Canadian VIGOUR Center University of Alberta Edmonton Alberta Canada.
Emory University School of Medicine Atlanta GA.
J Am Heart Assoc. 2021 Jan 5;10(1):e018104. doi: 10.1161/JAHA.120.018104. Epub 2020 Dec 19.
Background The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial failed to show a reduction in hard clinical end points with an early invasive strategy in stable ischemic heart disease (SIHD). However, the influence of left main disease and high-risk coronary anatomy was left unaddressed. In a large angiographic disease-based registry, we examined the modulating effect of revascularization on long-term outcomes in anatomically high-risk SIHD. Methods and Results 9016 patients with SIHD with high-risk coronary anatomy (3 vessel disease with ≥70% stenosis in all 3 epicardial vessels or left main disease ≥50% stenosis [isolated or in combination with other disease]) were selected for study from April 1, 2002 to March 31, 2016. The primary composite of all-cause death or myocardial infarction (MI) was compared between revascularization versus conservative management. A total of 5487 (61.0%) patients received revascularization with either coronary artery bypass graft surgery (n=3312) or percutaneous coronary intervention (n=2175), while 3529 (39.0%) patients were managed conservatively. Selection for coronary revascularization was associated with improved all-cause death/MI as well as longer survival compared with selection for conservative management (Inverse Probability Weighted hazard ratio [IPW-HR] 0.62; 95% CI 0.58 to 0.66; <0.001; IPW-HR 0.57; 95% CI 0.53-0.61; <0.001, respectively). Similar risk reduction was noted with percutaneous coronary intervention (IPW-HR 0.64, 95% CI 0.59-0.70, <0.001) and coronary artery bypass graft surgery (IPW-HR 0.61; 95% CI 0.57-0.66; <0.001). Conclusions Revascularization in patients with SIHD with high-risk coronary anatomy was associated with improved long-term outcome compared with conservative therapy. As such, coronary anatomical profile should be considered when contemplating treatment for SIHD.
ISCHEMIA（国际比较医疗效果与有创治疗的研究）试验未能显示在稳定型缺血性心脏病（SIHD）中早期有创策略可降低硬性临床终点。然而，左主干病变和高危冠状动脉解剖结构的影响仍未得到解决。在一个大型基于血管造影的疾病登记处，我们研究了血运重建对解剖学高危 SIHD 长期结局的调节作用。
2002 年 4 月 1 日至 2016 年 3 月 31 日，从高危冠状动脉解剖结构的 SIHD 患者中选择了 9016 例患者（所有 3 个心外膜血管狭窄≥70%的 3 血管疾病或左主干病变狭窄≥50%[孤立或与其他病变联合]）进行研究。比较了血运重建与保守治疗的全因死亡或心肌梗死（MI）的主要复合终点。共有 5487 例（61.0%）患者接受了血运重建，其中 3312 例行冠状动脉旁路移植术（CABG），2175 例行经皮冠状动脉介入治疗（PCI），而 3529 例（39.0%）患者接受了保守治疗。与选择保守治疗相比，选择冠状动脉血运重建与全因死亡/MI 降低以及生存时间延长相关（逆概率加权风险比[IPW-HR]0.62；95%CI0.58 至 0.66；<0.001；IPW-HR0.57；95%CI0.53-0.61；<0.001）。经皮冠状动脉介入治疗（IPW-HR0.64，95%CI0.59-0.70，<0.001）和冠状动脉旁路移植术（IPW-HR0.61；95%CI0.57-0.66；<0.001）也观察到了类似的风险降低。
与保守治疗相比，高危冠状动脉解剖结构的 SIHD 患者的血运重建与长期预后改善相关。因此，在考虑 SIHD 的治疗时，应考虑冠状动脉解剖结构特征。
