Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Entrevägen 2, 182 88 Stockholm, Sweden.
Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Nobels väg 13, 17177 Stockholm, Sweden.
Eur Heart J. 2023 Aug 7;44(30):2833-2842. doi: 10.1093/eurheartj/ehad369.
An observational nationwide all-comers prospective register study to analyse outcomes after coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in unprotected left main coronary artery (LMCA) disease.
All patients undergoing coronary angiography in Sweden are registered in the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry. Between 01/01/2005 and 12/31/2015, 11 137 patients with LMCA disease underwent CABG (n = 9364) or PCI (n = 1773). Patients with previous CABG, ST-elevation myocardial infarction (MI) or cardiac shock were excluded. Death, MI, stroke, and new revascularization during follow-up until 12/31/2015 were identified using national registries. Cox regression with inverse probability weighting (IPW) and an instrumental variable (IV), administrative region, were used. Patients undergoing PCI were older, had higher prevalence of comorbidity but lower prevalence of three-vessel disease. PCI patients had higher mortality than CABG patients after adjustments for known cofounders with IPW analysis (hazard ratio [HR] 2.0 [95% confidence interval (CI) 1.5-2.7]) and known/unknown confounders with IV analysis (HR 1.5 [95% CI 1.1-2.0]). PCI was associated with higher incidence of major adverse cardiovascular and cerebrovascular events (MACCE; death, MI, stroke, or new revascularization) than CABG, with IV analysis (HR 2.8 [95% CI 1.8-4.5]). There was a quantitative interaction for diabetic status regarding mortality (P = 0.014) translating into 3.6 years (95% CI 3.3-4.0) longer median survival time favouring CABG in patients with diabetes.
In this non-randomized study, CABG in patients with LMCA disease was associated with lower mortality and fewer MACCE compared to PCI after multivariable adjustment for known and unknown confounders.
本研究旨在通过观察性全国性所有患者前瞻性注册研究，分析非保护左主干冠状动脉（LMCA）疾病患者接受冠状动脉旁路移植术（CABG）或经皮冠状动脉介入治疗（PCI）后的结局。
在瑞典，所有接受冠状动脉造影的患者都将在瑞典网络系统中进行登记，以增强和发展基于证据的心脏病治疗，并根据推荐的治疗方法进行评估。2005 年 1 月 1 日至 2015 年 12 月 31 日期间，共有 11137 例 LMCA 疾病患者接受了 CABG（n = 9364）或 PCI（n = 1773）。排除了先前接受 CABG、ST 段抬高型心肌梗死（MI）或心源性休克的患者。通过国家登记册确定随访期间至 2015 年 12 月 31 日的死亡、MI、卒中和再次血运重建。使用逆概率加权（IPW）和工具变量（IV）的 Cox 回归分析，以行政区域作为协变量。接受 PCI 的患者年龄较大，合并症患病率较高，但三血管疾病的患病率较低。经 IPW 分析（风险比[HR]2.0[95%置信区间（CI）1.5-2.7]）和 IV 分析（HR 1.5[95%CI 1.1-2.0]）校正已知混杂因素后，PCI 患者的死亡率高于 CABG 患者。与 CABG 相比，PCI 与更高的主要不良心血管和脑血管事件（MACCE；死亡、MI、卒中和新血运重建）发生率相关，IV 分析显示（HR 2.8[95%CI 1.8-4.5]）。对于糖尿病患者的死亡率，存在关于糖尿病状态的定量交互作用（P = 0.014），这意味着 CABG 患者的中位生存时间延长了 3.6 年（95%CI 3.3-4.0）。
在这项非随机研究中，与多变量校正已知和未知混杂因素后接受 PCI 的患者相比，LMCA 疾病患者接受 CABG 治疗的死亡率较低，MACCE 较少。
