Wijeysundera Harindra C, Bennell Maria C, Qiu Feng, Ko Dennis T, Tu Jack V, Wijeysundera Duminda N, Austin Peter C
Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite A202, Toronto, ON, M4N3M5, Canada,
J Gen Intern Med. 2014 Jul;29(7):1031-9. doi: 10.1007/s11606-014-2813-1. Epub 2014 Mar 8.
Randomized studies have shown optimal medical therapy to be as efficacious as revascularization in stable ischemic heart disease (IHD). It is not known if these efficacy results are reflected by real-world effectiveness.
To evaluate the comparative effectiveness of routine medical therapy versus revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in stable IHD.
Observational cohort study.
Stable IHD patients from 1 October 2008 to 30 September 2011, identified using a Registry of all angiography patients in Ontario, Canada.
Revascularization, defined as PCI/CABG within 90 days after index angiography.
Death, myocardial infarction (MI) or repeat PCI/CABG. Revascularization was compared to medical therapy using a) multivariable Cox-proportional hazard models with therapy strategy treated as a time-varying covariate; and b) a propensity score matched analysis. Post-angiography medication use was determined.
We identified 39,131 stable IHD patients, of whom 15,139 were treated medically, and 23,992 were revascularized (PCI = 15,604; CABG = 8,388). Mean follow-up was 2.5 years. Revascularization was associated with fewer deaths (HR 0.76; 95 % CI 0.68-0.84; p < 0.001) ,MIs (HR 0.78; 95 % CI 0.72-0.85; p < 0.001) and repeat PCI/CABG (HR 0.59; 95 % CI 0.50-0.70; p < 0.001) than medical therapy. In the propensity-matched analysis of 12,362 well-matched pairs of revascularized and medical therapy patients, fewer deaths (8.6 % vs 12.7 %; HR 0.75; 95 % CI 0.69-0.81; p < 0.001) , MIs (11.7 % vs 14.4 %; HR 0.84; 95 % CI 0.77-0.93 p < 0.001) and repeat PCI/CABG ( 17.4 % vs 24.1 %;HR 0.67; 95 % 0.63-0.71; p < 0.001) occurred in revascularized patients, over the 4.1 years of follow-up. The revascularization patients had higher uptake of clopidogrel (70.3 % vs 27.2 %; p < 0.001), β-blockers (78.2 % vs 76.7 %; p = 0.010), and statins (94.7 % vs 91.5 %, p < 0.001) in the 1-year post-angiogram.
Stable IHD patients treated with revascularization had improved risk-adjusted outcomes in clinical practice, potentially due to under-treatment of medical therapy patients.
随机研究表明，在稳定型缺血性心脏病（IHD）中，最佳药物治疗与血运重建同样有效。目前尚不清楚这些疗效结果是否能反映现实世界中的有效性。
评估在稳定型IHD中，常规药物治疗与经皮冠状动脉介入治疗（PCI）或冠状动脉旁路移植术（CABG）血运重建的比较有效性。
观察性队列研究。
2008年10月1日至2011年9月30日的稳定型IHD患者，通过加拿大安大略省所有血管造影患者登记处确定。
血运重建，定义为在首次血管造影后90天内进行PCI/CABG。
死亡、心肌梗死（MI）或再次进行PCI/CABG。使用以下方法将血运重建与药物治疗进行比较：a）将治疗策略视为时变协变量的多变量Cox比例风险模型；b）倾向评分匹配分析。确定血管造影后的药物使用情况。
我们确定了39131例稳定型IHD患者，其中15139例接受药物治疗，23992例接受血运重建（PCI = 15604；CABG = 8388）。平均随访2.5年。与药物治疗相比，血运重建与更少的死亡（风险比[HR] 0.76；95%置信区间[CI] 0.68 - 0.84；p < 0.001）、心肌梗死（HR 0.78；95% CI 0.72 - 0.85；p < 0.001）和再次进行PCI/CABG（HR 0.59；95% CI 0.50 - 0.70；p < 0.001）相关。在对12362对匹配良好的血运重建和药物治疗患者进行的倾向匹配分析中，在4.1年的随访期间，血运重建患者的死亡（8.6%对12.7%；HR 0.75；95% CI 0.69 - 0.81；p < 0.001）、心肌梗死（11.7%对14.4%；HR 0.84；95% CI 0.77 - 0.93；p < 0.001）和再次进行PCI/CABG（17.4%对24.1%；HR 0.67；95% CI 0.63 - 0.71；p < 0.001）发生率更低。血运重建患者在血管造影后1年内氯吡格雷（70.3%对27.2%；p < 0.001）、β受体阻滞剂（78.2%对76.7%；p = 0.010）和他汀类药物（94.7%对91.5%，p < 0.001）的使用率更高。
在临床实践中，接受血运重建治疗的稳定型IHD患者经风险调整后的结局得到改善，这可能是由于药物治疗患者治疗不足所致。
