根据支架亚型分层的手术与经皮冠状动脉血运重建术后的中长期死亡率：对6682例多支血管疾病患者的分析
Mid-to-long term mortality following surgical versus percutaneous coronary revascularization stratified according to stent subtype: An analysis of 6,682 patients with multivessel disease.
作者信息
Raja Shahzad G, Ilsley Charles, De Robertis Fabio, Lane Rebecca, Kabir Tito, Bahrami Toufan, Simon Andre, Popov Aron, Dalby Miles C, Mason Mark, Grocott-Mason Richard, Smith Robert D, Iqbal M Bilal
机构信息
Department of Cardiac Surgery, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, United Kingdom.
Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, United Kingdom.
出版信息
PLoS One. 2018 Feb 6;13(2):e0191554. doi: 10.1371/journal.pone.0191554. eCollection 2018.
BACKGROUND
Studies comparing coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) have largely been performed in the bare-metal stent (BMS) and first-generation drug eluting stent (F-DES) era. Second-generation DES (S-DES) have shown improved outcomes when compared to F-DES, but data comparing CABG with PCI using S-DES is limited. We compared mortality following CABG versus PCI for patients with multivessel disease and analyzed different stent types.
METHODS
A total of 6,682 patients underwent multivessel revascularization at Harefield Hospital, UK. We stratified CABG patients into single arterial graft (SAG) or multiple arterial grafts (MAG); and PCI patients into BMS, F-DES or S-DES groups. We analyzed all-cause mortality at 5 years.
RESULTS
4,388 patients had CABG (n[SAG] = 3,358; n[MAG] = 1,030) and 2,294 patients had PCI (n[BMS] = 416; n[F-DES] = 752; n[S-DES] = 1,126). PCI had higher 5-year mortality with BMS (HR = 2.27, 95% CI:1.70-3.05, p<0.001); F-DES (HR = 1.52, 95% CI:1.14-2.01, p = 0.003); and S-DES (HR = 1.84, 95% CI:1.42-2.38, p<0.001). This was confirmed in inverse probability treatment weighted analyses. When adjusting for both measured and unmeasured factors using instrumental variable analyses, PCI had higher 5-year mortality with BMS (Δ = 15.5, 95% CI:3.6,27.5, p = 0.011) and FDES (Δ = 16.5, 95% CI:6.6,26.4, p<0.001), but had comparable mortality with CABG for PCI with SDES (Δ = 0.9, 95% CI: -9.6,7.9, p = 0.844), and when exclusively compared to CABG patients with SAG (Δ = 0.4, 95% CI: -8.0,8.7, p = 0.931) or MAG (Δ = 4.6, 95% CI: -0.4,9.6, p = 0.931).
CONCLUSIONS
In this real-world analysis, when adjusting for measured and unmeasured confounding, PCI with SDES had comparable 5-year mortality when compared to CABG. This warrants evaluation in adequately-powered randomized controlled trials.
背景
比较冠状动脉旁路移植术（CABG）和经皮冠状动脉介入治疗（PCI）的研究大多是在裸金属支架（BMS）和第一代药物洗脱支架（F-DES）时代进行的。与F-DES相比，第二代DES（S-DES）已显示出更好的治疗效果，但使用S-DES比较CABG和PCI的数据有限。我们比较了多支血管病变患者CABG与PCI后的死亡率，并分析了不同的支架类型。
方法
英国哈雷菲尔德医院共有6682例患者接受了多支血管血运重建。我们将CABG患者分为单动脉移植（SAG）或多动脉移植（MAG）组；PCI患者分为BMS、F-DES或S-DES组。我们分析了5年时的全因死亡率。
结果
4388例患者接受了CABG（n[SAG]=3358；n[MAG]=1030），2294例患者接受了PCI（n[BMS]=416；n[F-DES]=752；n[S-DES]=1126）。使用BMS的PCI患者5年死亡率更高（HR=2.27，95%CI：1.70-3.05，p<0.001）；使用F-DES的患者（HR=1.52，95%CI：1.14-2.01，p=0.003）；以及使用S-DES的患者（HR=1.84，95%CI：1.42-2.38，p<0.001）。这在逆概率治疗加权分析中得到了证实。当使用工具变量分析对测量和未测量因素进行调整时，使用BMS的PCI患者5年死亡率更高（Δ=15.5，95%CI：3.6，27.5，p=0.011）和使用F-DES的患者（Δ=16.5，95%CI：6.6，26.4，p<0.001），但对于使用S-DES的PCI患者，其死亡率与CABG相当（Δ=0.9，95%CI：-9.6，7.9，p=0.844），并且当仅与CABG的SAG患者（Δ=0.4，95%CI：-8.0，8.7，p=0.931）或MAG患者（Δ=4.6，95%CI：-0.4，9.6，p=0.931）比较时也是如此。
结论
在这项真实世界分析中，在对测量和未测量的混杂因素进行调整后，使用S-DES的PCI与CABG相比，5年死亡率相当。这值得在有足够样本量的随机对照试验中进行评估。
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