Primerjava popolne in nepopolne revaskularizacije srčne mišice pri bolnikih z miokardnim infarktom z elevacijo ST spojnice in večžilno koronarno boleznijo

Utemeljitev: Takojšen perkutani koronarni poseg (PCI) je zlati standard zdravljenja bolnikov z akutnim miokardnim infarktom in elevacijo ST spojnice (STEMI). Približno polovica bolnikov s STEMI ima pomembno zoženje tudi ne-tarčnih koronarnih arterij. Podatki o koristnosti perkutane popolne revaskularizacije (CR) STEMI bolnikov z večžilno koronarno boleznijo (MVD) so nasprotujoči. Cilj naše raziskave je raziskati dolgoročni vpliv CR bolnikov s STEMI in MVD znotraj prvotnega bolnišničnega zdravljenja (PBZ) na celokupno in srčno-žilno preživetje, pojavnost skupnega opazovanega dogodka srčno-žilne umrljivosti ali ponovnega bolnišničnega zdravljenja (SBZ) zaradi srčno-žilnih vzrokov in varnost PCI pri CR v primerjavi z IR med PBZ. Metode: V retrospektivno raziskavo smo vključili zaporedne bolnike obravnavane v Univerzitetnem kliničnem centru Ljubljana (UKCL) zaradi STEMI in MVD od 1.1.2009 do 3.4.2011, sledenje je potekalo do 1.4.2017. Pregledali smo koronarograme in za MVD šteli zožitve ne-tarčnih koronarnih arterij (angiografski premer > 2 mm in zožitev ? 50 % glede na referenčni premer pred ali za zožitvijo), ki so bile zdravljene s PCI v CR ali z zdravili v nepopolno revaskularizirani (IR) skupini med PBZ. Izključitveni kriteriji so bili smrt pred ali med PCI tarčne koronarne arterije, kirurška revaskularizacija med PBZ in neuspešna PCI tarčne koronarne arterije (Thromolisys in Myocardial Infarction (TIMI) rezultat < 2). Uspešnost PCI smo ocenili s TIMI točkovnikom, tveganje za PCI ne- tarčnih koronarnih arterij pa smo ocenili z rezidualnim Synergy Between PCI With Taxus and Cardiac Surgery score I (rSYNTAX I) točkovnikom. Primerjali smo izhod naslednjih dogodkov med CR in IR skupinama: 1. Celokupno in srčno žilno umrljivost, 2. Skupni opazovani dogodek srčno-žilne umrljivosti ali SBZ zaradi srčno-žilnih vzrokov, 3. Varnost PCI pri CR v primerjavi z IR med PBZ. Za oceno primerljivosti skupin smo zabeležili demografske značilnosti, srčno-žilne bolezni in dejavnike tveganja za srčno-žilne bolezni, PCI posege in njihove karakteristike, laboratorijske spremenljivke (maksimalna vrednost troponina in kreatinina, minimalna vrednost hemoglobina ter vrednosti lipidograma), dvoravninski iztisni delež levega prekata (LVEF), pojavnost kradiogenega šoka in predpisana zdravila za srčno-žilno zdravljenje pred in med PBZ. Izvedli smo statistično analizo zbranih podatkov. Raziskavo je odobrila Komisija za medicinsko etiko Republike Slovenije. Rezultati: Med 810 STEMI bolniki smo identificirali 258 bolnikov z MVD, 23 (9 %) bolnikov smo morali izključiti zaradi vključitvenih in izključitvenih kriterijev raziskave. Med 235 bolniki jih je bilo 70 (30 %) v CR in 165 (70 %) v IR skupini. Mediani čas sledenja bolnikov je bil 7,0 let (razpon 6,0 – 8,2 let). Med CR in IR skupinama ni bilo pomembnih razlik demografskih značilnosti, srčno- žilnih bolezni in dejavnikov tveganja, opazovanih laboratorijskih kazalcev, prizadetosti tarčnih koronarnih arterij, pojavnosti resnih zapletov med PCI, LVEF in v zdravljenju z zdravili ob vključitvi v raziskavo. Bolniki v IR skupini so imeli več zožitev ne-tarčnih koronarnih arterij (p = 0,005), kroničnih koronarnih zapor (CTO) (p < 0,001) in manj opravljenih PCI (p < 0,001) med PBZ. Bolniki v IR skupini so bili redkeje zdravljeni z zaviralci beta (p = 0,031) in statini (p = 0,004) ob odpustu/premestitvi v regionalno bolnišnico, kot bolniki v CR skupini. Bolniki v CR skupini so imeli nižjo celokupno (15,7 % vs. 35,8 %, p = 0,003) in srčno-žilno umrljivost (12,9 % vs. 23,6 %, p = 0,046) kot bolniki v IR skupini. Tveganje za celokupno smrt je bila 2,6-krat večja v IR skupini (HR 0,386 