冠状动脉造影首诊科室对血管重建方式的影响

目的探讨冠状动脉造影（CAG）首诊科室（内科系统或外科）对血管重建方式的影响。方法入选2003年10月至2004年6月在我院行CAG和血管重建的患者2156例,记录患者的基础临床与CAG特征、血管重建情况和住院临床结果等,分析CAG首诊科室对不同病变与临床特征冠心病患者血管重建方式的影响。结果在2156例患者中,1667例患者CAG首诊内科系统,其中1336例（80．1％）接受经皮冠状动脉介入治疗（PCI）,326例（19．6％）接受冠状动脉旁路移植术（CABG）,5例（0．3％）接受PCI＋CABG;489例患者CAG首诊外科,其中52例（10．6％）接受PCI,437例（89．4％）接受CABG。两组完全血管重建率分别为63．3％和75．5％（P〈0．01）。亚组分析显示,在包括1支病变、2支病变、含前降支近段的2支病变、3支病变、3支病变伴左心室射血分数（LVEF）〈0．50、多支病变、糖尿病多支病变、左主干病变、前降支近段病变、开口病变、慢性完全闭塞病变、支架内再狭窄病变和弥漫病变等所有亚组中,首诊外科CAG后的CABG率均高于首诊内科CAG的患者（P均〈0．01）。多因素Logistic回归分析发现,首诊外科行CAG（OR值为59．074,95％可信区间：39．319—88．753,P〈0．01）、病变血管支数、左主干病变、前降支近段病变、CTO病变是预测CABG的独立相关因素。CAG首诊外科的患者住院病死率（3．9％）和新发心肌梗死的发生率（1．8％）高于CAG首诊内科的患者（分别为1．2％、0．5％,P均〈0．01）。结论心脏内科与外科医师选择血管重建方式存在明显差异,需要累积更多的循证医学资料,制定明确的血管重建指南,指导心脏内、外科医师选择较为合理的血管重建方式。

Influence of initial admission department for coronary arteriography on choice of mode of coronary revascularization

Objective To investigate the influence of initial admission department for coronary arteriography on the choice of mode of coronary revascularization. Methods From October 2003 to June 2004 2156 patients with coronary heart disease were admitted into the department of internal medicine (1667 cases) or department of surgery (489 cases) to undergo coronary arteriography (CAG) and coronary revascularization. The influence of the initial admission departments on the choice of mode of coronary revascularization for the patients with different clinical manifestations and angiographic characteristics, including one-vessel disease, two-vessel disease, three-vessel disease, and multi-vessel disease of different types was analyzed. Results 1336 (80.1), 326 (19.6%), and 5 (0.3%) of the 1667 patients initially admitted to the department of internal medicine, received percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and CABG+PCI respectively with a complete revascularization rate of 63.3%. 52 (10.6%) and 437 (89.4%) of the 489 patients initially admitted to the department of surgery received PCI and CABG respectively with a complete revascularization rate of 75.5%. The CABG rates for the patients different types of lesion were all significantly higher in the patients initially admitted to the department of surgery than in the patients initially admitted in the department of internal medicine (all P<0.05). The in-hospital death rate, new-onset myocardial infarction rate, and main adverse cardio-cerebral event rate of the patients admitted into the department of surgery were 3.9%, 1.8%, and 5.7% respectively, all significantly higher than those of the patients initially admitted in the department of internal medicine (1.2%, 0.5%, and 1.5% respectively, all P<0.01). Logistic regression showed that initial admission into department of surgery, number of diseased vessels, left main trunk disease, proximal descending anterior branch disease, and chronic total occlusion rate were independent predictor for choice of CABG (all P<0.01). Conclusion Cardiologists are more likely to choose PCI and cardiac surgeons are more likely to choose CABG. It is imperative to collect more evidence-based data so as to develop guidelines for the choice of reasonable mode of revascularization.