Pryor D B, Harrell F E, Rankin J S, Lee K L, Muhlbaier L H, Oldham H N, Hlatky M A, Mark D B, Reves J G, Califf R M
Department of Medicine, Duke University Medical Center, Durham, N.C. 27710.
Circulation. 1987 Nov;76(5 Pt 2):V13-21.
Previous comparisons of medical and surgical therapy for coronary artery disease were performed in the 1970s and may need to be updated to reflect current treatment efficacy. The purpose of this investigation was to determine the impact on long-term patient survival of changes over time in medical and surgical therapy. Among 5125 patients referred for catheterization between 1969 and 1984, 2261 underwent surgery, and 2864 received medical therapy. Survival in both medically and surgically treated patients improved over time. The improvement in medical patients was due to less sick patients being treated (a decreasing baseline risk), while that observed in surgical patients was due to refinements in care. The rate of improvement in survival over time was much greater in surgical patients, and the difference as compared with medical therapy was highly significant (treatment interaction with time p less than .0001). Estimates of 5 year survival adjusted for baseline risk factors for a patient in 1977 with one-, two-, or three-vessel disease and an ejection fraction of 0.40 were 0.88, 0.80, and 0.64 in medically treated, and 0.88, 0.87, and 0.80 in surgically treated patients. Corresponding projected estimates for 1984 were unchanged for medical patients but improved for surgical patients (0.93, 0.92, and 0.90). Thus, the projected survival benefits of surgery in 1984 appear more significant for all categories of coronary artery disease because of a differential improvement in surgical therapy. These data are relevant to therapeutic decision making for current patients and emphasize the importance of continued analysis of this topic as treatment efficacies change over time.
先前对冠状动脉疾病的药物治疗和手术治疗的比较是在20世纪70年代进行的，可能需要更新以反映当前的治疗效果。本研究的目的是确定药物治疗和手术治疗随时间的变化对患者长期生存的影响。在1969年至1984年间转诊进行导管插入术的5125例患者中，2261例接受了手术治疗，2864例接受了药物治疗。药物治疗和手术治疗患者的生存率均随时间提高。药物治疗患者生存率的提高是由于接受治疗的病情较轻的患者减少（基线风险降低），而手术治疗患者生存率的提高则是由于治疗的改进。手术患者生存率随时间的提高率要大得多，与药物治疗相比差异非常显著（治疗与时间的交互作用p<0.0001）。1977年，一名患有单支、双支或三支血管疾病且射血分数为0.40的患者，根据基线风险因素调整后的5年生存率估计值，药物治疗患者分别为0.88、0.80和0.64，手术治疗患者分别为0.88、0.87和0.80。1984年相应的预测估计值，药物治疗患者不变，但手术治疗患者有所改善（0.93、0.92和0.90）。因此，由于手术治疗的差异改善，1984年手术治疗对所有类型冠状动脉疾病的预测生存益处似乎更为显著。这些数据与当前患者的治疗决策相关，并强调随着治疗效果随时间变化，持续分析该主题的重要性。
