q波AMI（72 [33%] vs 514 [23%]，p < 0.01）。住院死亡率在既往接受过或未接受过CABG的患者之间没有差异（15 [7%] vs 195 19%]）。在出院时，有冠状动脉旁路移植术史的患者在24小时动态心电图监测中有更多的复杂心室异位活动（74例患者中的48例[65%] vs 797例患者中的327例[41%]，p < 0.0001），放射性核素射血分数< 0.45（99例患者中的53例[54%] vs 1,024例患者中的430例[42%]，p < 0.01）。在前2个月接受冠状动脉造影的患者中，多支冠状动脉疾病在既往接受过冠状动脉旁路移植术的患者中更常见（78/107 [73%] vs 508/959 [53%]，p < 0.01）。在既往接受过CABG的患者中，25/133例（19%）的所有移植物均闭塞，而40/133例（30%）的任何移植物仅轻微狭窄。移植物完全闭塞的比例从AMI前7年内接受手术的患者中的7/61（11%）增加到AMI前7年内接受CABG的患者中的17/71（24%）（p < 0.10）。既往接受过CABG的患者出院后1年心源性死亡率显著较高（28/175 116%）vs 152/1827 8%，p < 0.01）。在多变量分析中，既往CABG对1年心源性死亡率具有临界（p < 0.054）独立重要性。因此，既往接受过CABG的患者构成了AMI出院后死亡的高风险人群。这一事实的存在主要是因为基础冠状动脉疾病的严重程度增加和左心室射血分数降低。
Little is known concerning the influence of remote prior coronary artery bypass grafting (CABG) on the outcome of patients with acute myocardial infarction (AMI). Therefore, this study evaluated 2,494 patients with AMI of whom 219 (8.8%) had a history of CABG a mean of 7.1 +/- 3.7 years before the index AMI. Compared with all other patients, those with a history of CABG had an increased prevalence of a history of prior AMI (153 [70%] vs 547 [24%]), congestive heart failure (48 [22%] vs 236 [10%]), and angina pectoris (165 [75%] vs 787 [35%]), all p < 0.001. There was no difference in age, but patients with prior CABG were more often men (192 [88%] vs 1,702 [75%], p < 0.001). During the hospitalization for AMI, patients with prior CABG had more recurrent ischemic pain (100 [46%] vs 732 [32%, p < 0.001]), and more frequently developed non-Q-wave AMI (72 [33%] vs 514 [23%], p < 0.01). In-hospital mortality did not differ among patients with or without prior CABG (15 [7%] vs 195 19%]). At hospital discharge, more patients with prior CABG had complex ventricular ectopic activity on 24-hour ambu electrocardiographic monitoring (48 of 74 [65%] vs 327 of 797 [41%], p < 0.0001), and radionuclide ejection fraction < 0.45 (53 of 99 [54%] vs 430 of 1,024 [42%], p < 0.01). Among patients undergoing coronary angiography during the first 2 months, multivessel coronary artery disease was more prevalent among patients with prior CABG (78 af 107 [73%] vs 508 of 959 [53%], p < 0.01). Among patients with prior CABG, 25 of 133 (19%) had all grafts occluded, whereas 40 of 133 (30%) had only minor narrowing in any graft. The proportion with totally occluded grafts increased from 7 of 61 (11%) in patients who underwent operation < 7 years before their AMI to 17 of 71 (24%) in patients with prior CABG greater-than-or-equal-to 7 years before the index AMI (p < 0.10). One-year cardiac mortality after hospital discharge was significantly higher in patients with prior CABG (28 of 175 116%] vs 152 of 1,827 [8%], p < 0.01). On multivariate analysis, prior CABG was of borderline (p < 0.054) independent importance to 1-year cardiac mortality. Thus, patients with prior CABG constitute a group at high risk for death after hospital discharge for AMI. This fact exists principally because of increased severity of underlying coronary artery disease and reduced left ventricular ejection fraction.