背景:症状与心肌缺血相符的患者心外膜冠状动脉血管舒缩反应性(ACVR)异常的患病率和意义仍不明确。我们的诊断策略是对每个在休息时出现胸痛的患者进行挑衅性测试(PT),冠状动脉造影未发现明显的心外膜冠状动脉疾病(目测狭窄≥70%).
目的:为了评估这种策略的ACVR发病率,PT安全性和患者预后。
方法:本研究为回顾性观察性研究,中位临床随访时间为5年。主要结果是PT患者的ACVR发生率。获得ACVR的危险因素和临床随访,以及主要不良心脑血管事件的发生率(MACCE;死亡,心血管死亡率,心肌梗塞,卒中和冠状动脉血运重建)报告。
结果:在2379例PT患者中有294例(12.4%)的ACVR被证实,在13,654名接受血管造影的患者中。ACVR患者更常见的是女性(43.9%vs.30.0%;P<0.0001),目前的吸烟者(37.4%与8.7%;P<0.0001),并有疑似急性冠脉综合征(36.7%vs.29.1%;P=0.005)与没有ACVR的患者相比。在临床随访期间,有(9.8%)ACVR患者的MACCE发生率高于无(3.7%)ACVR患者(风险比[HR]4.15,95%置信区间[CI]2.62-6.57;P<0.0001),包括更多的心肌梗塞(4.0%vs.0.4%;HR17.8,95%CI6.41-49.5;P<0.0001)和更多的心肌血运重建(6.1%vs.1.1%;HR9.36,95%CI4.67-18.74;P<0.0001)与基线PT正常的患者相比。
结论:在休息时出现与心肌缺血一致的症状的患者中,ACVR是常见的,冠状动脉无明显狭窄。PT是确定复发性缺血事件高危人群的安全性策略。
BACKGROUND: The prevalence and significance of abnormal epicardial coronary vasomotor reactivity (ACVR) in patients with symptoms compatible with myocardial ischaemia remains ill-defined. Our diagnostic strategy is to perform a provocative test (PT) in every patient presenting with chest pain at rest, for whom coronary angiography does not reveal significant epicardial coronary artery disease (≥70% stenosis by visual assessment).
OBJECTIVE: To evaluate such a strategy in terms of incidence of ACVR, PT safety and patient outcomes.
METHODS: The present study was a retrospective observational study with a median clinical follow-up of 5years. The primary outcome was incidence of ACVR in patients with PT. Risk factors for ACVR and clinical follow-up were obtained, and the rate of major adverse cardiovascular and cerebrovascular events (MACCE; death, cardiovascular mortality, myocardial infarction, stroke and coronary revascularization) was reported.
RESULTS: ACVR was documented in 294 (12.4%) of the 2379 patients with PT, out of the 13,654 patients undergoing angiography. Patients with ACVR were more often female (43.9% vs. 30.0%; P<0.0001), current smokers (37.4% vs. 8.7%; P<0.0001) and had a suspected acute coronary syndrome (36.7% vs. 29.1%; P=0.005) at admittance compared with patients without ACVR. During clinical follow-up, MACCE occurred more frequently in patients with (9.8%) than in those without (3.7%) ACVR (hazard ratio [HR] 4.15, 95% confidence interval [CI] 2.62-6.57; P<0.0001), including more myocardial infarctions (4.0% vs. 0.4%; HR 17.8, 95% CI 6.41-49.5; P<0.0001) and more myocardial revascularizations (6.1% vs. 1.1%; HR 9.36, 95% CI 4.67-18.74; P<0.0001) compared with patients with normal PT at baseline.
CONCLUSIONS: ACVR is frequent in patients with symptoms compatible with myocardial ischaemia at rest, with no significant coronary stenosis. PT is a safe strategy to identify a population at high risk of recurrent ischaemic events.