Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York City, NY 10029, USA
Peter Munk Cardiac Centre, University of Toronto, 585 University Avenue, Room 4N474, Toronto, Ontario M5G 2N2, Canada.
Eur Heart J. 2016 Dec 7;37(46):3440-3447. doi: 10.1093/eurheartj/ehw378. Epub 2016 Aug 29.
The optimal method of coronary revascularization among patients with diabetes mellitus (DM) and multivessel coronary artery disease (CAD) complicated by chronic kidney disease (CKD) remains unknown.
To examine the impact of coronary artery bypass surgery (CABG) vs. percutaneous coronary intervention (PCI) on cardiovascular outcomes in patients with diabetes with and without CKD.
We conducted an 'as-treated' subgroup analysis of the FREEDOM trial to examine the therapeutic efficacy of CABG vs. PCI among patients with DM stratified by the presence (n = 451) or absence (n = 1392) of CKD. We defined CKD as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m. Baseline characteristics and clinical outcomes were compared between PCI and CABG groups within each CKD stratum. The primary endpoint was the composite occurrence of all-cause death, stroke or myocardial infarction [major adverse cardiovascular and cerebrovascular events (MACCE)]. Event rates were estimated at 5 years using the Kaplan-Meier approach and hazard ratios (HRs) for CABG (vs. PCI) were generated using Cox regression.
Patients with CKD (mean eGFR 47 mL/min/1.73m) were older and more often female compared to those without renal impairment. Over a median follow-up of 3.8 years, the effect of CABG on MACCE was consistent among those with CKD (26.0% vs. 35.6%; HR [95% CI]: 0.73 [0.50-1.05]) and without CKD (16.2% vs. 23.6%; HR [95% CI)]: 0.76 [0.58-1.00]) with no evidence of interaction (p = 0.83). Stroke rates were non-significantly higher with CABG whereas rates of MI and repeat revascularization were significantly reduced with CABG in both groups.
Compared to PCI, the effects of CABG on long-term risks for MACCE observed in the FREEDOM trial are preserved among patients with mild to moderate CKD.
患有糖尿病（DM）和多支冠状动脉疾病（CAD）合并慢性肾脏病（CKD）的患者，其冠状动脉血运重建的最佳方法仍不清楚。
研究冠状动脉旁路移植术（CABG）与经皮冠状动脉介入治疗（PCI）对合并或不合并 CKD 的糖尿病患者心血管结局的影响。
我们对 FREEDOM 试验进行了“按治疗分组”的亚组分析，以检查 CABG 与 PCI 在 DM 患者中的疗效，这些患者根据 CKD 的存在（n=451）或不存在（n=1392）进行分层。我们将 CKD 定义为估计肾小球滤过率（eGFR）<60 mL/min/1.73m。在每个 CKD 亚组内比较 PCI 和 CABG 组之间的基线特征和临床结局。主要终点是全因死亡、卒中和心肌梗死的复合发生率[主要不良心血管和脑血管事件（MACCE）]。使用 Kaplan-Meier 方法估计 5 年时的事件发生率，并使用 Cox 回归生成 CABG（与 PCI 相比）的危险比（HR）。
与无肾功能损害的患者相比，CKD 患者（平均 eGFR 47 mL/min/1.73m）年龄更大，女性更多。在中位随访 3.8 年期间，CABG 对 MACCE 的影响在 CKD 患者中是一致的（26.0% vs. 35.6%；HR[95%CI]：0.73[0.50-1.05]）和无 CKD 患者中也是一致的（16.2% vs. 23.6%；HR[95%CI]：0.76[0.58-1.00]），无交互作用的证据（p=0.83）。CABG 组的中风发生率略高，但 CABG 组的 MI 和再次血运重建率显著降低。
与 PCI 相比，FREEDOM 试验中观察到的 CABG 对轻度至中度 CKD 患者长期 MACCE 风险的影响是一致的。
Zotero 插件