Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA.
Duke Clinical Research Institute, Durham, NC, USA.
EuroIntervention. 2024 Oct 21;20(20):e1276-e1287. doi: 10.4244/EIJ-D-24-00240.
Whether revascularisation (REV) improves outcomes in patients with three-vessel coronary artery disease (3V-CAD) is uncertain.
Our objective was to evaluate outcomes with REV (percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]) versus medical therapy in patients with 3V-CAD.
ISCHEMIA participants with 3V-CAD on coronary computed tomography angiography without prior CABG were included. Outcomes following initial invasive management (INV) with REV (PCI or CABG) versus initial conservative management (CON) with medical therapy alone were evaluated. Regression modelling was used to estimate the outcomes if all participants were to undergo prompt REV versus those assigned to CON. Outcomes were cardiovascular (CV) death/myocardial infarction (MI), death, CV death, and quality of life. Bayesian posterior probability for benefit (Pr [benefit]) for 1 percentage point lower 4-year rates with REV versus CON were evaluated.
Among 1,236 participants with 3V-CAD (612 INV/624 CON), REV was associated with lower 4-year CV death/MI (adjusted 4-year difference: -4.4, 95% credible interval [CrI] -8.7 to -0.3 percentage points, Pr [benefit]=94.8%) when compared with CON, with similar results for PCI versus CON (-5.8, 95% CrI: -10.8 to -0.5 percentage points, Pr [benefit]=96.4%) and CABG versus CON (-3.7, 95% CrI: -8.8 to 1.5 percentage points, Pr [benefit]=84.7%). Adjusted 4-year REV versus CON differences were as follows: death -1.2 (95% CrI: -4.7 to 2.2) percentage points, CV death -2.3 (95% CrI: -5.5 to 0.8) percentage points, with similar results for PCI and for CABG. The Pr (benefit) for death with REV (PCI or CABG) versus CON was 49-63%. The adjusted 12-month Seattle Angina Questionnaire-7 summary score differences favoured REV: REV versus CON 4.6 (95% CrI: 2.7-6.4) percentage points; PCI versus CON 3.6 (95% CrI: 1.2-5.8) percentage points and CABG versus CON 4.3 (95% CrI: 1.5-6.9) percentage points with high Pr (benefit).
In participants with 3V-CAD, REV (either PCI or CABG) was associated with a lower 4-year CV death/MI rate and improved quality of life, with similar results for PCI versus CON and CABG versus CON. The differences in all-cause mortality between REV and CON were small with wide confidence intervals. (ClinicalTrials.gov: NCT01471522).
在三支血管病变（3V-CAD）患者中，血运重建（REV）是否改善结局尚不确定。
本研究旨在评估 3V-CAD 患者接受 REV（经皮冠状动脉介入治疗 [PCI] 或冠状动脉旁路移植术 [CABG]）与单纯药物治疗的结局。
纳入冠状动脉计算机断层血管造影术（CCTA）显示三支血管病变且无 CABG 史的 ISCHEMIA 研究参与者。评估初始有创治疗（INV）中采用 REV（PCI 或 CABG）与初始单纯药物治疗（CON）的结局。采用回归模型估算所有参与者接受即刻 REV 与接受 CON 治疗的结局。结局为心血管（CV）死亡/心肌梗死（MI）、死亡、CV 死亡和生活质量。采用贝叶斯后验概率（Pr[获益]）评估 4 年时采用 REV 治疗较 CON 治疗可降低 1%的发生率。
在 1236 例 3V-CAD 患者（612 例 INV/624 例 CON）中，与 CON 相比，REV 可降低 4 年 CV 死亡/MI 发生率（校正后 4 年差异：-4.4%，95%可信区间 [CrI]：-8.7%至-0.3%，Pr[获益]=94.8%），PCI 与 CON 相比（-5.8%，95% CrI：-10.8%至-0.5%，Pr[获益]=96.4%）和 CABG 与 CON 相比（-3.7%，95% CrI：-8.8%至 1.5%，Pr[获益]=84.7%）也有类似结果。校正后 4 年时，REV 与 CON 的差异如下：死亡为-1.2（95% CrI：-4.7%至 2.2%），CV 死亡为-2.3（95% CrI：-5.5%至 0.8%），PCI 和 CABG 也有类似结果。REV（PCI 或 CABG）与 CON 相比，死亡的 Pr[获益]为 49%-63%。校正后 12 个月西雅图心绞痛问卷-7 综合评分差异有利于 REV：REV 与 CON 相比为 4.6（95% CrI：2.7%至 6.4），PCI 与 CON 相比为 3.6（95% CrI：1.2%至 5.8%），CABG 与 CON 相比为 4.3（95% CrI：1.5%至 6.9%），Pr[获益]较高。
在 3V-CAD 患者中，REV（无论 PCI 还是 CABG）可降低 4 年 CV 死亡/MI 发生率，并改善生活质量，且 PCI 与 CON 及 CABG 与 CON 的结果相似。REV 与 CON 相比，全因死亡率的差异较小，但置信区间较宽。（临床试验.gov：NCT01471522）
