康复治疗对稳定型心绞痛患者介入治疗后心功能和生活质量的影响

目的 观察康复治疗对冠心病稳定型心绞痛患者经皮冠脉介入（PCI）治疗后心功能和生活质量的影响。方法 将我院2014年3月~2014年9月收治的行PCI的76例慢性稳定性心绞痛患者随机均分为康复治疗组和常规治疗组,常规治疗组行常规治疗,康复治疗组在常规治疗基础上按照冠心病康复与二级预防中国专家共识进行4个月的心脏康复治疗,观察两组患者的服药依从性、危险因素（吸烟、高血压病和高低密度脂蛋白胆固醇血症）控制情况和NYHA心功能分级,通过心电图运动平板试验观察运动耐量,通过超声心动图测定左室射血分数(LVEF),使用西雅图心绞痛量表(SAQ)对患者的生活质量进行评估,记录两组患者的主要心脏不良事件(MACE)和康复治疗引起的并发症。结果 与常规治疗组比较,康复治疗组的服药依从性和危险因素控制情况更好,NYHA心功能分级更低〔(1.05±0.23) vs.(1.32±0.47),P<0.05〕,而运动耐量〔代谢当量,(10.6±2.0) METs vs.( 8.9±2.0) METs,P<0.05〕、左室射血分数（LVEF）〔(56 ±7)% vs.(49±8)%,P<0.05〕和西雅图心绞痛量表评分（SAQ）〔躯体活动受限程度(PL)（78±7） vs.（67±7）、治疗满意度(TS)（83±9） vs.（75±7）、疾病认识程度(DP)（55±17） vs.（48±14）,均P<0.05〕更高,差异具有统计学意义;两组患者均未出现MACE,康复治疗未引起并发症。结论 康复治疗能显著提高稳定型心绞痛患者PCI后的心脏功能和生活质量。     

Health-related quality of life after percutaneous coronary intervention versus coronary bypass surgery in high-risk patients with medically refractory ischemia

OBJECTIVES: We compared six-month health-related quality of life (HRQL) for high-risk patients with medically refractory ischemia randomized to percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery. BACKGROUND: Mortality rates after PCI and CABG surgery are similar. Therefore, differences in HRQL outcomes may help in the selection of a revascularization procedure. METHODS: Patients were enrolled in a Veterans Affairs multicenter randomized trial comparing PCI versus CABG for patients with medically refractory ischemia and one or more risk factors for adverse outcome; 389 of 423 patients (92%) alive six months after randomization completed an Short Form-36 (SF-36) health status survey. Primary outcomes were the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the SF-36. Multivariable analyses were used to evaluate whether PCI or CABG surgery was associated with better PCS or MCS scores after adjusting for over 20 baseline variables. RESULTS: There were no significant differences in either PCS scores (38.7 vs. 37.3 for PCI and CABG, respectively; p = 0.23) or MCS scores (45.5 vs. 46.1, p = 0.58) between the treatment arms. In multivariable models, there remained no difference in HRQL for post-PCI versus post-CABG patients (for PCS, absolute difference = 0.56 +/- standard error of 1.14, p = 0.63; for MCS, absolute difference = -1.23 +/- 1.12, p = 0.27). We had 97% power to detect a four-point difference in scores, where four to seven points is a clinically important difference. CONCLUSIONS: High-risk patients with medically refractory ischemia randomized to PCI versus CABG surgery have equivalent six-month HRQL. Therefore, HRQL concerns should not drive decision-making regarding selection of a revascularization procedure for these patients.     

冠状动脉搭桥与冠脉介入治疗的比较

冠状动脉旁路移植术（CABG）和经皮冠状动脉介入术（PCI）是目前治疗冠状动脉狭窄的两种主要治疗方法。CABG是半个世纪以来治疗冠心病经典手段之一,近年来由于对桥血管的选择和保护、全动脉再血管化等的重视,其近远期治疗效果明显提高。随着介入技术的发展,这项技术以其微创、安全、易于被患者所接受等特点,适应证不断扩大。本文就近年来CABG和PCI在治疗冠心病方面的发展和优势作一综述。     

冠状动脉旁路移植术和药物支架植入术远期疗效的比较

目的比较冠心病患者非药物治疗手段冠状动脉旁路移植术（CABG）和经皮冠状动脉介入治疗（PCI）术后的桥血管和支架的再通率。方法CABG术后和药物支架植入术后再次出现心绞痛症状的冠心病患者各40例,其年龄、性别、心肌梗死、高血压、高脂血症、心功能不全、脑卒中、药物治疗病史具有可比性。通过冠状动脉造影术比较两组患者的桥血管和药物支架的效率和寿命的远期效果。结果与行CABG患者的桥血管比较,行PCI患者的药物支架远期狭窄或者闭塞率降低34．3％。与行CABG患者的左乳内动脉（LIMA）桥血管比较,行PCI患者的左前降支的药物支架远期狭窄或者闭塞率降低14．8％。与行CABG患者的左回旋支和右冠状动脉静脉桥血管比较,行PCI患者的左回旋支以及右冠状动脉的药物支架远期狭窄或者闭塞率降低49．8％。结论冠状动脉药物支架植入术的远期通畅率较CABG明显增高,冠状动脉药物支架植入术的药物支架的效率和寿命要优于CABG的桥血管。     

