Clinical Characteristics Of VAP Patients With Coronary Artery Stenosis And The Prognostic Impact Of PCI

Background:Variant angina pectoris(VAP)is caused by coronary artery spasm(CAS).When epicardial CAS presents as focal or diffuse resulting in coronary artery occlusion and/or subtotal occlusion,transient transmural ischemia occurs.Thus,transient T-wave elevation and/or ST-segment elevation(ST-T elevation)can be seen on the electrocardiogram during the attack of VAP.Studies have found CAS usually occurs in coronary atherosclerotic lesions of varying degrees.Coronary plaque can cause CAS,and CAS can also cause or exacerbate coronary atherosclerosis,leading to plaque progression and damage or rupture.In the clinical treatment of VAP patients with normal or mild coronary artery stenosis,calcium channel blockers(CCBs)and nitrates are usually well controlled with a good prognosis.According to a new study,VAP patients with coronary angiography(CAG)showing significant coronary artery stenosis had significantly worse clinical outcomes and a high incidence of major adverse cardiovascular events(MACE).Whether such VAP patients can be treated with percutaneous coronary intervention(PCI)to improve prognosis is clinically controversial,and there is a lack of large-scale prospective studies.The consensus of domestic experts does not recommend PCI to treat VAP,and the Japanese Circulation Association has classified PCI as a class Ⅱ recommendation for VAP patients with coronary artery stenosis.Therefore,the clinical outcome and prognosis of PCI are still unclear for VAP patients with coronary artery stenosis.Purpose:To investigate the clinical characteristics of VAP patients with coronary artery stenosis and the prognostic impact of PCI,so as to provide evidence for clinical diagnosis and treatment of VAP patients with coronary artery stenosis.Methods:The clinical data of VAP patients who underwent CAG at a multi-center from September 2018 to May 2021 were retrospectively analyzed.VAP patients with coronary artery stenosis were selected and their clinical characteristics were analyzed.These patients were divided into two groups according to whether PCI was performed,and the clinical outcomes and long-term prognosis of the two groups were compared during the follow-up period.Result:1.A total of 221 VAP patients were enrolled and divided into two groups according to the presence or absence of organic coronary artery stenosis,including 97 patients in the stenosis group and 124 patients in the non-stenosis group.Both groups were mainly middle-aged men,mostly in quiet state.The stenosis group had a higher proportion of men and smokers(P=0.015,P<0.001),and the duration of angina attack was longer(13.74±6.35vsl 1.45 ±5.39min,P=0.010),and there were more mixed predispositions(P<0.001),while the non-stenosis group had more resting patients(P=0.010).2.The coronary arteries of all VAP patients were divided into two groups:spastic coronary artery(n=281)and non-spastic coronary artery(n=382).The incidence of significant stenosis in spastic coronary arteries was higher,and the difference was statistically significant(P=0.001).3.Among VAP patients with coronary artery stenosis,36 were treated with PCI and the remaining 61 were treated with medication alone.PCI group and non-PCI group were divided according to whether or not PCI was performed.The degree of coronary artery stenosis in the PCI group was significantly higher than that in the non-PCI group.And there was no statistical difference in other clinical features(76.06±6.81vs67.97±7.90%,P<0.001).4.The median follow-up was 23(17～29)months.MACE occurred in 6 of the 36 patients in the PCI group and 23 of the 61 patients in the non-PCI group.Comparing the clinical results of the two groups,the incidence of revascularization in the non-PCI group was significantly higher than that in the PCI group(21.3vs5.6%,P=0.038),and the PCI group received less antiangina drugs than the non-PCI group(1.56±0.96vsl.93±0.84,P=0.035).There was no statistical difference in other clinical results.5.Cox univariate analysis showed that PCI was a protective factor for reducing the incidence of MACE in VAP patients with coronary artery stenosis(HAZARD ratio=2.769,95%confidence interval:1.109～6.910,P=0.029).During follow-up,the incidence of MACE was significantly lower in patients treated with PCI compared with those treated without PCI(16.7vs37.8%,P=0.029).PCI was still an independent protective factor for reducing the incidence of MACE after adjusting for multiple risk factors in multivariate analysis(HAZARD ratio=3.028,95%confidence interval:1.031～8.892,P=0.044).6.In the PCI group,6 patients were readmitted for recurrent angina,including 1 patient with CAS in stent-implanted coronary arteries and 5 patients with CAS in non-stent-implanted coronary arteries.Conclusion:1.Significant coronary artery stenosis is not uncommon in patients with VAP,and the incidence of stenosis in spastic coronary arteries is higher.2.PCI is an independent protective factor for the occurrence of MACE in VAP patients with coronary artery stenosis and can improve the long-term prognosis.3.VAP patients still need to receive long-term anti-angina drugs after PCI,because CAS can occur at the site of non-stent implantation.