Marui Akira, Kimura Takeshi, Nishiwaki Noboru, Mitsudo Kazuaki, Komiya Tatsuhiko, Hanyu Michiya, Shiomi Hiroki, Tanaka Shiro, Sakata Ryuzo
Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Cardiovascular Surgery, Nara Hospital Kinki University School of Medicine, Ikoma, Japan.
Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
Am J Cardiol. 2015 Apr 15;115(8):1063-72. doi: 10.1016/j.amjcard.2015.01.544. Epub 2015 Feb 2.
We investigated the impact of diabetes mellitus on long-term outcomes of percutaneous coronary intervention (PCI) in the drug-eluting stent era versus coronary artery bypass grafting (CABG) in a real-world population with advanced coronary disease. We identified 3,982 patients with 3-vessel and/or left main disease of 15,939 patients with first coronary revascularization enrolled in the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2 (patients without diabetes: n = 1,984 [PCI: n = 1,123 and CABG: n = 861], and patients with diabetes: n = 1,998 [PCI: n = 1,065 and CABG: n = 933]). Cumulative 5-year incidence of all-cause death after PCI was significantly higher than after CABG both in patients without and with diabetes (19.8% vs 16.2%, p = 0.01, and 22.9% vs 19.0%, p = 0.046, respectively). After adjusting confounders, the excess mortality risk of PCI relative to CABG was no longer significant (hazard ratio [HR] 1.16; 95% confidence interval [CI] 0.88 to 1.54; p = 0.29) in patients without diabetes, whereas it remained significant (HR 1.31; 95% CI 1.01 to 1.70; p = 0.04) in patients with diabetes. The excess adjusted risks of PCI relative to CABG for cardiac death, myocardial infarction (MI), and any coronary revascularization were significant in both patients without (HR 1.59, 95% CI 1.01 to 2.51, p = 0.047; HR 2.16, 95% CI 1.20 to 3.87, p = 0.01; and HR 3.30, 95% CI 2.55 to 4.25, p <0.001, respectively) and with diabetes (HR 1.45, 95% CI 1.00 to 2.51, p = 0.047; HR 2.31, 95% CI 1.31 to 4.08, p = 0.004; and HR 3.70, 95% CI 2.91 to 4.69, p <0.001, respectively). There was no interaction between diabetic status and the effect of PCI relative to CABG for all-cause death, cardiac death, MI, and any revascularization. In conclusion, in both patients without and with diabetes with 3-vessel and/or left main disease, CABG compared with PCI was associated with better 5-year outcomes in terms of cardiac death, MI, and any coronary revascularization. There was no difference in the direction and magnitude of treatment effect of CABG relative to PCI regardless of diabetic status.
我们在一个患有晚期冠状动脉疾病的真实世界人群中，研究了糖尿病对药物洗脱支架时代经皮冠状动脉介入治疗（PCI）与冠状动脉旁路移植术（CABG）长期预后的影响。我们在京都PCI/CABG注册队列-2中，从15939例首次进行冠状动脉血运重建的患者中，识别出3982例患有三支血管和/或左主干病变的患者（无糖尿病患者：n = 1984 [PCI：n = 1123，CABG：n = 861]；糖尿病患者：n = 1998 [PCI：n = 1065，CABG：n = 933]）。在无糖尿病和有糖尿病的患者中，PCI术后全因死亡的累积5年发生率均显著高于CABG术后（分别为19.8%对16.2%，p = 0.01；22.9%对19.0%，p = 0.046）。在调整混杂因素后，无糖尿病患者中PCI相对于CABG的额外死亡风险不再显著（风险比[HR] 1.16；95%置信区间[CI] 0.88至1.54；p = 0.29），而在糖尿病患者中仍显著（HR 1.31；95% CI 1.01至1.70；p = 0.04）。在无糖尿病（HR 1.59，95% CI 1.01至2.51，p = 0.047；HR 2.16，95% CI 1.20至3.87，p = 0.01；HR 3.30，95% CI 2.55至4.25，p <0.001）和有糖尿病（HR 1.45，95% CI 1.00至2.51，p = 0.047；HR 2.31，95% CI 1.31至4.08，p = 0.004；HR 3.70，95% CI 2.91至4.69，p <0.001）的患者中，PCI相对于CABG在心脏死亡、心肌梗死（MI）和任何冠状动脉血运重建方面的额外调整风险均显著。在全因死亡、心脏死亡、MI和任何血运重建方面，糖尿病状态与PCI相对于CABG的治疗效果之间没有相互作用。总之，在患有三支血管和/或左主干病变的无糖尿病和有糖尿病患者中，就心脏死亡、MI和任何冠状动脉血运重建而言，与PCI相比，CABG与更好的5年预后相关。无论糖尿病状态如何，CABG相对于PCI的治疗效果方向和幅度均无差异。
