Influence of diabetes mellitus on long-term (five-year) outcomes of drug-eluting stents and coronary artery bypass grafting for multivessel coronary revascularization

Diabetes mellitus is a major risk factor for coronary artery disease (CAD) and for diffuse and progressive atherosclerosis. We evaluated the outcomes of drug-eluting stent (DES) placement and coronary artery bypass grafting (CABG) in 891 diabetic patients (489 for DES implantation and 402 for CABG) and 2,151 nondiabetic patients (1,058 for DES implantation and 1,093 for CABG) with multivessel CAD treated from January 2003 through December 2005 and followed up for a median 5.6 years. Outcomes of interest included death; the composite outcome of death, myocardial infarction (MI), or stroke; and repeat revascularization. In diabetic patients, after adjusting for baseline covariates, 5-year risk of death (hazard ratio 1.01, 95% confidence interval 0.77 to 1.33, p = 0.96) and the composite of death, MI, or stroke (hazard ratio 1.03, 95% confidence interval 0.80 to 1.31, p = 0.91) were similar in patients undergoing DES or CABG. However, rate of repeat revascularization was significantly higher in the DES group (hazard ratio 3.69, 95% confidence interval 2.64 to 5.17, p <0.001). These trends were consistent in nondiabetic patients (hazard ratio 0.80, 95% confidence interval 0.55 to 1.16, p = 0.23 for death; hazard ratio 0.77, 95% confidence interval 0.56 to 1.05, p = 0.10 for composite of death, MI, or stroke; hazard ratio 2.77, 95% CI 1.95 to 3.91, p <0.001 for repeat revascularization). There was no significant interaction between diabetic status and treatment strategy on clinical outcomes (p for interaction = 0.36 for death; 0.20 for the composite of death, MI, or stroke; and 0.40 for repeat revascularization). In conclusion, there was no significant prognostic influence of diabetes on long-term treatment with DES or CABG in patients with multivessel CAD.     

糖尿病多支冠状动脉病变患者不同血管重建疗效的比较

目的:评价对糖尿病多支冠状动脉病变患者的裸支架(BMS)置入、药物洗脱支架(DES)置入和冠状动脉搭桥手术(CABG)3种不同血管重建的疗效。方法:选择接受血管重建治疗的糖尿病伴多支冠状动脉病变患者427例,比较其BMS、DES和CABG不同治疗方法的疗效和随访2年的临床结果。结果:BMS、DES和CABG3组间住院时期的不良心脑血管事件(MACCE)发生率比较,差异均无统计学意义。2年随访结果中,BMS组、DES组再次血管重建率分别为17.6%、10.4%,均显著高于CABG组的1.9%(P<0.01);BMS组的总MACCE发生率为23.1%,显著高于CABG组的10.7%(P<0.01),而DES的总MACCE发生率与CABG组相比差异无统计学意义。结论:糖尿病多支血管病变患者置入BMS后再次血管重建率和总MACCE发生率显著高于CABG,而DES的中期临床疗效并不逊于CABG。     

Revascularization of left anterior descending coronary artery in patients with single and multivessel disease: comparison between off-pump internal thoracic artery and drug-eluting stent

