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心肌梗死的多支血管PCI完全血运重建
Complete Revascularization with Multivessel PCI for Myocardial Infarction


Shamir R. Mehta ... 心脑血管疾病 • 2019.10.10
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心肌梗死的完全血运重建
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COMPLETE研究:STEMI多支血管完全血运重建获益

 

高雅楠,刘巍*

首都医科大学附属北京安贞医院心内科

*通讯作者

 

急诊PCI广泛应用于ST段抬高型心肌梗死(STEMI)患者的再灌注治疗。STEMI患者往往存在多支血管病变,研究已经证实对STEMI患者的罪犯病变行PCI治疗可以降低心血管死亡率和心肌梗死再发风险。然而,对于非罪犯病变是否需要处理目前尚无定论,非罪犯病变PCI治疗能否进一步降低远期不良事件发生风险目前也仍未可知。COMPLETE研究的出现填补了这一空缺1

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摘要


背景

在ST段抬高型心肌梗死(STEMI)患者中,罪犯病变的经皮冠状动脉介入治疗(PCI)降低了心血管原因死亡或心肌梗死的风险。非罪犯病变的PCI可否进一步降低上述事件的风险尚未明确。

 

方法

我们将患多支冠状动脉病变且已成功接受罪犯病变PCI的STEMI患者随机分组,分别接受完全血运重建策略(对血管造影显示的显著非罪犯病变行PCI)或不接受进一步血运重建。随机分组根据非罪犯病变PCI的计划时间(即首次住院治疗期间或之后)进行分层。第一项联合主要结局是由心血管原因死亡或心肌梗死构成的复合结局;第二项联合主要结局是由心血管原因死亡、心肌梗死或缺血驱动的血运重建构成的复合结局。

 

结果

在中位随访3年时,完全血运重建组2,016例患者中的158例(7.8%)和仅罪犯病变PCI组2,025例患者中的213例(10.5%)发生了第一项联合主要结局(风险比,0.74;95%置信区间[CI],0.60~0.91;P=0.004)。完全血运重建组179例患者(8.9%)和仅罪犯病变PCI组339例患者(16.7%)发生了第二项联合主要结局(风险比,0.51;95% CI,0.43~0.61;P<0.001)。对于两项联合主要结局而言,不论非罪犯病变PCI的计划时间如何,我们均观察到患者接受完全血运重建的获益(对于第一项和第二项联合主要结局的交互作用,分别为P=0.62和P=0.27)。

 

结论

在有多支冠状动脉病变的STEMI患者中,在降低心血管原因死亡或心肌梗死的风险,以及降低心血管原因死亡、心肌梗死或缺血驱动的血运重建的风险方面,完全血运重建优于仅罪犯病变PCI(由加拿大健康研究所[Canadian Institutes of Health Research]等资助;COMPLETE在ClinicalTrials.gov注册号为NCT01740479)。





作者信息

Shamir R. Mehta, M.D., David A. Wood, M.D., Robert F. Storey, M.D., Roxana Mehran, M.D., Kevin R. Bainey, M.D., Helen Nguyen, B.Sc., Brandi Meeks, M.Sc., Giuseppe Di Pasquale, M.D., Jose López-Sendón, M.D., David P. Faxon, M.D., Laura Mauri, M.D., Sunil V. Rao, M.D., Laurent Feldman, M.D., P. Gabriel Steg, M.D., Álvaro Avezum, M.D., Tej Sheth, M.D., Natalia Pinilla-Echeverri, M.D., Raul Moreno, M.D., Gianluca Campo, M.D., Benjamin Wrigley, M.D., Sasko Kedev, M.D., Andrew Sutton, M.D., Richard Oliver, M.D., Josep Rodés-Cabau, M.D., Goran Stanković, M.D., Robert Welsh, M.D., Shahar Lavi, M.D., Warren J. Cantor, M.D., Jia Wang, M.Sc., Juliet Nakamya, Ph.D., Shrikant I. Bangdiwala, Ph.D., and John A. Cairns, M.D. for the COMPLETE Trial Steering Committee and Investigators*
From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON (S.R.M., H.N., B.M., T.S., N.P.-E., J.N., J.W., S.I.B.), the University of British Columbia, Vancouver (D.A.W., J.A.C.), the University of Alberta, Mazankowski Alberta Heart Institute, Edmonton (K.R.B., R.W.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City (J.R.-C.), the University of Western Ontario, London Health Sciences Centre, London (S.L.), and the University of Toronto, Toronto Southlake Regional Health Centre, Toronto (W.J.C.) — all in Canada; the Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, Sheffield (R.F.S.), the Royal Wolverhampton Hospitals NHS Trust, Wolverhampton (B.W.), the University Clinic of Cardiology, South Tees Hospitals NHS Foundation Trust, Middlesbrough (A.S.), and Hull University Teaching Hospitals NHS Trust, Hull (R.O.) — all in the United Kingdom; the Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.); Ospedale Maggiore, Bologna (G.D.P.), the Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (G.C.), and Maria Cecilia Hospital, GVM Care and Research, Cotignola (G.C.) — all in Italy; University Hospital La Paz, Madrid (J.L.-S., R.M.); Brigham and Women’s Hospital and Harvard Medical School, Boston (D.P.F., L.M.); Duke University Medical Center, Durham, NC (S.V.R.); Hôpital Bichat, Assistance Publique–Hôpitaux de Paris, Paris (L.F., P.G.S.); Hospital Alemão Oswaldo Cruz, Instituto Dante Pazzanese de Cardiologia, São Paulo (A.A.); the University Clinic of Cardiology, University St. Cyril and Methodius, Skopje, Macedonia (S.K.); and the Clinical Center of Serbia, Belgrade (G.S.). Address reprint requests to Dr. Mehta at the Population Health Research Institute, McMaster University and Hamilton Health Sciences, David Braley Research Bldg., Hamilton General Hospital, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada, or at smehta@mcmaster.ca. *A complete list of the COMPLETE trial steering committee members and investigators is provided in the Supplementary Appendix, available at NEJM.org.

 

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