药物洗脱支架对首诊心内科患者转行冠状动脉搭桥治疗的影响

Impact of drug-eluting stents on transferring treatment with coronary surgical revascularization among patients initially admitted to department of internal medicine

目的了解药物洗脱支架(DES)对首诊于心内科的冠心病患者转诊行冠状动脉搭桥术(CABG)的影响。方法入选2001年7月1日至2002年6月30日(BMS 时代)以及2003年7月1日至2004年6月30日(DES 时代)首诊于北京安贞医院心内科并接受经皮冠状动脉介入(PCI)或冠状动脉搭桥(CABG)的2598例患者,分析 BMS 时代与 DES 时代患者转行 CABG 术的临床及冠状动脉病变特征,评价 DES 对转诊 CABG 治疗的影响。结果 DES 时代1333例(80.1%)患者接受 PCI 治疗,331例(19.9%)患者转行 CABG 术,BMS 时代721例(77.2%)患者接受 PCI 治疗,213例(22.8%)患者转行 CABG 术,转诊率下降约12.7%。与 BMS 时代相比,DES 时代左主干病变(1.4%比3.2%,P=0.025)前降支近端(39.8%比44.2%,P=0.047)与弥漫长病变患者(11.2%比19.7%,P=0.021)接受 PCI 治疗的比例明显增加,但无论是否置入 DES,左主干病变、慢性闭塞病变、前降支近段病变以及开口病变的患者仍是接受 CABG 治疗的最常见冠状动脉病变类型。DES 时代接受 PCI治疗的患者再次血管重建率明显低于 BMS 时代(12.7%比7.1%,P<0.001)。多变量 Logistic 分析显示,病变血管支数、左主干病变、慢性闭塞病变以及前降支近端病变是选择 CABG 的主要预测因素。结论 DES 对冠心病患者血管重建方式及策略产生了一定的影响,在非 DES 时代需要转诊行 CABG治疗的冠状动脉病变,在 DES 时代接受 PCI 治疗置入 DES。

Objective To evaluate the impact of drng-eluting stent （DES） on transferring treatment with coronary surgical revascularization among the patients initially admitted to department of internal medicine. Methods 2598 patients initially admitted in department of internal medicine underwent revascularization by percutaneous coronary intervention （ PCI ） or coronary artery bypass grafting （ CABG ） before the introduction of DES from 1 July 2001 to 30 June 2002 [bare metal stent（ BMS）era group, n = 923） or after the introduction of DES from 1 July 2003 to 30 June 2004 （ DES era group）. The clinical manifestations and coronary angiography characteristics were analyzed retrospectively. Results In the DES era group 1333 patients （80. 1% ） were revascularized with PCI, and 331 patient （19. 9% ） were transferred to treatment with CABG; and in the BMS era group, 721 patients （77.2%） underwent PCI, and 213 patients （22.8%） were transferred to treatment with CABG. The rate of transference to CABG of the DES era group was lower by 12.7% compared with the BMS era group. The rates of left main coronary disease, proximal left anterior descending coronary stenosis and diffuse long lesions among the patients revascularized with PCI in the DES era group were 3. 2%, 44. 2% , and 19. 7% respectively, all significantly higher than those in the BMS era group （ 1.4% , 39.8%, and 11.2%, P = 0. 025, P = 0.047, and =0.021 respectively） . But no matter if DES was implanted or not, left main coronary disease, proximal left anterior descending coronary stenosis, diffuse long lesions and ostial lesions were the most common coronary lesions in the patients revascularized with CABG. Logistic regression showed that number of diseased vessels, left main coronary disease, chronic total occlusion lesions, and proximal left anterior descending coronary stenosis were independent predictor for transferring treatment with CABG （ all P 〈 0.0001 ）. Conclusion DES has a certain impact on the coronary revascularization strategies, because the rate of in-stent restenosis and repeat revascularization are lower significantly after implantation of DES than after implantation of BMS. Many coronary lesions that should undergo CABG in non-DES era may be revascularized with PCI and implantation of DES.