Omerovic Elmir, Råmunddal Truls, Petursson Petur, Angerås Oskar, Rawshani Araz, Jha Sandeep, Skoglund Kristofer, Mohammad Moman A, Persson Jonas, Alfredsson Joakim, Hofmann Robin, Jernberg Tomas, Fröbert Ole, Jeppsson Anders, Hansson Emma C, Dellgren Göran, Erlinge David, Redfors Björn
Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
Eur Heart J. 2025 Feb 7;46(6):518-531. doi: 10.1093/eurheartj/ehae700.
The long-term outcomes of percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG) in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and multivessel disease remain debated.
The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry was used to analyse 57 097 revascularized patients with NSTEMI with multivessel disease in Sweden from January 2005 to June 2022. The primary endpoint was all-cause mortality, encompassing both in-hospital and long-term mortality; the secondary endpoints included myocardial infarction (MI), stroke, new revascularization, and heart failure. Multilevel logistic regression with follow-up time as a log-transformed offset variable and double-robust adjustment with the instrumental variable method were applied to control for known and unknown confounders.
Percutaneous coronary intervention was the primary therapy in 42 190 (73.9%) patients, while 14 907 (26.1%) received CABG. Percutaneous coronary intervention patients were generally older with more prior cardiovascular events, whereas CABG patients had higher incidences of diabetes, hypertension, left main and three-vessel disease, and reduced ejection fraction. Over a median follow-up of 7.1 years, PCI was associated with higher risks of death [adjusted odds ratio (aOR) 1.67; 95% confidence interval (CI) 1.54-1.81] and MI (aOR 1.51; 95% CI 1.41-1.62) but there was no significant difference in stroke. Repeat revascularization was three times more likely to PCI (aOR 3.01; 95% CI 2.57-3.51), while heart failure risk was 15% higher (aOR 1.15; 95% CI 1.07-1.25). Coronary artery bypass grafting provided longer survival within 15 years, especially in patients under 70 years of age, with left main disease or left ventricular dysfunction, though this benefit diminished over shorter time horizons.
Coronary artery bypass grafting is associated with lower risks of mortality, MI, repeat revascularization, and heart failure in patients with NSTEMI, particularly in high-risk subgroups. However, its survival benefit lessens with shorter life expectancy.
非ST段抬高型心肌梗死（NSTEMI）合并多支血管病变患者经皮冠状动脉介入治疗（PCI）与冠状动脉旁路移植术（CABG）的长期疗效仍存在争议。
采用瑞典心脏病循证治疗强化与发展网络系统（SWEDHEART）注册研究，分析2005年1月至2022年6月在瑞典接受血运重建的57097例NSTEMI合并多支血管病变患者。主要终点为全因死亡率，包括住院期间和长期死亡率；次要终点包括心肌梗死（MI）、中风、再次血运重建和心力衰竭。应用以随访时间为对数转换偏移变量的多水平逻辑回归分析，并采用工具变量法进行双重稳健调整，以控制已知和未知的混杂因素。
42190例（73.9%）患者以PCI作为主要治疗方法，14907例（26.1%）接受CABG。PCI患者通常年龄较大，既往心血管事件较多，而CABG患者糖尿病、高血压、左主干和三支血管病变以及射血分数降低的发生率较高。在中位随访7.1年期间，PCI与更高的死亡风险[调整优势比（aOR）1.67；95%置信区间（CI）1.54 - 1.81]和MI风险（aOR 1.51；95% CI 1.41 - 1.62）相关，但中风方面无显著差异。再次血运重建在PCI患者中发生的可能性高3倍（aOR 3.01；95% CI 2.57 - 3.51），而心力衰竭风险高15%（aOR 1.15；95% CI 1.07 - 1.25）。冠状动脉旁路移植术在15年内提供了更长的生存期，尤其是在70岁以下、患有左主干疾病或左心室功能障碍的患者中，尽管这种益处随着时间缩短而减弱。
冠状动脉旁路移植术与NSTEMI患者较低的死亡、MI、再次血运重建和心力衰竭风险相关，特别是在高危亚组中。然而，随着预期寿命缩短，其生存益处会减少。
