Gabaldon-Perez Ana, Marcos-Garces Victor, Gavara Jose, Rios-Navarro Cesar, Miñana Gema, Bayes-Genis Antoni, Husser Oliver, Sanchis Juan, Nunez Julio, Chorro Francisco Javier, Bodi Vicente
Department of Cardiology, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain.
INCLIVA Health Research Institute, 46010 Valencia, Spain.
J Clin Med. 2021 Feb 5;10(4):610. doi: 10.3390/jcm10040610.
Ischemic heart disease (IHD) persists as the leading cause of death in the Western world. In recent decades, great headway has been made in reducing mortality due to IHD, based around secondary prevention. The advent of coronary revascularization techniques, first coronary artery bypass grafting (CABG) surgery in the 1960s and then percutaneous coronary intervention (PCI) in the 1970s, has represented one of the major breakthroughs in medicine during the last century. The benefit provided by these techniques, especially PCI, has been crucial in lowering mortality rates in acute coronary syndrome (ACS). However, in the setting where IHD is most prevalent, namely chronic coronary syndrome (CCS), the increase in life expectancy provided by coronary revascularization is controversial. Over more than 40 years, several clinical trials have been carried out comparing optimal medical treatment (OMT) alone with a strategy of routine coronary revascularization on top of OMT. Beyond a certain degree of symptomatic improvement and lower incidence of minor events, routine invasive management has not demonstrated a convincing effect in terms of reducing mortality in CCS. Based on the accumulated evidence more than half a century after the first revascularization procedures were used, invasive management should be considered in those patients with uncontrolled symptoms despite OMT or high-risk features related to left ventricular function, coronary anatomy, or functional assessment, taking into account the patient expectations and preferences.
缺血性心脏病（IHD）仍然是西方世界的主要死因。近几十年来，基于二级预防，在降低IHD死亡率方面取得了巨大进展。冠状动脉血运重建技术的出现，先是20世纪60年代的冠状动脉旁路移植术（CABG），然后是70年代的经皮冠状动脉介入治疗（PCI），是上个世纪医学上的重大突破之一。这些技术，尤其是PCI所带来的益处，对于降低急性冠状动脉综合征（ACS）的死亡率至关重要。然而，在IHD最为普遍的情况下，即慢性冠状动脉综合征（CCS）中，冠状动脉血运重建所带来的预期寿命增加存在争议。在40多年的时间里，已经进行了多项临床试验，比较单纯的最佳药物治疗（OMT）与在OMT基础上进行常规冠状动脉血运重建的策略。除了一定程度的症状改善和较低的轻微事件发生率外，常规侵入性治疗在降低CCS死亡率方面尚未显示出令人信服的效果。基于首次血运重建手术使用半个多世纪以来积累的证据，对于那些尽管接受了OMT但症状仍未得到控制或具有与左心室功能、冠状动脉解剖结构或功能评估相关的高危特征的患者，应考虑侵入性治疗，同时要考虑患者的期望和偏好。
