Cartlidge Timothy, Kovacevic Mila, Navarese Eliano Pio, Werner Gerald, Kunadian Vijay
Cardiothoracic Directorate, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK.
Cardiovascular Diseases of Vojvodina, Cardiology Clinic, Sremska Kamenica, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.
Heart. 2023 Sep 13;109(19):1429-1435. doi: 10.1136/heartjnl-2022-321870.
Contemporary randomised trials of percutaneous coronary intervention (PCI) in chronic coronary syndrome (CCS) demonstrate no difference between patients treated with a conservative or invasive strategy with respect to all-cause mortality or myocardial infarction, although trials lack power to test for individual endpoints and long-term follow-up data are needed. Open-label trials consistently show greater improvement in symptoms and quality of life among patients with stable angina treated with PCI. Further studies are awaited to clarify this finding. In patients with severe left ventricular (LV) systolic dysfunction and obstructive coronary artery disease in the Revascularization for Ischemic Ventricular Dysfunction trial, PCI has not been found to improve all-cause mortality, heart failure hospitalisation or recovery of LV function when compared with medical therapy. PCI was, however, performed without additional hazard and so remains a treatment option when there are favourable patient characteristics. The majority of patients reported no angina, and the low burden of angina in many of the randomised PCI trials is a widely cited limitation. Despite contentious evidence, elective PCI for CCS continues to play a significant role in UK clinical practice. While PCI for urgent indications has more than doubled since 2006, the rate of elective PCI remains unchanged. PCI remains an important strategy when symptoms are not well controlled, and we should maximise its value with appropriate patient selection. In this review, we provide a framework to assist in critical interpretation of findings from most recent trials and meta-analysis evidence.
当代针对慢性冠状动脉综合征（CCS）患者的经皮冠状动脉介入治疗（PCI）随机试验表明，采用保守或侵入性策略治疗的患者在全因死亡率或心肌梗死方面并无差异，不过这些试验缺乏检验个体终点的效力，且需要长期随访数据。开放标签试验始终显示，接受PCI治疗的稳定型心绞痛患者在症状及生活质量方面有更大改善。有待进一步研究以阐明这一发现。在缺血性心室功能障碍血运重建试验中，对于严重左心室（LV）收缩功能障碍和阻塞性冠状动脉疾病患者，与药物治疗相比，未发现PCI能改善全因死亡率、心力衰竭住院率或LV功能恢复情况。然而，进行PCI并无额外风险，因此在患者特征有利时仍是一种治疗选择。大多数患者报告无心绞痛症状，许多随机PCI试验中心绞痛负担较低是一个被广泛提及的局限性。尽管证据存在争议，但CCS的择期PCI在英国临床实践中仍继续发挥重要作用。自2006年以来，紧急指征的PCI数量增加了一倍多，而择期PCI的比率保持不变。当症状控制不佳时，PCI仍然是一项重要策略，我们应通过适当选择患者来最大化其价值。在本综述中，我们提供了一个框架，以协助对最新试验和荟萃分析证据的结果进行批判性解读。
