在過去15年內 與PCI有關的中風發生率穩定
在過去15年內 與PCI有關的中風發生率穩定
作者：Susan Jeffrey
出處：WebMD醫學新聞
November 20, 2009 (佛州奧蘭多) — 梅約診所的研究者報告指出，在他們的診所，與經皮冠狀動脈介入治療(percutaneous coronary intervention，PCI)有關的中風，以及暫時性腦缺血發作(transient ischemic attack，TIA)比率，過去15年穩定維持在大約0.39%。
他們將此結果視為好消息。資深作者、梅約診所基金會的Rajiv Gulati博士向Medscape Neurology表示，雖然我們面對的是年長、病重、複雜疾病患者，相關的中風發生率依舊沒有改變。
Gulati博士報告指出，風險最高的是年長女性；最近有心肌梗塞者、或明顯腎功能不佳者；以及接受多處血管PCI者。
他表示，這讓我們可以辨識哪些人風險較高，之後預先提出警告，我們可以在發生中風時設法留意，並立即啟動我們的協定來試圖處理它。
他們的結果發表於美國心臟協會2009年科學會議。
【PCI相關中風比率穩定】
作者們指出，研究顯示，與PCI有關的早期死亡和嚴重心臟副作用比率隨著時間降低，與失能有關而最令人擔心的中風比率則是相當穩定，在PCI登記中心的手術前後中風發生率範圍從0.15到0.44。
該研究中，Gulati博士等人希望確認時間傾向與預測因子，著眼於他們診所的PCI相關中風的住院和長期結果。他們針對梅約診所心導管實驗室資料庫，所有在1994-2008年間接受PCI的病患進行回溯分析。
這段期間，17,249名病患有21,502例因PCI而住院；研究者區別所有與這些手術有關的中風或TIA案例，之後將這些案例和沒有中風或TIA的對照組進行比較。
PCI相關中風定義是手術之後48小時內的事件，由神經科醫師和/或經影像檢查進行臨床診斷，當診斷不確定時，由神經科醫師獨立判定。他們承認，使用此一方法仍可能漏失一些中風事件，例如次發而死亡者或中風症狀不明確者。
Gulati博士表示，我們發現，冠狀動脈血管修復術有84件腦血管事件，大約0.39%的風險，其中，19件(23%)為TIA。
多數中風(92%)是缺血性的，6%是出血性的，2%為不明原因。全部只有1例未經電腦斷層或磁振造影確認。
多數事件(58%)發生在前循環，另有23%發生在後循環；13%同時包括前循環和後循環。
Gulati博士指出，我們探討這15年間的時間傾向，我認為相當有趣，這段期間各年的中風風險並未改變，因此，雖然我們面對的是年長、病重、複雜疾病患者，PCI或血管修復術相關的中風發生率依舊沒有改變。
他指出，一如預期，人口統計學和手術相關因素與中風風險增加有關，包括年長、女性、手術前7天內心肌梗塞、曾發生過中風、冠狀動脈內血栓、多處血管PCI。
與PCI相關的中風也和住院死亡率顯著增加有關，比無中風者的20.2%增加1.8%(P < .001)。
Gulati博士指出，重點是，對於中風住院存活者，出現中風表示未來10年的死亡率較高。校正其他變項之後，則未達統計上的顯著意義(P = .15)。
他指出，在某些方面這不令人驚訝，因為他們是年長、重病患者，但是我認為，與PCI相關的中風代表住院死亡率風險高、以及未來10年死亡率增加是相當重要的資訊。
【共病狀態】
美國心臟協會理事長候選人、邁阿密大學Miller醫學院的Ralph Sacco醫師受邀對這些發現發表評論時表示， 雖然這是單一中心的研究，但研究者回顧了相當多的病患，確認了PCI後的中風風險相對較低，似乎可以穩定15年。
Sacco醫師向Medscape Neurology表示，儘管科技上可能改變，中風風險依舊穩定，這表示中風風險可能和手術之外的共病狀態有關。
該研究也有助於辨識高風險病患的可能預測因子，包括年長、女性、之前的中風、最近的心肌梗塞、多處血管手術、心臟內血栓，80歲以上曾中風者的風險最大。
他結論表示，該研究增加了我們關於PCI相關中風的長期結果、決定因素與中風的知識。
Gulati博士和Sacco醫師皆宣告沒有相關財務關係。
美國心臟協會(AHA)2009年科學會議：摘要4298。發表於2009年11月16日。
Stroke Incidence Related to PCI Steady for 15 Years
By Susan Jeffrey
Medscape Medical News
November 20, 2009 (Orlando, Florida) — Mayo Clinic researchers are reporting that rates of stroke and transient ischemic attack (TIA) related to percutaneous coronary intervention (PCI) at their institution have remained steady during the last 15 years at approximately 0.39%.
