目的 分析经皮冠状动脉介入治疗(PCI)对≥70岁的老年冠状动脉慢性完全闭塞(CTO)患者预后的影响. 方法 登记2011年1月至2013年12月连续在我院拟行PCI的445例冠状动脉有CTO病变的患者,分为≥70岁老年组和<70岁组,主要终点为3年因心绞痛、再次心肌梗死、心力衰竭而住院或行再次血运重建和心血管死亡的复合终点. 结果 ≥70岁老年组200例(44.9%),<70岁组245例(55.1%),≥70岁老年组冠状动脉左主干(LM)病变、3支病变及J-CTO评分≥2分患者的比例分别为22.5%(45例)、83.0%(166例)和32.0%(64例),显著高于<70岁组13.9%(34例)、73.5%(180例)和23.3%(57例)(χ2 = 5.607、5.782、4.243,P= 0.018、0.016、0.039).≥70岁老年组对CTO病变尝试行PCI开通的病变处比例(53/222,23.9%)显著低于<70岁组(109/275,39.6%)(χ2 =13.891,P<0.001);两组患者CTO病变 PCI成功干预的比例分别为71.7%(38例)和82.6%(90例)(χ2 =2.541,P=0.111).≥70岁老年组患者的3年发生心血管死亡和主要终点的比例分别为12.5%(25例)、31.5%(63例),均显著高于<70岁组3.3%(8例)、22.9%(56例)(χ2 =13.677、4.199,P=0.000、0.040).≥70岁老年组中,CTO病变经PCI开通患者的3年因心绞痛、心肌梗死、心力衰竭而住院或再次血运重建的比例低于CTO未开通的患者〔9.1%(3例/33例)比22.8%(34例/149例)〕,但差异无统计学意义(χ2 =3.143,P=0.076),这两组的3年心血管死亡大致相同〔15.2%(5例/33例)比12.8%(19例/149例)〕(χ2 =0.007,P=0.933).多因素分析结果显示,左主干(LM)合并冠状动脉3支病变(OR=3.804,95% CI:1.274~11.356,P=0.017)是老年冠状动脉CTO患者3年心血管死亡的独立预测因素. 结论 PCI开通老年患者的CTO病变,未见能显著改善预后;LM合并冠状动脉3支病变可能是老年冠状动脉CTO患者3年心血管死亡的独立预测因素.%Objective To evaluate the clinical impact of percutaneous coronary intervention (PCI)on prognosis in elderly patients(≥70 years old)with coronary artery chronic total occlusion (CTO). Methods A total of 445 consecutive patients with a angiography-confirmed CTO lesions registered from January 2011 to December 2013 were divided into the elderly group(≥70 years)and the non-elderly group(< 70 years).The primary endpoints measured were defined as the composite outcomes of hospitalization due to angina,re-infarction,heart failure,repeat re-vascularization,and cardiac death at 36 months follow-up. Results The elderly group included 200 patients(44.9%) and the non-elderly group included 245 patients(55.1%).During the follow-up,the proportions of coronary lesion were significantly higher in the elderly group with left main(LM)disease(45, 22.5%),three-vessel disease(166,83.0%)and J-CTO score≥2(64,32.0%)than in the non-elderly group with diseases of LM,three-vessel,and J-CTO score ≥ 2〔(34,13.9%);(180,73.5%);(57, 23.3%),respectively〕(χ2 =5.607,5.782,4.243;P=0.018,0.016,0.039).T he ratio of the patients undergoing PCI-reperfusion therapy of CTO was higher in non-elderly group(109/275,39.6%)than in elderly group(53/222,23.9%)(χ2 =13.891,P<0.001),while CTO PCI success rate was similar between the two groups(38 patients,71.7% vs.90 patients,82.6%,χ2 = 2.541,P= 0.111).The elderly group versus non-elderly group showed that the 3-year cardiac mortality rate was 12.5%(25 patients)versus 3.3%(8 patients)(χ2 =13.677,P<0.011),and the incidence rate of 3-year primary endpoint was 31.5%(63 patients)versus 22.9%(56 patients)(χ2 =4.199,P=0.040).Among the elderly group,patients without CTOs re-vascularized by PCI had a greater tendency toward higher risk of hospitalization due to angina,re-infarction,heart failure,or repeat re-vascularization than patients with CTOs re-vascularized by PCI(34/149,22.8% vs.3/33,9.1%,χ2 =3.143,P=0.076),while they had comparable incidence of 3-year cardiac death(19/149,12.8% vs.5/33,15.2%,χ2 = 0.007,P=0.933).Multivariate analysis revealed that after adjusting for baseline and procedure differences,LM combined with three vessel disease(OR= 3.804,95% CI:1.274 to 11.356,P= 0.017)remained an independent predictor for 3-year cardiac mortality in elderly patients with CTOs. Conclusions Elderly patients with CTO have mostly a serious coronary artery disease and a poor prognosis.Although CTO is re-vascularized by PCI,long-term clinical outcome seems not more to be improved in elderly patients with CTOs.LM combined with three-vessel disease might be an independent predictor for 3-year cardiac mortality in elderly CTO patients.
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