Exploration Of Interventional Treatment Plan For High-risk Lesions Of Coronary Heart Disease And Prediction Model Of Bleeding Risk After Thrombolysis

Part Ⅰ:Intravascular Ultrasound Guidance Improves the Long-term Prognosis in Patients with Unprotected Left Main Coronary Artery Disease Undergoing Percutaneous Coronary InterventionBackground and Objectives:This study compared the long term outcomes in patients with unprotected left main coronary artery(LMCA)disease who underwent stenting under the guidance of intravascular ultrasound(IVUS)or conventional angiography at a large single center.Methods:The primary outcome was the composite of all-cause death and myocardial infarction(MI)at 3 years.Target vessel revascularization(TVR)at 3 years was one of the secondary outcomes.Results:Between January 2004 and December 2011,a total of 1,899 patients who underwent IVUS-guided(n=713,37.5%)or conventional angiography-guided(n=1186,62.5%)stenting were included.At 3 years,the unadjusted primary outcome trended lower in the IVUS-guided group versus the angiography-guided(6.9%vs.8.4%,p=0.22)although the TVR was similar between two groups(6.0%vs.6.0%,p=0.97).However,after adjustment for differences in baseline risk factors,IVUS-guidance was associated with significantly lower incidence of the composite of all-cause death and MI(hazard ratio[HR]:0.65;95%confidence interval[CI]:0.50 to 0.84;p=0.001),although there was still no significant difference in TVR between the two groups(HR:1.09;95%CI:0.84 to 1.42;p=0.53).Conclusions:IVUS guidance has benefits in improving the long-term prognosis for unprotected LMCA stenting.Part Ⅱ:The Effectiveness and Safety of a Drug-eluting Balloon versus a Drug-eluting Stent for Small Coronary Vessel DiseaseBackground and Objectives:Percutaneous coronary interventions in small vessels is common and plagued by lower procedural success and higher rates of adverse events including restenosis and stent thrombosis compared to large vessels.We sought to compare the effectiveness and safety of a drug-coated balloons(DCB)for the treatment of de novo lesions in small coronary vessels with a zotarolimus drug-eluting stents(DES).Methods:In this noninferiority trial,eligible patients with reference vessel diameter between 2.25 mm and 2.75 mm were randomized to the DCB or the DES in a 1:1 ratio stratified by diabetes and number of lesions treated.Patients with RVD between 2.00 mm and 2.25 mm were enrolled in a nested very small vessel registry.The primary endpoint was the In-segment diameter stenosis at 9 months after the operation.Results:Between August 2016 and June 2017,a total of 230 subjects at 12 sites were randomized to the DCB group(n=116)or DES group(n=114);32 patients were treated with the DCB in the very small vessel cohort.Nine-month in-segment percentage diameter stenosis was 29.3±20.2%with the DCB versus 23.9±15.9%with the DES;the 1-sided 97.5%upper conf idence limit of the difference was 10.6%,achieving non-inferiority of the DCB compared with the DES(p for non-inferiority<0.001).256(97.7%)patients completed 2 years of follow-up.There was no significant difference in TLF between the DCB and DES groups(5.2 vs.3.7%,p=0.75).Conclusions:Compared to the second-generation DES,the DCB did not increase the risk of clinical outcomes.Late catch-up phenomen requiring revascularization was not significant in this study.Part Ⅲ:The predictors of bleeding after Fibrinolytic therapy for ST-segment elevation myocardial infarctionBackground and Objectives:Fibrinolytic therapy remains a mainstay of acute reperfusion for patients with ST segment elevation myocardial infarction(STEMI)in many countries and is the only treatment option in settings where primary percutaneous coronary intervention(PCI)is not available.Bleeding is a common complication effecting the prognosis of patients above.Most prediction tools assessing the bleeding risk after fibrinolysis were derived from western populations with acute ischemic stroke patients.In this current study we sought to explore the risk factors of bleeding after fibrinolytic therapy in a Chinese population,and to develop a risk prediction tool for bleeding after fibrinolysis derived from a comprehensive multivariate analysis.Methods:Databases from the China Patient.centered Evaluative Assessment of Cardiac Evems(China PEACE)Retrospective AMI Study were utilized for model derivation(n=3257).A multivariable forward stepwise logistic regression was used to examine correlates of in-hospital bleeding,and the variables were subsequently weighted and integrated into a scoring system.Results:We performed multivariate regression analysis that demonstrated 5 variables which remained statistically significantly associated with the in-hospital bleeding were included in the final model.The variables included:time from symptom onset to admission,systolic blood pressure,creatine,white blood cell count and history of diabetes.The c statistic for the model was 0.65(95%confidence interval[CI]:0.61 to 0.69,p<0.01).Conclusion:This risk score is a simple robust tool for predicting the in-hospital bleeding risk of patients with STEMI undergoing fibrinolytic therapy.