Hamm C W, Reimers J, Ischinger T, Rupprecht H J, Berger J, Bleifeld W
Department of Cardiology, University Hospital Eppendorf, Hamburg, Germany.
N Engl J Med. 1994 Oct 20;331(16):1037-43. doi: 10.1056/NEJM199410203311601.
The standard treatment for patients with symptomatic multivessel coronary artery disease is coronary-artery bypass grafting (CABG). Percutaneous transluminal coronary angioplasty (PTCA) is widely used as an alternative approach to revascularization, but a systematic comparison of the two procedures is needed. We compared the outcomes in patients one year after complete revascularization with CABG or PTCA.
A total of 8981 patients with multivessel coronary disease were screened at eight clinical sites, and 359 patients were randomly assigned to undergo CABG (177 patients) or PTCA (182 patients). Enrollment required that complete revascularization of at least two major vessels supplying different myocardial regions be deemed clinically necessary and technically feasible.
Among the patients in the CABG group, an average of 2.2 +/- 0.6 vessels were grafted, and among those in the PTCA group, 1.9 +/- 0.5 vessels were dilated. After CABG, hospitalization was longer (median, 19, as compared with 5 days for PTCA), and Q-wave myocardial infarction in relation to the procedure was more frequent (8.1 percent, as compared with 2.3 percent after PTCA; P = 0.022), whereas in-hospital mortality did not differ significantly between the two groups (2.5 percent in the CABG group and 1.1 percent in the PTCA group). At discharge 93 percent of the patients in the CABG group were free of angina, as compared with 82 percent of those in the PTCA group (P = 0.005). During the first year of follow-up, further interventions were necessary in 44 percent of the patients in the PTCA group (repeated PTCA in 23 percent, CABG in 18 percent, and both in 3 percent) but in only 6 percent of the patients in the CABG group (repeated CABG in 1 percent and PTCA in 5 percent; P < 0.001). Seventy-four percent of the patients in the CABG group and 71 percent of those in the PTCA group were free of angina one year after treatment. Exercise capacity improved similarly in both groups. However, 22 percent of the CABG group, as compared with only 12 percent of the PTCA group, did not require antianginal medication (P = 0.041).
In selected patients with multivessel coronary disease, PTCA and CABG as initial treatments resulted in equivalent improvement in angina after one year. However, in order to achieve similar clinical outcomes, the patients treated with PTCA were more likely to require further interventions and antianginal drugs, whereas the patients treated with CABG were more likely to sustain an acute myocardial infarction at the time of the procedure.
有症状的多支冠状动脉疾病患者的标准治疗方法是冠状动脉旁路移植术（CABG）。经皮腔内冠状动脉成形术（PTCA）作为一种替代的血运重建方法被广泛应用，但需要对这两种手术进行系统比较。我们比较了接受CABG或PTCA完全血运重建术后一年患者的结局。
在八个临床地点对总共8981例多支冠状动脉疾病患者进行了筛查，359例患者被随机分配接受CABG（177例患者）或PTCA（182例患者）。入选要求至少两支供应不同心肌区域的主要血管的完全血运重建在临床和技术上被认为是必要的。
CABG组患者平均移植2.2±0.6支血管，PTCA组患者平均扩张1.9±0.5支血管。CABG术后住院时间更长（中位数为19天，而PTCA为5天），与手术相关的Q波心肌梗死更常见（8.1%，而PTCA后为2.3%；P = 0.022），而两组住院死亡率无显著差异（CABG组为2.5%，PTCA组为1.1%）。出院时，CABG组93%的患者无心绞痛，而PTCA组为82%（P = 0.005）。在随访的第一年，PTCA组44%的患者需要进一步干预（23%重复PTCA，18%接受CABG，3%两者都做），而CABG组仅6%的患者需要进一步干预（1%重复CABG，5%接受PTCA；P < 0.001）。治疗后一年，CABG组74%的患者和PTCA组71%的患者无心绞痛。两组运动能力改善相似。然而，CABG组22%的患者不需要抗心绞痛药物，而PTCA组仅12%（P = 0.041）。
在选定的多支冠状动脉疾病患者中，PTCA和CABG作为初始治疗在一年后心绞痛改善方面效果相当。然而，为了获得相似的临床结局，接受PTCA治疗的患者更可能需要进一步干预和抗心绞痛药物，而接受CABG治疗的患者在手术时更可能发生急性心肌梗死。