They interpret the results as good news. "Despite the fact that we're dealing with an older, sicker population, with more complex disease, the incidence of PCI-related stroke remains unchanged," senior author Rajiv Gulati, MD, PhD, from the Mayo Clinic Foundation in Rochester, Minnesota, told Medscape Neurology.
At highest risk were older women; those with recent myocardial infarction (MI), intracoronary thrombus, or significant renal impairment; and those undergoing multivessel PCI, Dr. Gulati reported.
"This gives us the ability to identify people at higher risk, and then forewarned, we can be on the look out for stroke when it does happen and activate our protocols immediately to try and deal with the event," he said.
Their results were presented here at the American Heart Association 2009 Scientific Sessions.
PCI-Related Stroke Steady
Studies have shown decreases in early mortality and composite major adverse cardiac events with PCI over time, but stroke, among the most feared outcomes because of its association with disability, has remained steady, the authors note. The incidence of periprocedural stroke in PCI registries has ranged from 0.15 to 0.44.
In this study, Dr. Gulati and colleagues aimed to determine temporal trends and predictors and look at in-hospital and long-term outcomes of strokes related to PCI at their institution. They performed a retrospective analysis of the Mayo Clinic catheter laboratory database of all patients who underwent PCI between 1994 and 2008.
During that period, 17,249 patients had 21,502 hospitalizations for PCI. They identified all cases of stroke or TIA related to these procedures and then compared these cases with patients without stroke or TIA as controls.
PCI-related stroke was defined as events usually within 48 hours of the procedures, diagnosed clinically by a neurologist and/or using imaging, with independent adjudication of the events by a neurologist when the diagnosis was unclear. Some stroke could have been missed using this method, they acknowledge, such as those secondary to death or cases in which stroke symptoms were not recognized as such.
"We found there were 84 cerebrovascular events or about a 0.39% risk with coronary angioplasty," Dr. Gulati said. Of these, 19 or 23% were TIAs.
Most strokes (92%) were ischemic, 6% were hemorrhagic, and 2% were of unknown origin. All but 1 were confirmed by either computed tomography or magnetic resonance imaging.
Most events (58%) were in the anterior circulation, with another 23% in the posterior circulation; 13% involved both the posterior and anterior circulation.
"We looked at temporal trends over the 15 years and, I think quite interestingly, found that the risk of stroke from year to year didn't change at all over this period," Dr. Gulati noted. "So despite the fact that we're dealing with a sicker population, older, with more complex disease, the incidence of a PCI or angioplasty-related stroke remains unchanged."
Demographic and procedural factors that independently predicted increased stroke risk were as expected, he noted, and included older age, female sex, MI within 7 days before the procedure, previous stroke, intracoronary thrombus, and multivessel PCI.
Stroke related to PCI was also associated with a significant increase in in-hospital mortality, increasing the risk from 1.8% in those without stroke to 20.2% (P < .001).
"Importantly, [in] people who did survive this stroke in-hospital, the presence of a stroke did confer a higher mortality over the next 10 years," Dr. Gulati added. The finding missed statistical significance after adjustment for other variables (P = .15).
"In some ways this is not surprising, because they were older, sicker people to begin with, but I think it's important information showing that having a stroke related to PCI confers a high risk of in-hospital mortality and also correlates with mortality over the subsequent 10 years," he added.
Comorbid Conditions
Asked for comment on these findings, Ralph Sacco, MD, from the Miller School of Medicine at the University of Miami in Florida and president-elect of the American Heart Association, said that although this study is from a single center, the investigators reviewed a large number of patients and confirm a relatively low risk of stroke after PCI, which appears to be stable for 15 years.
"Despite likely changes in technology, the stroke risk has remained stable, which implies that stroke risk is probably associated with comorbid conditions rather than the procedures themselves," Dr. Sacco told Medscape Neurology.
The study also helps identify some possible predictors of stroke in high-risk patients, including older age, female sex, prior stroke, recent MI, multivessel procedures, and intracardiac thrombus, with the greatest risk found among those with prior stroke older than 80 years.
"The study adds to our knowledge of the risk, determinants, and long-term outcomes of peri-PCI stroke," he concluded.
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Dr. Gulati and Dr. Sacco have disclosed no relevant financial relationships.
American Heart Association (AHA) 2009 Scientific Sessions: Abstract 4298. Presented November 16, 2009.