STUDY OBJECTIVES: The left anterior descending artery (LADA), particularly when the proximal segment of the vessel is involved, is a challenging area for percutaneous coronary interventions (PCIs); therefore, coronary artery bypass grafting is often considered and sometimes performed even in patients with single-vessel disease involving the LADA. This study compares mid-term results of LADA revascularization with a drug-eluting stent (DES), with off-pump coronary artery bypass grafting (OPCAB) in patients with single-vessel or multivessel coronary artery disease (CAD). DESIGN: Matched-groups, retrospective cohort comparison between the DES and OPCAB. PATIENTS: From June 2002 to December 2003, 354 patients underwent myocardial revascularization of the LADA by OPCAB, and 168 by DES. After matching for age, sex, and extent of CAD, two groups (116 patients each) were used to compare the two revascularization modalities. The groups were similar; however, an ejection fraction of <30%, old myocardial infarction, and use of an intraaortic balloon pump were more prevalent in the OPCAB group. RESULTS: The average number of coronary vessels treated per patient in the two groups was similar (OPCAB, 1.97; DES, 1.6; p = 0.581). The 30-day mortality rate was 0.9% in the OPCAB group and 0% in the DES group (p = 0.329). The mean duration of follow-up was 12 months. There was one late death in each group. Angina returned in 31% of patients in the DES group and in 11.2% of the patients in the OPCAB group (p = 0.001). There were 12 reinterventions in the DES group compared to three reinterventions in the surgical group (p = 0.020). The only independent predictor (Cox proportional hazards regression model) of the return of angina (risk ratio [RR], 3.36; 95% confidence interval [CI], 1.57 to 7.14) and reintervention (RR, 3.9; 95% CI, 1.34 to 11.24) was assignment to the DES group. CONCLUSIONS: The mid-term clinical outcome of OPCAB in patients with CAD, including multivessel disease, was better than that for PCIs with only one DES used in patients with similar extents of CAD.     

Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel disease: the final analysis of the Arterial Revascularization Therapies Study (ARTS) randomized trial

OBJECTIVES: The long-term (five-year) comparative results of treatment of multivessel coronary artery disease with stenting or coronary artery bypass grafting (CABG) is at present unknown. BACKGROUND: The Arterial Revascularization Therapies Study (ARTS) was designed to compare CABG and stenting in patients with multivessel disease. METHODS: A total of 1,205 patients with the potential for equivalent revascularization were randomly assigned to CABG (n = 605) or stent implantation (n = 600). The primary clinical end point was freedom from major adverse cardiac and cerebrovascular events (MACCE) at one year; MACCE at five-year follow-up constituted the final secondary end point. RESULTS: At five years, there were 48 and 46 deaths in the stent and CABG groups, respectively (8.0% vs. 7.6%; p = 0.83; relative risk [RR], 1.05; 95% confidence interval [CI], 0.71 to 1.55). Among 208 diabetic patients, mortality was 13.4% in the stent group and 8.3% in the CABG group (p = 0.27; RR, 1.61; 95% CI, 0.71 to 3.63). Overall freedom from death, stroke, or myocardial infarction was not significantly different between groups (18.2% in the stent group vs. 14.9% in the surgical group; p = 0.14; RR, 1.22; 95% CI, 0.95 to 1.58). The incidence of repeat revascularization was significantly higher in the stent group (30.3%) than in the CABG group (8.8%; p < 0.001; RR, 3.46; 95% CI, 2.61 to 4.60). The composite event-free survival rate was 58.3% in the stent group and 78.2% in the CABG group (p < 0.0001; RR, 1.91; 95% CI, 1.60 to 2.28). CONCLUSIONS: At five years there was no difference in mortality between stenting and surgery for multivessel disease. Furthermore, the incidence of stroke or myocardial infarction was not significantly different between the two groups. However, overall MACCE was higher in the stent group, driven by the increased need for repeat revascularization.     