Patient preferences for coronary artery bypass graft surgery or percutaneous intervention in multivessel coronary artery disease

Objectives: Determine if patients prefer multivessel percutaneous coronary intervention (mv‐PCI) over coronary artery bypass graft surgery (CABG) for treatment of symptomatic multivessel coronary artery disease (mv‐CAD) despite high 1‐year risk. Background: Patient risk perception and preference for CABG or mv‐PCI to treat medically refractory mv‐CAD are poorly understood. We hypothesize that patients prefer mv‐PCI instead of CABG even when quoted high mv‐PCI risk. Methods: 585 patients and 31 physicians were presented standardized questionnaires with a hypothetical scenario describing chest pain and medically refractory mv‐CAD. CABG or mv‐PCI was presented as treatment options. Risk scenarios included variable 1‐year risks of death, stroke, and repeat procedures for mv‐PCI and fixed risks for CABG. Participants indicated their preference of revascularization method based on the presented risks. We calculated the odds that patients or physicians would favor mv‐PCI over CABG across a range of quoted risks of death, stroke, and repeat procedures. Results: For nearly all quoted risks, patients preferred mv‐PCI over CABG, even when the risk of death was double the risk with CABG or the risk of repeat procedures was more than three times that for CABG (P < 0.0001). Compared to patients, physicians chose mv‐PCI less often than CABG as the risk of death and repeat procedures increased (P < 0.001 and P = 0.004, respectively). Conclusion: Patients favor mv‐PCI over CABG to treat mv‐CAD, even if 1‐year risks of death and repeat procedures far exceed risk with CABG. Physicians are more influenced by actual risk and prefer mv‐PCI less than patients despite similarly quoted 1‐year risks. © 2013 Wiley Periodicals, Inc.     

The role of coronary artery bypass surgery versus percutaneous intervention in patients with diabetes and coronary artery disease

Patients with diabetes mellitus (DM) often exhibit a complex coronary anatomy, making coronary revascularization challenging. Coronary artery bypass grafting surgery (CABG) is currently considered the preferred revascularization method in patients with DM and multivessel disease. Percutaneous coronary intervention (PCI) has advanced with new stent generations having been developed in the recent years, but they have not yet been adequately compared against CABG in the population with DM. Comorbidities, such as renal disease and heart failure, lead to worse prognosis following a revascularization procedure and require especial consideration when choosing between CABG versus PCI. The presence of significant left main disease may also impose additional challenges to coronary revascularization, particularly when accompanied by the involvement of multivessel disease. Most of the evidence regarding revascularization in patients with DM is compiled from studies enrolling patients with stable ischemic heart disease, and trials with patients in the acute coronary syndrome setting are lacking.     

并发心房颤动对经皮冠状动脉介入治疗效果的影响

目的:探讨并发心房颤动(房颤)对冠心病患者经皮冠状动脉介入治疗(PCI)近期和远期临床结果的影响。方法:选择接受PCI治疗的冠心病患者3 893例,根据有无房颤分为无房颤组(A组,3 802例)和并发房颤组(B组,91例),分析房颤对冠心病患者PCI术后住院和随访期间不良心脑血管事件(MACCE)的影响。结果:A组与B组院内死亡、心肌梗死、脑卒中和再次血运重建发生率比较,差异无统计学意义;A组、B组随访时间中位数分别为535d、520d,B组MACCE发生率较A组有增高趋势(15.4%∶11.4%),主要为全因死亡率较高(5.7%∶1.7%,P=0.019),心肌梗死、脑卒中和再次血运重建发生率相当。结论:并发房颤的冠心病患者接受PCI术后的远期死亡率明显高于无房颤患者,房颤是预测PCI术后远期死亡率增高的独立危险因素。     

Meta-analysis of percutaneous coronary intervention versus coronary artery bypass graft surgery in patients with diabetes and left main and/or multivessel coronary artery disease

