杨红,刘森,刘成,魏梦伟,邵琪琪,周雅琪,付真彦

• 1:新疆医科大学第一附属医院(第一临床医学院)心脏中心

摘要(Abstract)：

目的 探讨光学相干断层成像（OCT）对急性冠状动脉综合征（ACS）患者非罪犯病变易损斑块性质的分析及对未来发生主要不良心血管事件（MACE）风险的预测价值。方法 选取新疆医科大学第一附属医院2015年2月至20 22年2月收治的接受经皮冠状动脉介入治疗及OCT检查的ACS患者488例作为研究对象，应用OCT对非罪犯病变进行分析，并对患者进行随访，中位随访时间为5(3,7)年。应用Kap lan-Me ier估计MACE的累积发病率，多变量Cox回归分析非罪犯病变中OCT参数发生MACE的风险，采用受试者工作特征（ROC）曲线评估OCT参数对非罪犯病变发生MACE的预测价值。结果 共检查出749个非罪犯病变，41个MACE由OCT成像的非罪犯病变引起。MACE发生率与具有薄纤维帽斑块（TCFA）和最小管腔面积（MLA）<3.5 mm~2特征的易损斑块明显相关（33%比3%;HR 13.62,95%CI 6.71～27.65,P<0.001）。多变量Cox回归分析显示，较小的最薄纤维帽厚度（HR 0.97,95%CI 0.96～0.99,P<0.001），较大的最大脂质弧度（HR 1.02,95%CI 1.01～1.03,P<0.001）和较小的MLA(HR 0.31,95%CI0.18～0.55,P<0.001)是非罪犯病变未来发生MACE的独立危险因素。最薄纤维帽厚度预测非罪犯病变发生MACE的ROC曲线下面积（AUC）为0.858(95%CI 0.802～0.913)，最佳截断值为66.5μm；最大脂质弧度预测非罪犯病变发生MACE的AUC为0.853(95%CI 0.786～0.920)，最佳截断值为180.35°；MLA预测非罪犯病变发生MACE的AUC为0.821(95%CI0.766～0.876)，最佳截断值为3.575 mm~2。结论 具有TCFA和MLA<3.5 mm~2特征的非罪犯病变与随后发生MACE的风险增加明显相关，最薄纤维帽厚度、最大脂质弧度和MLA对非罪犯病变未来发生MACE有一定的预测价值。

关键词(KeyWords)： 急性冠状动脉综合征;非罪犯病变;易损斑块;经皮冠状动脉介入治疗;光学相干断层成像

Abstract:

Keywords:

基金项目(Foundation): 国家重点研发计划项目（2021YFC2500600、2021YFC2500605）;; 自治区重点研发计划项目（2022B03022-4）

