Santucci Andrea, Cavallini Claudio
Azienda Ospedaliera S.Maria della Misericordia, Piazzale Menghini 1, 06129 Perugia, Italy.
Eur Heart J Suppl. 2021 Oct 8;23(Suppl E):E55-E58. doi: 10.1093/eurheartj/suab088. eCollection 2021 Oct.
In patients with acute coronary syndrome, an aggressive approach with coronary angiography and revascularization leads to important benefits compared to medical therapy alone. On the contrary, the prognostic impact of coronary revascularization in patients suffering from stable coronary artery disease has long been the subject of debate. The pivotal study in this area is COURAGE, published in 2007, in which coronary revascularization showed no benefit about the combined endpoint of death from all causes and acute myocardial infarction (AMI), compared to medical therapy. The ISCHEMIA study, published in 2020, compared selective coronary angiography and revascularization vs. a non-invasive approach. By protocol, the patients were initially evaluated with coronary computed axial tomography angiography: in case of coronary stenosis >50%, they were then randomized to the two strategies. While in the invasive arm patients were revascularized, in the non-invasive arm revascularization was used only in case of patient destabilization. As in COURAGE, the results of ISCHEMIA did not demonstrate superiority of revascularization over medical therapy alone for a combined endpoint of cardiovascular death, AMI, or hospitalization for unstable angina, heart failure, or cardiac arrest. Based on recent evidence from ISCHEMIA, it is therefore confirmed that coronary revascularization in stable patients does not seem to improve the prognosis compared to medical therapy alone.
在急性冠状动脉综合征患者中，与单纯药物治疗相比，采用冠状动脉造影和血运重建的积极治疗方法可带来显著益处。相反，冠状动脉血运重建对稳定型冠状动脉疾病患者预后的影响长期以来一直是争论的焦点。该领域的关键研究是2007年发表的COURAGE研究，其中冠状动脉血运重建与药物治疗相比，在全因死亡和急性心肌梗死（AMI）的联合终点方面未显示出益处。2020年发表的ISCHEMIA研究比较了选择性冠状动脉造影和血运重建与非侵入性方法。根据方案，患者最初采用冠状动脉计算机断层扫描血管造影进行评估：如果冠状动脉狭窄>50%，然后将他们随机分为两种策略。在侵入性治疗组中患者接受血运重建，而在非侵入性治疗组中，仅在患者病情不稳定时才使用血运重建。与COURAGE研究一样，ISCHEMIA研究的结果并未证明血运重建在心血管死亡、AMI或因不稳定型心绞痛、心力衰竭或心脏骤停住院的联合终点方面优于单纯药物治疗。因此，根据ISCHEMIA的最新证据，已证实与单纯药物治疗相比，稳定型患者的冠状动脉血运重建似乎并不能改善预后。
