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缺血性心肌病患者的心肌存活性和远期结局
Myocardial Viability and Long-Term Outcomes in Ischemic Cardiomyopathy


Julio A. Panza ... 心脑血管疾病 • 2019.08.22
相关阅读
• 缺血性心力衰竭患者的心肌存活性检测 • 肥厚型心肌病的临床病程和治疗

NEJM发表STICH10年结果:CABG生存获益明显,存活心肌检查价值何在

 

杨溢,朱云鹏,赵强*

上海交通大学医学院附属瑞金医院心外科

*通讯作者

 

STICH(surgical treatment for ischemic heart failure)研究是2002年发起的目前全球最大的一项针对缺血性心肌病(冠心病合并严重心力衰竭,左心室射血分数[EF]≦35%)的前瞻性随机对照临床试验1,旨在:①比较药物治疗联合冠状动脉旁路移植术(CABG)与单纯心力衰竭“黄金三角”药物治疗的疗效。②评价CABG同期行外科左室成形术(SVR)的临床疗效。

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摘要


背景

对于可从外科血运重建中获益的缺血性心肌病患者,心肌存活性评估在识别此类患者时发挥的作用目前仍有争议。此外,虽然改善左心室功能是血运重建的目标之一,但其与后续结局之间的关系尚不明确。

 

方法

我们在适合接受冠状动脉旁路移植术(CABG)且左心室射血分数≤35%的601例冠心病患者中,利用单光子发射计算机断层扫描、多巴酚丁胺负荷超声心动图或上述两种方法对心肌存活性进行了前瞻性评估。患者被随机分组,分别接受CABG联合药物治疗或接受单独药物治疗。本试验在基线时和随访4个月后测定了318例患者的左心室射血分数。主要终点是全因死亡。中位随访持续时间为10.4年。

 

结果

与单独药物治疗相比,CABG联合药物治疗与较低的全因死亡率相关(CABG组298例患者中有182例死亡 vs. 药物治疗组303例患者中有209例死亡;校正风险比,0.73;95%置信区间,0.60~0.90)。然而,在有或无心肌存活与CABG联合药物治疗优于单独药物治疗的有益作用之间,并未观察到显著交互作用(交互作用的P=0.34)。不论治疗分组如何,本试验仅在有心肌存活的患者中观察到左心室射血分数增加。左心室射血分数的变化与后续死亡情况不相关。

 

结论

本研究的结果不支持以下观点,缺血性心肌病患者的心肌存活与CABG的远期益处相关。不论接受哪种治疗,有存活心肌均与左心室收缩功能改善相关,但上述改善与远期生存不相关(由美国国立卫生研究院资助;STICH在ClinicalTrials.gov注册号为NCT00023595)。





作者信息

Julio A. Panza, M.D., Alicia M. Ellis, Ph.D., Hussein R. Al-Khalidi, Ph.D., Thomas A. Holly, M.D., Daniel S. Berman, M.D., Jae K. Oh, M.D., Gerald M. Pohost, M.D., George Sopko, M.D., Lukasz Chrzanowski, M.D., Daniel B. Mark, M.D., Tomasz Kukulski, M.D., Liliana E. Favaloro, M.D., Gerald Maurer, M.D., Pedro S. Farsky, M.D., Ru-San Tan, M.D., Federico M. Asch, M.D., Eric J. Velazquez, M.D., Jean L. Rouleau, M.D., Kerry L. Lee, Ph.D., and Robert O. Bonow, M.D.
From Westchester Medical Center, New York Medical College, Valhalla (J.A.P.); Duke Clinical Research Institute, Durham, NC (A.M.E., H.R.A.-K., D.B.M., K.L.L.); Northwestern University, Chicago (T.A.H., R.O.B.); Cedars Sinai Medical Center (D.S.B.) and the University of Southern California (G.M.P.), Los Angeles; Mayo Clinic, Rochester, MN (J.K.O.); the National Heart, Lung, and Blood Institute, Bethesda, MD (G.S.); Medical University of Lodz, Lodz (L.C.), and Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze (T.K.) — both in Poland; University Hospital Favaloro Foundation, Buenos Aires (L.E.F.); Medical University of Vienna, Vienna (G.M.); Instituto Dante Pazzanese de Cardiologia, São Paulo (P.S.F.); National Heart Center, Singapore (R.-S.T.); MedStar Washington Hospital Center, Washington, DC (F.M.A.); Yale University School of Medicine, New Haven, CT (E.J.V.); and Montreal Heart Institute, Montreal (J.L.R.). Address reprint requests to Dr. Panza at the Division of Cardiology, Westchester Medical Center, 100 Woods Rd., Macy Pavillion, Suite 100, Valhalla, NY 10595, or at julio.panza@wmchealth.org.

 

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