Tsuyuki Ross T, Shrive Fiona M, Galbraith P Diane, Knudtson Merril L, Graham Michelle M
Division of Cardiology, University of Alberta, Edmonton, Alta.
CMAJ. 2006 Aug 15;175(4):361-5. doi: 10.1503/cmaj.060108.
Although practice guidelines recommend coronary revascularization for patients with heart failure, the evidence to support this recommendation is weak. The objective of our study was to determine the association of coronary revascularization with survival in patients who have had heart failure.
Data were obtained from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), a clinical outcome-monitoring initiative that has captured data on all patients undergoing cardiac catheterization in the province of Alberta since 1995. Our study included data from patients with a history of heart failure and with documented coronary artery disease; patients with normal coronary arteries or prior coronary artery bypass grafting (CABG) were excluded. We constructed survival curves and adjusted them by the corrected group prognosis method (incorporating all clinical variables in APPROACH). Propensity scores were used to account for clinical characteristics that could influence the decision to revascularize.
A total of 2538 patients (mean age 68 yr, standard deviation [SD] 11 yr, 31% female) underwent revascularization; 1690 patients (mean age 69 [SD 11] yr, 34% female) did not. Crude 1-year mortality was 11.8% among patients who underwent revascularization, compared with 21.6% among those who did not. Adjusted survival curves diverged early and continued up to 7 years of follow-up (hazard ratio 0.50, 95% confidence interval 0.44-0.57). Propensity scores showed improved survival with revascularization across all quintiles of likelihood of revascularization.
This new evidence lends support to practice guidelines, which recommend revascularization in patients with heart failure and coronary disease.
尽管实践指南推荐对心力衰竭患者进行冠状动脉血运重建，但支持这一推荐的证据并不充分。我们研究的目的是确定冠状动脉血运重建与心力衰竭患者生存率之间的关联。
数据来自阿尔伯塔省冠心病结局评估项目（APPROACH），这是一项临床结局监测倡议，自1995年以来收集了阿尔伯塔省所有接受心导管检查患者的数据。我们的研究纳入了有心力衰竭病史且有冠状动脉疾病记录的患者；排除冠状动脉正常或曾接受冠状动脉旁路移植术（CABG）的患者。我们构建了生存曲线，并采用校正组预后方法（纳入APPROACH中的所有临床变量）进行调整。倾向评分用于考虑可能影响血运重建决策的临床特征。
共有2538例患者（平均年龄68岁，标准差[SD]11岁，女性占31%）接受了血运重建；1690例患者（平均年龄69[SD 11]岁，女性占34%）未接受血运重建。接受血运重建的患者1年粗死亡率为11.8%，未接受血运重建的患者为21.6%。调整后的生存曲线在早期出现分歧，并持续至7年随访期（风险比0.50，95%置信区间0.44 - 0.57）。倾向评分显示，在血运重建可能性的所有五分位数中，血运重建均能改善生存情况。
这一新证据支持了实践指南，指南推荐对心力衰竭和冠心病患者进行血运重建。