The optimal coronary revascularization strategy for patients with diabetes and left main and/or multivessel disease is undetermined. The aim of our study was to evaluate percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) in those patients. We identified 13 articles, published before October 2011, enrolling 6992 patients, whose follow-up period ranged from 1 to 5 years. Patients with PCI had a significant reduction in cerebral vascular attack (CVA) (OR, 0.29; 95 % CI, 0.16–0.51; p < 0.0001, I ² = 0 %) as compared with CABG, whereas there was a fourfold increased risk of repeat revascularization associated with PCI even using drug-eluting stent (OR, 4.44; 95 % CI, 3.42–5.78; Χ² = 4.92, p < 0.00001, I ² = 0 %). The overall mortality (OR, 0.97; 95 % CI, 0.81–1.15; p = 0.70, I ² = 0 %) was comparable between the PCI and CABG. However, in subgroup analysis, the composite outcome (death/myocardial infarction/CVA) was significantly reduced in favor of DES implantation (OR, 0.79; 95 % CI, 0.63–0.99; Χ² = 1.07, p = 0.04, I ² = 0 %). Our study confirmed the cerebral vascular benefits of PCI by significantly reducing CVA risks, and the composite outcome was better in patients undergoing PCI with drug-eluting stent, despite a higher repeat revascularization rate. It poses imperative demands for future prospective randomized studies to define the optimal strategy in patients with diabetes and left main and/or multivessel disease.     

Impact of aging on the clinical outcomes of Japanese patients with coronary artery disease after percutaneous coronary intervention

Japan has become an aging society, resulting in an increased prevalence of coronary artery disease. However, clinical outcomes of elderly Japanese patients after percutaneous coronary intervention (PCI) remain unclear. Of the 15,227 patients in the Shinken Database, a single-hospital-based cohort of new patients, 1,214 patients who underwent PCI, was evaluated to determine the differences in clinical outcomes between the elderly (≥75 years) (n = 260) and the non-elderly (<75 years) (n = 954) patients. A major adverse cardiac event (MACE) was defined as a composite end point, including all-cause death, myocardial infarction (MI), and target lesion revascularization. Male gender and obesity were less common, and the estimated glomerular filtration rate (eGFR) was significantly lower in the elderly than in the non-elderly. Left ventricular ejection fraction (LVEF) was comparable between these groups. Left main trunk disease and multivessel disease were more common in the elderly than in the non-elderly group. Occurrence of MACE was frequent, and the incidences of all-cause death, cardiac death, and the admission rate for heart failure were significantly higher in the elderly patients. Multivariate analysis showed that prior MI, low eGFR, and poor LVEF were independent predictors for all-cause death in the elderly patients. Elderly patients had worse clinical outcomes than the non-elderly patients. Low eGFR and LVEF were independent predictors of all-cause death after PCI, suggesting that left ventricular dysfunction and renal dysfunction might synergistically contribute to the adverse clinical outcomes of the elderly patients undergoing PCI.     

Coronary artery bypass surgery versus percutaneous coronary intervention with drug-eluting stent implantation in patients with multivessel coronary disease

BACKGROUND: Drug-eluting stents (DES) constitute a major breakthrough in restenosis prevention after percutaneous coronary intervention (PCI). This study compared the clinical outcomes of PCI using DES versus coronary artery bypass graft (CABG) in patients with multivessel coronary artery disease (MVD) in real-world. METHODS: From January 2003 to December 2004, 466 consecutive patients with MVD underwent revascularization, 235 by PCI with DES and 231 by CABG. The study end-point was the incidence of major adverse cardiovascular events (MACEs) at the first 30 days after procedure and during follow-up. RESULTS: Most preoperative characteristics were similar in the two groups, but left main disease (24.7% vs 2.6%, P<0.001) and three-vessel disease (65% vs 54%, P = 0.02) were more prevalent in CABG group. The number of coronary lesions was also greater in CABG group (3.7 +/- 1.1 vs 3.3 +/- 1.1, P<0.001). Despite higher early morbidity (3.9% vs 0.8%, P = 0.03) associated with CABG, there were no significant differences in composite MACEs at the first 30 days between the two groups. During follow-up (mean 25+/-8 months), the incidence of death, myocardial infarction, or cerebrovascular event was similar in both groups (PCI 6.3% vs CABG 5.6%, P = 0.84). However, bypass surgery still afforded a lower need for repeat revascularization (2.8% vs 10.4%, p = 0.001). Consequently, overall MACE rate (14.5% vs 7.9%, P = 0.03) remained higher after PCI. CONCLUSION: PCI with DES is a safe and feasible alternative to CABG for selected patients with MVD. The reintervention gap was further narrowed in the era of DES. Aside from restenosis, progression of disease needs to receive substantial emphasis.     

