左主干冠状动脉血运重建后再入院的发生率、预测因素和影响。
Incidence, Predictors, and Impact of Hospital Readmission After Revascularization for Left Main Coronary Disease.
机构信息
Memorial Sloan Kettering Cancer Center, New York and Weill Cornell College of Medicine, New York, New York, USA; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.
Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.
出版信息
J Am Coll Cardiol. 2024 Mar 19;83(11):1073-1081. doi: 10.1016/j.jacc.2024.01.012.
BACKGROUND
The frequency of and relationship between hospital readmissions and outcomes after revascularization for left main coronary artery disease (LMCAD) are unknown.
OBJECTIVES
The purpose of this study was to study the incidence, predictors, and clinical impact of readmissions following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for LMCAD.
METHODS
In the EXCEL (XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, 1,905 patients with LMCAD were randomized to PCI vs CABG. The cumulative incidence of readmissions was analyzed with multivariable Anderson-Gill and joint frailty models to account for recurrent events and the competing risk of death. The impact of readmission on subsequent mortality within 5-year follow-up was determined in a time-adjusted Cox proportional hazards model.
RESULTS
Within 5 years, 1,868 readmissions occurred in 851 of 1,882 (45.2%) hospital survivors (2.2 ± 1.9 per patient with readmission[s], range 1-16), approximately one-half for cardiovascular causes and one-half for noncardiovascular causes (927 [49.6%] and 941 [50.4%], respectively). One or more readmissions occurred in 463 of 942 (48.6%) PCI patients vs 388 of 940 (41.8%) CABG patients (P = 0.003). After multivariable adjustment, PCI remained an independent predictor of readmission (adjusted HR: 1.22; 95% CI: 1.10-1.35; P < 0.0001), along with female sex, comorbidities, and the extent of CAD. Readmission was independently associated with subsequent all-cause death, with interaction testing indicating a higher risk after PCI than CABG (adjusted HR: 5.72; 95% CI: 3.42-9.55 vs adjusted HR: 2.72; 95% CI: 1.64-4.88, respectively; P = 0.03).
CONCLUSIONS
In the EXCEL trial, readmissions during 5-year follow-up after revascularization for LMCAD were common and more frequent after PCI than CABG. Readmissions were associated with an increased risk of all-cause death, more so after PCI than with CABG.
背景
左主干冠状动脉疾病（LMCAD）血运重建后再入院的频率及其与结局的关系尚不清楚。
目的
本研究旨在研究经皮冠状动脉介入治疗（PCI）和冠状动脉旁路移植术（CABG）治疗 LMCAD 后再入院的发生率、预测因素和临床影响。
方法
在 EXCEL（XIENCE 与冠状动脉旁路移植术治疗左主干血运重建效果比较）试验中，1905 例 LMCAD 患者被随机分为 PCI 组和 CABG 组。采用多变量 Anderson-Gill 和联合脆弱性模型分析再入院的累积发生率，以考虑到复发性事件和死亡的竞争风险。采用时间调整 Cox 比例风险模型确定 5 年随访期间再入院对随后死亡率的影响。
结果
5 年内，1882 例存活患者中有 851 例（45.2%）发生 1868 次再入院（再入院患者平均每人 2.2±1.9 次，范围为 1-16 次），约一半为心血管原因，一半为非心血管原因（927 例[49.6%]和 941 例[50.4%]）。PCI 组 463 例（48.6%）和 CABG 组 388 例（41.8%）患者中各有 1 例或更多次再入院（P=0.003）。多变量调整后，PCI 仍然是再入院的独立预测因素（调整后 HR：1.22；95%CI：1.10-1.35；P<0.0001），此外还包括女性、合并症和 CAD 程度。再入院与随后的全因死亡独立相关，交互检验表明 PCI 后风险高于 CABG（调整后 HR：5.72；95%CI：3.42-9.55 与调整后 HR：2.72；95%CI：1.64-4.88；P=0.03）。
结论
在 EXCEL 试验中，LMCAD 血运重建后 5 年随访期间再入院很常见，PCI 后比 CABG 后更频繁。再入院与全因死亡风险增加相关，PCI 后比 CABG 后更明显。
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