Objectives

The goal of this analysis was to examine the comparative effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention among patients aged less than 60 years.

Methods

We performed a multicenter, retrospective analysis of all cardiac revascularization procedures from 2005 to 2015 among 7 medical centers. Inclusion criteria were age less than 60 years and 70% stenosis or greater in 1 or more major coronary artery distribution. Exclusion criteria were left main 50% or greater, ST-elevation myocardial infarction, emergency status, and prior revascularization procedure. After applying inclusion and exclusion criteria, the final study cohort included 1945 patients who underwent cardiac surgery and 2938 patients who underwent percutaneous coronary intervention. The primary end point was all-cause mortality stratified by revascularization strategy. Secondary end points included stroke, repeat revascularization, and 30-day mortality. We used inverse probability weighting to balance differences among the groups.

Results

After adjustment, there was no significant difference in 30-day mortality (surgery: 0.8%; percutaneous coronary intervention: 0.7%, P = .86) for patients with multivessel disease. Patients undergoing surgery had a higher risk of stroke (1.3% [n = 25] vs 0.07% [n = 2], P < .001). Overall, surgery was associated with superior 10-year survival compared with percutaneous coronary intervention (hazard ratio, 0.71; 95% confidence interval, 0.57-0.88; P = .002). Repeat procedures occurred in 13.4% (n = 270) of the surgery group and 36.4% (n = 1068) of the percutaneous coronary intervention group, with both groups mostly undergoing percutaneous coronary intervention as their second operation. Accounting for death as a competing risk, at 10 years, surgery resulted in a lower cumulative incidence of repeat revascularization compared with percutaneous coronary intervention (subdistribution hazard ratio, 0.34; 95% confidence interval, 0.28-0.40; P < .001).

Conclusions

Among patients aged less than 60 years with 2-vessel disease that includes the left anterior descending or 3-vessel coronary artery disease, surgery was associated with greater long-term survival and decreased risk of repeat revascularization.

中文翻译：

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早期冠状动脉疾病血运重建策略的比较有效性：多中心分析

目标

该分析的目的是检查冠状动脉旁路移植术与经皮冠状动脉介入治疗在年龄小于 60 岁的患者中的比较效果。

方法

我们对 7 个医疗中心 2005 年至 2015 年的所有心脏血运重建手术进行了多中心回顾性分析。纳入标准是年龄小于 60 岁和 1 个或多个主要冠状动脉分布中 70% 或更大的狭窄。排除标准是左主干 50% 或更高、ST 段抬高心肌梗死、紧急状态和先前的血运重建手术。应用纳入和排除标准后，最终研究队列包括 1945 名接受心脏手术的患者和 2938 名接受经皮冠状动脉介入治疗的患者。主要终点是按血运重建策略分层的全因死亡率。次要终点包括卒中、重复血运重建和 30 天死亡率。我们使用逆概率加权来平衡组间的差异。

结果

调整后，多支血管病变患者的 30 天死亡率（手术：0.8%；经皮冠状动脉介入治疗：0.7%， P  = .86）没有显着差异。接受手术的患者卒中风险较高（1.3% [n = 25] vs 0.07% [n = 2]，P  < .001）。总体而言，与经皮冠状动脉介入治疗相比，手术的 10 年生存率更高（风险比，0.71；95% 置信区间，0.57-0.88；P = .002)。手术组 13.4%（n = 270）和经皮冠状动脉介入治疗组 36.4%（n = 1068）发生重复手术，两组大多以经皮冠状动脉介入治疗作为第二次手术。将死亡作为竞争风险考虑在内，与经皮冠状动脉介入治疗相比，在 10 年时，手术导致重复血运重建的累积发生率较低（亚分布风险比，0.34；95% 置信区间，0.28-0.40；P  < .001）。

结论

在 60 岁以下患有 2 支血管疾病（包括左前降支或 3 支冠状动脉疾病）的患者中，手术与更长的长期生存率和降低再次血运重建的风险相关。