合并糖尿病的冠状动脉慢性闭塞病变治疗策略探讨

Therapeutic strategy for chronic total occlusion of coronary artery complicated by diabetes mellitus

目的探讨合并糖尿病的冠状动脉慢性闭塞病变(CTO)的处理策略。方法本研究连续入选2007年1月1日至2017年12月31日于北京安贞医院住院治疗的合并糖尿病的冠状动脉单支血管CTO患者(其治疗方式为药物治疗),根据是否尝试行经皮冠状动脉介入治疗(PCI),将患者分为:初始CTO-药物治疗(CTO-I-MT组)及失败的CTO-PCI(failed CTO-PCI,CTO-F-PCI),主要终点指标为主要不良心血管事件(MACEs),MACEs为复合终点,包括心源性死亡、靶血管再灌注(TVR)及再发非致死性心肌梗死。其他次要终点尚包括全因死亡及再灌注。采用多因素Cox回归模型校正协变量对于结局的影响。结果共纳入922例患者:CTO-I-MT组561例,CTO-F-PCI组361例。经40.00(四分位数间距22.00~77.00)月随访,在主要终点MACEs方面,2组间无差异[未校正HR:0.939,95%CI:0.727~1.212;校正HR(模型1):1.011,95%CI:0.755~1.353;校正HR(模型2):0.987,95%CI:0.735~1.326]。敏感性分析显示当Rentrop≥2级(侧枝循环好)时,CTO-F-PCI组有优于CTO-I-MT组的趋势;当侧支循环不好(Rentrop<2级)时,CTO-I-MT组有优于CTO-F-PCI组的趋势。结论对于合并糖尿病的CTO患者,即使行PCI失败,其疗效与初始接受药物保守治疗患者相当,应积极进行PCI尝试。

Objective To investigate the therapeutic strategy of chronic total occlusion of coronary artery(CTO)complicated by diabetes mellitus(DM).Methods The patients with single-vessel CTO complicated by DM were continuously chosen from Beijing Anzhen Hospital from Jan.1,2007 to Dec.31,2017.All patients were divided,according to whether they received PCI or not,into group of initial CTO-medical therapy(CTO-I-MT group)and group of failed CTO-PCI(CTO-F-PCI group).The main endpoint indexes were major adverse cardiovascular events(MACEs),which were composited endpoint,including cardiac death,target vessel revascularization(TVR)and recurrent non-fatal myocardial infarction,and other secondary endpoints included all-cause mortality and reperfusion.The influence of corrected covariance on outcomes in patients was analyzed by using multi-factor Cox regression model.Results There were totally 922 patients chosen and 561 in CTO-I-MT group and 361 in CTOF-PCI group.After followed up for 40.00 months(inter-quartile range:22.00~77.00),there was no difference in MACEs between 2 group[non-corrected HR:0.939,95%CI:0.727~1.212;corrected HR(model 1):1.011,95%CI:0.755~1.353;corrected HR(model 2):0.987,95%CI:0.735~1.326].The results of analysis on sensitivity showed that CTO-F-PCI was tend to superior to CTO-I-MT when Rentrop≥2(good collateral circulation),and CTO-I-MT was tend to superior to CTO-F-PCI when Rentrop<2(poor collateral circulation).Conclusion The curative effect is similar between CTO-I-MT group and CTO-F-PCI group,even though PCI is failed.Thus PCI can be tried actively in patient with CTO complicated by DM.