Javaid Aamir, Steinberg Daniel H, Buch Ashesh N, Corso Paul J, Boyce Steven W, Pinto Slottow Tina L, Roy Probal K, Hill Peter, Okabe Teruo, Torguson Rebecca, Smith Kimberly A, Xue Zhenyi, Gevorkian Natalie, Suddath William O, Kent Kenneth M, Satler Lowell F, Pichard Augusto D, Waksman Ron
Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington, DC 20010, USA.
Circulation. 2007 Sep 11;116(11 Suppl):I200-6. doi: 10.1161/CIRCULATIONAHA.106.681148.
Advances in coronary artery bypass grafting (CABG) surgery and percutaneous coronary intervention (PCI) with drug-eluting stents have dramatically improved results of these procedures. The optimal treatment for patients with multivessel coronary artery disease is uncertain given the lack of prospective, randomized data reflecting current practice. This study represents a "real-world" evaluation of current technology in the treatment of multivessel coronary artery disease.
A total of 1680 patients undergoing revascularization for multivessel coronary artery disease were identified. Of these, 1080 patients were treated for 2-vessel disease (196 CABG and 884 PCI) and 600 for 3-vessel disease (505 CABG and 95 PCI). One-year mortality, cerebrovascular events, Q-wave myocardial infarction, target vessel failure, and composite major adverse cardiovascular and cerebrovascular events were compared between the CABG and PCI cohorts. Outcomes were adjusted for baseline covariates and reported as hazard ratios. The unadjusted major adverse cardiovascular and cerebrovascular event rate was reduced with CABG for patients with 2-vessel disease (9.7% CABG versus 21.2% PCI; P<0.001) and 3-vessel disease (10.8% CABG versus 28.4% PCI; P<0.001). Adjusted outcomes showed increased major adverse cardiovascular and cerebrovascular event with PCI for patients with 2-vessel (hazard ratio 2.29; 95% CI 1.39 to 3.76; P=0.01) and 3-vessel disease (hazard ratio 2.90; 95% CI 1.76 to 4.78; P<0.001). Adjusted outcomes for the nondiabetic subpopulation demonstrated equivalent major adverse cardiovascular and cerebrovascular event with PCI for 2-vessel (hazard ratio 1.77; 95% CI 0.96 to 3.25; P=0.07) and 3-vessel disease (hazard ratio 1.70; 95% CI 0.77 to 3.61; P=0.19).
Compared with PCI with drug-eluting stents, CABG resulted in improved major adverse cardiovascular and cerebrovascular event in patients with 2- and 3-vessel coronary artery disease, primarily in those with underlying diabetes. Coronary artery bypass surgery may be the preferred revascularization strategy in diabetic patients with multivessel coronary artery disease.
冠状动脉旁路移植术（CABG）以及药物洗脱支架的经皮冠状动脉介入治疗（PCI）技术取得了进展，极大地改善了这些手术的效果。由于缺乏反映当前实践的前瞻性随机数据，多支冠状动脉疾病患者的最佳治疗方案尚不确定。本研究是对多支冠状动脉疾病治疗中当前技术的一项“真实世界”评估。
共纳入1680例接受多支冠状动脉疾病血运重建的患者。其中，1080例患者为双支血管病变（196例行CABG，884例行PCI），600例为三支血管病变（505例行CABG，95例行PCI）。比较了CABG组和PCI组的1年死亡率、脑血管事件、Q波心肌梗死、靶血管失败以及主要不良心血管和脑血管复合事件。对基线协变量进行调整后得出结果，并以风险比报告。对于双支血管病变患者，CABG组未调整的主要不良心血管和脑血管事件发生率降低（CABG组为9.7%，PCI组为21.2%；P<0.001）；对于三支血管病变患者，该发生率同样降低（CABG组为10.8%，PCI组为28.4%；P<0.001）。调整后的结果显示，双支血管病变患者PCI组的主要不良心血管和脑血管事件增加（风险比2.29；95%可信区间1.39至3.76；P=0.01），三支血管病变患者也如此（风险比2.90；95%可信区间1.76至4.78；P<0.001）。非糖尿病亚组的调整后结果显示，双支血管病变患者PCI组的主要不良心血管和脑血管事件相当（风险比1.77；95%可信区间0.96至3.25；P=0.07），三支血管病变患者也类似（风险比1.70；95%可信区间0.77至3.61；P=0.19）。
与药物洗脱支架PCI相比，CABG可改善双支和三支冠状动脉疾病患者的主要不良心血管和脑血管事件，主要是在合并潜在糖尿病的患者中。冠状动脉旁路移植术可能是多支冠状动脉疾病糖尿病患者首选的血运重建策略。