老年多支血管病变患者置入药物洗脱支架与冠状动脉旁路移植术后近远期临床结果

目的:本研究旨在比较老年(年龄≥75岁)稳定性冠心病合并多支血管病变患者行经皮冠状动脉介入治疗(PCI)置入药物洗脱支架(DES)与冠状动脉旁路移植术(CABG)的近远期临床结果。方法:本研究于2003年7月至2006年12月,连续入选年龄≥75岁稳定性冠心病合并多支血管病变患者363例,在我院行PCI置入DES(n=269)或CABG(n=94)治疗。主要终点为24个月时主要不良心脑血管事件(MACCE),次要终点为24个月时全因死亡及非致死性心肌梗死(MI)、脑血管事件和再次血运重建以及全因死亡、非致死性MI和脑血管事件复合终点事件。结果:住院期间,CABG组的病死率(7.4%vs.1.9%,P=0.023)和非致死性MI的发生率(3.2%vs.0,P=0.023),明显高于DES组,CABG组的MACCE的发生率也明显高于DES组(10.6%vs.1.9%,P=0.001)。多因素回归分析结果显示:24个月时,CABG组和DES组的主要终点事件的风险未见明显差异[22.3%vs.15.2%,风险比(HR)=1.62,95%CI 0.63～3.31,P=0.379],两组的全因死亡、心源性死亡、非致死性MI、脑血管事件和再次血运重建的风险也没有明显差异;CABG组全因死亡、非致死性MI和脑血管事件复合终点事件的风险明显高于DES组(19.1%vs.8.2%,HR 3.87,95%CI:1.24～12.37,P=0.009)。结论:本研究提示,与DES相比,CABG可能会增加75岁以上多支血管病变患者的远期全因死亡、非致死性MI和脑血管事件复合终点事件的风险,而未降低再次血运重建和MACCE。     

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.     

In hospital observation of patients with acute coronary syndrome without ST elevation and multivessels coronary artery disease treated with early invasive strategy. Comparison of results of percutaneous coronary intervention and coronary artery by-pass grafting

Acute coronary syndromes (ACS) without persistent ST-segment elevation are the main cause of hospitalization, morbidity and mortality. The objective of this study was to compare clinical and angiographic parameters as well as in-hospital results of treating 307 consecutive patients with ACS without persistent ST-segment elevation with either PCI or CABG. Inclusion criteria were: rest angina within the last 24 hours, ST-segment depression (> 0.5 mm), T-wave inversion (> 1 mm) in at least two leads, positive serum cardiac markers. PCI was performed in 75.9% of patients and 24.1% of patients underwent CABG. Both groups did not differ as to age, sex, history of diabetes, arterial hypertension, heart failure, smoking and ejection fraction. Positive troponin was significantly more frequent in the PCI group. 51% of PCI patients and 80% of CABG patients had complete revascularization (p = 0.00001). Independent predictors of in-hospital death in the CABG group were: inability to determine culprit vessel during coronary angiography due to lesions' severity (OR 13.65; 95% CI 9.40-15.20; p = 0.007) and heart failure (OR 15.58; 95% CI 12.29-18.01; p = 0.003). In the PCI group these independent predictors were: Braunwald's IIIC unstable angina (OR 5.48; 95% CI 3.10-7.17; p = 0.04) and diabetes (OR 2.22; 95% CI 1.07-3.90; p = 0.003). In-hospital mortality rate was significantly higher in the CABG group (8.1% vs 1.7% p < 0.01). Patients with multivessel coronary artery disease and ACS without ST-segment elevation treated with PCI have better in-hospital outcome than patients assigned to CABG, but the rate of complete revascularization is lower.     

Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease.

OBJECTIVES: This study evaluated the clinical outcomes of consecutive, selected patients treated with coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for unprotected left main coronary artery (ULMCA) disease. BACKGROUND: Although recent data suggest that PCI with DES provides better clinical outcomes compared to bare-metal stenting for ULMCA disease, there is a paucity of data comparing PCI with DES to CABG. METHODS: Since April 2003, when DES first became available at our institution, 123 patients underwent CABG, and 50 patients underwent PCI with DES for ULMCA disease. RESULTS: High-risk patients (Parsonnet score >15) comprised 46% of the CABG group and 64% of the PCI group (p = 0.04). The 30-day major adverse cardiac and cerebrovascular event (MACCE) rate for CABG and PCI was 17% and 2% (p < 0.01), respectively. The mean follow-up was 6.7 +/- 6.2 months in the CABG group and 5.6 +/- 3.9 months in the PCI group (p = 0.26). The estimated MACCE-free survival at six months and one year was 83% and 75% in the CABG group versus 89% and 83% in the PCI group (p = 0.20). By multivariable Cox regression, Parsonnet score, diabetes, and CABG were independent predictors of MACCE. CONCLUSIONS: Despite a higher percentage of high-risk patients, PCI with DES for ULMCA disease was not associated with an increase in immediate or medium-term complications compared with CABG. Our data suggest that a randomized comparison between the two revascularization strategies for ULMCA may be warranted.     

