两种血运重建方式对冠状动脉粥样硬化性心脏病合并左室收缩功能不全患者预后影响的系统评价与 Meta 分...

李波¹，吴春蓉²，付世全¹，陈青梅¹，李元静¹ 

1. 重庆市江津区中心医院 心内科 (重庆  402260) ;  2. 重庆市江津区中心医院 肿瘤科 (重庆 402260)

通信作者：吴春蓉, Email: [e-mail]

关键词：冠状动脉旁路移植术；经皮冠状动脉介入术；冠状动脉粥样硬化性心脏病；左室收缩功能不全

基金项目：重庆市江津区科技计划项目（Y2017014）

引用本文：李波, 吴春蓉, 付世全, 陈青梅, 李元静. 两种血运重建方式对冠状动脉粥样硬化性心脏病合并左室收缩功能不全患者预后影响的系统评价与 Meta 分析. 中国胸心血管外科临床杂志, 2019, 26(2): 158-164. doi: 10.7507/1007-4848.201712068

摘   要

目的  比较冠状动脉旁路移植术（CABG）和经皮冠状动脉介入术（PCI）对冠状动脉粥样硬化性心脏病（冠心病）合并左室收缩功能不全患者的临床疗效。 

方法 计算机检索 PubMed、The Cochrane Library 及 EMbase数据库，检索时间为建库至 2017 年 10 月。同时浏览相关文献的引文目录，纳入符合要求的临床试验、队列研究和病例对照研究。本研究的终点包括全因死亡率、心肌梗死、再次血运重建和卒中，其效应量均用相对危险度（RR）及其 95% 置信区间（CI）表示。 

结果  最终纳入 15 项队列研究和 2 项随机对照试验，共计患者 11 985 例，其中 CABG 组 6 322 例，PCI 组 5 663 例。Meta 分析结果表明，CABG 组患者的全因死亡率低于 PCI 组患者（18.6% vs.23.0%），差异具有统计学意义［RR=0.87，95% CI（0.81，0.94），P<0.001］。CABG 组再次血运重建的风险也显著低于 PCI 组［RR=0.28，95% CI（0.19，0.42），P<0.001］，而两组患者的心肌梗死［RR=0.78，95% CI（0.47，1.32），P=0.36］和卒中［RR=1.28，95% CI（0.89，1.86），P=0.18］的发生率无明显差异。 

结论  CABG 治疗冠心病合并左室收缩功能不全患者的疗效优于 PCI。鉴于纳入研究的质量限制，该结论尚需更多大样本的随机对照试验来进一步验证。

Abstract

Objective  To compare the clinical efficacy of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with coronary heart disease and left ventricular systolic dysfunction.

Methods A computer-based search in PubMed, The Cochrane Library and EMbase up to October 2017, together with reference screening, was performed to identify eligible clinical trials, cohort studies and case-control studies. The outcomes of this meta-analysis included all-cause mortality, myocardial infarction, revascularization and stroke, and the effect sizes for them were presented as relative risk (RR) with its 95% confidence intervals (CI).

Results Fifteen cohort studies and 2 randomized controlled trials were finally included with a total of 11 985 patients, of whom 6 322 were in the CABG group and 5 663 in the PCI group. The result of meta-analysis showed that all-cause mortality was significantly lower in the CABG group than that in the PCI group (18.6% vs. 23.0%, RR=0.87, 95% CI 0.81 to 0.94, P<0.001). In addition, CABG was associated with a remarkably reduced risk of revascularization (RR=0.28, 95% CI 0.19 to 0.42, P<0.001) compared with PCI, with no significant difference in incidence of myocardial infarction (RR=0.78, 95% CI 0.47 to 1.32, P=0.36) and stroke (RR=1.28, 95% CI 0.89 to 1.86, P=0.18).

Conclusion CABG is superior to PCI in the treatment for patients with coronary heart disease and left ventricular systolic dysfunction. Owing to the limited quality of included studies, additional large, randomized controlled trails are still required to confirm this finding.

  图  

图1  文献筛选流程图

图2  全因死亡率的 Meta 分析

图3  心肌梗死、再次血运重建和卒中的 Meta 分析

全文见：www.tcsurg.org/article/10.7507/1007-4848.201712068