Department of Cardiology, National University of Ireland, Galway, Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
Department of Cardiology, National University of Ireland, Galway, Galway, Ireland; National Heart and Lung Institute, Imperial College London, London, United Kingdom.
JACC Cardiovasc Interv. 2022 Jan 24;15(2):193-204. doi: 10.1016/j.jcin.2021.10.026. Epub 2021 Dec 29.
The aim of this study was to assess 10-year all-cause mortality in patients with heavily calcified lesions (HCLs) undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).
Limited data are available on very long term outcomes in patients with HCLs according to the mode of revascularization.
This substudy of the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study assessed 10-year all-cause mortality according to the presence of HCLs within lesions with >50% diameter stenosis and identified during the calculation of the anatomical SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score among 1,800 patients with the 3-vessel disease and/or left main disease randomized to PCI or CABG in the SYNTAX trial. Patients with HCLs were further stratified according to disease type (3-vessel disease or left main disease) and assigned treatment (PCI or CABG).
The 532 patients with ≥1 HCL had a higher crude mortality rate at 10 years than those without (36.4% vs 22.3%; HR: 1.79; 95% CI: 1.49-2.16; P < 0.001). After adjustment, an HCL remained an independent predictor of 10-year mortality (HR: 1.36; 95% CI: 1.09-1.69; P = 0.006). There was a significant interaction in mortality between treatment effect (PCI and CABG) and the presence or absence of HCLs (P = 0.005). In patients without HCLs, mortality was significantly higher after PCI than after CABG (26.0% vs 18.8%; HR: 1.44; 95% CI: 0.97-1.41; P = 0.003), whereas in those with HCLs, there was no significant difference (34.0% vs 39.0%; HR: 0.85; 95% CI: 0.64-1.13; P = 0.264).
At 10 years, the presence of an HCL was an independent predictor of mortality, with a similar prognosis following PCI or CABG. Whether HCLs require special consideration when deciding the mode of revascularization beyond their current contribution to the anatomical SYNTAX score deserves further evaluation. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES], NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX], NCT00114972).
本研究旨在评估经皮冠状动脉介入治疗（PCI）或冠状动脉旁路移植术（CABG）治疗重度钙化病变（HCL）患者的 10 年全因死亡率。
根据血运重建方式，目前关于 HCL 患者的极长期结局数据有限。
本研究是 SYNTAXES（紫杉醇 PCI 与心脏手术联合治疗的协同作用）研究的一个亚组研究，根据 >50%直径狭窄病变内存在 HCL 及其在计算解剖学 SYNTAX（紫杉醇 PCI 与心脏手术联合治疗的协同作用）评分时的存在情况，评估了 10 年全因死亡率，共纳入 1800 例 3 支血管疾病和/或左主干疾病患者，这些患者被随机分配至 PCI 或 CABG 治疗，该评分在 SYNTAX 试验中。HCL 患者根据疾病类型（3 支血管疾病或左主干疾病）和治疗方法（PCI 或 CABG）进一步分层。
与无 HCL 患者相比，≥1 个 HCL 患者的 10 年死亡率更高（36.4% vs 22.3%；HR：1.79；95%CI：1.49-2.16；P<0.001）。调整后，HCL 仍然是 10 年死亡率的独立预测因素（HR：1.36；95%CI：1.09-1.69；P=0.006）。治疗效果（PCI 和 CABG）与 HCL 存在与否之间的死亡率存在显著交互作用（P=0.005）。在无 HCL 患者中，PCI 后死亡率明显高于 CABG（26.0% vs 18.8%；HR：1.44；95%CI：0.97-1.41；P=0.003），而在有 HCL 患者中，两者之间无显著差异（34.0% vs 39.0%；HR：0.85；95%CI：0.64-1.13；P=0.264）。
在 10 年时，HCL 的存在是死亡率的独立预测因素，PCI 或 CABG 后预后相似。在决定血运重建方式时，HCL 是否需要特别考虑，超出其目前对解剖学 SYNTAX 评分的贡献，值得进一步评估。（紫杉醇 PCI 与心脏手术联合治疗的协同作用：SYNTAX 延长生存 [SYNTAXES]，NCT03417050；SYNTAX 研究：紫杉醇洗脱支架与冠状动脉旁路移植术治疗狭窄动脉 [SYNTAX]，NCT00114972）。