Midterm outcomes and quality of life following percutaneous coronary intervention in nonagenarians

The midterm clinical and functional benefits of percutaneous coronary intervention in patients aged ≥90 years have not been clearly defined. From January 2005 to June 2009, 173 patients aged ≥90 years underwent diagnostic cardiac catheterization, of whom 90 underwent percutaneous coronary intervention. There were 45 men (50%) and 45 women (50%), with a mean age of 92 years (range 90 to 101). Of these, 24 patients (27%) presented with ST-segment elevation myocardial infarction, 31 (34%) with non-ST-segment elevation myocardial infarction, 28 (31%) with unstable angina pectoris, and 2 (2%) with stable angina pectoris; 5 patients (6%) were studied for preoperative risk assessment. A total of 127 lesions were successfully treated using 102 drug-eluting stents and 37 bare-metal stents, with a mean of 1.5 stents per patient. Postprocedural complications included renal insufficiency in 5 patients (5.6%), heart failure in 6 patients (6.7%), and cardiogenic shock in 2 patients (2.2%). Seventy-seven patients (85.6%) experienced no postprocedural complications. In-hospital mortality was 7.8%, and actuarial survival was 61.5 ± 5.2% at 24 months and 31.6 ± 6.1% at 48 months. The SF-36 Health Survey was administered at follow-up, and results demonstrated a quality of life similar to that of the general population corrected for age and gender. In conclusion, this study demonstrates that percutaneous coronary intervention in nonagenarians can be accomplished with low mortality and morbidity and excellent midterm results. Moreover, functional improvement in nonagenarians supports enhanced quality of life comparable to that of the general population.     

心脏运动康复对PCI术后冠心病患者心肺功能及生活质量的影响

目的评价心脏运动康复对冠心病经皮冠状动脉介入治疗(PCI)术后患者心肺功能及生活质量的影响。方法入选确诊并已行PCI出院的冠心病患者110例,按个人意愿分为康复组和对照组各55例,收集患者的一般资料、入选时和运动治疗6月后心肺运动试验、心脏超声的相关指标及西雅图心绞痛量表(SAQ)等数据,并进行统计学分析,评估心脏运动康复对冠心病PCI术后患者心肺功能及生活质量的影响。结果 6个月运动康复治疗后,康复组患者无氧阈(AT)、最大摄氧量(VO2max)、氧脉搏(O2pulse)、最大运动时间、左心室射血分数(LVEF)、SAQ评分均优于干预前与对照组,差异有统计学意义(P0. 05)。结论心脏运动康复治疗可以改善冠心病PCI术后患者的心肺功能,提高患者的运动耐力及生活质量,是冠心病PCI术后患者二级预防的重要组成部分。     

冠脉旁路移植术对冠心病三支病变患者近期生活质量的影响

目的 观察冠脉旁路移植术(CABC)对冠心病三支病变患者生活质量的影响.方法 将69例患者按其意愿分为两组,CABG组行CABG术治疗,药物组行标准药物治疗.两组在确诊后于治疗前及治疗后1 a分别填写西雅图心绞痛调查量表(SAQ),观察躯体活动受限程度(PL)、心绞痛稳定程度(AS)、心绞痛发作程度(AF)、治疗满意程度(TS)、疾病认识程度(DP)6个维度积分.结果 两组治疗前后整体生活质量有明显提高(P<0.01),CABG组术后各项指标改善程度较药物组显著(P<0.01);CABG组术前TS、DP低于药物组(P<0.05),术后和药物组无明显差异(P>0.05).结论 CABG术可明显改善冠心病三支病变患者生活质量;尽量减少手术创伤,减少术后并发症,术前及术后加强心理干预是进一步提高患者生活质量的重要措施.     

经皮冠状动脉介入治疗对冠状动脉无保护左主干患者生活质量的影响

目的 对经皮冠状动脉介入（PCI）治疗无保护左主干（ULMCA）冠心病患者治疗前后的生活质量进行评价。 方法 收集2017年9月～2019年12月于西京医院心内科成功行PCI术的UMLCA患者（n=74）入院时的临床基本特征,随访术后不良事件（全因死亡、非致死性心肌梗死、临床驱动的再次血运重建）,通过测评SF-12量表和西雅图心绞痛量表,比较PCI术前术后生活质量的改变。 结果 男性患者61例（82%）,并发高血压病41例（55%）,糖尿病22例（30%）,吸烟史25例（34%）,体质量指数24(23, 27) kg/m2。造影结果中冠状动脉左主干的狭窄程度(68±16)%、Gensini评分(140±43)分。左主干开口部位病变44例（60%）,并发三支冠脉血管病变70例（95%）,植入支架总长度为88（47,113）mm,手术持续时间为178 (108.270) min,造影剂使用量为300（195,400）ml。PCI术后电话随访（平均5.06月）,全因死亡3例（4%）;临床驱动的再次血运重建4例（6%）。经过单因素分析提示患者年龄每增加1岁,术后主要不良心血管事件（MACE）的发生率增加1.15倍。两个量表均显示ULMCA病变患者的术后评分在各个维度上都比术前高（P<0. 05,P < 0. 01）。 结论 PCI治疗可改善ULMCA病变冠心病患者的生活质量。