Department of Medicine Washington University School of Medicine St. Louis MO.
Washington University School of Medicine St. Louis MO.
J Am Heart Assoc. 2021 Jan 19;10(2):e019114. doi: 10.1161/JAHA.120.019114. Epub 2021 Jan 14.
Background In chronic coronary syndromes, myocardial ischemia is associated with a greater risk of death and nonfatal myocardial infarction (MI). We sought to compare the effect of initial revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) plus optimal medical therapy (OMT) with OMT alone in patients with chronic coronary syndrome and myocardial ischemia on long-term death and nonfatal MI. Methods and Results Ovid Medline, Embase, Scopus, and Cochrane Library databases were searched for randomized controlled trials of PCI or CABG plus OMT versus OMT alone for patients with chronic coronary syndromes. Studies were screened and data were extracted independently by 2 authors. Random-effects models were used to generate pooled treatment effects. The search yielded 7 randomized controlled trials that randomized 10 797 patients. Median follow-up was 5 years. Death occurred in 640 of the 5413 patients (11.8%) randomized to revascularization and in 647 of the 5384 patients (12%) randomized to OMT (odds ratio [OR], 0.97; 95% CI, 0.86-1.09; =0.60). Nonfatal MI was reported in 554 of 5413 patients (10.2%) in the revascularization arms compared with 627 of 5384 patients (11.6%) in the OMT arms (OR, 0.75; 95% CI, 0.57-0.99; =0.04). In subgroup analysis, nonfatal MI was significantly reduced by CABG (OR, 0.35; 95% CI, 0.21-0.59; <0.001) but was not reduced by PCI (OR, 0.92; 95% CI, 0.75-1.13; =0.43) (-interaction <0.001). Conclusions In patients with chronic coronary syndromes and myocardial ischemia, initial revascularization with PCI or CABG plus OMT did not reduce long-term mortality compared with OMT alone. CABG plus OMT reduced nonfatal MI compared with OMT alone, whereas PCI did not.
在慢性冠状动脉综合征中，心肌缺血与死亡和非致死性心肌梗死（MI）的风险增加相关。我们旨在比较初始血运重建（经皮冠状动脉介入治疗 [PCI] 或冠状动脉旁路移植术 [CABG] 加最佳药物治疗 [OMT]）与单独 OMT 对慢性冠状动脉综合征合并心肌缺血患者的长期死亡和非致死性 MI 的影响。
检索了 Ovid Medline、Embase、Scopus 和 Cochrane 图书馆数据库，以寻找 PCI 或 CABG 加 OMT 与单独 OMT 治疗慢性冠状动脉综合征患者的随机对照试验。由两位作者独立筛选研究和提取数据。采用随机效应模型生成汇总治疗效果。检索结果产生了 7 项随机对照试验，共纳入 10797 名患者。中位随访时间为 5 年。640 名（11.8%）接受血运重建治疗的患者和 647 名（12%）接受 OMT 治疗的患者发生死亡（比值比 [OR]，0.97；95%置信区间 [CI]，0.86-1.09；=0.60）。5413 名接受血运重建治疗的患者中有 554 名（10.2%）发生非致死性 MI，5384 名接受 OMT 治疗的患者中有 627 名（11.6%）发生非致死性 MI（OR，0.75；95%CI，0.57-0.99；=0.04）。亚组分析显示，CABG 显著降低非致死性 MI 的发生率（OR，0.35；95%CI，0.21-0.59；<0.001），但 PCI 无此作用（OR，0.92；95%CI，0.75-1.13；=0.43）（交互检验<0.001）。
在慢性冠状动脉综合征合并心肌缺血患者中，与单独 OMT 相比，初始 PCI 或 CABG 加 OMT 治疗并未降低长期死亡率。CABG 加 OMT 治疗可降低非致死性 MI 的发生率，而 PCI 则无此作用。
