Peduzzi P, Detre K, Murphy M L, Thomsen J, Hultgren H, Takaro T
VA Medical Center, West Haven, CT 06516.
Circulation. 1991 Mar;83(3):747-55. doi: 10.1161/01.cir.83.3.747.
The 10-year incidence of myocardial infarction (fatal and nonfatal) and the prognosis after infarction were evaluated in 686 patients with stable angina who were randomly assigned to medical or surgical treatment in the Veterans Administration Cooperative Study of Coronary Artery Bypass Surgery.
Myocardial infarction was defined by either new Q wave findings or clinical symptoms compatible with myocardial infarction accompanied by serum enzyme elevations with or without electrocardiographic findings. Treatment comparisons were made according to original treatment assignment; 35% of the medical cohort had bypass surgery during the 10-year follow-up period. The overall cumulative infarction rate was somewhat higher in patients assigned to surgery (36%) than in medical patients (31%) (p = 0.13) due to perioperative infarctions (13%) and an accelerated infarction rate after the fifth year of follow-up (average, 2.4%/yr in the surgical group versus 1.4%/yr in the medical group). The 10-year cumulative incidence of death or myocardial infarction was also higher in surgical (54%) than in medical (49%) patients (p = 0.20). According to the Cox model, the estimated risk of death after infarction was 59% lower in surgical than in medical patients (p less than 0.0001). The reduction in postinfarction mortality with surgery was most striking in the first month after the event: 99% in the first month (p less than 0.0001) and 49% subsequently (p less than 0.0001). The estimated risk of death in the absence of infarction was nearly identical regardless of treatment (p = 0.75). Exclusion of perioperative infarctions did not alter the findings.
Although surgery does not reduce the incidence of myocardial infarction overall, it does reduce the risk of mortality after infarction, particularly in the first 30 days after the event (fatal infarctions).
在退伍军人管理局冠状动脉搭桥手术合作研究中，对686例稳定型心绞痛患者进行了随机分组，分别接受内科治疗或外科治疗，并评估了心肌梗死（致命性和非致命性）的10年发病率以及梗死后的预后情况。
心肌梗死的定义为出现新的Q波表现，或伴有血清酶升高且有或无心电图表现的符合心肌梗死的临床症状。根据最初的治疗分配进行治疗比较；在10年随访期内，35%的内科队列患者接受了搭桥手术。由于围手术期心肌梗死（13%）以及随访第5年后梗死发生率加速上升（手术组平均每年2.4%，内科组平均每年1.4%），接受手术治疗的患者总体累积梗死率（36%）略高于内科治疗患者（31%）（p = 0.13）。手术患者的死亡或心肌梗死10年累积发生率（54%）也高于内科患者（49%）（p = 0.20）。根据Cox模型，梗死后手术患者的估计死亡风险比内科患者低59%（p < 0.0001）。梗死后手术降低死亡率的效果在事件发生后的第一个月最为显著：第一个月降低99%（p < 0.0001），随后降低49%（p < 0.0001）。无论治疗方式如何，无梗死情况下的估计死亡风险几乎相同（p = 0.75）。排除围手术期心肌梗死并不改变研究结果。
虽然手术总体上并未降低心肌梗死的发生率，但确实降低了梗死后的死亡风险，尤其是在事件发生后的前30天（致命性梗死）。
