Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy.
Division of Cardiology, SS. Annunziata Savigliano, ASL CN 1, Savigliano, Italy.
Int J Cardiol. 2024 Feb 1;396:131428. doi: 10.1016/j.ijcard.2023.131428. Epub 2023 Oct 9.
The optimal revascularization strategy in patients with heart failure with reduced ejection fraction (HFrEF) remains to be elucidated. The aim of this paper is to compare the mid-term mortality rate among patients with severely reduced ejection fraction (EF) and complex coronary artery disease who underwent coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI) with Impella support, or without.
Randomized control trials and propensity-adjusted observational studies including patients with ischemic cardiomyopathy (ICM) and severe EF reduction undergoing revascularization were selected. Different revascularization strategies (CABG, supported PCI, and PCI without Impella) were compared in pairwise and network meta-analysis. The primary endpoint was mid-term mortality (within the first year after revascularization).
Fifteen studies, mostly observational (17,841 patients; 6779 patients treated with CABG, 8478 treated with PCI without Impella, and 2584 treated with Impella-supported PCI) were included in this analysis. The median age was 67.8 years (IQR 65-70.1), 21.2% (IQR 16.4-26%) of patients were female sex, and a high prevalence of cardiovascular risk factors was noted across the entire population. At pairwise analysis, CABG and PCI without Impella showed similar one-year all-cause mortality (10.6% [IQR 7.5-12.6%] vs 12% [IQR 8.4-11.5%]) RR 0.85 CI 0.67-1.09, while supported PCI reduced one-year all-cause mortality compared to PCI without Impella (9.4% [IQR 5.7-12.5%] vs 10.6% [IQR 8.9-10.7%]) RR 0.77 CI 0.6-0.89. At network meta-analysis, supported PCI showed better results (RR 0.75, 95% CI 0.59-0.94) compared to CABG.
Our analysis found that supported PCI may have a benefit over standard PCI in patients in direct comparison, and over CABG from indirect comparison, and with HFrEF undergoing revascularization. Further RCTs are needed to confirm this result. (PROSPERO CRD42023425667).
在射血分数降低的心力衰竭（HFrEF）患者中，最佳的血运重建策略仍有待阐明。本文旨在比较严重射血分数降低（EF）和复杂冠状动脉疾病患者行冠状动脉旁路移植术（CABG）、有 Impella 支持的经皮冠状动脉介入治疗（PCI）和无 Impella 支持的 PCI 的中期死亡率。
选择了包括缺血性心肌病（ICM）和严重 EF 降低患者的随机对照试验和倾向调整观察性研究。在成对和网络荟萃分析中比较了不同的血运重建策略（CABG、有支持的 PCI 和无 Impella 的 PCI）。主要终点是中期死亡率（血运重建后 1 年内）。
本分析纳入了 15 项研究，主要为观察性研究（17841 例患者；6779 例接受 CABG 治疗，8478 例接受无 Impella 的 PCI 治疗，2584 例接受 Impella 支持的 PCI 治疗）。中位年龄为 67.8 岁（IQR 65-70.1），21.2%（IQR 16.4-26%）为女性，整个人群均存在较高的心血管危险因素患病率。在成对分析中，CABG 和无 Impella 的 PCI 显示出相似的 1 年全因死亡率（10.6%[IQR 7.5-12.6%] vs 12%[IQR 8.4-11.5%]）RR 0.85 CI 0.67-1.09，而有支持的 PCI 与无 Impella 的 PCI 相比降低了 1 年全因死亡率（9.4%[IQR 5.7-12.5%] vs 10.6%[IQR 8.9-10.7%]）RR 0.77 CI 0.6-0.89。在网络荟萃分析中，有支持的 PCI 与 CABG 相比（RR 0.75，95%CI 0.59-0.94）和与无 Impella 的 PCI 相比（RR 0.75，95%CI 0.59-0.94）均显示出更好的结果。
我们的分析发现，与 CABG 相比，直接比较时，有支持的 PCI 可能对接受血运重建的患者比标准 PCI 更有益，与间接比较时，有支持的 PCI 也可能对 CABG 更有益，且射血分数降低的心力衰竭患者。需要进一步的 RCT 来证实这一结果。（PROSPERO CRD42023425667）。
