Division of Cardiovascular Medicine, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, 1900 University Boulevard Birmingham, AL 35233, USA.
Eur Heart J Qual Care Clin Outcomes. 2017 Jul 1;3(3):173-182. doi: 10.1093/ehjqcco/qcx008.
The optimal revascularization strategy for left main coronary artery disease (LMD) remains controversial, especially with two recent randomized controlled trials showing conflicting results. We sought to address this controversy with our analysis.
Comprehensive literature search was performed. We compared percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for LMD revascularization using standard meta-analytic techniques. A 21% higher risk of long-term major adverse cardiac and cerebrovascular event [MACCE; composite of death, myocardial infarction (MI), stroke, and repeat revascularization] was observed in patients undergoing PCI in comparison with CABG [risk ratio (RR) 1.21, 95% confidence interval (CI) 1.05-1.40]. This risk was driven by higher rate of repeat revascularization in those undergoing PCI (RR 1.61, 95% CI 1.34-1.95). On the contrary, MACCE rates at 30 days were lower in PCI when compared with CABG (RR 0.55, 95% CI 0.39-0.76), which was driven by lower rates of stroke in the PCI arm (RR 0.41, 95% CI 0.17-0.98). At 1 year, lower stroke rates (RR 0.21, 95% CI 0.08-0.59) in the PCI arm were balanced by higher repeat revascularization rates in those undergoing PCI (RR 1.78, 95% CI 1.33-2.37), resulting in a clinical equipoise in MACCE rates between the two revascularization strategies. There was no difference in death or MI between PCI when compared with CABG at any time point.
Outcomes of CABG vs. PCI for LMD revascularization vary over time. Therefore, individualized decisions need to be made for LMD revascularization using the heart team approach.
左主干冠状动脉疾病（LMD）的最佳血运重建策略仍存在争议，特别是最近两项随机对照试验的结果相互矛盾。我们试图通过分析来解决这一争议。
进行了全面的文献检索。我们使用标准的荟萃分析技术比较了 LMD 血运重建中经皮冠状动脉介入治疗（PCI）和冠状动脉旁路移植术（CABG）的效果。与 CABG 相比，PCI 患者发生长期主要不良心脑血管事件（MACCE；包括死亡、心肌梗死（MI）、卒中和再次血运重建）的风险增加 21%[风险比（RR）1.21，95%置信区间（CI）1.05-1.40]。这一风险是由 PCI 患者再次血运重建率较高所致（RR 1.61，95%CI 1.34-1.95）。相反，与 CABG 相比，PCI 患者的 30 天 MACCE 发生率较低（RR 0.55，95%CI 0.39-0.76），这是由于 PCI 组的卒中发生率较低（RR 0.41，95%CI 0.17-0.98）所致。在 1 年时，PCI 组的卒中发生率较低（RR 0.21，95%CI 0.08-0.59），但再次血运重建率较高（RR 1.78，95%CI 1.33-2.37），这两种血运重建策略在 MACCE 发生率上达到了临床平衡。与 CABG 相比，PCI 组在任何时间点的死亡率或 MI 发生率均无差异。
CABG 与 PCI 治疗 LMD 血运重建的结果随时间而变化。因此，需要通过心脏团队方法对 LMD 血运重建做出个体化决策。
