糖尿病合并非ST段抬高型急性冠状动脉综合征多支血管病变患者的外科手术与经皮冠状动脉血运重建治疗：来自急性导管插入术和早期干预分诊策略试验的分析
Surgical versus percutaneous coronary revascularization for multivessel disease in diabetic patients with non-ST-segment-elevation acute coronary syndrome: analysis from the Acute Catheterization and Early Intervention Triage Strategy trial.
作者信息
Ben-Gal Yanai, Mohr Rephael, Feit Frederick, Ohman E Magnus, Kirtane Ajay, Xu Ke, Mehran Roxana, Stone Gregg W
机构信息
From the Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel (Y.B.-G., R. Mohr); Department of Cardiology, New York University School of Medicine (F.F.); Department of Cardiology, Duke University Medical Center, Durham, NC (E.M.O.); Department of Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital (A.K., K.X., G.W.S.); Department of Cardiology, Mount Sinai Medical Center, New York, NY (R. Mehran); and Cardiovascular Research Foundation, New York, NY (A.K., K.X., R. Mehran, G.W.S.).
出版信息
Circ Cardiovasc Interv. 2015 Jun;8(6). doi: 10.1161/CIRCINTERVENTIONS.114.002032.
BACKGROUND
The preferred revascularization strategy for diabetic patients with acute coronary syndromes and multivessel coronary artery disease is uncertain. We evaluated the outcomes of diabetic patients with moderate and high-risk acute coronary syndrome and multivessel disease managed with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG).
METHODS AND RESULTS
Among 13 819 moderate and high-risk acute coronary syndrome patients enrolled in the Acute Catheterization and Early Intervention Triage Strategy (ACUITY) trial, 1772 diabetic patients had multivessel disease with left anterior descending artery involvement and were managed by PCI (n=1349) or CABG (n=423). Propensity scoring was applied to adjust for differences in baseline clinical and angiographic characteristics, yielding a total of 326 matched patients (163 managed by PCI and 163 managed by CABG). At 30 days, treatment with PCI compared with CABG was associated with lower rates of major bleeding (15.3% versus 55.6%; P<0.0001), blood transfusions (9.2% versus 43.2%; P<0.0001), and acute kidney injury (13.4% versus 33.6%; P<0.0001), but more unplanned revascularization procedures (6.9% versus 1.9%; P=0.03). At 1 year PCI was associated with higher rates of repeat revascularization procedures (19.5% versus 5.2%; P=0.0001), with nonsignificantly different rates of myocardial infarction, stroke, and death at either 30 days or 1 year.
CONCLUSIONS
In the large-scale ACUITY trial, diabetic patients with acute coronary syndrome and multivessel disease treated with PCI rather than CABG had less bleeding and acute kidney injury, greater need for repeat revascularization procedures, and comparable rates of myocardial infarction, stroke, and death through 1-year follow-up.
CLINICAL TRIAL REGISTRATION
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.
背景
糖尿病合并急性冠状动脉综合征及多支冠状动脉疾病患者的首选血运重建策略尚不确定。我们评估了接受经皮冠状动脉介入治疗（PCI）与冠状动脉旁路移植术（CABG）的中度和高危急性冠状动脉综合征合并多支血管疾病的糖尿病患者的预后。
方法与结果
在纳入急性导管插入术和早期干预分诊策略（ACUITY）试验的13819例中度和高危急性冠状动脉综合征患者中，1772例糖尿病患者患有累及左前降支的多支血管疾病，并接受了PCI（n = 1349）或CABG（n = 423）治疗。应用倾向评分来调整基线临床和血管造影特征的差异，共产生326例匹配患者（163例接受PCI治疗，163例接受CABG治疗）。在30天时，与CABG相比，PCI治疗的主要出血率（15.3%对55.6%；P<0.0001）、输血率（9.2%对43.2%；P<0.0001）和急性肾损伤率（13.4%对33.6%；P<0.0001）较低，但非计划血运重建手术更多（6.9%对1.9%；P = 0.03）。在1年时，PCI与更高的重复血运重建手术率相关（19.5%对5.2%；P = 0.0001），在30天或1年时心肌梗死、中风和死亡率无显著差异。
结论
在大规模ACUITY试验中，接受PCI而非CABG治疗的急性冠状动脉综合征合并多支血管疾病的糖尿病患者出血和急性肾损伤较少，重复血运重建手术的需求更大，在1年随访中，心肌梗死、中风和死亡率相当。
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