多血管病变糖尿病患者旁路移植与药物洗脱支架的 14 项试验的荟萃分析。

Meta-analysis of 14 trials comparing bypass grafting vs drug-eluting stents in diabetic patients with multivessel coronary artery disease.

机构信息

Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.

出版信息

Nutr Metab Cardiovasc Dis. 2014 Apr;24(4):344-54. doi: 10.1016/j.numecd.2013.11.002. Epub 2013 Dec 4.

DOI:10.1016/j.numecd.2013.11.002

PMID:24373711

Abstract

BACKGROUND AND AIM

Clinical trials have reported lower mortality and repeated revascularization rate in diabetic patients treated with coronary artery bypass grafting (CABG) as compared to percutaneous revascularization. However, these studies were conducted in the era of bare-metal stents. Therefore, we performed a meta-analysis to compare CABG to PCI with drug-eluting stents (DES) in diabetic patients with multivessel and/or left main disease.

METHODS AND RESULTS

The literature was scanned by formal search of electronic databases (Medline, EMBASE, and Cochrane databases), and major international scientific session abstracts from 2000 to 2013. Primary endpoint was mortality. A total of 14 (4 randomized and 10 non-randomized) trials were finally included, with a total of 7072 patients. Up to 5 years follow-up, CABG was associated with a reduction in mortality (7.3% vs 10.4%, OR[95%CI] = 0.65[0.55-0.77], p < 0.0001; phet = 0.00001), with similar results in both RCTs (OR[95%CI] = 0.64[0.50-0.82], p = 0.0005) and NRCTs (OR[95%CI] = 0.75[0.6-0.94)], p = 0.01) (p int = 0.93). A significant relationship was observed between risk profile and benefits in mortality with CABG (p < 0.001). CABG reduced target vessel revascularization (TVR; 5.2% vs 15.7%, OR[95%CI] = 0.30[0.25-0.36], p < 0.00001, p het = 0.02), with a relationship between risk profile and the benefits from CABG as compared to DES (p < 0.0001). CABG was associated with a lower rate of MACCE (14.9% vs 22.9%, OR[95%CI] = 0.59[0.51-0.67], p < 0.00001, p het<0.00001) but higher risk of CVA (3.6% vs 1.4%, OR[95%CI] = 2.34[1.63-3.35], p < 0.00001, p het = 0.71).

CONCLUSIONS

The present meta-analysis demonstrates that among diabetic patients with multivessel disease and/or left main disease, CABG provides benefits in mortality and TVR, especially in high-risk patients but it is counterbalanced by a higher risk of stroke. Future trials are certainly needed in the era of new DES and improved antiplatelet therapies.

摘要

背景和目的

临床研究报告称，与经皮冠状动脉介入治疗（PCI）相比，糖尿病患者接受冠状动脉旁路移植术（CABG）治疗的死亡率和再次血运重建率更低。然而，这些研究是在裸金属支架时代进行的。因此，我们进行了一项荟萃分析，比较了多支血管病变和/或左主干病变的糖尿病患者接受 CABG 与药物洗脱支架（DES）PCI 的效果。

方法和结果

通过正式检索电子数据库（Medline、EMBASE 和 Cochrane 数据库）和 2000 年至 2013 年的主要国际科学会议摘要进行文献扫描。主要终点是死亡率。最终共纳入 14 项研究（4 项随机对照研究和 10 项非随机对照研究），共 7072 例患者。5 年随访结果显示，CABG 可降低死亡率（7.3%比 10.4%，OR[95%CI] = 0.65[0.55-0.77]，p<0.0001；phet = 0.00001），且在 RCTs（OR[95%CI] = 0.64[0.50-0.82]，p = 0.0005）和 NRCTs（OR[95%CI] = 0.75[0.6-0.94]，p = 0.01）中结果相似（pint = 0.93）。CABG 与死亡率降低之间存在显著的风险相关性（p<0.001）。CABG 可降低靶血管血运重建率（TVR；5.2%比 15.7%，OR[95%CI] = 0.30[0.25-0.36]，p<0.00001，p het = 0.02），且与 DES 相比，CABG 降低死亡率的获益与风险相关（p<0.0001）。CABG 与较低的 MACCE 发生率（14.9%比 22.9%，OR[95%CI] = 0.59[0.51-0.67]，p<0.00001，p het<0.00001）相关，但与更高的中风风险（3.6%比 1.4%，OR[95%CI] = 2.34[1.63-3.35]，p<0.00001，p het = 0.71）相关。