急诊PCI策略：单纯处理罪犯血管还是完全血运重建

急性冠脉综合征（Acute Coronary Symptom, ACS）的主要有效治疗方法之一是急诊经皮冠状动脉介入治疗术（Percutaneous Coronary Intervention, PCI）。目前大多数观点以及指南均建议，对于ST段抬高的急性心肌梗死患者，急诊PCI时仅对罪犯血管进行干预1，对非罪犯血管无明确的建议，仅当患者出现心源性休克时才推荐对多支血管上存在的病变进行PCI2。对于非ST段抬高急性冠脉综合征的患者，应根据不同的危险分层决定治疗策略，对于极高危的非ST段心肌梗死患者建议发病2小时以内即应进行紧急PCI，仍建议仅对可能的罪犯血管进行PCI；当无法判定罪犯血管时，可选择对多支供血重要的血管进行PCI 3。

资料显示40％～65％的急性心肌梗死患者存在多支血管病变4，具有多支血管病变的急性心肌梗死患者急诊行冠状动脉旁路移植术的比例较单支血管病变患者高，心肌梗死后再发心肌缺血、再次血运重建尤其对非罪犯血管病变的再次血运重建的比例在多支血管病变患者中比例均增高5。因此，对于具有多支病变的急性心肌梗死患者，单纯处理罪犯血管还是进行完全血运重建对急性心肌梗死的治疗学具有重要意义。

急性心肌梗死患者冠状动脉粥样改变并非局限于某一冠状动脉局部，而是遍布整个冠状动脉血管床5。血管内超声显示，急性心肌梗死时，罪犯血管的靶病变与非靶病变以及非罪犯血管的粥样斑块比较，具有较多的血栓、较强的低回声、较长的病变、较大的弹力膜面积以及更重的斑块负荷等特征6。有研究认为，对于具有多支血管病变的心肌梗死患者，同时对罪犯血管和非罪犯血管进行治疗，再发心肌梗死、靶血管血运重建以及主要心脏不良事件的发生率增加。多因素分析显示，多支血管同时进行PCI是主要心脏不良事件发生的独立危险因素7。急性心肌梗死时，机体内促血栓形成以及炎症反应因素增加8-10，这可能是梗死相关冠状动脉支架植入后较非梗死相关动脉再狭窄率高的原因之一11。另外，有研究显示，急性心肌梗死时非罪犯血管的病变有可能被估计过重，这可能与急性心肌梗死时，血液循环中的缩血管物质如内皮素、血管加压素等被激活，同时一氧化氮、腺苷等扩血管物质的活性减低有关12。

但也有研究认为，对于具有多支冠状动脉病变的急性心肌梗死患者，对罪犯血管进行治疗的同时，对非罪犯血管进行治疗是安全可行的。有研究发现，同台接受完全血运重建的心肌梗死患者（除外心源性休克以及左主干狭窄超过50％），主要心脏不良事件（包括再发心肌缺血、再发心肌梗死、急性心力衰竭和住院死亡率）的发生率降低，住院时间明显缩短，但可能因PCI术中对比剂应用较多，患者一过性肾功能不全的发生率增加13-14。对上述患者进行完全血运重建的理论依据是，非罪犯血管的粥样斑块可能是不稳定的，这些粥样斑块病变可能进展迅速而导致不良的预后15-16。针对上述争议，我们中心对93例具有多支冠状动脉病变的ST段抬高急性心肌梗死患者的罪犯血管进行急诊PCI治疗，直接PCI后7至15天在同一次住院期间对非罪犯血管也进行了PCI治疗，结果显示，完全血运重建的患者与未行完全血运重建的149例患者相比，心绞痛发生率降低，左室射血分数增加，死亡、再次心肌梗死、靶血管血运重建以及主要心脏不良事件的发生率无明显差别。对上述患者进行择期PCI，可能降低过多的对比剂对肾功能造成的损害，避免急诊PCI时对非罪犯血管病变的不恰当估计导致的过度介入治疗，降低具有高危因素患者接受PCI治疗的风险17（如心脏破裂等）；同时，因为同次住院期间对非梗死相关但有缺血意义的病变(即患者有胸痛并且该病变具有相应的动态心电图或运动负荷试验心电图ST-T改变)及时进行了干预，使患者心绞痛及心功能获得明显改善，同时因减少了患者的住院次数而提高了效价比。

