接受重複經皮冠狀動脈治療冠心症患者之預測因子及預後分析

目的: 冠心症之主要治療方法為藥物,冠狀動脈介入治療及外科手術。對於不穩定心絞痛的病患可選擇做冠狀動脈介入治療，藉由打通冠狀動脈血管，改善病患生活品質。然而仍有部份病人仍會產生再狹窄及需要重複冠狀動脈介入。何種病人容易產生冠狀動脈再狹窄及需要重複冠狀動脈介入?此類病人預後如何？目前台灣地區之文獻極為少見。方法: 本研究主要採用前瞻性世代研究法 (Prospective cohort study),統計自民國九十六年五月自民國一百零三年六月底,於佛教慈濟醫院台中分院心臟內科接受冠狀動脈介入治療之1126例病人,依照病人接受單次冠狀動脈介入治療及多次冠狀動脈介入治療分成兩組,比較兩組病人其首次基線生化值及心導管檢查血行動力學數值,暴露之危險因子(如糖尿病,高血壓及高血脂,抽煙等), 及治療方法之差異(如單純氣球擴張術,普通金屬支架,藥物塗抹支架),以邏輯式回歸分析(logistic regression)及 Cox proportional hazard model 等方法,找出台灣地區冠心症患者接受重複冠狀動脈治療之預測因子及影響預後之因子。結果: 多次冠狀動脈介入治療之病例組共收錄 276 位病人, 單次冠狀動脈介入治療之對照組共收錄 850 位病人。與單次接受冠狀動脈介入治療患者相比,我們發現在多次冠狀動脈介入治療患者中.有較高之中央主動脈脈搏壓(central aortic pulse pressure, 66.79 ± 22.74 vs 60.48 ± 20.11 mmHg , P=0.006), 及男性比例(P=0.012)。在多次冠狀動脈介入治療患者中,使用阿斯匹靈(Aspirin),利尿劑 (diuretics),血管張力素轉化脢抑制劑 (Angiotensin Converting Enzyme Inhibitors), 及乙型交感神經阻斷劑比例較高 ( all P <0.05)。病例組發生心肌梗塞之機率亦遠高於對照組 (P<0.001) ,惟病例組與照組之心因性死亡率並無差異,病例組與對照組之總死亡率亦無差異者。以多重邏輯氏迴歸分析,我們發現升高之中央脈搏壓(elevated central pulse pressure) ,男性性別,使用利尿劑,乙型交感神經阻斷劑, 使用血管張力素轉化酶抑制劑 (ACE inhibitors) ,有病變之血管數目(number of diseased vessels),心肌梗塞(myocardial infarction) 為多次冠狀動脈介入治療之危險因子(predictors)。雖然多次冠狀動脈介入治療患者有較高比例之復發性心肌梗塞 (P<0.001),惟兩組之間長期存活率並無明顯差異。此外, 我們發現升高之中央脈搏壓(elevated central pulse pressure)為多次冠狀動脈介入治療患者發生心肌梗塞之危險因子(P=0.010)。升高之中央脈搏壓亦為多次冠狀動脈介入治療患者心血管死亡 (CV death) 之危險性因子(P=0.041), 升高之中央脈搏壓亦為多次冠狀動脈介入治療患者任何原因死亡 ( all-cause death) 之危險性因子(P=0.004 )。結論: 升高之中央脈搏壓(elevated central pulse pressure) ,男性性別,使用利尿劑,乙型交感神經阻斷劑, 使用血管張力素轉化酶抑制劑 (ACE inhibitors), ,有病變之血管數目(number of diseased vessels),復發之心肌梗塞( recurrent MI) 為多次冠狀動脈介入治療之危險因子(predictors) 升高之中央脈搏壓(elevated central pulse pressure)為多次冠狀動脈介入治療患者發生心肌梗塞, 心血管死亡,任何原因死亡之危險因子。

關鍵字

重複冠狀動脈介入；中央脈搏壓

並列摘要

Background: Coronary artery disease (CAD) is a common heart disease which needs urgent medical attention. Percutaneous coronary intervention (PCI) is common and necessary for patients with CAD but it has not completely evaluated in cases with repeated PCI. Therefore, the aim of this study was to examine the risk factors and prognosis in patients with CAD requiring repeated PCI. Methods and Materials: This is a prospectively observational study. A total of 1,126 patients with CAD requiring PCI were collected. Clinical parameters including baseline characteristics, hemodynamic data, location of vascular lesions, SYNTAX score, left ventricular ejection fraction, central pulse pressure (CPP), risk factors and invasive strategies were analyzed to identify the risk factors for patients requiring repeated PCI. We further analyzed the prognosis including risk for myocardial infarction (MI), cardiovascular (CV) mortality, and all-cause mortality in patients with repeated PCI Results: Among patients with PCI, 276 patients received repeated PCI. Patients in the repeated PCI group had a higher CPP (66.7 vs. 62.5 mmHg; P=0.006) and male preponderance (P=0.012). Drugs including diuretics, beta-blockers (BB), Angiotensin Converting Enzyme inhibitors (ACEI) and aspirin were all used more frequently in the repeated PCI group (all P<0.05). Freedom from MI was lower in the repeated PCI group than the single PCI group (P<0.001).Logistic regression revealed that CPP, number of diseased vessels, male gender, usage of aspirin, diuretics, beta-blockers and ACEI, MI were all predictors for requiring repeated PCI (all P< 0.05). In addition, CPP was a predictors for MI attack, CV mortality, and all-cause mortality in the repeated PCI group (P=0.010, P=0.041, P=0.004, respectively) Conclusions: Elevated CPP, male gender, multiple diseased vessels, male gender, and the usage of aspirin, diuretics, beta-blockers, ACE inhibitors and MI were predictors for repeated PCI. Most importantly, CPP is strongly associated with MI attack, CV death, and all- cause mortality and could serve as a prognostic parameter for mortality in patients with CAD after performing repeated PCI.

並列關鍵字

repeated percutaneous coronary intervention ； central pulse pressure

參考文獻

repeated coronary revascularization after intra-coronary

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接受重複經皮冠狀動脈治療冠心症患者之預測因子及預後分析

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