Chacko Liza, P Howard James, Rajkumar Christopher, Nowbar Alexandra N, Kane Christopher, Mahdi Dina, Foley Michael, Shun-Shin Matthew, Cole Graham, Sen Sayan, Al-Lamee Rasha, Francis Darrel P, Ahmad Yousif
Imperial College London, United Kingdom (L.C., J.H., C.R., A.N.N., C.K., D.M.,M.F., M.S.-S., G.C., S.S., R.A.-L., D.P.F., Y.A.).
Columbia University Medical Center, New York (Y.A.).
Circ Cardiovasc Qual Outcomes. 2020 Feb;13(2):e006363. doi: 10.1161/CIRCOUTCOMES.119.006363. Epub 2020 Feb 17.
In patients presenting with ST-segment-elevation myocardial infarction, percutaneous coronary intervention (PCI) reduces mortality when compared with fibrinolysis. In other forms of coronary artery disease (CAD), however, it has been controversial whether PCI reduces mortality. In this meta-analysis, we examine the benefits of PCI in (1) patients post-myocardial infarction (MI) who did not receive immediate revascularization; (2) patients who have undergone primary PCI for ST-segment-elevation myocardial infarction but have residual coronary lesions; (3) patients who have suffered a non-ST-segment-elevation acute coronary syndrome; and (4) patients with truly stable CAD with no recent infarct. This analysis includes data from the recently presented International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) and Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI (COMPLETE) trials.
We systematically identified all randomized trials of PCI on a background of medical therapy for the treatment of CAD. The ISCHEMIA trial, presented in November 2019, was eligible for inclusion. Data were combined using a random-effects meta-analysis. The primary end point was all-cause mortality. Forty-six trials, including 37 757 patients, were eligible. In the 3 unstable scenarios, PCI had the following effects on mortality: unrevascularized post-MI relative risk (RR) 0.68 (95% CI, 0.45-1.03); =0.07; multivessel disease following ST-segment-elevation myocardial infarction (RR, 0.84 [95% CI, 0.69-1.04]; =0.11); non-ST-segment-elevation acute coronary syndrome (RR, 0.84 [95% CI, 0.72-0.97]; =0.02). Overall, in these unstable scenarios PCI was associated with a significant reduction in mortality (RR, 0.84 [95% CI, 0.75-0.93]; =0.02). In unstable CAD, PCI also reduced cardiac death (RR, 0.69 [95% CI, 0.53-0.90]; =0.007) and MI (RR, 0.74 [95% CI, 0.62-0.90]; =0.002). For stable CAD, PCI did not reduce mortality (RR, 0.98 [95% CI, 0.87-1.11]), cardiac death (RR, 0.89 [95% CI, 0.71-1.12]; =0.33), or MI (RR, 0.96 [95% CI, 0.86-1.08]; =0.54).
PCI prevents death, cardiac death, and MI in patients with unstable CAD. For patients with stable CAD, PCI shows no evidence of an effect on any of these outcomes.
在表现为ST段抬高型心肌梗死的患者中，与纤溶治疗相比，经皮冠状动脉介入治疗（PCI）可降低死亡率。然而，在其他形式的冠状动脉疾病（CAD）中，PCI是否能降低死亡率一直存在争议。在这项荟萃分析中，我们研究了PCI在以下几类患者中的益处：（1）未接受即刻血运重建的心肌梗死（MI）后患者；（2）因ST段抬高型心肌梗死接受了直接PCI但仍有残余冠状动脉病变的患者；（3）患有非ST段抬高型急性冠状动脉综合征的患者；（4）真正稳定的CAD且近期无梗死的患者。本分析纳入了最近公布的国际医学与介入治疗比较健康效果研究（ISCHEMIA）以及急性ST段抬高型心肌梗死早期PCI术后完全血运重建与仅罪犯血管血运重建策略治疗多支血管病变的比较研究（COMPLETE）试验的数据。
我们系统地检索了所有以药物治疗为背景的CAD患者PCI随机试验。2019年11月公布的ISCHEMIA试验符合纳入标准。采用随机效应荟萃分析合并数据。主要终点为全因死亡率。46项试验符合标准，共纳入37757例患者。在3种不稳定情况下，PCI对死亡率的影响如下：MI后未行血运重建患者相对危险度（RR）为0.68（95%可信区间[CI]，0.45 - 1.03）；P = 0.07；ST段抬高型心肌梗死后多支血管病变患者（RR，0.8四[95% CI，0.69 - 1.04]；P = 0.11）；非ST段抬高型急性冠状动脉综合征患者（RR，0.84 [95% CI，0.72 - 0.97]；P = 0.02）。总体而言，在这些不稳定情况下PCI与死亡率显著降低相关（RR，0.84 [95% CI，0.75 - 0.93]；P = 0.02）。在不稳定CAD患者中，PCI还降低了心源性死亡（RR，0.69 [95% CI，0.five - 0.90]；P = 0.007）和MI（RR，0.74 [95% CI，0.62 - 0.90]；P = 0.002）。对于稳定CAD患者，PCI未降低死亡率（RR，0.98 [95% CI，0.87 - 1.11]）、心源性死亡（RR，0.89 [95% CI，0.71 - 1.12]；P = 0.33）或MI（RR，0.96 [95% CI，0.86 - 1.08]；P = 0.54）。
PCI可预防不稳定CAD患者的死亡、心源性死亡和MI。对于稳定CAD患者，没有证据表明PCI对这些结局有任何影响。
