合并射血分数减低的复杂冠状动脉病变患者接受不同血运重建术疗效分析

Prognostic impact of different revascularization strategies on patients with coronary artery disease in combination with reduced ejection fraction

目的探讨冠状动脉左主干(LM)病变和(或)三支血管病变的冠心病患者,在同时合并射血分数减低的心力衰竭(HFrEF)情况下,接受不同血运重建策略治疗对近期及远期预后的影响。方法选取2009年1月至2018年1月就诊于首都医科大学附属北京安贞医院合并HFrEF并成功行血运重建治疗的LM病变和(或)三支病变冠心病患者进行病例注册分析。根据纳入及排除标准最终入选患者902例,其中接受经皮冠状动脉介入治疗(PCI)置入药物洗脱支架228例(PCI组),接受冠状动脉旁路移植术(CABG)治疗674例(CABG组)。根据术后平均3.1年随访资料对两组患者主要不良心脑血管事件(MACCE)进行比较,同时分析左心功能变化情况。结果经单因素回归分析后,将差异具有统计学意义的因素(吸烟史、陈旧性前壁心肌梗死病史、既往PCI史、既往CABG史、SYNTAX评分)纳入Cox多因素回归分析,结果显示:成功进行血运重建治疗后1年CABG组患者的MACCE发生率高于PCI组(17.66%比14.04%,HR 1.362,95%CI 1.211~2.070,P<0.010)。对MACCE单个事件比较显示,CABG组患者的全因死亡率高于PCI组(12.61%比6.14%,HR 2.134,95%CI 1.832~3.182,P<0.010),而再次血运重建率较低(2.97%比4.82%,HR 0.696,95%CI 0.518~0.922,P=0.026);两组患者卒中及因心力衰竭入院事件发生率比较,差异均无统计学意义(均P>0.05)。经多因素回归分析校正混杂因素,术后3年随访结果显示:两组患者的MACCE发生率相似,同时在单独事件全因死亡风险、心原性死亡风险方面差异无统计学意义(均P>0.05)。相较于PCI组,CABG组具有较高的卒中发生率(5.93%比3.07%,HR 1.894,95%CI 1.528~2.673,P=0.014)和较低的再次血运重建率(8.31%比13.16%,HR 0.558,95%CI 0.362~0.714,P<0.010)。并依据SYNTAX评分分值分为SYNTAX评分低分(≤22分)、SYNTAX评分中分(23~32分)、SYNTAX评分高分(≥33分),单因素回归分析筛选各组间具有统计学差异的因素纳入Cox多因素回归分析,经校正混杂因素后术后3年随访结果显示,对于SYNTAX评分低分患者,CABG组心原性死亡风险高于PCI组(HR 1.253,95%CI 0.748~2.003,P=0.048),两组全因死亡风险相似;而对于SYNTAX评分高分患者,CABG组的全因死亡事件、心原性死亡发生率均略低于PCI组,但差异均无统计学意义(HR 0.796,95%CI 0.318~1.274,P=0.057;HR 0.941,95%CI 0.295~1.681,P=0.623)。结论合并HFrEF的复杂冠状动脉病变的冠心病患者接受PCI的远期预后并不劣于接受CABG治疗,对于存在左心功能障碍的冠心病患者,PCI也可作为血运重建治疗策略。

Objective To explore the short and longer outcomes of heart failure with reduced ejection fraction(HFrEF)patients with unprotected left main(LM)and/or multivessel disease after two different revascularization strategies.Methods HFrEF patients with left main and/or multivessel disease who had undergone successful revascularization between January 2009 and January 2018 in Anzhen hospital were analyzed based on registries.A total of 902 patients met the inclusion and exclusion criteria were fi nally selected,including 228 cases of PCI and 674 cases of CABG.The MACCE after a mean follow up of 3.1 years were compared,as well as the change of left ventricular function.Results After adjustment on variables with signifi cant diff erence based on univariate regression,including tobacco,prior anterior myocardial infarction,prior PCI,prior CABG,and SYNTAX score,multivariate Cox regression showed:the risks of MACCE at one year after revascularization were higher in CABG group(17.66%vs.14.04%,HR 1.362,95%CI 1.211-2.070,P<0.010)than PCI group.The risk of mortality was higher(12.61%vs.6.14%,HR 2.134,95%CI 1.832-3.182,P<0.010),while second revascularization rate was lower(2.97%vs.4.82%,HR 0.696,95%CI 0.518-0.922,P=0.026)in CABG group.There was no difference in stroke or hospitalization for heart failure.Three-year outcomes showed that the risks of MACCE,all-cause mortality or cardiac death were no statistical signifi cance between CABG and PCI group(P>0.05).The incidence of stroke was higher(5.93%vs.3.07%,HR 1.894,95%CI 1.528-2.673,P=0.014)and second revascularization rate was lower(8.31%vs.13.16%,HR 0.558,95%CI 0.362-0.714,P<0.010)in CABG group.And for patients with a lower SYNTAX score,the cardiac mortality was higher in CABG group(HR 1.253,95%CI 0.748-2.003,P=0.048),while the all-cause mortality was similar.For patients with SYNTAX score≥33,the all-cause mortality or the cardiac mortality in CABG group were lower than the PCI group but with no significance(HR 0.796,95%CI 0.318-1.274,P=0.057;HR 0.941,95%CI 0.295-1.681,P=0.623;respectively).Conclusions In HFrEF patients with complicated coronary artery disease underwent successful revascularization,PCI was not inferior to CABG for long-term survival.PCI should be taken into consideration to become an alternative strategy to patients with left ventricular systolic dysfunction.