藥物支架與冠狀動脈搭橋手術(shù)治療冠心病多支病變療效對比-胡盛壽

胡盛壽2008年12月----來自單中心的三年隨訪結(jié)果

背景真實(shí)世界里，藥物支架與冠狀動脈搭橋治療冠心病多支病變的爭論一直未停止。解放軍胸科醫(yī)院

衛(wèi)生部心血管疾病防治中心，阜外心血管病醫(yī)院中國第一臺CABG中國第一枚藥物支架植入國家心臟病中心1956196219741957199620032007

阜外一覽：方案

阜外一覽：

方案1537cases阜外醫(yī)院的兩項(xiàng)注冊登記研究方案

FuwaiHospitalCABGRegistry(1999~now)

FuwaiHospitalPCIRegistry(2002~now)

AmHeartJ,HEART兩項(xiàng)注冊登記研究包含了患者的詳細(xì)信息；

統(tǒng)一的參數(shù)標(biāo)準(zhǔn)；

專用的電子化數(shù)據(jù)收集和報(bào)告系統(tǒng)。JTCVS,EJCTS,HEART

研究人群(2004年5月至2005年12月)方案先前接受過再血管化治療

合并左主干病變

發(fā)生于24小時(shí)內(nèi)的急性心肌梗死

入選標(biāo)準(zhǔn)排除標(biāo)準(zhǔn)入選3,720患者:CABG(n=1,886);DES(n=1,834)觀察終點(diǎn):早期:院內(nèi)/30天死亡；遠(yuǎn)期:死亡；心梗；靶血管再血管化。

定義：死亡:任何原因?qū)е滤劳觯?/p>

心肌梗死:在隨訪過程中出現(xiàn)異常Q波或再入院時(shí)出現(xiàn)的心肌梗死或因心肌梗死再入院；靶血管血運(yùn)重建:經(jīng)血運(yùn)重建的血管需要再次血管化。方案方案統(tǒng)計(jì)分析:

觀察性研究存在：

*選擇性偏移*潛在的混雜因素的影響統(tǒng)計(jì)學(xué)調(diào)整：*住院及30天死亡率：Stepwiselogisticregressionmodel*遠(yuǎn)期隨訪結(jié)果：StepwiseCoxproportionalhazardsmodels*傾向性積分方案搭橋組,n=1886896例(47.5%)行OPCAB1850例(98.1%)接受至少1根乳內(nèi)動脈橋

平均搭橋支數(shù):2.86

平均末梢吻合個數(shù):4.28藥物支架治療組,n=1834

當(dāng)個患者平均支架植入枚數(shù)：

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

平均支架直徑3.05±0.46mm.

兩聯(lián)抗血小板治療:阿司匹林+波力維結(jié)果結(jié)果結(jié)果住院/30天死亡率的risk-adjustedrate無明顯差別

AdjustedOR,0.779;95%CI,0.514to1.186;P=0.269非調(diào)整住院/30天死亡率：

0.9%forCABGvs0.6%forDES結(jié)果結(jié)果?Table1中變量經(jīng)危險(xiǎn)度調(diào)整后的對比全組傾向配對792對患者Cox多變量分析結(jié)果靶血管重建治療后36個月以內(nèi)未經(jīng)調(diào)整過的靶血管重建率曲線結(jié)果全組傾向配對792對患者配對組的Kaplan-Meier分析結(jié)果全組傾向配對792對患者配對組的Kaplan-Meier分析結(jié)果我們的主要發(fā)現(xiàn)CABG組有較低的死亡率，心梗發(fā)生率及靶血管再血管化率四個亞組（糖尿病，年齡大于70歲，3支病變，2支病變）的數(shù)據(jù)分析提示CABG有更好遠(yuǎn)期安全性及有效性。

討論與評論冠心病多支病變的再血管化:DESvs.Bypass仍存爭議！終點(diǎn)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復(fù)合事件6.47.90.39MACCE11.219.1<0.0013支病變組觀察第12個月MohrEFTCT2008;討論與評論SYNTAXtrial的結(jié)果冠心病多支病變的再血管化:DESvs.Bypass

仍存爭議！討論與評論冠心病多支病變的再血管化:DESvs.Bypass

仍存爭議！討論與評論CABG治療多支病變的優(yōu)勢?

PCI治療“罪犯”

病變

.CABG作用于血管包括了“罪犯”病變和未來可能的“罪犯”病變CABG的優(yōu)勢即在于此不同F(xiàn)uwaiDatabase討論與評論ClevelandDatabaseCABG治療多支病變的優(yōu)勢?阜外外科醫(yī)師培訓(xùn)討論與評論LIMA——前降支搭橋的金標(biāo)準(zhǔn)TatoulisJTCVS,2004CABG治療多支病變的優(yōu)勢?↓↓行CABG的患者效果更佳（死亡率，心梗率，再血管化率），盡管他們病情更重，亞組（糖尿病，年齡大于70歲，3支病變，2支病變）分析也提示CABG組有更好遠(yuǎn)期安全性及有效性。討論與評論我們的研究提示

非隨機(jī)性選擇偏差單中心研究局限

討論與評論鳴謝兩個數(shù)據(jù)庫的所有工作團(tuán)隊(duì)阜外-牛津中心統(tǒng)計(jì)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