稳定性冠心病三支病变患者三种治疗策略对比分析

Efficacy comparison of 3 strategies for real-world stable coronary artery disease patients with three-vessel disease

目的对比研究真实世界中国人稳定性冠心病（SCAD）三支病变患者行冠状动脉介入治疗（PCI）、冠状动脉旁路移植术（CABG）和单纯药物治疗3种治疗方式的有效性。方法连续入组2004年4月至2011年2月阜外医院收治的冠心病三支病变患者8 943例，回顾性分析其中SCAD三支病变患者共3 435例，包括PCI 1 313例（38.2%），CABG 1 259例（36.7%），单纯药物治疗863例（25.1%），均完成1和2年随访。分别将PCI和CABG组、PCI组和单纯药物治疗组、CABG组和单纯药物治疗组以邻近法1∶1进行倾向性评分匹配，得出CABG和PCI组各758例，PCI和单纯药物治疗组各552例，CABG和单纯药物治疗组各639例。行Kaplan-Meier生存曲线和多因素Cox回归分析3种治疗倾向性评分匹配前后1和2年的随访结果。结果PCI、CABG和单纯药物治疗3组基线资料包括年龄、性别、体重指数、冠心病家族史、高脂血症史、糖尿病史、心肌梗死史、卒中史、既往血运重建、外周血管病史、术前SNYTAX积分、左心室射血分数、血红蛋白、血肌酐、高敏C反应蛋白、甘油三酯及药物治疗情况等差异均有统计学意义（P均〈0.05）。接受这3种方法治疗的患者1和2年随访全因死亡率分别为：0.6%（8/1 313）、1.1%（14/1 259）、3.4%（29/863）（P〈0.001）和1.1%（14/1 313）、1.5%（19/1 259）、7.3%（63/863）（P〈 0.001）。Cox回归分析显示，与PCI组比较，CABG组1年主要心脑血管不良事件（MACCE）风险较低（HR=0.51，95%CI 0.33~0.77，P=0.001），归因于心肌梗死风险（HR=0.09，95%CI 0.01~0.76，P=0.027）和再次血运重建风险（HR=0.21，95%CI 0.10~0.41，P〈0.001）较低，全因死亡（HR=1.21，95%CI 0.48~3.00，P=0.69）和卒中发生率（HR=2.31，95%CI 0.82~6.47，P=0.112）组间差异无统计学意义；随访至2年，CABG组卒中风险较高（HR=2.20，95%CI 1.06~4.55，P=0.034），心肌梗死风险（HR=0.19，95%CI 0.06~0.59，P=0.004）和再次血运重建风险（HR=0.22，95%CI 0.13~0.37，P〈0.001）仍较低，MACCE风险较低（HR=0.49，95%CI 0.36~0.68，P〈0.001）。与单纯药物治疗组比较，PCI组2年全因死亡（HR=0.22，95%CI 0.12~0.42，P〈0.001）和MACCE风险（HR=0.63，95%CI 0.47~0.83, P=0.001）较低；CABG组2年全因死亡（HR=0.21, 95%CI 0.13~0.37，P〈0.001）、MACCE（HR=0.31, 95%CI 0.23~0.42，P〈0.001）、心肌梗死（HR=0.19，95%CI 0.06~0.60，P=0.004）和再次血运重建风险（HR=0.24，95%CI 0.13~0.41, P〈0.001）均较低。经倾向性评分匹配后，1和2年随访的多因素Cox分析结果和匹配前的结果基本一致。结论对SCAD三支病变患者，CABG较PCI能降低术后心肌梗死和再次血运重建风险，但卒中发生率更高。单纯药物治疗的患者临床预后显著劣于行血运重建的患者。

ObjectiveTo compare the effectiveness of percutaneous coronary intervention （PCI）, coronary artery bypass grafting （CABG） or medical therapy （MT） alone for real-world stable coronary artery disease （SCAD） patients with three-vessel disease （TVD） in China's Mainland. MethodsA total of 8 943 consecutive cases with TVD hospitalized in our center from April 2004 to February 2011 were screened for this study. In this cohort, 3 435 cases diagnosed as SCAD were analyzed. PCI, CABG, MT alone were performed in 1 313 （38.2%）, 1 259 （36.7%） and 863 （25.1%） patients, respectively. Propensity score matching （PSM） analysis using nearest neighbor matching with a 1∶1 ratio was applied, and 758 pairs of CABG and PCI groups, 552 pairs of PCI and MT groups, 639 pairs of CABG and MT groups were selected, respectively. 1- and 2-year clinical outcomes were evaluated among PCI, CABG and MT group. Kaplan-Meier curves and multivariable Cox regression method were used for survival analysis.ResultsSignificant differences were found at baseline between PCI, CABG and MT group, including age, gender, body mass index, family history of coronary artery disease, hyperlipidemia, diabetes mellitus, previous myocardial infarction, stroke, previous revascularization, peripheral vascular disease, SNYTAX score, left ventricular ejection fraction, hemoglobin, serum creatinine, high-sensitivity C-reactive protein, triglyceride and medication （all P〈0.05） . All-cause death rates of 1- and 2-year follow-up of PCI, CABG and MT group were 0.6% （8/1 313）, 1.1% （14/1 259）, 3.4% （29/863） （P〈0.001） and 1.1%（14/1 313）, 1.5%（19/1 259）, 7.3%（63/863） （P〈0.001）, respectively. Multivariate Cox regression analysis showed that 1-year MACCE rate （HR=0.51, 95%CI 0.33-0.77, P=0.001） was significantly reduced, due to the significant decrease of myocardial infarction （MI） rate （HR=0.09, 95%CI 0.01-0.76, P=0.027） and repeat revascularization rate （HR=0.21, 95%CI 0.10-0.41, P〈0.001） in CABG group compared to PCI group, while all-cause death （HR=1.21, 95%CI 0.48-3.00, P=0.69） and stroke rate （HR=2.31, 95%CI 0.82-6.47, P=0.112） were similar between 2 groups. 2-year outcome showed CABG was associated with higher stroke rate （HR=2.20, 95%CI 1.06-4.55, P=0.034） and lower MI （HR=0.19, 95%CI 0.06-0.59, P=0.004） and repeat revascularization rate （HR=0.22, 95%CI 0.13-0.37, P〈0.001）, and lower MACCE rate （HR=0.49, 95%CI 0.36-0.68, P〈0.001）. Compared to MT group, 2-year all-cause death （HR=0.22, 95%CI 0.12-0.42, P〈0.001） and MACCE rate （HR=0.63, 95%CI 0.47-0.83, P=0.001） were lower in PCI group, while 2-year all-cause death （HR=0.21, 95%CI 0.13-0.37, P〈0.001）, MACCE （HR=0.31, 95%CI 0.23-0.42, P〈0.001）, MI （HR=0.19, 95%CI 0.06-0.60, P=0.004） and repeat revascularization rate （HR=0.24, 95%CI 0.13-0.41, P〈0.001） were lower in CABG group. Results of multivariate Cox regression analysis after PSM were consistent with above results. ConclusionFor SCAD patients with TVD, CABG shows better effectiveness by reducing MI and revascularization risk as compared to PCI, even though stroke risk is somehow higher in CABG patients. Patients received MT alone are associated with worse outcomes than those undergoing revascularization strategies.