不宜行冠状动脉旁路移植术的高危冠心病患者介入治疗与药物治疗的疗效对比

Percutaneous coronary intervention versus drug therapy in the patients not indicated for coronary artery bypass grafting

摘要:

目的 联合使用SYNTAX及EURO评分,研究存在左主干和 (或)三支病变但不适宜行冠状动脉旁路移植术的高危患者经皮冠状动脉介入(PCI)治疗与药物治疗的预后,指导临床制订个体化的治疗策略。方法 对冠状动脉造影示左主干和(或)三支病变的患者逐一完成SYNTAX及EURO评分的计算,选择SYNTAX评分>27分、EURO评分>6分的115例患者,按治疗策略分组为PCI组和药物治疗组,随访18个月。主要终点为主要不良心血管事件(MACE)发生率,包括全因死亡、非致死性心肌梗死及临床驱动的靶血管血运重建；次要终点事件包括:心源性再入院、心功能减退及再发心绞痛的发生率。采用Kaplan-Meier 法计算生存率,Log rank检验生存时间分布,Cox比例风险模型进行单因素及多因素分析。结果 101例患者完成18个月的随访。PCI组6例(11.76%)、药物治疗组17例(34.00%)发生MACE,PCI组未发生MACE的比例显著高于药物组。未发生MACE生存曲线的log-rank检验结果显示,2组出院后不良心血管事件生存率差异有统计学意义(χ²=11.131,P=0.001)。PCI组和药物治疗组估算平均生存时间分别为12.7个月和9.7个月。Cox模型似然比检验结果显示治疗方法对未发生MACE者的生存时间有影响(P=0.001,回归系数B=0.882,相对危险度=2.416)。结论 中期随访结果显示,对于SYNTAX评分>27分、不适宜冠脉搭桥的左主干和(或)三支血管病变患者,选择PCI优于单纯药物治疗。

Abstract:

Objective To investigate the prognostic value of SYNTAX score and EURO score in the patients with left main and/or 3-vessel lesions, who received percutaneous coronary intervention (PCI) and conservative treatment because they were not indicated for coronary artery bypass grafting, thus providing clinical guide for individual treatment strategy. Methods Risk scoring systems (EURO score and SYNTAX score) were used for patients with left main and/or 3-vessel lesions confirmed by coronary artery angiography. A total of 115 patients with SYNTAX score> 27 and EURO score> 6 were randomly divided into PCI group and drug group with a follow-up of 18 months. The primary endpoint was the incidence of major adverse cardiovascular events (MACE), consisting of all-cause mortality, non-fatal myocardial infarction, and clinically driven target revascularization. The secondary endpoints included cardioversion, cardiac dysfunction and recurrent angina. Kaplan-Meier method was used for the measurement of survival rate, Log-rank test for survival time distribution, and Cox proportional hazards model for univariate and multivariate analysis. Results In the 18-month follow-up, 6 patients (11.76%) suffered MACEs in the PCI group against 17 patients (34.00%) in the drug group, with a significant higher proportion of non-MACEs in the former than in the latter. Survival curves obtained with the log-rank test in patients without adverse cardiovascular events after discharge showed a significant difference between the two groups (χ²=11.131, P=0.001). The average survival in the PCI group was 12.7 months, and 9.7 months in the drug group. The likelihood ratio test in Cox model showed that the treatment method had an impact on the MACE-free survival time (P=0.001, regression coefficient B=0.882,RR=2.416). Conclusion Mid-term follow-up showed that PCI was better than drug therapy for patients with left main and/or 3-vessel lesions, who were not indicated for coronary artery bypass grafting with a SYNTAX score>27.