Gaudino Mario, Hameed Irbaz, Khan Faiza M, Tam Derrick Y, Rahouma Mohamed, Yongle Ruan, Naik Ajita, Di Franco Antonino, Demetres Michelle, Petrie Mark C, Jolicoeur E Marc, Girardi Leonard N, Fremes Stephen E
Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA.
Schulich Heart Centre, Sunnybrook Health Science University of Toronto, Toronto, ON, Canada.
Eur J Cardiothorac Surg. 2020 Oct 21. doi: 10.1093/ejcts/ezaa319.
The optimal revascularization strategy for patients with ischaemic left ventricular systolic dysfunction (iLVSD) remains controversial. We aimed to compare percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and medical therapy (MT) in a network meta-analysis.
All randomized controlled trials and observational studies comparing any combination of PCI, CABG and MT in patients with iLVSD were analysed in a frequentist network meta-analysis (generic inverse variance method). Primary outcome was mortality at longest available follow-up. Secondary outcomes were cardiac death, stroke, myocardial infarction (MI) and repeat revascularization (RR).
Twenty-three studies were included (n = 23 633; 4 randomized controlled trials). Compared to CABG, PCI was associated with higher mortality [incidence rate ratio (IRR) 1.32, 95% confidence interval (CI) 1.13-1.53], cardiac death (IRR 1.65, 95% CI 1.18-2.33), MI (IRR 2.18, 95% CI 1.70-2.80) and RR (IRR 3.75, 95% CI 2.89-4.85). Compared to CABG, MT was associated with higher mortality (IRR 1.52, 95% CI 1.26-1.84), cardiac death (IRR 3.83, 95% CI 2.12-6.91), MI (IRR 3.22, 95% CI 1.52-6.79) and RR (IRR 3.37, 95% CI 1.67-6.79). Compared to MT, PCI was associated with lower cardiac death (IRR 0.43, 95% CI 0.24-0.78). CABG ranked as the best revascularization strategy for mortality, cardiac death, MI and RR; MT ranked as the strategy associated with the lowest incidence of stroke. Left ventricular ejection fraction, year of study, use of drug-eluting stents did not affect relative treatment effects.
CABG appears to be the best therapy for iLVSD, although mainly based on observational data. Definitive randomized controlled trials comparing CABG and PCI in iLVSD are required.
缺血性左心室收缩功能障碍（iLVSD）患者的最佳血运重建策略仍存在争议。我们旨在通过网状Meta分析比较经皮冠状动脉介入治疗（PCI）、冠状动脉旁路移植术（CABG）和药物治疗（MT）。
在一项基于频率论的网状Meta分析（通用逆方差法）中，分析了所有比较iLVSD患者PCI、CABG和MT任意组合的随机对照试验和观察性研究。主要结局是最长随访期时的死亡率。次要结局是心源性死亡、卒中、心肌梗死（MI）和再次血运重建（RR）。
纳入23项研究（n = 23633；4项随机对照试验）。与CABG相比，PCI与更高的死亡率[发病率比（IRR）1.32, 95%置信区间（CI）1.13 - 1.53]、心源性死亡（IRR 1.65, 95% CI 1.18 - 2.33）、MI（IRR 2.18, 95% CI 1.70 - 2.80）和RR（IRR 3.75, 95% CI 2.89 - 4.85）相关。与CABG相比，MT与更高的死亡率（IRR 1.52, 95% CI 1.26 - 1.84）、心源性死亡（IRR 3.83, 95% CI 2.12 - 6.91）、MI（IRR 3.22, 95% CI 1.52 - 6.79）和RR（IRR 3.37, 95% CI 1.67 - 6.79）相关。与MT相比，PCI与更低的心源性死亡相关（IRR 0.43, 95% CI 0.24 - 0.78）。CABG在死亡率、心源性死亡、MI和RR方面被列为最佳血运重建策略；MT被列为与卒中发生率最低相关的策略。左心室射血分数、研究年份、药物洗脱支架的使用不影响相对治疗效果。
CABG似乎是iLVSD的最佳治疗方法，尽管主要基于观察性数据。需要开展比较iLVSD患者CABG和PCI的确定性随机对照试验。
PROSPERO注册号：132414。