Comparison of one-year outcomes of percutaneous coronary intervention versus coronary artery bypass grafting in patients with unprotected left main coronary artery disease and acute coronary syndromes (from the CUSTOMIZE Registry)

Uncertainty surrounds the optimal revascularization strategy for patients with left main coronary artery disease presenting with acute coronary syndromes (ACSs), and adequately sized specific comparisons of percutaneous and surgical revascularization in this scenario are lacking. The aim of this study was to evaluate the incidence of 1-year major adverse cardiac events (MACEs) in patients with left main coronary artery disease and ACS treated with percutaneous coronary intervention (PCI) and drug-eluting stent implantation or coronary artery bypass grafting (CABG). A total of 583 patients were included. At 1 year, MACEs were significantly higher in patients treated with PCI (n = 222) compared to those treated with CABG (n = 361, 14.4% vs 5.3%, p <0.001), driven by a higher rate of target lesion revascularization (8.1% vs 1.7%, p = 0.001). This finding was consistent after statistical adjustment for MACEs (adjusted hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.2 to 5.9, p = 0.01) and target lesion revascularization (adjusted HR 8.0, 95% CI 2.2 to 28.7, p = 0.001). No statistically significant differences between PCI and CABG were noted for death (adjusted HR 1.1, 95% CI 0.4 to 3.0, p = 0.81) and myocardial infarction (adjusted HR 4.8, 95% CI 0.3 to 68.6, p = 0.25). No interaction between clinical presentation (ST-segment elevation myocardial infarction or unstable angina/non-ST-segment elevation myocardial infarction) and treatment (PCI or CABG) was observed (p for interaction = 0.68). In conclusion, in patients with left main coronary artery disease and ACS, PCI is associated with similar safety compared to CABG but higher risk of MACEs driven by increased risk of repeat revascularization.     

Potential shift from coronary bypass surgery to percutaneous coronary intervention for multivessel disease and its economic impact in the drug-eluting stent era

BACKGROUND: Drug-eluting stents (DES) may promote percutaneous coronary intervention (PCI) procedures in patients traditionally referred for coronary artery bypass graft (CABG) surgery and may save money. OBJECTIVES: The purpose of the present study was to quantify the potential shift from CABG surgery to multivessel PCI in the DES era and to model the economic consequences. METHODS: Based on predefined criteria, the feasibility of PCI was evaluated in patients with multivessel coronary artery disease who underwent CABG surgery before the availability of DES at the Centre Hospitalier de l'Université de Montréal's Notre-Dame Hospital (Montreal, Quebec). Modelling was used to evaluate the potential cost savings using multivessel PCI instead of CABG surgery. Equal one-year outcomes in both groups were assumed, with the exception of a 10% repeat revascularization (RR) rate in the DES group and a 4% RR rate in the CABG group. The impact of those assumptions was evaluated using 1000 Monte Carlo simulations. RESULTS: The authors retrospectively evaluated that, of 289 patients who underwent CABG without concomitant valve surgery between January and December 2003, only 22 patients (8%) were good candidates for multivessel DES implantation. The procedures would have involved an average of 3.6 DES per patient. The average cost per revascularization procedure was $14,402 with surgery and $11,220 for multivessel DES implantation (using $2,200 DES), leading to a savings of $3,182 per patient. However, after including RR procedures, PCI would only have been associated with savings of $812 per surgery avoided. Monte Carlo analysis revealed that surgery may be less expensive than PCI in 36% of patients. CONCLUSIONS: Most patients who underwent CABG surgery in 2003 were retrospectively judged to be ineligible for multivessel PCI with DES. In the rare eligible patient, multivessel PCI with DES is not expected to produce savings to health care costs in Canada unless the DES purchase cost continues to decrease.     

