Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.
J Am Coll Cardiol. 2013 Apr 16;61(15):1616-23. doi: 10.1016/j.jacc.2013.01.043.
This study sought to compare the survival of asymptomatic patients with previous revascularization and ischemia, who subsequently underwent repeat revascularization or medical therapy (MT).
Coronary artery disease is progressive and recurring; thus, stress myocardial perfusion scintigraphy (MPS) is widely used to identify ischemia in patients with previous revascularization.
Of 6,750 patients with previous revascularization undergoing MPS between January 1, 2005, and December 31, 2007, we identified 769 patients (age 67.7 ± 9.5 years; 85% men) who had ischemia and were asymptomatic. A propensity score was developed to express the associations of revascularization. Patients were followed up over a median of 5.7 years (interquartile range: 4.7 to 6.4 years) for all-cause death. A Cox proportional hazards model was used to identify the association of revascularization with all-cause death, with and without adjustment for the propensity score. The model was repeated in propensity-matched groups undergoing MT versus revascularization.
Among 769 patients, 115 (15%) underwent revascularization a median of 13 days (interquartile range: 6 to 31 days) after MPS. There were 142 deaths; mortality with MT and revascularization were 18.3% and 19.1% (p = 0.84). In a Cox proportional hazards model (chi-square test = 89.4) adjusting for baseline characteristics, type of previous revascularization, MPS data, and propensity scores, only age and hypercholesterolemia but not revascularization were associated with mortality. This result was confirmed in a propensity-matched group.
Asymptomatic patients with previous revascularization and inducible ischemia on MPS realize no survival benefit from repeat revascularization. In this group of post-revascularization patients, an ischemia-based treatment strategy did not alter mortality.
本研究旨在比较先前接受过血运重建和缺血的无症状患者的生存情况，这些患者随后接受了再次血运重建或药物治疗（MT）。
冠状动脉疾病是进行性和复发性的；因此，应激心肌灌注闪烁显像（MPS）广泛用于识别先前接受过血运重建的患者的缺血。
在 2005 年 1 月 1 日至 2007 年 12 月 31 日期间，我们从 6750 例先前接受过血运重建的患者中识别出 769 例（年龄 67.7±9.5 岁；85%为男性）患有缺血且无症状的患者。我们制定了一个倾向评分来表达血运重建的关联。对所有患者进行了中位 5.7 年（四分位间距：4.7 至 6.4 年）的随访，以评估全因死亡。使用 Cox 比例风险模型来确定血运重建与全因死亡的相关性，同时考虑和不考虑倾向评分的调整。该模型在接受 MT 与血运重建的倾向匹配组中重复使用。
在 769 例患者中，115 例（15%）在 MPS 后中位 13 天（四分位间距：6 至 31 天）接受了血运重建。共有 142 例死亡；MT 和血运重建的死亡率分别为 18.3%和 19.1%（p=0.84）。在 Cox 比例风险模型（卡方检验=89.4）中，调整基线特征、先前血运重建类型、MPS 数据和倾向评分后，只有年龄和高胆固醇血症与死亡率相关，而不是血运重建。在倾向匹配组中也得到了这一结果。
MPS 显示先前接受过血运重建和可诱导缺血的无症状患者从再次血运重建中未获得生存获益。在这组接受过血运重建的患者中，基于缺血的治疗策略并未改变死亡率。
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