依维莫司洗脱支架或旁路手术治疗多支冠状动脉疾病。
Everolimus-eluting stents or bypass surgery for multivessel coronary disease.
机构信息
From New York University School of Medicine, New York (S. Bangalore, Y.G., S. Blecker, J.X.); and the School of Public Health, State University of New York at Albany, Albany (Z.S., E.L.H.).
出版信息
N Engl J Med. 2015 Mar 26;372(13):1213-22. doi: 10.1056/NEJMoa1412168. Epub 2015 Mar 16.
BACKGROUND
Results of trials and registry studies have shown lower long-term mortality after coronary-artery bypass grafting (CABG) than after percutaneous coronary intervention (PCI) among patients with multivessel disease. These previous analyses did not evaluate PCI with second-generation drug-eluting stents.
METHODS
In an observational registry study, we compared the outcomes in patients with multivessel disease who underwent CABG with the outcomes in those who underwent PCI with the use of everolimus-eluting stents. The primary outcome was all-cause mortality. Secondary outcomes were the rates of myocardial infarction, stroke, and repeat revascularization. Propensity-score matching was used to assemble a cohort of patients with similar baseline characteristics.
RESULTS
Among 34,819 eligible patients, 9223 patients who underwent PCI with everolimus-eluting stents and 9223 who underwent CABG had similar propensity scores and were included in the analyses. At a mean follow-up of 2.9 years, PCI with everolimus-eluting stents, as compared with CABG, was associated with a similar risk of death (3.1% per year and 2.9% per year, respectively; hazard ratio, 1.04; 95% confidence interval [CI], 0.93 to 1.17; P=0.50), higher risks of myocardial infarction (1.9% per year vs. 1.1% per year; hazard ratio, 1.51; 95% CI, 1.29 to 1.77; P<0.001) and repeat revascularization (7.2% per year vs. 3.1% per year; hazard ratio, 2.35; 95% CI, 2.14 to 2.58; P<0.001), and a lower risk of stroke (0.7% per year vs. 1.0% per year; hazard ratio, 0.62; 95% CI, 0.50 to 0.76; P<0.001). The higher risk of myocardial infarction with PCI than with CABG was not significant among patients with complete revascularization but was significant among those with incomplete revascularization (P=0.02 for interaction).
CONCLUSIONS
In a contemporary clinical-practice registry study, the risk of death associated with PCI with everolimus-eluting stents was similar to that associated with CABG. PCI was associated with a higher risk of myocardial infarction (among patients with incomplete revascularization) and repeat revascularization but a lower risk of stroke. (Funded by Abbott Vascular.).
背景
临床试验和注册研究的结果表明，多支血管病变患者行冠状动脉旁路移植术（CABG）的长期死亡率低于经皮冠状动脉介入治疗（PCI）。这些先前的分析并未评估第二代药物洗脱支架的 PCI。
方法
在一项观察性注册研究中，我们比较了接受 CABG 的多支血管病变患者与接受依维莫司洗脱支架 PCI 的患者的结局。主要结局是全因死亡率。次要结局是心肌梗死、卒中和再次血运重建的发生率。采用倾向评分匹配方法组建基线特征相似的患者队列。
结果
在 34819 名符合条件的患者中，9223 名接受依维莫司洗脱支架 PCI 的患者和 9223 名接受 CABG 的患者具有相似的倾向评分，并纳入分析。平均随访 2.9 年后，与 CABG 相比，依维莫司洗脱支架 PCI 与相似的死亡风险相关（分别为每年 3.1%和 2.9%；风险比，1.04；95%置信区间[CI]，0.93 至 1.17；P=0.50），心肌梗死（每年 1.9%与 1.1%；风险比，1.51；95%CI，1.29 至 1.77；P<0.001）和再次血运重建（每年 7.2%与 3.1%；风险比，2.35；95%CI，2.14 至 2.58；P<0.001）的风险更高，卒中和中风的风险更低（每年 0.7%与 1.0%；风险比，0.62；95%CI，0.50 至 0.76；P<0.001）。完全血运重建患者的 PCI 与 CABG 相比，心肌梗死风险更高，但不完全血运重建患者的 PCI 与 CABG 相比，心肌梗死风险更高（P=0.02 交互作用）。
结论
在一项当代临床实践注册研究中，与依维莫司洗脱支架 PCI 相关的死亡风险与 CABG 相关的死亡风险相似。PCI 与心肌梗死（不完全血运重建患者）和再次血运重建的风险增加相关，但与中风的风险降低相关。（由 Abbott Vascular 资助）。
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