作者(Author): 杨红,刘森,刘成,魏梦伟,邵琪琪,周雅琪,付真彦

参考文献(References)：

• [1] Stone PH, Libby P, Boden WE. Fundamental pathobiology of coronary atherosclerosis and clinical implicati ons for chronic ischemic heart disease management-the plaque hypothesis:a narrative review[J]. JAMA Cardiol, 2023, 8(2):192-201. DOI:10.1001/jamacardio.2022.3926.
• [2] Varenhorst C,Hasvold P,Johansson S,et al. Culprit and nonculprit recurrent ischemic events in patients with myocardial infarction:data from SWEDEHEART(Swedish Web S ystem for enhancement and development of evidence-based care in heart disease evaluated according to recommended therapies)[J].J Am Heart Assoc,2018,7(1):e007174. DOI:10.1161/jaha.117.007174.
• [3] Romagnoli E, Gatto L, Prati F. The CLlMA study:assessing therisk of myocardial infarction with a new anatomical score[J]. Eur Heart J Suppl, 2019, 21(Suppl B):B80-B83.DOI:10.1093/eurheartj/suz032.
• [4] Jiang S, Fang C, Xu X, et al. Identification of 12 high-risk coronary lesions by 3-vessel optical coherence tomography[J].J Am Coll Cardiol, 2023,81(13):1217-1230. DOI:10.1016/j.jacc.2023.01.030.
• [5] Lv R,Maehara A,Matsumura M,et al. Using optical coherence tomography and intravascular ultrasound imaging to quantify coronary plaque cap thickness and vulnerability:a pilot study[J]. Biomed Eng Online,2020,19(1):90. DOI:10.1186/s12938-020-00832-w.
• [6]折振兴，于波.易损斑块成像进展[J].中国介入心脏病学杂志，2022, 30(3):208-213. DOI:10.3969/j.issn.1004-8812.2022.03.009.
• [7] Dai J, Xing L, Jia H, et al. In vivo predictors of plaque erosion in patients with ST segment elevation myocardial infarction:a clinical, angiographical, and intravascular optical coherence tomography study[J]. Eur Heart J, 2018,39(22):2077-2085. DOI:10.1093/eurheartj/ehy101.
• [8]吴涵芝，尹艳伟，叶新和，等.急性冠状动脉综合征中非罪犯病变管理的研究进展[J].中国介入心脏病学杂志，2023,31(5):373-379.DOI:10. 3969/j. issn. 1004-8812. 2023. 05.009.
• [9]中华医学会心血管病学分会，中华心血管病杂志编辑委员会.光学相干断层成像技术在冠心病介入诊疗中应用的中国专家共识[J].中华心血管病杂志，2023,51(2):109-123.DOI:10.3760/cma.j.cn112148-20220602-00436.
• [10] Ibanez B,James S,Agewall S,et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation:the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology(ESC)[J]. Eur Heart J,2018,39(2):119-177. DOI:10.1093/eurheartj/ehx393.
• [11] Fearon WF. Assessing nonculprit coronary disease in ST-segment elevation myocardial infarction with physiological testing[J].JAMA Cardiol,2019,4(8):745-746. DOI:10.1001/jamacardio.2019.2217.
• [12] Park DW,Clare RM,Schulte PJ,et al. Extent,location,and clinical significance of non-infarct related coronary artery disease among patients with ST-elevation myocardial infarction[J]. JAMA, 2014,312(19):2019-2027. DOI:10.1001/jama.2014.15095.
• [13] Scirica BM,Bergmark BA,Morrow DA,et al. Nonculprit lesion myocardial infarction following percutaneous coronary intervention in patients with acute coronary syndrome[J]. J Am Coll Cardiol, 2020,75(10):1095-1106. DOI:10.1016/j.jacc.2019.12.067.
• [14]卢亚辉，侯昌，刘健. 2020年冠状动脉腔内影像学研究进展[J].中国介入心脏病学杂志，2021, 29(11):637-641.DOI:10. 3969/j. issn. 1004-8812. 2021. 11. 007.
• [15] van Nunen LX,Zimmermann FM,Tonino PAL,et al.Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease(FAME):5-year follow-up of a randomised controlled trial[J]. Lancet,2015,386(10006):1853-1860. DOI:10.1016/s0140-6736(15)00057-4.
• [16] Martins JL,Afreixo V,Santos J,et al. Fractional flow reserveguided strategy in acute coronary syndrome. A systematic review and meta-analysis[J]. Arq Bras Cardiol,2018,111(4):542-550. DOI:10.5935/abc.20180170.
• [17] C e r r a t o E, M e jía-R e n t e ría H, D e h b i H M, e t a l. Revascularization deferral of nonculprit stenoses on the basis of fractional flow reserve:1-year outcomes of 8,579 patients[J]. JACC Cardiovasc Interv,2020,13(16):1894-1903.DOI:10.1016/j.jcin.2020.05.024.
• [18] Hong YJ,Ahn Y,Jeong MH. Role of intravascular ultrasound in patients with acute myocardial infarction[J]. Korean Circ J,2015,45(4):259-265. DOI:10.4070/kcj.2015.45.4.259.
• [19] Maehara A,Cristea E,Mintz GS,et al. Definitions and methodology for the grayscale and radiofrequency intravascular ultrasound and coronary angiographic analyses[J]. JACC Cardiovasc Imaging, 2012, 5(3 Suppl):S1-S9. DOI:10.1016/j.jcmg.2011.11.019.
• [20] Stone GW,Maehara A,Lansky AJ,et al. A prospective naturalhistory study of coronary atherosclerosis[J]. N Engl J Med, 2011, 364(3):226-235. DOI:10.1056/NEJMoa1002358.
• [21] Erlinge D,Maehara A,Ben-Yehuda O,et al. Identification of vulnerable plaques and patients by intracoronary near-infrared spectroscopy and ultrasound(PROSPECTⅡ)：a prospective natural history study[J]. Lancet, 2021, 397(10278):985-995. DOI:10.1016/s0140-6736(21)00249-x.
• [22] Fujii K,Kubo T,Otake H,et al. Expert consensus statement for quantitative measurement and morphological assessment of optical coherence tomography:update 2022[J]. Cardiovasc Interv Ther, 2022, 37(2):248-254. DOI:10.1007/s12928-022-00845-3.
• [23] Nicholls SJ, Kataoka Y, Nissen SE, et al. Effect of evolocumab on coronary plaque phenotype and burden in statin treated patients following myocardial infarction[J]. JACC Cardiovasc Imaging, 2022, 15(7):1308-1321. DOI:10.1016/j.jcmg.2022.03.002.
• [24] R?ber L, Ueki Y, Otsuka T, et al. Ef fect of alirocumab added to high intensity statin therapy on coronary atherosclerosis in patients with acute myocardial infarction:the PACMAN AMI randomized clinical trial[J]. JAMA, 2022, 327(18):1771-1781. DOI:10.1001/jama.2022.5218.
• [25] Prati F,Romagnoli E,Gatto L,et al. Relationship between coronary plaque morphology of the left anterior descending artery and12 months clinical outcome:the CLIMA study[J]. Eur Heart J,2020, 41(3):383-391. DOI:10.1093/eurheartj/ehz520.
• [26] Kubo T,Ino Y,Mintz GS,et al. Optical coherence tomography detection of vulnerable plaques at high risk of developing acute coronary syndrome[J]. Eur Heart J Cardiovasc Imaging,2021,22(2):1376-1384. DOI:10.1093/ehjci/jeab028.
• [27] Narula J, Nakano M, Virmani R, et al. Histopathologic characteristics of atherosclerotic coronary disease and implications of the findings for the invasive and noninvasive detection of vulnerable plaques[J]. J Am Coll Cardiol, 2013,61(10):1041-1051.DOI:10.1016/j.jacc.2012.10.054.
• [28] Yonetsu T, Kakuta T, Lee T, et al. In vivo critical fibrous cap thickness for rupture-prone coronary plaques assessed by optical coherence tomography[J]. Eur Heart J, 2011,32(10):1251-1259. DOI:10.1093/eurheartj/ehq518.
• [29] Sibbald M, Pinilla-Echeverri N, Alameer M, et al. Using optical coherence tomography to identify lipid and its impact on interventions and clinical events-a scoping review[J]. Circ J,2021,85(11):2053-2062.DOI:10.1253/circj.CJ-21-0377.
• [30] Xing L, Higuma T, Wang Z, et al. Clinical significance of lipid rich plaque detected by optical coherence tomography:a 4 year follow up study[J]. J Am Coll Cardiol, 2017, 69(20):2502-2513. DOI:10.1016/j. jacc.2017.03.556.