95 % CI 0,20-0,74 p = 0,004), med tem ko je bilo tveganje za srčno-žilno smrt 2,1-krat večje v IR skupini (HR 0,486 95 % CI 0,24-1,00 p = 0,051). S proporcionalnim Coxovim modelom, prilagojenim za izbrane moteče spremenljivke, smo pokazali, da sta clokupna in srčno-žilna umrljivost statistično značilno povezani z naslednjimi dejavniki: starostjo (p < 0,001 p < 0,001), sladkorno bolezenijo (p = 0,042 p = 0,166), visokimi vrednostmi serumskega kreatinina (p = 0,001 p = 0,018) in kardiogenim šokom ob prezentaciji (p < 0,001 p < 0,001), ne pa tudi s CR ob PBZ (p = 0,139 p = 0,560). Kardio-vaskularni vzroki za SBZ ter pojavnost nadaljnjih revaskularizacijskih posegov sta bili primerljivi med CR in IR skupino med časom spremljanja. SBZ CR bolnikov ni bilo povezano s celokupno in srčno-žilno umrljivostjo (p = 0,86 p = 0,40), med tem ko je bilo statistično značilno povezano s celokupno in srčno-žilno umrljivostjo IR skupine (p = 0,01 p = 0,03). V PBZ ni bilo razlik med pojavnostjo zapletov zaradi PCI med CR in IR skupino (p = 0,199). Pojavnost zapletov ob ponovni PCI je bila med SBZ večja kot ob PBZ (OR 2,83 95 % CI 1,091-6,972 p = 0,019), med tem ko je bilo število zapletov ob doseženi CR primerljivo med PBZ CR skupine in SBZ IR skupine (OR 3,86 95 % CI 0,48-31,55 p = 0,121). Zaključki: Bolniki s STEMI in MVD, ki so bili zdravljeni s CR srčne mišice ob PBZ, so imeli boljše dolgoročno celokupno in srčno-žilno preživetje, kot bolniki v IR skupini. Po prilagoditvi za moteče spremenljivke način revaskularizacije ni pomembno vplival na preživetje. Skupni opazovani dogodek srčno-žilne smrti ali SBZ zaradi srčno-žilnega vzroka je bil pogostejši v IR kot v CR skupini. Pogostost SBZ zaradi srčno-žilnega vzroka in ponovne revaskularizacije je bila med CR in IR primerljiva, a so bolniki v IR skupini, ki so prišli na SBZ imeli pomembno boljše celokupno in srčno- žilno preživetje kot bolniki, ki niso prišli na SBZ. Med CR in IR skupino ni bilo pomembnih razlik v pojavnosti zapletov med PBZ. CR s PCI je bila primerljivo varna ob PBZ kot ob SBZ. Background: Prompt percutaneous coronary revascularization (PCI) is the gold standard treatment of ST-elevation myocardial infarction (STEMI) patients. Around half of STEMI patients have severe stenosis of non-culprit coronary arteries. Data on the benefit of complete revascularization (CR) of STEMI patients with multivessel coronary artery disease (MVD) are conflicting. Our study aimed to evaluate the impact of CR during index hospitalization (PBZ) on long-term survival in STEMI patients with MVD, on the combined endpoint of cardiovascular mortality or rehospitalization (SBZ) due to cardiovascular causes and safety of PCI in CR in comparison to IR during PBZ. Methods: Consecutive STEMI patients with MVD treated at University Medical Centre Ljubljana (UKCL) from 1st January 2009 to 3rd April 2011, followed up until 1st April 2017, were evaluated in this retrospective study. To fulfil the MVD criteria, coronary angiograms were reviewed for non-culprit coronary artery stenosis (angiographic diameter > 2 mm in and ⡥ 50 % stenosis compared to reference diameter before or after the stenosis) that were treated with PCI in the CR group or with medical therapy in incomplete revascularization (IR) group during PBZ. Exclusion criteria were death before or at the time of PCI of the culprit coronary artery, the need for surgical coronary revascularization at the time of PBZ and an unsuccessful PCI of the culprit coronary artery (Thrombolysis in Myocardial Infarction (TIMI) score < 2). The success of PCI was evaluated with TIMI flow, while the risk of PCI of non-culprit was evaluated with residual Synergy Between PCI With Taxus and Cardiac Surgery score I (rSYNTAX I). We compared CR and IR groups according to these endpoints: 1st