The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY.
Department of Cardiology The Royal Melbourne Hospital Melbourne Victoria Australia.
J Am Heart Assoc. 2024 Jun 4;13(11):e033931. doi: 10.1161/JAHA.123.033931. Epub 2024 May 31.
Patients may prefer percutaneous coronary intervention (PCI) over coronary artery bypass graft (CABG) surgery, despite heart team recommendations. The outcomes in such patients have not been examined. We sought to examine the results of PCI in patients who were recommended for but declined CABG.
Consecutive patients with stable ischemic heart disease and unprotected left main or 3-vessel disease or Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery score >22 who underwent PCI after heart team review between 2013 and 2020 were included. Patients were categorized into 3 groups according to heart team recommendations on the basis of appropriate use criteria: (1) PCI-recommended; (2) CABG-eligible but refused CABG (CABG-refusal); and (3) CABG-ineligible. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year. The study included 3687 patients undergoing PCI (PCI-recommended, n=1718 [46.6%]), CABG-refusal (n=1595 [43.3%]), and CABG-ineligible (n=374 [10.1%]). Clinical and procedural risk increased across the 3 groups, with the highest comorbidity burden in CABG-ineligible patients. Composite events within 1 year after PCI occurred in 55 (4.1%), 91 (7.0%), and 41 (14.8%) of patients in the PCI-recommended, CABG-refusal, and CABG-ineligible groups, respectively. After multivariable adjustment, the risk of the primary composite outcome was significantly higher in the CABG-refusal (hazard ratio [HR], 1.67 [95% CI, 1.08-3.56]; =0.02) and CABG-ineligible patients (HR, 3.26 [95% CI, 1.28-3.65]; =0.004) groups compared with the reference PCI-recommended group, driven by increased death and stroke.
Cardiovascular event rates after PCI were significantly higher in patients with multivessel disease who declined or were ineligible for CABG. Our findings provide real-world data to inform shared decision-making discussions.
尽管心脏团队建议进行冠状动脉旁路移植术（CABG），但患者可能更倾向于经皮冠状动脉介入治疗（PCI）。尚未对这类患者的结局进行研究。我们旨在研究经心脏团队审查后建议进行但拒绝 CABG 的患者行 PCI 的结果。
连续纳入 2013 年至 2020 年间接受经心脏团队审查后行 PCI 的稳定型缺血性心脏病患者，且存在无保护左主干病变或 3 支血管病变或血管搭桥术 SYNTAX 评分>22 分。根据合适的使用标准，根据心脏团队的建议将患者分为 3 组：（1）推荐 PCI；（2）CABG 适应证但拒绝 CABG（CABG 拒绝）；（3）CABG 禁忌。主要终点是 1 年内死亡、心肌梗死或卒中的复合终点。研究纳入 3687 例行 PCI（推荐 PCI，n=1718 [46.6%]）、CABG 拒绝（n=1595 [43.3%]）和 CABG 禁忌（n=374 [10.1%]）的患者。随着临床和手术风险的增加，CABG 禁忌组的合并症负担最高。PCI 推荐组、CABG 拒绝组和 CABG 禁忌组患者在 PCI 后 1 年内的复合事件发生率分别为 55（4.1%）、91（7.0%）和 41（14.8%）。多变量调整后，CABG 拒绝组（危险比[HR]，1.67 [95%CI，1.08-3.56]；=0.02）和 CABG 禁忌组（HR，3.26 [95%CI，1.28-3.65]；=0.004）患者的主要复合结局风险显著高于参考 PCI 推荐组，这主要是由于死亡和卒中发生率增加所致。
多支血管病变且拒绝或不适合 CABG 的患者行 PCI 后心血管事件发生率显著升高。我们的研究结果提供了真实世界的数据，有助于开展共同决策讨论。
