药物支架与冠状动脉搭桥手术治疗冠心病多支病变疗对比胡盛寿

1、药物支架与冠状动脉搭桥手术治疗冠药物支架与冠状动脉搭桥手术治疗冠心病多支病变疗效对比心病多支病变疗效对比胡盛寿胡盛寿 2008年年12月月-来自单中心的三年随访结果来自单中心的三年随访结果 背景 真实世界里，药物支架与冠状动脉搭桥治疗冠心病多支真实世界里，药物支架与冠状动脉搭桥治疗冠心病多支病变的争论一直未停止。病变的争论一直未停止。 1956196219741957199620032007 方案 方案cabg- 手术量与死亡率手术量与死亡率(1997-2007)1537 casespci与与cag的手术量的手术量(2003-2007)阜外医院的两项注册登记研究阜外医院的两项注册登记研究 方案

2、u fuwai hospital cabg registry (1999now)u fuwai hospital pci registry (2002now) am heart j, heart 两项注册登记研究包含了患者的详细信息； 统一的参数标准； 专用的电子化数据收集和报告系统。jtcvs, ejcts, heart 研究人群研究人群 (2004年年5月至月至 2005年年12月月) 方案 三支病变的患者 接受了单纯搭桥手术或接受至少一枚药物支架治疗的患者 先前接受过再血管化治疗 合并左主干病变 发生于24小时内的急性心肌梗死 入选标准入选标准排除标准排除标准入选入选3,720 患者患者

3、: cabg (n=1,886) ; des (n=1,834)n 观察终点: 早期: 院内 / 30天 死亡； 远期: 死亡； 心梗； 靶血管再血管化。 n 定义：死亡:任何原因导致死亡； 心肌梗死: 在随访过程中出现异常q波或再入院时出现的心肌梗死 或因心肌梗死再入院；靶血管血运重建:经血运重建的血管需要再次血管化。 方案n 随访 临床随访 电话随访 病例记录 独立的事件鉴定委员会（内、外科医生） 药物支架组平均随访33.1个月 搭桥组平均随访38.9个月 方案n统计分析统计分析 : 观察性研究存在： * 选择性偏移 * 潜在的混杂因素的影响 统计学调整： * 住院及30天死亡率：step

4、wise logistic regression model * 远期随访结果：stepwise cox proportional hazards models * 倾向性积分 方案p搭桥组, n=1886 896 例(47.5%) 行opcab 1850 例(98.1%) 接受至少1根乳内动脉桥 平均搭桥支数: 2.86 平均末梢吻合个数: 4.28 p药物支架治疗组, n=1834 当个患者平均支架植入枚数： 2.680.95 (2.251.25 des and 0.430.72 bms). 平均支架直径 3.050.46mm. 两联抗血小板治疗: 阿司匹林 + 波力维 结果遵照当前的指南

5、行冠状动脉搭桥及pci术 结果 结果住院/30天死亡率的risk-adjusted rate无明显差别 adjusted or, 0.779; 95% ci, 0.514 to 1.186; p = 0.269 非调整住院/30 天死亡率： 0.9 % for cabg vs 0.6 % for des 结果 结果 table 1中变量经危险度调整后的对比全组倾向配对792对患者cox 多变量分析 结果靶血管重建 治疗后治疗后3636个月以内未经调整过的靶血管重建率曲线个月以内未经调整过的靶血管重建率曲线 结果全组倾向配对全组倾向配对792对患者对患者配对组的配对组的kaplan-meier分

6、析分析 结果全组倾向配对全组倾向配对792对患者对患者配对组的配对组的kaplan-meier分析分析 结果我们的主要发现我们的主要发现pcabg组有较低的死亡率，心梗发生率及靶血管再血管化率p四个亚组（糖尿病，年龄大于70岁，3支病变，2支病变）的数据分析提示cabg有更好远期安全性及有效性。 讨论与评论讨论与评论n冠心病多支病变的再血管化冠心病多支病变的再血管化: des vs. bypass 仍存争议！仍存争议！终点终点cabg (%)des (%)p死亡死亡 2.94.40.18卒中卒中 1.90.80.09心梗心梗 2.65.20.04再血管化再血管化 5.414.70.001复合事

7、件复合事件 6.47.90.39macce11.219.10.001 3支病变组观察第支病变组观察第12个月个月mohr ef tct 2008; 讨论与评论讨论与评论syntax trial的结果的结果 n冠心病多支病变的再血管化冠心病多支病变的再血管化: des vs. bypass 仍存争议！仍存争议！ 讨论与评论讨论与评论n冠心病多支病变的再血管化冠心病多支病变的再血管化: des vs. bypass 仍存争议！仍存争议！ 讨论与评论讨论与评论 cabg 治疗多支病变的优势治疗多支病变的优势? pci治疗治疗 “罪犯罪犯” 病变病变 . cabg作用于作用于血管血管包括包括了了 “罪

8、犯罪犯”病变和未来可病变和未来可能的能的“罪犯罪犯”病变病变cabg的优势即在于此不的优势即在于此不同同fuwai database 讨论与评论讨论与评论cleveland database cabg 治疗多支病变的优势治疗多支病变的优势? 搭桥手术数量增多，围手术期结果改善搭桥手术数量增多，围手术期结果改善 阜外外科医师培训 讨论与评论讨论与评论lima前降支搭桥的金标准tatoulistatoulis jtcvs,2004jtcvs,2004 cabg 治疗多支病变的优势治疗多支病变的优势? 3-5年先心病手术年先心病手术3-5年瓣膜手术年瓣膜手术搭桥手术搭桥手术 行cabg的患者效果更佳

