Krishnaswami Ashok, McCulloch Charles E, Tawadrous Magdy, Jang James J, Lee Hon, Melikian Vicken, Yee Gennie, Leong Thomas K, Go Alan S
Division of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
Eur J Cardiothorac Surg. 2015 May;47(5):e193-8. doi: 10.1093/ejcts/ezv104.
To determine the relative risks of long-term mortality between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) among patients with end-stage renal disease (ESRD).
We identified 1015 patients with ESRD who underwent coronary revascularization between 1996 and 2008 within Kaiser Permanente Northern California. We obtained clinical variables from health plan databases, state death certificates and social security administration files. Our primary and secondary outcomes, respectively, were all-cause mortality and repeat revascularization. Our primary predictor was CABG compared with PCI. We used a Cox proportional hazards model for multivariable analyses.
The mean age of CABG and PCI patients was similar (64.7 ± 10.6 and 63.4 ± 9.3, respectively, P = 0.06). The CABG group had a higher proportion of diabetics (P = 0.045), and higher nitrate use (P = 0.01). Adjusted for age, gender, race, year of index revascularization, number of vessels intervened, duration of dialysis and baseline comorbidities, patients referred for CABG during the first year had a hazard ratio (HR) of 1.16 [95% confidence interval (CI), 0.80-1.67] for mortality compared with PCI. During Years 1-5, the HR was 0.91 (95% CI, 0.63-1.33) with an overall HR of 0.73 (95% CI, 0.43-1.22). The sub-HR as calculated by the Fine-Gray competing risk model was 0.51 (95% CI, 0.31-0.85).
As there are no randomized clinical trials in this area, our observational study adds to the growing body of literature that suggests a significant decrease in repeat revascularization with CABG and at least equivalency in long-term mortality with CABG when compared with PCI in ESRD patients.
确定终末期肾病（ESRD）患者冠状动脉旁路移植术（CABG）和经皮冠状动脉介入治疗（PCI）后长期死亡的相对风险。
我们纳入了1996年至2008年期间在北加利福尼亚州凯撒医疗集团接受冠状动脉血运重建的1015例ESRD患者。我们从健康计划数据库、州死亡证明和社会保障管理档案中获取临床变量。我们的主要和次要结局分别是全因死亡率和再次血运重建。我们的主要预测因素是CABG与PCI的比较。我们使用Cox比例风险模型进行多变量分析。
CABG组和PCI组患者的平均年龄相似（分别为64.7±10.6和63.4±9.3，P = 0.06）。CABG组糖尿病患者比例更高（P = 0.045），硝酸盐使用量更高（P = 0.01）。在调整年龄、性别、种族、首次血运重建年份、干预血管数量、透析时间和基线合并症后，第一年接受CABG的患者与PCI相比，死亡风险比（HR）为1.16 [95%置信区间（CI），0.80 - 1.67]。在第1 - 5年，HR为0.91（95%CI，0.63 - 1.33），总体HR为0.73（95%CI，0.43 - 1.22）。通过Fine - Gray竞争风险模型计算的亚HR为0.51（95%CI，0.31 - 0.85）。
由于该领域尚无随机临床试验，我们的观察性研究增加了越来越多的文献资料，表明ESRD患者中，与PCI相比，CABG可显著减少再次血运重建，且在长期死亡率方面至少相当。
