Tianjin Medical University Graduate School, Tianjin, China.
Department of Cardiology, Tianjin Chest Hospital, Tianjin, China.
ESC Heart Fail. 2022 Jun;9(3):1749-1755. doi: 10.1002/ehf2.13852. Epub 2022 Feb 22.
The best revascularization strategy for patients with ischaemic heart failure (IHF) remains unclear. Current evidence and guidelines mainly focus on patients with severe ischaemic heart failure (ejection fraction [EF] < 35%). There are limited data comparing clinical outcomes of coronary artery bypass grafting (CABG) with implantation of drug-eluting stents (DESs) in patients with mild to moderate ischaemic heart failure (EF 35-50%). It is therefore unknown whether percutaneous coronary intervention (PCI) with DES implantation can provide comparable outcomes to CABG in these patients.
From January 2016 to December 2017, we enrolled patients with mildly to moderately reduced EF (35-50%) who had undergone PCI with DESs or CABG. Patients with a history of CABG, presented with acute ST-elevation myocardial infarction (MI) or acute heart failure, and patients who had undergone CABG concomitant valvular or aortic surgery were excluded. Propensity score-matching analysis was performed between the two groups. Kaplan-Meier analysis and multivariate Cox proportional hazard regression were applied to assess all-cause mortality and individual end points. A total of 2050 patients (1330 PCIs and 720 CABGs) were included, and median follow-up was 45 months (interquartile range 40 to 54). There were significant differences in all-cause death between the two groups: 77 patients in the PCI group and 27 in the CABG group (DES vs. CABG: 5.8% vs. 3.8%, P = 0.045). After propensity score matching for the entire population, 601 matched pairs were obtained. The long-term cumulative rate of all-cause death was significantly different between the two groups (DES vs. CABG: 5.8% vs. 2.7%, P = 0.006). No differences were found in the rates of cardiac death (DES vs. CABG: 4.8% vs. 3.0%, P = 0.096), recurrent MI (DES vs. CABG: 4.0% vs. 2.8%, P = 0.234), and stroke (DES vs. CABG: 6.8% vs. 5.2%, P = 0.163). The rate of repeat coronary revascularization was significantly higher in the PCI group than in the CABG group (12.1% vs. 6.0%, P = 0.000).
Considering the higher long-term survival rate and lower repeat-revascularization rate, CABG may be superior to DES implantation in patients with mildly to moderately reduced EF (35-50%) and significant CAD.
对于缺血性心力衰竭（IHF）患者，最佳血运重建策略仍不清楚。目前的证据和指南主要集中在严重缺血性心力衰竭（射血分数[EF]＜35%）的患者。在轻度至中度缺血性心力衰竭（EF 35-50%）患者中，比较冠状动脉旁路移植术（CABG）与药物洗脱支架（DES）植入的临床结果的相关数据有限。因此，尚不清楚在这些患者中，经皮冠状动脉介入治疗（PCI）联合 DES 植入是否可以提供与 CABG 相当的结果。
2016 年 1 月至 2017 年 12 月，我们纳入了接受 DES 支架置入 PCI 或 CABG 的轻度至中度 EF（35-50%）降低的患者。排除有 CABG 病史、表现为急性 ST 段抬高型心肌梗死（MI）或急性心力衰竭、或同时行 CABG 瓣膜或主动脉手术的患者。对两组患者进行倾向评分匹配分析。应用 Kaplan-Meier 分析和多变量 Cox 比例风险回归评估全因死亡率和各终点。共纳入 2050 例患者（1330 例行 PCI，720 例行 CABG），中位随访时间为 45 个月（四分位距 40-54）。两组全因死亡存在显著差异：PCI 组 77 例，CABG 组 27 例（DES 与 CABG：5.8%比 3.8%，P=0.045）。对整个人群进行倾向评分匹配后，得到 601 对匹配。两组全因死亡的长期累积率有显著差异（DES 与 CABG：5.8%比 2.7%，P=0.006）。两组间心脏性死亡（DES 与 CABG：4.8%比 3.0%，P=0.096）、复发性 MI（DES 与 CABG：4.0%比 2.8%，P=0.234）和卒中（DES 与 CABG：6.8%比 5.2%，P=0.163）发生率无差异。PCI 组再次血运重建率显著高于 CABG 组（12.1%比 6.0%，P=0.000）。
考虑到长期生存率更高和再次血运重建率更低，CABG 可能优于 DES 植入治疗 EF（35-50%）且有显著 CAD 的轻度至中度缺血性心力衰竭患者。