9、（死亡率，心梗率，再血管化率），尽管他们病情更重病情更重， 亚组（糖尿病，年龄大于70岁，3支病变，2支病变）分析也提示cabg组有更好远期安全性及有效性。 讨论与评论讨论与评论我们的研究提示我们的研究提示p 非随机性p 选择偏差p 单中心n 研究局限 讨论与评论讨论与评论鸣谢鸣谢n两个数据库的所有工作团队两个数据库的所有工作团队n阜外阜外-牛津中心牛津中心n统计研究中心统计研究中心thank you！comparison of drug-eluting stents and coronary artery bypass surgery for the treatment of multive

10、ssel coronary diseaseshengshou hu m.d., faccdepartment of cardiac surgerynational heart center & fu wai hospital, beijing, chinathree-year follow-up results from a single center backgroundwe therefore compared the long-term safety and efficacy of pci with des and cabg in patients with mvd. 19561

11、96219741957199620032007 methods methodscabg- amounts and mortalities(1997-2007)1537 cases amounts of pci and cag(2003-2007)two registries of fuwai hospital methodsu fuwai hospital cabg registry (1999now)u fuwai hospital pci registry (2002now) am heart j, heart the two registries contain detailed inf

12、ormation. uniform definitions for these elements are used in our study. data were prospectively collected with the use of a dedicated computer-based reporting system.jtcvs, ejcts, heart study population (from apr. 2004, to dec. 2005) methods patients with mvd treated with isolated cabg or des (with

13、or without bms) previously undergone revascularization with left main disease acute mi within 24 hrs before revascularization inclusionexclusion3,720 mvd patients: cabg (n=1,886) ; des (n=1,834)n end points: early: in-hospital / 30-day death; long-term: death; mi; target-vessel revascularization (tv

14、r) during follow-up.p definitionsdeath: death from any cause. mi: documentation of a new abnormal q wave after the index treatment or myocardial infarctions at readmission (emergency admission with a principal diagnosis of mi). tvr: the need for revascularization of the target (treated) vessel. meth

15、ods follow-up office visit telephone contact medical records independent events adjudication committee 33.1 months for des group 38.9 months for cabg group methodsnstatistical analysis : observational study * treatment-selection bias * potential confounding variables robust adjustment was performed

16、* stepwise logistic regression model for in- hospital / 30-day mortality * stepwise cox proportional hazards models for long-term outcomes. * propensity analysis 2-tailed, and a significant level of 0.05 spss version 13.0 and matlab 6.1 methodsncabg group, n=1886 896 patients (47.5%) underwent opcab

17、 1850 patients (98.1%) received at least one ita the mean number of bypass grafts per patient: 2.86 the mean number of distal anastomoses per patient: 4.28 pdrug-eluting stents group, n=1834 the mean total number of stents implanted in a patient was 2.680.95 (2.251.25 des and 0.430.72 bms). the mean

18、 stent diameter was 3.050.46mm. dual anti-platelet therapy: aspirin + plavix resultsboth cabg and pci with des were performed according to current guidelines results results no significant difference in the risk-adjusted rate of in-hospital/30-day mortality adjusted or, 0.779; 95% ci, 0.514 to 1.186

19、; p = 0.269 unadjusted in-hospital/30 day mortality 0.9 % for cabg vs 0.6 % for des results results adjusted for candidate variables in table 1 propensity matching for the entire cohort created 792 matched pairs of patientscox multivariable analyses resultstarget-vessel revascularization36-month una

20、djusted curves for target-vessel revascularization after the initial procedure for the entire cohort. resultspropensity matching for the entire cohort created 792 matched pairs of patientskaplan-meier analysis in the matched cohort resultspropensity matching for the entire cohort created 792 matched

21、 pairs of patientskaplan-meier analysis in the matched cohort resultsprincipal findings of our data patients treated with cabg had lower rates of death, mi, and tvr than those treated with des in four subgroups of patients (dm, 70 + yrs of age, 3-vd, 2-vd), our data still favored cabg for long-term

22、safety and efficacy. discussion and commentnmultivessel revascularization: des vs. bypass controversial!end pointcabg (%)des (%)pdeath 2.94.40.18stroke 1.90.80.09mi 2.65.20.04revascularization 5.414.70.001death/stroke/mi 6.47.90.39macce11.219.10.001 12-mo end points in 3vd subsetmohr ef tct 2008; di

23、scussion and commentthe results of the much-awaited syntax trial nmultivessel revascularization: des vs. bypass controversial! discussion and commentnmultivessel revascularization: des vs. bypass controversial! discussion and commentis the advantage of cabg for multivessel revascularization explicab

24、le? pci is targeted at the “culprit” lesion or lesions. cabg is directed at the vessel including the “culprit” lesion or lesions and future culprits. the difference accounts for the superiority of cabgfuwai database discussion and commentcleveland database is the advantage of cabg for multivessel revascularization explicable? improved peri-operative outcomes of bypass surgerysurg