冠心病合并2型糖尿病患者冠状动脉多支病变PCI与CABG术后5年随访

目的比较冠状动脉粥样硬化性心脏病(冠心病)合并2型糖尿病冠状动脉多支病变患者经皮冠状动脉介入治疗(PCI)置入药物涂层支架(DES)与冠状动脉旁路移植术(CABG)后远期疗效。方法连续入选2002年12月至2008年12月住院期间的冠心病合并2型糖尿病患者,并成功行择期血运重建的多支冠状动脉病变患者,分为CABG组(n=270),DES组(n=285)。随访5年,从术后30 d开始到5年止结束,随访包括全因死亡、心源性死亡、非致死性卒中、非致死性心肌梗死、心绞痛复发和再次血运重建的主要不良心脑血管事件(MACE)。结果入选患者随访率100%。CABG组与DES组两组间5年全因死亡率(1.11%vs.1.40%)、心源性死亡率(0%vs.0%)、非致死性卒中发生率(2.22%vs.2.81%)无统计学差异(P0.05)。DES组非致死性心肌梗死发生率(3.15%)、心绞痛复发率(17.89%)、再次血运重建率(12.28%)均高于CABG组(分别为1.11,5.56%,0.74%),差异均有统计学意义(P0.05~0.01)。结论多支冠状动脉病变合并2型糖尿病患者CABG与PCI治疗5年生存率无明显差异,但多支冠状动脉病变合并2型糖尿病患者DES支架置入远期心绞痛复发率、再次血运重建率,非致死性心肌梗死发生率高于CABG组。     

冠心病多支病变雷帕霉素洗脱支架置入与冠状动脉旁路移植术的疗效对比

目的:对比雷帕霉素洗脱支架(SES)置入与冠状动脉旁路移植术(CABO)的近期与中期临床疗效.方法:单中心回顾性连续入选2003年7月～2004年6月期间行择期血运重建的多支冠状动脉病变患者,分为CAB(;组(811例),SES组(251例).随访终点事件包括死亡、心肌梗死、脑卒中和再次血运重建等主要不良心脑血管事件(MACCE).采用Kaplan-Meier方法估计无事件生存率.采用Logistic多元回归方法调整分析治疗对终点事件的相对影响.结果:随访率90.3%.中位随访时间19个月.随访30 d,CABG组MACCE的发生率高于SES组(5.4%: 1.6%,OR 3.66,95%CI 1.26～10.61),CABG组的病死率高于SES组(4.6%:1.2%,OR4.02,95%CI 1.18～13.74).至随访结束,SES组累积病死率低于CAB(;组(3.1%:7.6%,OR 0.44,95%CI0.19～0.99),但再次血运重建率高于CABG组(8.4%:1.5%,OR 6.83,95%CI 3.07～15.19),MACCE 2组间差异无统计学意义.以30 d为分期分析,CABG组30d生存率低于SES组(95.4%;98.8%,P＜0.05),2组30d后生存率差异无统计学意义(97.2%:98.3%,P＞0.05).结论:多支冠状动脉病变CABG与SES置入比较,CABG的30 d病死率高于SES置入,30 d后病死率差异无统计学意义;多支冠状动脉SES置入的中期血运重建率高于CABG.     

Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study. Northern New England Cardiovascular Disease Study Group