总之，对于具有多支血管病变的急性心肌梗死患者，是否应该进行完全血运重建，以及进行完全血运重建的时机、条件等目前仍是值得深入研究的问题18。笔者个人观点，在有缺血证据的前提下，同次住院期内择期对非罪犯血管进行血运重建的策略可能是比较正确的选择。
 
参考文献
1.   [Guidelines for percutaneous coronary intervention (2009)]. Zhonghua Xin Xue Guan Bing Za Zhi. 2009;37(1):4-25.
2.   Kushner FG, Hand M, Smith SC, Jr., et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2009;54(23):2205-2241.
3.   Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization: a report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2009;53(6):530-553.
4.   Shihara M, Tsutsui H, Tsuchihashi M, Tada H, Kono S, Takeshita A. In-hospital and one-year outcomes for patients undergoing percutaneous coronary intervention for acute myocardial infarction. Am J Cardiol. 2002;90(9):932-936.
5.   Goldstein JA, Demetriou D, Grines CL, Pica M, Shoukfeh M, O＇Neill WW. Multiple complex coronary plaques in patients with acute myocardial infarction. N Engl J Med. 2000;343(13):915-922.
6.   Kotani J, Mintz GS, Castagna MT, et al. Intravascular ultrasound analysis of infarct-related and non-infarct-related arteries in patients who presented with an acute myocardial infarction. Circulation. 2003;107(23):2889-2893.
7.   Corpus RA, House JA, Marso SP, et al. Multivessel percutaneous coronary intervention in patients with multivessel disease and acute myocardial infarction. Am Heart J. 2004;148(3):493-500.
8.   Ambrose JA, Weinrauch M. Thrombosis in ischemic heart disease. Arch Intern Med. 1996;156(13):1382-1394.
9.   Haught WH, Mansour M, Rothlein R, et al. Alterations in circulating intercellular adhesion molecule-1 and L-selectin: further evidence for chronic inflammation in ischemic heart disease. Am Heart J. 1996;132(1 Pt 1):1-8.
10.  Bogaty P, Robitaille NM, Solymoss S, et al. Atherogenic, hemostatic, and other potential risk markers in subjects with previous isolated myocardial infarction compared with long-standing uncomplicated stable angina. Am Heart J. 1998;136(5):884-893.
11.  Hong MK, Park SW, Lee CW, et al. Six-month angiographic follow-up after intravascular ultrasound-guided stenting of infarct-related artery: comparison with non-infarct-related artery. Am Heart J. 2001;141(5):832-836.
12.  Hanratty CG, Koyama Y, Rasmussen HH, Nelson GI, Hansen PS, Ward MR. Exaggeration of nonculprit stenosis severity during acute myocardial infarction: implications for immediate multivessel revascularization. J Am Coll Cardiol. 2002;40(5):911-916.
13.  Qarawani D, Nahir M, Abboud M, Hazanov Y, Hasin Y. Culprit only versus complete coronary revascularization during primary PCI. Int J Cardiol. 2008;123(3):288-292.
14.  Di Mario C, Mara S, Flavio A, et al. Single vs multivessel treatment during primary angioplasty: results of the multicentre randomised HEpacoat for cuLPrit or multivessel stenting for Acute Myocardial Infarction (HELP AMI) Study. Int J Cardiovasc Intervent. 2004;6(3-4):128-133.
15.  Gibson CM, Ryan KA, Murphy SA, et al. Impaired coronary blood flow in nonculprit arteries in the setting of acute myocardial infarction. The TIMI Study Group. Thrombolysis in myocardial infarction. J Am Coll Cardiol. 1999;34(4):974-982.
16.  Asakura M, Ueda Y, Yamaguchi O, et al. Extensive development of vulnerable plaques as a pan-coronary process in patients with myocardial infarction: an angioscopic study. J Am Coll Cardiol. 2001;37(5):1284-1288.
17.  Han YL, Wang B, Wang XZ, et al. Comparative effects of percutaneous coronary intervention for infarct-related artery only or for both infarct- and non-infarct-related arteries in patients with ST-elevation myocardial infarction and multi-vessel disease. Chin Med J (Engl). 2008;121(23):2384-2387.
18.  Celik T, Iyisoy A, Jata B, Kardesoglu E, Isik E. Culprit only versus multivessel coronary revascularization in patients presenting with acute ST elevation myocardial infarction: unending debate. Int J Cardiol. 2009;137(1):65-66.