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-胡盛寿

胡盛寿2008年12月----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病变的争论一直未停止。解放军胸科医院

卫生部心血管疾病防治中心，阜外心血管病医院中国第一台CABG中国第一枚药物支架植入国家心脏病中心1956196219741957199620032007

阜外一览：方案

阜外一览：

方案1537cases阜外医院的两项注册登记研究方案

FuwaiHospitalCABGRegistry(1999~now)

FuwaiHospitalPCIRegistry(2002~now)

AmHeartJ,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(2004年5月至2005年12月)方案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

入选标准排除标准入选3,720患者:CABG(n=1,886);DES(n=1,834)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。

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。方案方案统计分析:

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：Stepwiselogisticregressionmodel*远期随访结果：StepwiseCoxproportionalhazardsmodels*倾向性积分方案搭桥组,n=1886896例(47.5%)行OPCAB1850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药物支架治疗组,n=1834

当个患者平均支架植入枚数：

2.68±0.95(2.25±1.25DESand0.43±0.72BMS).

平均支架直径3.05±0.46mm.

两联抗血小板治疗:阿司匹林+波力维结果结果结果住院/30天死亡率的risk-adjustedrate无明显差别

AdjustedOR,0.779;95%CI,0.514to1.186;P=0.269非调整住院/30天死亡率：

0.9%forCABGvs0.6%forDES结果结果†Table1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36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792对患者配对组的Kaplan-Meier分析结果全组倾向配对792对患者配对组的Kaplan-Meier分析结果我们的主要发现CABG组有较低的死亡率，心梗发生率及靶血管再血管化率四个亚组（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。

讨论与评论冠心病多支病变的再血管化:DESvs.Bypass仍存争议！终点CABG(%)DES(%)p死亡2.94.40.18卒中1.90.80.09心梗2.65.20.04再血管化5.414.7<0.001复合事件6.47.90.39MACCE11.219.1<0.0013支病变组观察第12个月MohrEFTCT2008;讨论与评论SYNTAXtrial的结果冠心病多支病变的再血管化:DESvs.Bypass

仍存争议！讨论与评论冠心病多支病变的再血管化:DESvs.Bypass

仍存争议！讨论与评论CABG治疗多支病变的优势?

PCI治疗“罪犯”

病变

.CABG作用于血管包括了“罪犯”病变和未来可能的“罪犯”病变CABG的优势即在于此不同FuwaiDatabase讨论与评论ClevelandDatabaseCABG治疗多支病变的优势?阜外外科医师培训讨论与评论LIMA——前降支搭桥的金标准TatoulisJTCVS,2004CABG治疗多支病变的优势?↓↓行CABG的患者效果更佳（死亡率，心梗率，再血管化率），尽管他们病情更重，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。讨论与评论我们的研究提示

非随机性选择偏差单中心研究局限

讨论与评论鸣谢两个数据库的所有工作团队阜外-牛津中心统计研究中心Thankyou！ComparisonofDrug-ElutingStentsandCoronaryArteryBypassSurgeryfortheTreatmentofMultivesselCoronaryDiseaseShengshouHuM.D.,FACCDepartmentofCardiacSurgeryNationalHeartCenter&FuWaiHospital,Beijing,ChinaThree-YearFollow-UpResultsfromaSinglecenter

BackgroundWethereforecomparedthelong-termsafetyandefficacyofPCIwithDESandCABGinpatientswithMVD.ChestHospital

CardiovascularInstitute&FuwaiHospitalFirstCABGinChinaFirstCoronaryAngiographyinChinaFirstOPCABinChinaFirstDESimplantationinChinaNationalHeartCenter1956196219741957199620032007

AGlanceatFuwaiHospitalMethods

AGlanceatFuwaiHospitalMethodsCABG-AmountsandMortalities(1997-2007)1537casesAmountsofPCIandCAG(2003-2007)TwoRegistriesofFuwaiHospitalMethods

FuwaiHospitalCABGRegistry(1999~now)FuwaiHospitalPCIRegistry(2002~now)

AmHeartJ,HEART

Thetworegistriescontaindetailedinformation.Uniformdefinitionsfortheseelementsareusedinourstudy.Datawereprospectivelycollectedwiththeuseofadedicatedcomputer-basedreportingsystem.JTCVS,EJCTS,HEART

StudyPopulation(FromApr.2004,toDec.2005)Methods

PatientswithMVDTreatedwithisolatedCABGorDES(withorwithoutBMS)

PreviouslyundergonerevascularizationWithleftmaindiseaseAcuteMIwithin24hrsbeforerevascularizationInclusionExclusion3,720MVDpatients:CABG(n=1,886);DES(n=1,834)Endpoints:Early:In-hospital/30-daydeath;

Long-term:Death;MI;target-vesselrevascularization(TVR)duringfollow-up.