OBJECTIVES: We sought to assess survival among patients with diabetes and multivessel coronary artery disease (MVD) after percutaneous coronary intervention (PCI) and after coronary artery bypass grafting surgery (CABG). BACKGROUND: The Bypass Angioplasty Revascularization Investigation (BARI) demonstrated that diabetics with MVD survive longer after initial CABG than after initial PCI. Other randomized trials or observational databases have not conclusively reproduced this result. METHODS: A large, regional database was linked to the National Death Index to assess five-year mortality. Of 7,159 consecutive patients with diabetes who underwent coronary revascularization in northern New England during 1992 to 1996, 2,766 (38.6%) were similar to those randomized in the BARI trial. Percutaneous coronary intervention was the initial revascularization strategy in 736 patients and CABG in 2,030. Cox proportional hazards regression was used to calculate risk-adjusted hazard ratios (HR) and 95% confidence intervals (CI 95%). RESULTS: Patients who underwent PCI were younger, had higher ejection fractions and less extensive coronary disease. After adjusting for differences in baseline clinical characteristics, patients with diabetes treated with PCI had significantly greater mortality relative to those undergoing CABG (HR = 1.49; CI 95%: 1.02 to 2.17; p = 0.037). Mortality risk tended to increase more among 1,251 patients with 3VD (HR = 2.02; CI 95%: 1.04 to 3.91; p = 0.038) than among 1,515 patients with 2VD (HR = 1.33; CI 95%: 0.84 to 2.1; p = 0.21). CONCLUSIONS: In this analysis of a large regional contemporary database of patients with diabetes selected to be similar to those enrolled in the BARI trial, five-year mortality was significantly increased after initial PCI. This supports the BARI conclusion on initial revascularization of patients with diabetes and MVD.     

Drug-eluting stents versus bypass surgery for multivessel coronary disease

Since the advent of coronary artery bypass graft (CABG) surgery and the development of percutaneous coronary intervention (PCI), there has been debate as to which is the most optimal revascularization strategy for patients with multivessel coronary artery disease. Over the past decade, this controversy has been heightened with the introduction into the PCI armamentarium of drug-eluting stents (DES) and their profound reduction of restenosis and subsequent repeat revascularization. This article reviews the key registries and randomized clinical trials of PCI-DES and CABG in multivessel disease. Focus is placed on the recent data and evidence for long-term outcomes in patients treated with DES or CABG for complex multivessel coronary disease, including unprotected left main disease. The article also discusses risk models and the decision process for appropriate selection of revascularization techniques in patients with multivessel coronary disease.     

Comparison of long-term outcome of off-pump coronary artery bypass grafting versus drug-eluting stents in triple-vessel coronary artery disease

After the introduction of drug-eluting stents (DESs), percutaneous coronary intervention with DESs has challenged coronary artery bypass grafting as the gold standard for the treatment of 3-vessel coronary artery disease. The purpose of this study was to compare the long-term clinical results between percutaneous coronary intervention with DESs and off-pump coronary artery bypass grafting (OPCAB) in 3-vessel coronary artery disease. Two hundred ninety propensity-score matched patients with 3-vessel coronary artery disease treated by DESs or OPCAB were included. Mean follow-up duration was 58.8 ± 11.5 months (2 to 73) and follow-up rate was 97.9%. Five-year survival rates were 94.8 ± 2.1% in the DES group and 96.5 ± 1.5% in the OPCAB group (p = 0.658). Five-year rates of freedom from major adverse cardiac and cerebrovascular event were 71.6 ± 4.1% in the DES group and 89.6 ± 2.5% in the OPCAB group (p < 0.001). Freedom from nonfatal myocardial infarction and target vessel revascularization rates were the determining factors between the 2 groups (p = 0.018 and p < 0.001, respectively). The OPCAB group showed better clinical outcomes compared to the DES group in 3-vessel coronary artery disease after 5-year follow-up. Freedom from major adverse cardiac and cerebrovascular event rate was significantly higher in the OPCAB group mainly because of the lower incidence of target vessel revascularization and nonfatal myocardial infarction. Longer follow-up with randomization will clarify our present conclusions.     

