冠状动脉多支血管病变伴慢性肾功能不全患者血管重建策略与预后的关系

Association of chronic kidney disease with clinical outcomes after revascularization for patients with multiple coronary artery disease

目的对比多支血管病变伴慢性肾脏疾病(CKD)患者经皮冠状动脉介入治疗(PCI)和冠状动脉旁路移植术(CABG)的2年临床预后。方法根据改良MDRD公式对北京安贞医院2004年到2006年因多支冠状动脉病变接受药物洗脱支架(DES)或CABG的患者的肾小球滤过率(GFR)进行计算,GFR<60mL/min诊断为CKD。共入选CKD患者1069例,其中724例接受DES,345例接受CABG。首要终点为2年内死亡、心肌梗死(MI)以及脑血管事件(CVE)的复合终点,次级终点为再次血管重建。结果在2年随访中,CABG组首要终点的发生率为9.9%,DES组为11.3%(P=0.528)。两组之间死亡率差异也无统计学意义(CABG组与DES组分别为3.5%比4.7%,P=0.422)。而DES组2年再次血管重建的比例显著高于CABG组(9.0%比4.1%,P=0.004)。Cox多因素回归分析表明,年龄、糖尿病、左心室功能不全(LVEF<30%)和急性冠状动脉综合征是复合终点发生的独立预测因素。结论在冠状动脉多支病变伴CKD患者中,CABG和DES两种血管重建策略显示出相同的死亡率和MI、CVE发生率。但DES组患者再次血管重建的发生率依然高于CABG组患者。

Objective To compare the clinical outcomes of CABG and PCI with drug-eluting stent （DES） in patients with muhivessel coronary artery disease and CKD. Methods Between January 2004 and June 2006, 1,069 patients with multivessel corona17 disease and CKD undergoing PCI with drug-eluting stent （DES） （ n = 724） or CABG （ n = 345 ） were evaluated. CKD was defined as estimated glomerular filtration rate （eGFR） 〈60 mL/min, calculated using the modified MDRD equation. The primary end point was the composite of all-cause death, non-fatal myocardial infarction （MI） , or eerebrovascular events （CVE）. The second end point was repeat revascularization. Results The cumulative incidence of 2-year composite emt points was 9. 9% in patients receiving CABG and 11.3% in those treated with DES （ P = 0. 528 ）. The incidence of all-cause death was 3.5% in patients undergoing CABG and 4.7% in tbose treated with DES （P = 0. 422）. However, CABG was associated with a reduced risk for repeat revascularization compared with treatment with DES （4. 1% vs. 9.0% , P = 0. 004）. After muhivariate adjustment, age, diabetes, left ventricular ejection fraction and acute coronary syndrome were independent predictors of composite end points. Conclusion Similar incidences of death, MI or CVE were recored between CABG and DES in patients with muhivessel disease and CKD. However, the rate of repeat revascularization was higher in patients treated with DES.