Iqbal M Bilal, Smith Robert D, Lane Rebecca, Patel Niket, Mattar Wala, Kabir Tito, Panoulas Vasileios, Mason Mark, Dalby Miles C, Grocott-Mason Richard, Ilsley Charles D
Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, United Kingdom.
Department of Cardiology, Royal Jubilee Hospital, Vancouver Island Health Authority, Victoria, British Columbia, Canada.
Catheter Cardiovasc Interv. 2018 Jun;91(7):1229-1239. doi: 10.1002/ccd.27331. Epub 2017 Sep 30.
More than half of the patients undergoing percutaneous coronary intervention (PCI) have multivessel disease. Whether complete revascularization impacts long-term mortality or whether selected patients or those with specific coronary anatomy benefit from complete revascularization is unclear.
A total of 14,452 patients underwent PCI between 2004 and 2015 at Harefield Hospital, UK. Of these, 7,076 patients had multivessel disease. We excluded 321 patients with left main-stem stenosis ≥50%, with 6,755 patients included in the analysis (936 patients had complete revascularization).
The unadjusted 3-year mortality rates were lower with complete revascularization (10.8% vs 13.1%, P = 0.047). However, multivariable-adjusted analyses indicated that complete revascularization was not independently associated with mortality (HR = 1.01, 95% CI: 0.78-1.31, P = 0.939). These findings were unchanged when addressing measured confounding using propensity-matched analyses (HR = 1.16, 95% CI: 0.81-1.65, P = 0.417) and inverse probability treatment weighted analyses (HR = 1.01, 95% CI: 0.77-1.33, P = 0.950); and unmeasured confounding using instrumental variable analyses (Δ = 0.9%, 95% CI: -2.5%, 4.3%, P = 0.958). There was no association with mortality and untreated LAD disease (HR = 0.92, 95% CI: 0.72-1.17, P = 0.482) and LCx disease (HR = 0.90, 95% CI: 0.74-1.10, P = 0.999). However, untreated proximal LAD disease (HR = 1.23, 95% CI: 1.06-1.51, P = 0.045) and RCA disease (HR = 1.36, 95% CI: 1.08-1.65, P = 0.007) was associated with increased mortality, particularly in patients with ST-elevation acute coronary syndrome (STEACS).
In this study of unselected patients undergoing PCI, complete revascularization did not confer a mortality benefit. However, the presence of untreated proximal LAD and RCA disease was prognostic in patients with STEACS. Thus, complete revascularization may be considered in select patient groups with anatomical subsets of coronary disease.
接受经皮冠状动脉介入治疗（PCI）的患者中，超过一半患有多支血管病变。完全血运重建是否会影响长期死亡率，或者特定患者或具有特定冠状动脉解剖结构的患者是否能从完全血运重建中获益，目前尚不清楚。
2004年至2015年期间，英国哈雷菲尔德医院共有14452例患者接受了PCI治疗。其中，7076例患者患有多支血管病变。我们排除了321例左主干狭窄≥50%的患者，6755例患者纳入分析（936例患者接受了完全血运重建）。
未调整的3年死亡率在完全血运重建组较低（10.8%对13.1%，P = 0.047）。然而，多变量调整分析表明，完全血运重建与死亡率无独立相关性（HR = 1.01，95%CI：0.78 - 1.31，P = 0.939）。当使用倾向匹配分析（HR = 1.16，95%CI：0.81 - 1.65，P = 0.417）和逆概率治疗加权分析（HR = 1.01，95%CI：0.77 - 1.33，P = 0.950）处理测量到的混杂因素时，这些结果不变；使用工具变量分析处理未测量到的混杂因素时结果也不变（Δ = 0.9%，95%CI：-2.5%，4.3%，P = 0.958）。死亡率与未治疗的左前降支病变（HR = 0.92，95%CI：0.72 - 1.17，P = 0.482）和回旋支病变（HR = 0.90，95%CI：0.74 - 1.10，P = 0.999）无关。然而，未治疗的近端左前降支病变（HR = 1.23，95%CI：1.06 - 1.51，P = 0.045）和右冠状动脉病变（HR = 1.36，95%CI：1.08 - 1.65，P = 0.007）与死亡率增加相关，特别是在ST段抬高型急性冠状动脉综合征（STEACS）患者中。
在这项对未选择的接受PCI治疗患者的研究中，完全血运重建并未带来死亡率获益。然而，未治疗的近端左前降支和右冠状动脉病变对STEACS患者具有预后意义。因此，对于具有特定冠状动脉解剖亚组的特定患者群体，可考虑进行完全血运重建。