In-hospital and long-term outcomes of multivessel percutaneous coronary revascularization after acute myocardial infarction

Multivessel percutaneous coronary intervention (PCI) early after acute myocardial infarction (AMI) is discouraged because of the potential for increased complications. However, with recent advances in PCI, the safety and long-term outcomes of multivessel PCI are unknown. We evaluated the outcomes of multivessel PCI early after AMI (ST-elevation and non-ST-elevation AMI). We identified all patients who had multivessel disease and underwent PCI within 7 days after an AMI from 1997 to 2002. Clinical outcomes were compared between patients who underwent multivessel PCI (n = 239) and patients who underwent treatment of the infarct-related artery alone (n = 1,145). The primary end point was cumulative survival at 6, 12, and 36 months. Secondary end points included a composite of mortality, recurrent infarction, coronary artery bypass graft, or target vessel revascularization at the same time points. There were 138 deaths and 351 occurrences of the composite end point during follow-up. The multivessel PCI group had a significantly higher prevalence of adverse prognostic indicators. Despite this, observed event rates were similar between the multivessel PCI and 1-vessel PCI groups. The Kaplan-Meier estimated 1-year survival was 0.91 (95% confidence interval [CI] 0.87 to 0.95) for the multivessel PCI group and 0.93 (95% CI 0.92 to 0.95) for the 1-vessel PCI group (p = 0.43). Similarly, 1-year survival free of recurrent infarction and target vessel revascularization rates were similar between the 2 groups: multivessel PCI 0.78 (95% CI 0.73 to 0.84) and 1-vessel PCI 0.78 (95% CI 0.75 to 0.81). Multivessel PCI in patients with multivessel coronary artery disease after AMI compared with 1-vessel PCI was not associated with an excess risk of death or of combined death, myocardial infarction, coronary artery bypass graft, or target vessel revascularization.     

PCI versus CABG for multivessel coronary disease in diabetics

Objectives: To explore the clinical performance of a strategy of revascularization by percutaneous coronary intervention (PCI) with drug‐eluting stent (DES) in diabetic patients with multivessel disease (MVD) compared with coronary artery bypass graft (CABG), when it is based on clinical judgment. Background: Diabetes mellitus (DM) is a major risk factor for poor outcome after PCI. However, PCI may result in better outcome if the choice of revascularization (PCI versus CABG) is based on the physician decision, rather than randomization. Limited experiences have compared revascularization by DES‐PCI versus CABG in DM patients with MVD. Methods: From August 2004 to August 2005, 220 consecutive DM patients with MVD underwent DES‐PCI (93) or CABG (127) at our Institution. The type of revascularization was dependent on patient and/or physician choice. Major adverse cardiac and cerebrovascular events (MACCE) included death, myocardial infarction, repeat coronary revascularization, and stroke. Results: Compared with PCI patients, CABG patients had higher prevalence of 3‐vessel disease (P < 0.001), significant LAD involvement (P < 0.001), presence of total occlusions (P = 0.04), collateral circulation (P < 0.001). At 2‐year follow‐up, MACCE were not different between CABG group and DES‐PCI group (OR 1.2; P = 0.6) and, only when the clinical judgment on the revascularization choice was excluded at propensity analysis, DES‐PCI increased the risk of 24‐month MACCE in total population (OR 1.8; P = 0.04). Conclusions: For patients with DM and MVD, a clinical judgment‐based revascularization by DES‐PCI is not associated with worse 2‐year outcome compared with CABG. © 2008 Wiley‐Liss, Inc.     

Impact of body mass index on the outcome of patients with multivessel disease randomized to either coronary artery bypass grafting or stenting in the ARTS trial: The obesity paradox II?

The effect of body mass index (BMI) on outcomes after coronary artery revascularization remains controversial. We studied 1,203 patients who had multivessel coronary artery disease and underwent stenting (n = 599) or coronary artery bypass grafting (CABG; n = 604) in the Arterial Revascularization Therapies Study. Patients were assigned to 1 of 3 groups according to BMI: <25, 25 to 30, and >30 kg/m(2). At 3-year follow-up, the incidence of death, cerebrovascular events, or myocardial infarction was similar for these BMI categories regardless of the revascularization technique used. Rates of repeat revascularization procedures were significantly higher among patients who had been randomized to stenting but were similar across BMI groups. For patients who had been randomized to undergo CABG, there was a significant decrease in repeat revascularization procedures in obese patients (p = 0.03). Among patients who underwent stenting, BMI had no effect on the 3-year combined end point of rate of major adverse cardiac or cerebrovascular events. Among patients who underwent CABG, major adverse cardiac or cerebrovascular event rates were significantly lower for patients who were obese (11%) or overweight (16%) compared with patients who had a normal BMI (24%; p = 0.008). Thus, in a large cohort of patients who had multivessel coronary artery disease and underwent surgical or percutaneous revascularization, BMI had no effect on 3-year outcome of those who underwent stenting. Conversely, among patients who underwent CABG, those who were overweight or obese had a significantly better outcome than did those who had a normal BMI with regard to survival without major adverse cardiac or cerebrovascular events, mainly due to lower rates of repeat revascularization procedures.     