All-cause mortality and cardiovascular mortality, 2nd Combined endpoint of cardiovascular mortality or SBZ due to cardiovascular causes, 3rd Safety of PCI in CR compared to IR during PBZ. Demographic characteristics, cardiovascular comorbidities and risk factors, PCI procedure characteristics, laboratory values (maximal serum troponin and creatinine levels, minimal serum haemoglobin levels and serum lipid levels), two-plane left ventricular ejection fraction (LVEF), cardiogenic shock, medical therapy for cardiovascular diseases were compared between CR and IR during PBZ. We performed a statistical analysis of the gathered data. Slovene National Ethic Committee approved the study. Results: Out of 810 STEMI patients we identified 258 patients with MVD, 23 (9 %) patients were excluded due to inclusion or exclusion criteria. 235 patients constituted the study cohort 70 (30 %) in CR and 165 (70 %) in the IR group. The Median follow-up time was 7.0 years (range 6.0 – 8.2 years). There were no significant differences in demographic characteristics, comorbidities and risk factors, laboratory values, culprit coronary artery involvement, the occurrence of serious complications during PCI, LVEF and therapy at inclusion in the study between the CR and IR groups. Patients in the IR group had more non-culprit stenoses (p = 0.005) and chronic total occlusions (CTO) (p < 0.001), and fewer PCIs done during PBZ (p < 0.001). At discharge/transfer time to the regional hospital patients in the IR group were less often prescribed beta-blocker (p = 0.031) and statin (p = 0.004) than patients in the CR group. Patients with CR had lower all-cause mortality (15.7 % vs. 35.8 %, p = 0.003) and lower cardiovascular mortality (12.9 % vs. 23.6 %, p = 0.046) compared to patients with IR. The hazard for all-cause mortality was 2.6 times higher in IR than CR group (HR 0.386, 95 % CI 0.20-0.74, p = 0.004), while the hazard for cardiovascular mortality was 2.1 times higher in the IR group (HR 0.486, 95 % CI 0.24-1.00, p = 0.051). Cox proportional hazard model adjusted for confounders showed no benefit of CR during PBZ on survival (p = 0.139, p = 0.560), but age (p < 0.001, p < 0.001), diabetes (p = 0.042, p = 0.166), high serum creatinine (p = 0.001, p = 0.018) and cardiogenic shock at presentation (p < 0.001, p < 0.001) impacted all-cause and cardiovascular mortality, respectively. Cardio-vascular reasons for SBZ and the need for repeat revascularization were not significantly different between CR and IR groups during follow-up. SBZ of the CR group did not influence all-cause and cardiovascular mortality (p = 0.86, p = 0.40), while significantly impacted all-cause and cardiovascular mortality in the IR group (p = 0.01, p = 0.03). During PBZ there were no differences in complication occurrence due to PCI between CR and IR (p = 0.199). The occurrence of complications was higher in SBZ than PBZ (OR 2.83, 95 % CI 1.091-6.972, p = 0.019), while the number of complications to reach CR in PBZ and SBZ in the IR group was not different (OR 3.86, 95 % CI 0.48-31.55, p = 0.121). Conclusions: Patients with STEMI and MVD who were treated with CR during PBZ showed lower long-term all-cause and cardiovascular mortality than patients with IR. After adjustments for confounders revascularization did not impact the survival. The combined endpoint of cardiovascular death and SBZ due to cardiovascular causes was significantly greater in IR than in CR. The occurrence rate of SBZ and revascularization was comparable between the groups but patients in the IR group that returned for SBZ had better all-cause and cardiovascular survival than patients that did not. Complication occurrence rates due to PCI during PBZ were not different between CR and IR. The safety of CR with PCI was comparable in PBZ and SBZ.