DefinitionsDeath:deathfromanycause.MI:documentationofanewabnormalQwaveaftertheindextreatmentormyocardialinfarctionsatreadmission(emergencyadmissionwithaprincipaldiagnosisofMI).TVR:theneedforrevascularizationofthetarget(treated)vessel.Methods

Follow-up

OfficevisitTelephonecontactMedicalrecords

Independenteventsadjudicationcommittee33.1monthsforDESgroup

38.9monthsforCABGgroup

MethodsStatisticalAnalysis:

Observationalstudy

*Treatment-selectionbias*PotentialconfoundingvariablesRobustadjustmentwasperformed

*Stepwiselogisticregressionmodelforin-hospital/30-daymortality*StepwiseCoxproportionalhazardsmodelsforlong-termoutcomes.*Propensity

analysis2-tailed,andasignificantlevelof0.05SPSSversion13.0andMATLAB6.1MethodsCABGgroup,n=1886896patients(47.5%)underwentOPCAB1850patients(98.1%)receivedatleastoneITAThemeannumberofbypassgraftsperpatient:2.86Themeannumberofdistalanastomosesperpatient:4.28Drug-elutingstentsgroup,n=1834Themeantotalnumberofstentsimplantedinapatientwas2.68±0.95(2.25±1.25DESand0.43±0.72BMS).Themeanstentdiameterwas3.05±0.46mm.Dualanti-platelettherapy:Aspirin+Plavix

ResultsBothCABGandPCIwithDESwereperformedaccordingtocurrentguidelines

Results

ResultsNosignificantdifferenceintherisk-adjustedrateofin-hospital/30-daymortality

AdjustedOR,0.779;95%CI,0.514to1.186;P=0.269Unadjustedin-hospital/30daymortality

0.9%forCABGvs0.6%forDES

Results

Results†AdjustedforcandidatevariablesinTable1Propensitymatchingfortheentirecohortcreated792matchedpairsofpatientsCoxmultivariableanalyses

ResultsTarget-vesselrevascularization36-monthunadjustedcurvesfortarget-vesselrevascularizationaftertheinitialprocedurefortheentirecohort.

ResultsPropensitymatchingfortheentirecohortcreated792matchedpairsofpatientsKaplan-MeieranalysisinthematchedCohort

ResultsPropensitymatchingfortheentirecohortcreated792matchedpairsofpatientsKaplan-MeieranalysisinthematchedCohort

ResultsPrincipalFindingsofOurDataPatientstreatedwithCABGhadlowerratesofdeath,MI,andTVRthanthosetreatedwithDES

Infoursubgroupsofpatients(DM,70+yrsofage,3-VD,2-VD),ourdatastillfavoredCABGforlong-termsafetyandefficacy.

DiscussionandCommentMultivesselRevascularization:DESvs.BypassControversial!EndpointCABG(%)DES(%)pDeath2.94.40.18Stroke1.90.80.09MI2.65.20.04Revascularization5.414.7<0.001Death/stroke/MI6.47.90.39MACCE11.219.1<0.00112-moendpointsin3VDsubsetMohrEFTCT2008;

DiscussionandCommentTheresultsofthemuch-awaitedSYNTAXtrialMultivesselRevascularization:DESvs.BypassControversial!

DiscussionandCommentMultivesselRevascularization:DESvs.BypassControversial!

DiscussionandCommentIstheadvantageofCABGformultivesselrevascularizationexplicable?

PCIistargetedatthe“culprit”

lesionorlesions.CABGisdirectedatthevesselincludingthe“culprit”lesionorlesionsandfutureculprits.ThedifferenceaccountsforthesuperiorityofCABGFuwaiDatabase

DiscussionandCommentClevelandDatabase

IstheadvantageofCABGformultivesselrevascula