Comparison of percutaneous interventions for unstable angina pectoris in patients with and without previous coronary artery bypass grafting

An increasing number of patients who have undergone previous coronary artery bypass grafting (CABG) are referred for percutaneous coronary revascularization. We identified patients who underwent percutaneous intervention for unstable angina from 1990 to 1998 at our institution and assigned them into 2 groups based on whether or not they had undergone previous CABG. There were 1,431 patients with and 4,629 patients without previous CABG. Previous CABG patients were older, had more atherosclerotic risk factors, more heart failure, lower ejection fraction, more multivessel disease, more multilesion treatment, more complex lesions, and less complete revascularization. Adjusting for baseline differences, previous CABG was associated with worse long-term mortality (RR 1.47, 95% confidence intervals [CI] 1.22 to 1.77, p < 0.001) and death, myocardial infarction, and/or revascularization (RR 1.16, 95% CI 1.04 to 1.30, p = 0.01); treatment of native lesions in patients with previous CABG versus treatment of vein graft lesions was associated with a reduction in this composite end point (RR 0.75, 95% CI 0.65 to 0.87, p < 0.001). Post-CABG patients treated between 1995 and 1998 had lower long-term mortality (RR 0.76, 95% CI 0.59 to 0.99, p = 0.04) and death, myocardial infarction, and/or revascularization (RR 0.76, 95% CI 0.66 to 0.88, p < 0.001) compared with those treated between 1990 and 1994. Thus, in patients with unstable angina referred for percutaneous revascularization, previous CABG is associated with reduced event-free survival, although the outcome of post-CABG patients treated from 1995 to 1998 is superior to that observed in patients treated from 1990 to 1994. In patients who underwent previous CABG, treatment of native lesions affords better long-term outcome than vein graft intervention.     

老年无保护左主干病变置人药物洗脱支架与行冠状动脉旁路移植术的预后比较

目的 对比老年无保护左主干病变患者置入药物洗脱支架(DES)和行冠状动脉旁路移植术(CABG)后2年的临床预后.方法 入选2004年1月至2006年6月因无保护左主干病变置入DES或行CABG的老年患者(≥70岁)共295例.随访2年,记录患者发生全因死亡、非致死性心肌梗死及靶病变血管重建的情况.结果 共206例患者行CABG,89例患者置入DES.随访2年的累积死亡率CABG组为10.2%,DES组为13.3%,两组之间差异无统计学意义(P=0.428).生存分析表明2年生存率CABG组为89.2%,DES组为86.4%,两组之间差异无统计学意义(P=0.668).2年心肌梗死发生率CABG组为10.1%,DES组为7.8%,两组之间差异无统计学意义(P=0.501).DES组2年内靶病变血管重建的发生率明显高于CABG组(13.5%比4.9%,P=0.015).多因素分析表明,年龄(HR:1.04,95% CI:1.01～1.09,P=0.024)、左心室功能不全(LVEF<30%)(HR:4.97,95%CI:1.22～24.85,P=0.018)以及2型糖尿病(HR:2.22,95%CI:1.31～4.86,P=0.001)均是死亡的独立危险因素.结论 对于≥170岁的老无保护左主干病变患者,行CABG和置入DES后2年的生存率相当,但置入DES的患者靶病变血管重建发生率明显高于行CABG的患者.