经皮冠状动脉介入治疗与冠状动脉旁路移植术治疗慢性肾脏病伴无保护左主干冠状动脉疾病患者的比较效果分析。
Comparative effectiveness analysis of percutaneous coronary intervention versus coronary artery bypass grafting in patients with chronic kidney disease and unprotected left main coronary artery disease.
机构信息
Division of Cardiology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
出版信息
EuroIntervention. 2020 May 20;16(1):27-35. doi: 10.4244/EIJ-D-18-01206.
AIMS
Outcomes according to the status of renal insufficiency have not been fully evaluated in left main coronary artery disease (LMCAD). In the present study therefore, we sought to evaluate clinical outcomes in patients with significant LMCAD stratified by the degree of renal insufficiency and the relative clinical outcomes after PCI and CABG stratified by the differential levels of renal function using data from the large multinational "all-comers" Interventional Research Incorporation Society-Left MAIN Revascularization (IRIS-MAIN) registry.
METHODS AND RESULTS
Among 4,894 patients with LMCAD, renal insufficiency was graded according to the estimated glomerular filtration rate (eGFR). The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), defined as death, myocardial infarction, stroke, or any revascularisation. The patients were stratified into three groups according to eGFR: 3,824 (78%) in group 1 (eGFR ≥60 ml·min-1·1.73 m2), 838 (17%) in group 2 (eGFR ≥30 and <60), and 232 (5%) in group 3 (eGFR <30). At two years, after adjustment, compared with group 1, the risk of MACCE was significantly higher in group 2 (hazard ratio [HR] 1.46, 95% confidence interval [CI]: 1.18-1.79) and in group 3 (HR 3.39, 95% CI: 2.61-4.40). The p interaction for MACCE across groups was 0.20. The adjusted risk of MACCE was similar between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in groups 1 and 2. However, PCI was associated with a significantly higher risk of MACCE compared to CABG (HR 1.88, 95% CI: 1.08-3.25) in group 3.
CONCLUSIONS
The degree of renal insufficiency was proportionately associated with unfavourable outcomes in patients with LMCAD. In group 3, PCI was associated with a higher risk of MACCE compared with CABG. Also, the effect of PCI versus CABG on MACCE was consistent, with PCI being associated with less bleeding and CABG being associated with less repeat revascularisation.
目的
在左主干冠状动脉疾病（LMCAD）中，肾功能不全的预后尚未得到充分评估。因此，本研究旨在利用大型多国“所有患者”介入研究协会-左主干血运重建（IRIS-MAIN）注册登记处的数据，根据肾功能不全程度评估有显著 LMCAD 患者的临床预后，并根据肾功能的不同水平评估经皮冠状动脉介入治疗（PCI）和冠状动脉旁路移植术（CABG）后的相对临床预后。
方法和结果
在 4894 例 LMCAD 患者中，根据估算肾小球滤过率（eGFR）对肾功能不全进行分级。主要终点为主要不良心脑血管事件（MACCE），定义为死亡、心肌梗死、卒中和任何血运重建。根据 eGFR 将患者分为三组：eGFR≥60ml·min-1·1.73m2 组 3824 例（78%），eGFR≥30 且<60 组 838 例（17%），eGFR<30 组 232 例（5%）。两年后，经调整后，与 eGFR≥60ml·min-1·1.73m2 组相比，eGFR≥30 且<60 组（HR 1.46，95%CI：1.18-1.79）和 eGFR<30 组（HR 3.39，95%CI：2.61-4.40）的 MACCE 风险显著更高。MACCE 组间的 p 交互作用为 0.20。在 eGFR≥30 且<60 组和 eGFR<30 组中，PCI 与 CABG 的 MACCE 调整风险相似。然而，与 CABG 相比，eGFR<30 组中 PCI 与 MACCE 风险显著更高（HR 1.88，95%CI：1.08-3.25）。
结论
肾功能不全程度与 LMCAD 患者的不良预后呈比例相关。在 eGFR<30 组中，与 CABG 相比，PCI 与 MACCE 风险更高。此外，PCI 与 CABG 对 MACCE 的影响一致，PCI 与出血减少相关，CABG 与再次血运重建减少相关。
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