择期冠状动脉造影发现冠状动脉严重病变的再血管化治疗和保守治疗的对比分析

Comparative Study Between Revascularization and Medical Therapy in Patients With Severe Coronary Artery Lesions Diagnosed by Elective Coronary Angiography

目的：比较冠状动脉（冠脉）伴或不伴左主干病变的三支病变患者接受再血管化治疗（REV）和保守治疗（MT）的长期预后。方法：连续入选我院在2007-01至2008-12间经择期冠脉造影发现的伴或不伴左主干病变的4 875例三支病变患者。其中705例（14.4%）患者为MT组,4 170例（85.6%）患者接受了REV为REV组。经倾向评分的逆概率加权方法调整使其基线均衡后,比较两组患者在随访中全因死亡率以及再血管化率。结果：在4 875例患者中,3 962例（81.2%）为单纯三支（右冠脉、左前降支、左回旋支）病变,913例（18.8%）患者为三支合并左主干病变。两组患者住院死亡率差异没有统计学意义[比值比（OR）=0.7,95%可信区间（CI）：0.3-1.4;P=0.30]。随访中位数为1年,MT组经校正的全因死亡率显著高于REV组[风险比（HR）=8.3,95%CI：6.7-11.1;P〈0.001],再血管化率也显著高于REV组（HR=1.4,95%CI：1.1-1.6;P〈0.001）。无论是否合并左主干病变,与REV相比,MT组的全因死亡率均明显较高（合并左主干：HR=10.4,95%CI：7.1-15.4,P〈0.001;单纯三支：HR=7.1,95%CI：5.3-10.0;P〈0.001）。结论：在真实世界中,对于择期冠脉造影发现的伴或不伴左主干病变的三支病变患者,经REV的长期预后明显优于MT。

Objective： To compare the long term prognosis between revascularization （REV） and medical therapy （MP） in patients with three-vessel disease （3VD） with or without left main （LM） lesion. Methods： A total of 4,875 consecutive patients with elective coronary angiography （CAG） diagnosed 3VD with or without LM lesion treated in our hospital from 2007-01 to 2008-12 were retrospectively studied. The patients were divided into 2 groups： MT group, n=705 （14.5%） and REV group, n=4170 （85.5%）. The all cause mortality and the rate of revascularization during follow-up period were compared between 2 groups by inverse-probability-weighting approach with propensity score. Results： There were 3962/4875 （81.3%） patients with simple 3VD （right, left anterior descending and left circumflex coronary arteries） and 913 （18.7%） with 3VD＋LM lesion. The in-hospital mortality was similar between 2 groups （OR=0.7, 95% CI 0.3-1.4, P=0.30）. With the longest 2-year follow-up study, the adjusted all cause mortality and the rate of revascularization in MT group were both higher than those in REV group （HR=8.3, 95% CI 6.7-11.1, P〈0.001） and （HR=1.4, 95% CI 1.1-1.6, P〈0.001）. No matter the patients with simple 3 VD or 3 VD＋LM lesion, compared with REV group, MT group had the higher all cause mortality, for 3VD＋LM lesion （HR=10.4, 95% CI 7.1-15.4, P〈0.001） and for simple 3VD （HR=7.1, 95% CI 5.3-10.0, P〈0.001）. Conclusion： In real world, the long term prognosis by revascularization treatment was superior to medical treatment inpatients with either simple 3 vessel coronary disease or 3 vessel combining LM disease.