White Anthony J, Kedia Gautam, Mirocha James M, Lee Michael S, Forrester James S, Morales Walter C, Dohad Suhail, Kar Saibal, Czer Lawrence S, Fontana Gregory P, Trento Alfredo, Shah Prediman K, Makkar Raj R
Cedars-Sinai Medical Center, University of California, Los Angeles School of Medicine, Los Angeles, California 90048, USA.
JACC Cardiovasc Interv. 2008 Jun;1(3):236-45. doi: 10.1016/j.jcin.2008.02.007.
The purpose of this study was to compare outcomes for drug-eluting stents (DES) and coronary artery bypass graft (CABG) surgery in patients with unprotected left main coronary artery (ULMCA) stenosis.
Expert guidelines recommend coronary artery bypass graft (CABG) surgery for the treatment of significant stenosis of the unprotected left main coronary artery (ULMCA) if the patient is eligible for CABG; however, treatment by percutaneous coronary intervention (PCI) is common.
Details of patients (n = 343, ages 69.9 +/- 11.9 years) undergoing coronary revascularization for ULMCA stenosis (April 2003 to January 2007) were recorded. A total of 223 patients were treated with CABG (mean [interquartile range]: follow-up 600 [226 to 977) days) and 120 by PCI (follow-up 362 [192 to 586) days). The hazard ratios (HRs) for death and major adverse cardiovascular and cerebrovascular events (MACCE) were calculated incorporating propensity score adjustment. Survival comparisons were conducted in propensity-matched subjects (n = 134), and in low- and high-risk subjects for CABG.
Patients treated by PCI were more likely to be >or=75 years of age (49% vs. 33%; p = 0.005), and of greater surgical risk (Parsonnet score 17.2 +/- 11.2 vs. 13.0 +/- 9.3; p < 0.001) than patients treated by CABG. Overall, the propensity-adjusted HR for death was not statistically different (HR 1.93, 95% confidence interval [CI] 0.89 to 4.19, p = 0.10), but MACCE was greater in the PCI group (HR 1.83, 95% CI 1.01 to 3.32, p = 0.05). In propensity-matched individuals, neither survival nor MACCE-free survival were different. Survival was equivalent among low-risk candidates, but PCI had a tendency to inferior survival in high-risk candidates (Ellis category IV, log-rank p = 0.05). Interaction testing, however, failed to demonstrate a difference in outcomes of the 2 revascularization techniques as a function of baseline risk assessment.
Overall, the propensity-adjusted risk of mortality for treatment of ULMCA disease does not differ between PCI- and CABG-treated groups. There appears to be sufficient equipoise that a randomized clinical trial to compare the techniques would not be ethically contraindicated.
本研究旨在比较药物洗脱支架（DES）与冠状动脉旁路移植术（CABG）治疗无保护左主干冠状动脉（ULMCA）狭窄患者的疗效。
专家指南建议，对于符合冠状动脉旁路移植术（CABG）条件的无保护左主干冠状动脉（ULMCA）严重狭窄患者，应采用冠状动脉旁路移植术（CABG）进行治疗；然而，经皮冠状动脉介入治疗（PCI）也较为常用。
记录了2003年4月至2007年1月期间因ULMCA狭窄接受冠状动脉血运重建的患者（n = 343，年龄69.9±11.9岁）的详细情况。共有223例患者接受了CABG治疗（平均[四分位间距]：随访600[226至977]天），120例接受了PCI治疗（随访362[192至586]天）。计算了纳入倾向评分调整后的死亡风险比（HRs）和主要不良心血管和脑血管事件（MACCE）。在倾向匹配的受试者（n = 134）以及CABG的低风险和高风险受试者中进行了生存比较。
与接受CABG治疗的患者相比，接受PCI治疗的患者年龄≥75岁的可能性更大（49%对33%；p = 0.005），手术风险更高（Parsonnet评分17.2±11.2对13.0±9.3；p < 0.001）。总体而言，倾向调整后的死亡HR无统计学差异（HR 1.93，95%置信区间[CI]0.89至4.19，p = 0.10），但PCI组的MACCE更高（HR 1.83，95%CI 1.01至3.32，p = 0.05）。在倾向匹配的个体中，生存率和无MACCE生存率均无差异。低风险候选者的生存率相当，但PCI在高风险候选者中的生存率有降低趋势（Ellis IV级，对数秩检验p = 0.05）。然而，交互作用检验未能显示两种血运重建技术的结果因基线风险评估而存在差异。
总体而言，PCI和CABG治疗组在治疗ULMCA疾病时经倾向调整后的死亡风险无差异。似乎有足够的 equipoise，即进行一项比较这两种技术的随机临床试验在伦理上并无禁忌。
