Parisi A F, Khuri S, Deupree R H, Sharma G V, Scott S M, Luchi R J
Veterans Administration Medical Centers, West Roxbury, Massachusetts.
Circulation. 1989 Nov;80(5):1176-89. doi: 10.1161/01.cir.80.5.1176.
We evaluated medical in comparison to surgical plus medical (surgical) treatment of unstable angina using a prospective randomized protocol that stratified patients by clinical presentation and by invasive evaluation of left ventricular (LV) function. Clinical presentations were as follows--type 1: progressive or new onset angina relieved by medication; type 2: prolonged bouts of angina poorly or incompletely relieved by medication. Abnormal LV function was arbitrarily defined as ejection fraction less than 0.50 or LV end-diastolic pressure 16 mm Hg or more. Of 468 patients, 237 were assigned to medical and 231 to surgical therapy. There were 374 type 1 and 94 type 2 patients. LV function was normal in 334 and abnormal in 134 patients. Compared with results at 24 months, this 60-month follow-up study showed important differences in survival for patients with three-vessel disease: 75% for medical and 89% for surgical patients (p less than 0.02). The cumulative 5-year rate of repeat hospitalizations for cardiac reasons was less with surgical patients for either clinical presentation. For type 1, medical patients had a 56% rate, and surgical patients had a 42% rate (p = 0.004). For type 2, medical patients had a 62% rate, and surgical patients had a 43% rate (p = 0.05). Overall mortality did not differ between the two treatments, and this remained true in type 1 versus type 2 patients and in those with normal versus abnormal LV function. However, regression analysis of medical and surgical groups with ejection fraction as a continuous variable showed that mortality of medical patients depended on ejection fraction (p = 0.004), whereas the mortality of surgical patients did not (p = 0.76), and survival in the surgical group was higher in the lowest ejection fraction tercile-73% for medical and 86% for surgical patients, p = 0.03. We conclude that surgery improves survival in patients with three-vessel disease and leads to fewer subsequent hospitalizations for cardiac reasons. An impaired ejection fraction had an adverse impact on survival of medical patients but not on surgical patients, and mortality in surgical patients was improved compared with medical patients in the lowest ejection fraction tercile.
我们采用前瞻性随机方案评估了不稳定型心绞痛的内科治疗与外科加内科（外科）治疗的效果，该方案根据临床表现和左心室（LV）功能的侵入性评估对患者进行分层。临床表现如下：1型：进行性或新发心绞痛，药物可缓解；2型：长时间发作的心绞痛，药物缓解不佳或不完全缓解。LV功能异常被随意定义为射血分数低于0.50或LV舒张末期压力为16mmHg或更高。在468例患者中，237例被分配接受内科治疗，231例接受外科治疗。有374例1型患者和94例2型患者。334例患者LV功能正常，134例异常。与24个月时的结果相比，这项60个月的随访研究显示，三支血管病变患者的生存率存在重要差异：内科治疗患者为75%，外科治疗患者为89%（p<0.02）。无论临床表现如何，外科治疗患者因心脏原因再次住院的累积5年发生率均较低。对于1型患者，内科治疗患者的发生率为56%，外科治疗患者为42%（p=0.004）。对于2型患者，内科治疗患者的发生率为62%，外科治疗患者为43%（p=0.05）。两种治疗方法的总体死亡率无差异，在1型与2型患者以及LV功能正常与异常的患者中均如此。然而，将射血分数作为连续变量对内科和外科组进行回归分析显示，内科治疗患者的死亡率取决于射血分数（p=0.004），而外科治疗患者的死亡率则不然（p=0.76），并且在射血分数最低的三分位数中，外科组的生存率更高——内科治疗患者为73%，外科治疗患者为86%，p=0.03。我们得出结论，手术可提高三支血管病变患者的生存率，并减少随后因心脏原因的住院次数。射血分数受损对内科治疗患者的生存有不利影响，但对外科治疗患者没有影响，并且在射血分数最低的三分位数中，外科治疗患者的死亡率与内科治疗患者相比有所改善。
