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心源性休克回到未来——初始仅肇事病变行PCI
Back to the Future in Cardiogenic Shock — Initial PCI of the Culprit Lesion Only


Judith S. Hochman ... 心脑血管疾病 • 2017.12.21
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CULPRIT-SHOCK研究看急性心肌梗死合并心源性休克的血运重建策略

 

王伟†,卜军‡,曾春雨†*

†第三军医大学大坪医院心内科,重庆市心血管病研究所;‡上海交通大学医学院附属仁济医院心内科

*通讯作者

 

在急性心肌梗死合并心源性休克患者中,冠状动脉多支病变者可达80%,多支病变较单支病变死亡率增加。对这些患者的治疗一般有三种策略:仅干预梗死相关血管(IRA;culprit PCI)、同次干预多支血管(MV-PCI)和分次干预多支血管。从理论上推测,同时解决多支病变,更易改善心肌缺血,保留心室功能,更可能使血流动力学稳定,降低死亡率;然而目前尚缺乏充分的循证医学证据,对于这部分人群最佳的血运重建策略仍不清楚1

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5%~10%的急性心肌梗死会并发心源性休克,并与40%~50%的早期死亡相关1。近20年前,是否应对心源性休克的闭塞冠状动脉紧急行血运重建(Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock,SHOCK)试验确定,ST段抬高型心肌梗死(STEMI)患者紧急行血运重建的死亡率低于初始内科稳定措施加延迟性择期血运重建2,3。SHOCK试验中,仅对肇事病变行经皮冠脉介入治疗(PCI)是初始血运重建中最常见的治疗。虽然更为完全的血运重建可能有望改善获益,但接受初始多支血管PCI的小规模亚组死亡率高于仅肇事病变行PCI的亚组(校正风险比,2.75;95%置信区间[CI],1.05~7.25;P=0.04)4。对10项队列研究(共计6,051例心源性休克患者)进行的一项荟萃分析也显示,多支血管行PCI者的早期死亡率高于仅肇事病变行PCI者(37.5% vs. 28.8%,P=0.001)5





作者信息

Judith S. Hochman, M.D., and Stuart Katz, M.D.
From the Department of Medicine (J.S.H., S.K.), the Cardiovascular Clinical Research Center (J.S.H.), and the Center for Advanced Cardiac Therapeutics (S.K.), New York University Langone Health, New York.

 

参考文献

1. Reyentovich A, Barghash MH, Hochman JS. Management of refractory cardiogenic shock. Nat Rev Cardiol 2016;13:481-492

2. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. N Engl J Med 1999;341:625-634

3. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. JAMA 2006;295:2511-2515

4. Webb JG, Lowe AM, Sanborn TA, et al. Percutaneous coronary intervention for cardiogenic shock in the SHOCK trial. J Am Coll Cardiol 2003;42:1380-1386

5. de Waha S, Jobs A, Eitel I, et al. Multivessel versus culprit lesion only percutaneous coronary intervention in cardiogenic shock complicating acute myocardial infarction: a systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care 2017 July 1 (Epub ahead of print).

6. Thiele H, Akin I, Sandri M, et al. PCI strategies in patients with acute myocardial infarction and cardiogenic shock. N Engl J Med 2017;377:2419-2432

7. Bainey KR, Welsh RC, Toklu B, Bangalore S. Complete vs culprit-only percutaneous coronary intervention in STEMI with multivessel disease: a meta-analysis and trial sequential analysis of randomized trials. Can J Cardiol 2016;32:1542-1551

8. Babaev A, Frederick PD, Pasta DJ, Every N, Sichrovsky T, Hochman JS. Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock. JAMA 2005;294:448-454

9. Thiele H, Zeymer U, Werdan K. Intraaortic balloon support for cardiogenic shock. N Engl J Med 2013;368:81-81

10. Agarwal S, Sud K, Martin JM, Menon V. Trends in the use of mechanical circulatory support devices in patients presenting with ST-segment elevation myocardial infarction. JACC Cardiovasc Interv 2015;8:1772-1774

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