Cardiac Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.
Circulation. 2011 May 31;123(21):2373-81. doi: 10.1161/CIRCULATIONAHA.110.005041. Epub 2011 May 16.
This study sought to evaluate the clinical impact of angiographic complete revascularization (CR) after drug-eluting stent implantation or coronary artery bypass graft surgery for multivessel coronary disease.
A total of 1914 consecutive patients with multivessel coronary disease undergoing drug-eluting stent implantation (1400 patients) or coronary artery bypass graft surgery (514 patients) were enrolled. Angiographic CR was defined as revascularization in all diseased segments according to the Synergy Between PCI With Taxus and Cardiac Surgery classification. The outcomes of patients undergoing CR were compared with those undergoing incomplete revascularization (IR) after adjustments with the inverse-probability-of-treatment weighting method. Angiographic CR was performed in 917 patients (47.9%) including 573 percutaneous coronary intervention (40.9%) and 344 coronary artery bypass graft (66.9%) patients. CR patients were younger and had more extensive coronary disease than IR patients. Over 5 years, CR patients had comparable incidences of death (8.9% versus 8.9%; adjusted hazard ratio, 1.04; 95% confidence interval, 0.76 to 1.43; P=0.81), the composite of death, myocardial infarction, and stroke (12.1% versus 11.9%; adjusted hazard ratio, 1.04; 95% confidence interval, 0.79 to 1.36; P=0.80), and the composite of death, myocardial infarction, stroke, and repeat revascularization (22.4% versus 24.9%; adjusted hazard ratio, 0.91; 95% confidence interval, 0.75 to 1.10; P=0.32) compared with IR patients. However, 368 patients (19.2%) with multivessel IR had a greater tendency toward higher risk of death, myocardial infarction, stroke, or repeat revascularization (30.3% versus 22.1%; adjusted hazard ratio, 1.27; 95% confidence interval, 0.97 to 1.66; P=0.079) than those without multivessel IR.
Angiographic CR with drug-eluting stent implantation or coronary artery bypass grafting did not improve long-term clinical outcomes in patients with multivessel disease. This finding supports the strategy of ischemia-guided revascularization.
本研究旨在评估多支血管病变患者行药物洗脱支架植入或冠状动脉旁路移植术后血管造影完全血运重建（CR）的临床影响。
共纳入 1914 例连续多支血管病变患者，分别行药物洗脱支架植入术（1400 例）或冠状动脉旁路移植术（514 例）。血管造影 CR 定义为根据 Synergy Between PCI With Taxus and Cardiac Surgery 分类，所有病变节段的血运重建。对接受 CR 的患者进行分析，并与接受不完全血运重建（IR）的患者进行比较，采用逆概率治疗加权法进行调整。917 例（47.9%）患者行血管造影 CR，其中经皮冠状动脉介入治疗（PCI）573 例（40.9%），冠状动脉旁路移植术 344 例（66.9%）。CR 组患者较 IR 组患者更年轻，且冠状动脉病变更广泛。5 年时，CR 组患者的死亡率（8.9%比 8.9%；调整后危险比，1.04；95%置信区间，0.76 至 1.43；P=0.81）、死亡、心肌梗死和卒中等复合终点事件（12.1%比 11.9%；调整后危险比，1.04；95%置信区间，0.79 至 1.36；P=0.80）以及死亡、心肌梗死、卒中和再次血运重建等复合终点事件（22.4%比 24.9%；调整后危险比，0.91；95%置信区间，0.75 至 1.10；P=0.32）均与 IR 组相似。然而，368 例（19.2%）多支血管 IR 患者的死亡、心肌梗死、卒中和再次血运重建等复合终点事件的风险更高（30.3%比 22.1%；调整后危险比，1.27；95%置信区间，0.97 至 1.66；P=0.079）。
药物洗脱支架植入或冠状动脉旁路移植术后行血管造影 CR 并不能改善多支血管病变患者的长期临床结局。这一发现支持缺血性指导血运重建的策略。
