多支冠状动脉旁路移植术与多支经皮冠状动脉介入治疗的疗效比较：一项队列研究。
Comparative effectiveness of multivessel coronary bypass surgery and multivessel percutaneous coronary intervention: a cohort study.
机构信息
Stanford University School of Medicine, Stanford, CA 94305, USA.
出版信息
Ann Intern Med. 2013 May 21;158(10):727-34. doi: 10.7326/0003-4819-158-10-201305210-00639.
BACKGROUND
Randomized trials of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) suggest that patient characteristics modify the effect of treatment on mortality.
OBJECTIVE
To assess whether clinical characteristics modify the comparative effectiveness of CABG versus PCI in an unselected, general patient population.
DESIGN
Observational treatment comparison using propensity score matching and Cox proportional hazards models.
SETTING
United States, 1992 to 2008.
PATIENTS
Medicare beneficiaries aged 66 years or older.
INTERVENTION
Multivessel CABG or multivessel PCI.
MEASUREMENTS
The CABG-PCI hazard ratio (HR) for all-cause mortality, with prespecified treatment-by-covariate interaction tests, and the absolute difference in life-years of survival in clinical subgroups after CABG or PCI, both over 5 years of follow-up.
RESULTS
Among 105 156 propensity score-matched patients, CABG was associated with lower mortality than PCI (HR, 0.92 [95% CI, 0.90 to 0.95]; P < 0.001). Association of CABG with lower mortality was significantly greater (interaction P ≤ 0.002 for each) among patients with diabetes (HR, 0.88), a history of tobacco use (HR, 0.82), heart failure (HR, 0.84), and peripheral arterial disease (HR, 0.85). The overall predicted difference in survival between CABG and PCI treatment over 5 years was 0.053 life-years (range, -0.017 to 0.579 life-years). Patients with diabetes, heart failure, peripheral arterial disease, or tobacco use had the largest predicted differences in survival after CABG, whereas those with none of these factors had slightly better survival after PCI.
LIMITATION
Treatments were chosen by patients and physicians rather than being randomly assigned.
CONCLUSION
Multivessel CABG is associated with lower long-term mortality than multivessel PCI in the community setting. This association is substantially modified by patient characteristics, with improvement in survival concentrated among patients with diabetes, tobacco use, heart failure, or peripheral arterial disease.
PRIMARY FUNDING SOURCE
National Heart, Lung, and Blood Institute.
背景
冠状动脉旁路移植术（CABG）和经皮冠状动脉介入治疗（PCI）的随机试验表明，患者特征可改变治疗对死亡率的影响。
目的
评估在未经选择的普通患者人群中，临床特征是否会改变 CABG 与 PCI 的比较效果。
设计
使用倾向评分匹配和 Cox 比例风险模型进行观察性治疗比较。
设置
美国，1992 年至 2008 年。
患者
年龄在 66 岁或以上的 Medicare 受益人群。
干预措施
多支血管 CABG 或多支血管 PCI。
测量
全因死亡率的 CABG-PCI 风险比（HR），并进行了预设的治疗-协变量交互检验，以及 CABG 或 PCI 后 5 年随访期间临床亚组的生存预期寿命绝对差异。
结果
在 105156 名倾向评分匹配的患者中，CABG 与 PCI 相比死亡率较低（HR，0.92 [95%CI，0.90 至 0.95]；P<0.001）。CABG 与死亡率降低的相关性在糖尿病（HR，0.88）、吸烟史（HR，0.82）、心力衰竭（HR，0.84）和外周动脉疾病（HR，0.85）患者中显著更大（每种情况下的交互 P≤0.002）。CABG 和 PCI 治疗在 5 年内的总体预期生存差异为 0.053 个生命年（范围，-0.017 至 0.579 个生命年）。患有糖尿病、心力衰竭、外周动脉疾病或吸烟的患者，CABG 后生存的预测差异最大，而没有这些因素的患者，PCI 后生存情况略好。
局限性
治疗是由患者和医生选择的，而不是随机分配的。
结论
在社区环境中，多支血管 CABG 与多支血管 PCI 相比，长期死亡率较低。这种关联在很大程度上受到患者特征的影响，生存率的提高集中在患有糖尿病、吸烟、心力衰竭或外周动脉疾病的患者中。
主要资金来源
美国国立心肺血液研究所。
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