2023 年第 1 期 第 18 卷

不同低密度脂蛋白胆固醇水平合并多支血管病变的急性ST段抬高型心肌梗死患者病变特点及预后分析

Characteristics and prognosis of ST-segment elevation myocardial infarction patients with multivessel disease in different levels of low-density lipoprotein cholesterol 

作者：赵雪东赵冠棋何雪黄鑫郑文

英文作者：Zhao Xuedong Zhao Guanqi He Xue Huang Xin Zheng Wen

单位：首都医科大学附属北京安贞医院心内冠心病中心二病房北京市心肺血管疾病研究所，北京100029

英文单位：The Second Ward Coronary Heart Disease Center Department of Cardiology Beijing Anzhen Hospital Capital Medical University Beijing Institute of Heart Lung and Blood Vessel Diseases Beijing 100029 China

关键词：ST段抬高型急性心肌梗死；多支血管病变；低密度脂蛋白胆固醇；预后

英文关键词：ST-segmentelevationacutemyocardialinfarction;Multivesseldisease;Low-densitylipoproteincholesterol;Prognosis

• 摘要：

• 目的  分析不同低密度脂蛋白胆固醇（LDL-C）水平的急性ST段抬高型心肌梗死（STEMI）合并多支血管病变(MVD)患者的病变特点及预后。方法 回顾性连续入选2005年1月至2015年1月就诊于首都医科大学附属北京安贞医院急诊科诊断为STEMI并成功完成直接经皮冠状动脉介入治疗的合并MVD患者1 033例。选取其中入院后24 h内采集空腹LDL-C并完成12个月随访的患者1 013例，根据LDL-C水平分成高LDL-C组（≥3.0 mmol/L），中等LDL-C组（1.8～＜3.0 mmol/L），低LDL-C组（＜1.8 mmol/L）。比较3组患者基线资料、冠状动脉病变和介入治疗情况及预后情况。采用Cox回归方法分析不同LDL-C水平与患者主要不良心脑血管事件（MACCE）和全因死亡的关系。结果 本研究中高LDL-C组488例，占48.2%，中等LDL-C组461例，占45.5%，低LDL-C组64例，占6.3%。低LDL-C组罪犯血管为左前降支的比例明显高于其余2组，而高LDL-C组罪犯血管为右冠状动脉的比例较高（均P＜0.05）。多元Cox回归分析结果显示，以中等LDL-C组作为参考，低LDL-C组MACCE发生风险（风险比=2.123, 95%置信区间：1.007～4.472,P=0.048）及全因死亡风险（风险比=5.307,95%置信区间：1.215～23.181,P=0.026）均较高，而高LDL-C组未显示类似差异（均P＞0.05）。结论 STEMI合并MVD患者中LDL-C≥3.0 mmol/L占比较高，相较于中等LDL-C组，并不增加长期心血管不良事件。而LDL-C＜1.8 mmol/L患者预后较差，相较于LDL-C较高的人群，这类患者从常规降脂等规范化治疗中获益较小，除了严格地降脂之外，应该更严格地控制包括残余心血管风险在内的各种危险因素。

• Objective To evaluate the characteristics and prognosis of ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) in different levels of low-density lipoprotein cholesterol (LDL-C). Methods A total of 1 033 patients were retrospectively enrolled, who were diagnosed with STEMI complicated with MVD and successfully completed primary percutaneous coronary intervention in Department of Emergency, Beijing Anzhen Hospital, Capital Medical University from January 2005 to January 2015. One thousand and thirteen patients of whom were detected fasting   LDL-C within 24 h after admission and completed 12-month follow-up were selected. According to the level of LDL-C, patients were divided into high LDL-C group (≥3.0 mmol/L), medium LDL-C group (1.8-＜3.0 mmol/L), and low LDL-C group (＜1.8 mmol/L). Baseline information, coronary artery pathology, interventional treatment status and prognosis of patients were compared among the three groups. Cox regression analysis was used to analyze the relationship of different LDL-C levels with major adverse cardio-cerebral vascular events (MACCE) and all-cause death. Results There were 488 cases in the high LDL-C group, accounting for 48.2%, 461 cases in the medium LDL-C group, accounting for 45.5%, and 64 cases in the low LDL-C group, accounting for 6.3%. The proportion of culprit vessel being left anterior descending branch in low LDL-C group was significantly higher than that in the other two groups, while the proportion of culprit vessel being right coronary artery in high LDL-C group was higher (all P＜0.05). Multivariate Cox regression analysis showed that, with the medium LDL-C group as a reference, the risks of MACCE (hazard ratio=2.123, 95% confidence interval: 1.007-4.472, P=0.048) and all-cause death (hazard ratio=5.307, 95% confidence interval: 1.215-23.181, P=0.026) in the low LDL-C group were higher, while the high LDL-C group did not show similar differences (all P＞0.05). Conclusions  The proportion of LDL-C≥3.0 mmol/L is higher in STEMI patients with MVD, which do not increase long-term cardiovascular adverse events compared with the medium LDL-C group. Patients with LDL-C＜1.8 mmol/L have a poor prognosis, and those benefit less from standardized treatment such as conventional lipid-lowering therapy compared with people with higher LDL-C. It is necessary to require stricter controls on lipid-lowering and various risk factors including cardiovascular residual risk.