Pereira Alexandre C, Lopes Neuza H M, Soares Paulo R, Krieger Jose Eduardo, de Oliveira Sergio A, Cesar Luiz A M, Ramires Jose A F, Hueb Whady
Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.
J Am Coll Cardiol. 2006 Sep 5;48(5):948-53. doi: 10.1016/j.jacc.2005.11.094. Epub 2006 Aug 17.
This study examined the predictive power of clinical judgment in the incidence of cardiovascular end points in a group of individuals with multivessel coronary artery disease (CAD) followed up in the MASS II (Medicine, Angioplasty, or Surgery Study II).
There is still no consensus on the best treatment for patients with stable multivessel CAD and preserved left ventricular function.
Preferred treatment allocation was recorded for each of the 611 randomized patients in the MASS II trial before randomization. We have divided our sample according to physician-guided decision and randomization result into two categories: concordant or discordant. The incidence of the points of cardiac death, myocardial infarction, and refractory angina was compared between concordant and discordant patients.
The number of concordant individuals was 292 (48.2%), and this number was not different between the three studied treatments (p = 0.11). A significant difference (p = 0.02) was disclosed because of an increased incidence of combined end point events in discordant patients. In the multivariate Cox hazard model, clinical judgment was a powerful predictor of outcome (p = 0.01) even after adjustment for other covariates. The main subgroup explaining this difference was a significant shift toward a worse outcome in the subgroup of discordant patients who underwent percutaneous coronary intervention (PCI) (p = 0.003).
Angiographic variables were more often used in making clinical decisions regarding PCI than clinical variables, and the only independent predictor of concordance status in the PCI group was the number of diseased vessels (p = 0.01). Our data are a reminder that physician judgment remains an important predictor of outcomes.
本研究在多支冠状动脉疾病（CAD）患者组成的队列中，检测了临床判断对心血管终点事件发生率的预测能力，这些患者来自MASS II（药物、血管成形术或手术研究II）研究并接受随访。
对于稳定型多支CAD且左心室功能保留的患者，最佳治疗方案仍未达成共识。
在MASS II试验中，对611例随机分组患者在随机分组前记录其首选治疗分配情况。我们根据医生指导的决策和随机分组结果将样本分为两类：一致组或不一致组。比较一致组和不一致组患者中心脏死亡、心肌梗死和顽固性心绞痛终点事件的发生率。
一致组个体数量为292例（48.2%），在三种研究治疗方案之间该数量无差异（p = 0.11）。由于不一致组患者联合终点事件发生率增加，出现了显著差异（p = 0.02）。在多变量Cox风险模型中，即使在对其他协变量进行调整后，临床判断仍是结局的有力预测因素（p = 0.01）。解释这一差异的主要亚组是接受经皮冠状动脉介入治疗（PCI）的不一致组患者亚组中结局显著变差（p = 0.003）。
在关于PCI的临床决策中，血管造影变量比临床变量更常被使用，PCI组中一致性状态的唯一独立预测因素是病变血管数量（p = 0.01）。我们的数据提醒我们，医生的判断仍然是结局的重要预测因素。
