Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Gothenburg, Sweden; Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA.
Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
J Am Coll Cardiol. 2024 Feb 6;83(5):549-558. doi: 10.1016/j.jacc.2023.11.002. Epub 2023 Nov 11.
In the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, the risk of ischemic events was similar in patients with stable coronary artery disease treated with an invasive (INV) strategy of angiography and percutaneous coronary intervention (PCI) or surgical (coronary artery bypass grafting [CABG]) coronary revascularization and a conservative (CON) strategy of initial medical therapy.
The authors analyzed separately the outcomes of INV patients treated with PCI or CABG.
Patients without preceding primary outcome events were categorized as INV-PCI or INV-CABG from the time of revascularization. The ISCHEMIA primary outcome (composite of cardiovascular death, protocol-defined myocardial infarction or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest) was used.
Among INV-CABG patients, primary outcome events occurred in 84 of 512 (16.4%) at a median follow-up of 2.85 years; 48 events (57.1%) occurred within 30 days after CABG, including 40 procedural MIs. Among INV-PCI patients, primary outcome events occurred in 147 of 1,500 (9.8%) at median follow-up of 2.94 years; 31 of which (21.1%) occurred within 30 days after PCI, including 24 procedural MIs. In comparison, 352 of 2,591 CON patients (13.6%) had primary outcome events at a median follow-up of 3.2 years, 22 of which (6.3%) occurred within 30 days of randomization. The adjusted primary outcome risks were higher after both CABG and PCI within 30 days (HR: 16.25 [95% CI: 11.44-23.07] and HR: 2.99 [95% CI: 1.97-4.53]) and lower thereafter (0.63 [95% CI: 0.44-0.89] and 0.66 [95% CI: 0.53-0.82]).
In ISCHEMIA, early revascularization by PCI and CABG was associated with higher early risks and lower long-term risks of cardiovascular events compared with CON. The early risk was greatest after CABG, owing to protocol-defined procedural MIs.
在 ISCHEMIA（国际比较健康效果研究，比较有创和药物治疗用于稳定型冠状动脉疾病的效果）试验中，接受有创（血管造影和经皮冠状动脉介入治疗[PCI]或冠状动脉旁路移植术[CABG]血运重建）策略或保守（初始药物治疗）策略治疗的稳定型冠状动脉疾病患者的缺血性事件风险相似。
作者分别分析了接受 PCI 或 CABG 治疗的 INV 患者的结局。
从血运重建时起，将无首发主要结局事件的患者分为 INV-PCI 或 INV-CABG。主要结局为心血管死亡、方案定义的心肌梗死或不稳定型心绞痛住院、心力衰竭或复苏性心脏骤停的复合终点。
在 INV-CABG 患者中，512 例患者中有 84 例（16.4%）在中位随访 2.85 年后发生主要结局事件；48 例（57.1%）事件发生在 CABG 后 30 天内，包括 40 例经皮心肌梗死。在 INV-PCI 患者中，1500 例患者中有 147 例（9.8%）在中位随访 2.94 年后发生主要结局事件；其中 31 例（21.1%）事件发生在 PCI 后 30 天内，包括 24 例经皮心肌梗死。相比之下，2591 例 CON 患者中有 352 例（13.6%）在中位随访 3.2 年后发生主要结局事件，其中 22 例（6.3%）在随机分组后 30 天内发生。CABG 和 PCI 后 30 天内的主要结局风险较高（HR：16.25[95%CI：11.44-23.07]和 HR：2.99[95%CI：1.97-4.53]），此后风险较低（0.63[95%CI：0.44-0.89]和 0.66[95%CI：0.53-0.82]）。
在 ISCHEMIA 试验中，与 CON 相比，PCI 和 CABG 的早期血运重建与较高的早期心血管事件风险和较低的长期风险相关。由于方案定义的经皮心肌梗死，CABG 后早期风险最大。
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