Golukhova Elena Zelikovna, Slivneva Inessa Viktorovna, Kozlova Olga Sergeevna, Berdibekov Bektur Shukurbekovich, Skopin Ivan Ivanovich, Merzlyakov Vadim Yuryevich, Baichurin Renat Kamilyevich, Sigaev Igor Yuryevich, Keren Milena Abrekovna, Alshibaya Mikhail Durmishkhanovich, Marapov Damir Ildarovich, Arzumanyan Milena Artemovna
A.N. Bakulev National Medical Scientific Center for Cardiovascular Surgery, 121552 Moscow, Russia.
Department of Cardiovascular and Comorbid Pathology, A.N. Bakulev National Medical Scientific Center for Cardiovascular Surgery, 121552 Moscow, Russia.
Pathophysiology. 2023 Dec 18;30(4):640-658. doi: 10.3390/pathophysiology30040046.
In this meta-analysis, we examine the advantages of invasive strategies for patients diagnosed with chronic coronary heart disease (CHD) and preserved left ventricular (LV) function, as well as those with significant LV systolic dysfunction (LV ejection fraction (EF) < 45%).
We conducted a systematic search to identify all randomized trials directly comparing invasive strategies with optimal medical therapy (OMT) in patients diagnosed with chronic CHD. Data from these trials were pooled using a random-effects meta-analysis. The primary outcome assessed was the all-cause mortality, while secondary endpoints included cardiovascular (CV) death, stroke, myocardial infarction (MI), and unplanned revascularization. This study was designed to assess the benefits of both invasive strategies and OMT in patients with preserved LV function and in those with LV systolic dysfunction. The statistical analysis of the data was conducted using the Review Manager (RevMan) software, version 5.4.1 (The Cochrane Collaboration, 2020).
Twelve randomized studies enrolling 13,912 patients were included in the final analysis. Among the patients with chronic CHD and preserved LV systolic function, revascularization did not demonstrate a reduction in all-cause mortality (8.52% vs. 8.45%, = 0.45), CV death (3.41% vs. 3.62%, = 0.08), or the incidence of MI (9.88% vs. 10.49%, = 0.47). However, the need for unplanned myocardial revascularization was significantly lower in the group following the initial invasive approach compared to patients undergoing OMT (14.75% vs. 25.72%, < 0.001). In contrast, the invasive strategy emerged as the preferred treatment modality for patients with ischemic LV systolic dysfunction. This approach demonstrated lower rates of all-cause mortality (40.61% vs. 46.52%, = 0.004), CV death (28.75% vs. 35.82%, = 0.0004), and MI (8.19% vs. 10.8%, = 0.03).
In individuals diagnosed with chronic CHD and preserved LV EF, the initial invasive approach did not demonstrate a clinical advantage over OMT. Conversely, in patients with ischemic LV systolic dysfunction, myocardial revascularization was found to reduce the risks of CV events and enhance the overall outcomes. These findings hold significant clinical relevance for optimizing treatment strategies in patients with chronic CHD, contingent upon myocardial contractility status.
在这项荟萃分析中，我们研究了侵入性策略对于诊断为慢性冠心病（CHD）且左心室（LV）功能保留的患者，以及左心室收缩功能严重障碍（左心室射血分数（EF）<45%）患者的优势。
我们进行了系统检索，以确定所有直接比较侵入性策略与最佳药物治疗（OMT）在诊断为慢性CHD患者中的随机试验。这些试验的数据使用随机效应荟萃分析进行汇总。评估的主要结局是全因死亡率，次要终点包括心血管（CV）死亡、中风、心肌梗死（MI）和非计划血管重建。本研究旨在评估侵入性策略和OMT在左心室功能保留患者和左心室收缩功能障碍患者中的益处。使用Review Manager（RevMan）软件5.4.1版（Cochrane协作网，2020年）对数据进行统计分析。
最终分析纳入了12项随机研究，共13912例患者。在慢性CHD且左心室收缩功能保留的患者中，血管重建并未显示全因死亡率降低（8.52%对8.45%，P = 0.45）、CV死亡（3.41%对3.62%，P = 0.08）或MI发生率降低（9.88%对10.49%，P = 0.47）。然而，与接受OMT的患者相比，初始采用侵入性方法的组中非计划心肌血管重建的需求显著更低（14.75%对25.72%，P<0.001）。相比之下，侵入性策略成为缺血性左心室收缩功能障碍患者的首选治疗方式。这种方法显示出全因死亡率（40.61%对46.52%，P = 0.004）、CV死亡（28.75%对35.82%，P = 0.0004）和MI（8.19%对10.8%，P = 0.03）的发生率更低。
在诊断为慢性CHD且左心室EF保留的个体中，初始侵入性方法并未显示出优于OMT的临床优势。相反，在缺血性左心室收缩功能障碍患者中，心肌血管重建被发现可降低CV事件风险并改善总体结局。这些发现对于根据心肌收缩状态优化慢性CHD患者的治疗策略具有重要的临床意义。
