无保护左主干血运重建：经皮冠状动脉介入治疗与冠状动脉旁路移植术。随机对照试验的最新系统评价和荟萃分析。
Unprotected left main revascularization: Percutaneous coronary intervention versus coronary artery bypass. An updated systematic review and meta-analysis of randomised controlled trials.
作者信息
Testa Luca, Latib Azeem, Bollati Mario, Antonio Montone Rocco, Colombo Antonio, Crea Filippo, Bedogni Francesco
机构信息
Dept. of Cardiology, IRCCS Pol S. Donato, Milan, Italy.
Interventional Cardiology Unit, San Raffaele Scientific Institute; EMO GVM Centro Cuore Columbus Milan, Italy.
出版信息
PLoS One. 2017 Jun 28;12(6):e0179060. doi: 10.1371/journal.pone.0179060. eCollection 2017.
BACKGROUND
The optimal treatment of unprotected left main (UPLM) with either PCI or CABG remains uncertain.
AIM
The purpose of this study was to determine the comparative safety and efficacy of PCI versus CABG in patients with UPLM disease.
METHODS
Search of BioMedCentral, CENTRAL, mRCT, PubMed, major cardiological congresses proceedings and references cross-check (updated November 2016). Outcomes were the rate of MACE [all cause death, MI, stroke], the rates of the individual components of MACE and the rate of target vessel revascularisation (TVR).
RESULTS
We identified 6 Randomised Controlled Trials totalling 4717 patients allocated to PCI or CABG. At 1 year follow up, PCI and CABG were substantially equivalent with respect to the rates of MACE [PCI 8.5% vs CABG 8.9%, OR 1.02,(0.76-1.36), p = 0.9], death [PCI 5.4% vs CABG 6.6%, OR 0.81,(0.63-1.03),p = 0.08] and MI [PCI 3.4% vs CABG 4.3%, OR 0.80(0.59-1.07), p = 0.14]. Notably, PCI was associated with a significantly lower rate of stroke [PCI 0.6% vs CABG 1.8%, OR 0.36,(0.17-0.79), p = 0.01] and with a significantly higher rate of TVR [PCI 8.7% vs CABG 4.5%, OR 2.00(1.46-2.75), p<0.01]. At a median follow up of 5years, the rates of MACE were similar between the two strategies: PCI 14.6% vs CABG 13.8%, OR 1.02(0.76-1.38), p = 0.89. Likewise, the rates of death [PCI 8% and CABG 7.7%, OR 1(0.77-1.31), P = 0.9], MI [PCI 6.1% vs CABG 5%, OR 1.41(0.85-2.34), P = 0.19, I2 59%], and stroke [PCI 2% vs CABG 2.2%, OR 0.85(0.42-1.81), p = 0.65,] were similar while PCI was associated with a significantly higher rate of TVR [14.5% vs CABG 8.9%, OR 1.73(1.41-2.13), p<0.01].
CONCLUSION
In patients with UPLM disease, PCI and CABG are associated with similar rates of MACE and mortality at 1 year as well as after 5 years. Differences can be detected for individual end points at both short and long term FU.
背景
对于无保护左主干（UPLM）病变，采用经皮冠状动脉介入治疗（PCI）还是冠状动脉旁路移植术（CABG）进行最佳治疗仍不确定。
目的
本研究旨在确定UPLM疾病患者中PCI与CABG相比的安全性和疗效。
方法
检索生物医学中心、Cochrane系统评价数据库、中国知网、PubMed、主要心脏病学大会论文集并进行参考文献交叉核对（2016年11月更新）。观察指标为主要不良心血管事件（MACE）发生率[全因死亡、心肌梗死（MI）、中风]、MACE各单项组成部分的发生率以及靶血管血运重建（TVR）率。
结果
我们纳入了6项随机对照试验，共纳入4717例分配接受PCI或CABG治疗的患者。在1年随访时，PCI和CABG在MACE发生率方面基本相当[PCI为8.5%，CABG为8.9%，比值比（OR）为1.02，（0.76 - 1.36），p = 0.9]，死亡发生率方面[PCI为5.4%，CABG为6.6%，OR为0.81，（0.63 - 1.03），p = 0.08]，MI发生率方面[PCI为3.4%，CABG为4.3%，OR为0.80（0.59 - 1.07），p = 0.14]。值得注意的是，PCI的中风发生率显著更低[PCI为0.6%，CABG为1.8%，OR为0.36，（0.17 - 0.79），p = 0.01]，而TVR发生率显著更高[PCI为8.7%，CABG为4.5%，OR为2.00（1.46 - 2.75），p<0.01]。在中位随访5年时，两种治疗策略的MACE发生率相似：PCI为14.6%，CABG为13.8%，OR为1.02（0.76 - 1.38），p = 0.89。同样，死亡发生率[PCI为8%，CABG为7.7%，OR为1（0.77 - 1.31），P = 0.9]、MI发生率[PCI为6.1% vs CABG为5%，OR为1.41（0.85 - 2.34），P = 0.19，I²为59%]和中风发生率[PCI为2%，CABG为2.2%，OR为0.85（0.42 - 1.81），p = 0.65]相似，而PCI与显著更高的TVR发生率相关[14.5% vs CABG为8.9%，OR为1.73（1.41 - 2.13），p<0.01]。
结论
对于UPLM疾病患者，PCI和CABG在1年及5年后的MACE发生率和死亡率相似。在短期和长期随访中，各单项终点指标存在差异。
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