American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland.
American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland; III Clinical Department of Cardiology, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland.
Am J Cardiol. 2014 Oct 1;114(7):979-87. doi: 10.1016/j.amjcard.2014.07.008. Epub 2014 Jul 16.
The optimal revascularization strategy in patients with complex coronary artery disease and non-ST-segment elevation acute coronary syndromes is undetermined. In this multicenter, prospective registry, 4,566 patients with non-ST-segment elevation myocardial infarctions, unstable angina, and multivessel coronary disease, including left main disease, were enrolled. After angiography, 3,033 patients were selected for stenting (10.3% received drug-eluting stents) and 1,533 for coronary artery bypass grafting. Propensity scores were used for baseline characteristic matching and result adjustment. Patients selected for percutaneous coronary intervention (PCI) were younger (mean age 64.4±10 vs 65.2±9 years, p=0.03) and more frequently presented with non-ST-segment elevation myocardial infarctions (32.0% vs 14.5%, p=0.01), cardiogenic shock (1.5% vs 0.7%, p<0.01), and history of PCI (13.1% vs 5.5%, p<0.01) or coronary artery bypass grafting (10.6% vs 4.6%, p<0.01). European System for Cardiac Operative Risk Evaluation scores were higher in PCI patients (5.4±2 vs 5.2±2, p<0.01). Patients referred for coronary artery bypass grafting more often presented with triple-vessel disease and left main disease (82.2% vs 33.8% and 13.7% vs 2.4%, respectively, p<0.01). After adjustment, 929 well-matched pairs were chosen. Early mortality was lower after PCI before matching (2.1% vs 3.1%, p<0.01), whereas after balancing, there was no difference (2.5% vs 2.8%, p=0.62). Three-year survival was in favor of PCI compared with surgery before (87.5% vs 82.8%, hazard ratio 1.44, 95% confidence interval 1.2 to 1.7, p<0.01) and after (86.4% vs 82.3%, hazard ratio 1.33, 95% confidence interval 1.05 to 1.7, p=0.01). Stenting was associated with improved outcomes in the following subgroups: patients aged >65 years, women, patients with unstable angina, those with European System for Cardiac Operative Risk Evaluation scores>5, those with Thrombolysis In Myocardial Infarction (TIMI) risk scores >4, those receiving drug-eluting stents, and those with 2-vessel disease. In conclusion, in patients presenting with non-ST-segment elevation acute coronary syndromes and complex coronary artery disease, immediate stenting was associated with lower mortality risk in the long term compared with surgical revascularization, especially in subgroups at high clinical risk.
在患有复杂冠状动脉疾病和非 ST 段抬高型急性冠状动脉综合征的患者中，最佳血运重建策略尚未确定。在这项多中心前瞻性注册研究中，纳入了 4566 名患有非 ST 段抬高型心肌梗死、不稳定型心绞痛和多支冠状动脉疾病（包括左主干疾病）的患者。在进行血管造影后，选择 3033 名患者进行支架置入术（10.3%接受药物洗脱支架），1533 名患者进行冠状动脉旁路移植术。使用倾向评分进行基线特征匹配和结果调整。选择进行经皮冠状动脉介入治疗（PCI）的患者更年轻（平均年龄 64.4±10 岁 vs 65.2±9 岁，p=0.03），更常出现非 ST 段抬高型心肌梗死（32.0% vs 14.5%，p=0.01）、心源性休克（1.5% vs 0.7%，p<0.01）和 PCI 史（13.1% vs 5.5%，p<0.01）或冠状动脉旁路移植术（10.6% vs 4.6%，p<0.01）史。PCI 患者的欧洲心脏手术风险评估系统评分更高（5.4±2 分 vs 5.2±2 分，p<0.01）。选择进行冠状动脉旁路移植术的患者更常出现三血管病变和左主干疾病（82.2% vs 33.8%和 13.7% vs 2.4%，分别，p<0.01）。调整后，选择了 929 对匹配良好的患者。在匹配前，PCI 后早期死亡率较低（2.1% vs 3.1%，p<0.01），但在平衡后，没有差异（2.5% vs 2.8%，p=0.62）。与手术相比，PCI 治疗后 3 年生存率更有利（87.5% vs 82.8%，危险比 1.44，95%置信区间 1.2 至 1.7，p<0.01），调整后也有类似结果（86.4% vs 82.3%，危险比 1.33，95%置信区间 1.05 至 1.7，p=0.01）。在以下亚组中，支架置入术与改善预后相关：年龄>65 岁的患者、女性患者、不稳定型心绞痛患者、欧洲心脏手术风险评估系统评分>5 的患者、血栓形成溶栓心肌梗死（TIMI）风险评分>4 的患者、接受药物洗脱支架的患者以及存在两血管病变的患者。总之，在患有非 ST 段抬高型急性冠状动脉综合征和复杂冠状动脉疾病的患者中，与外科血运重建相比，即刻支架置入术与长期较低的死亡率风险相关，尤其是在高临床风险的亚组中。
