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[NEJM发表论文]:缺血性心肌病心肌活性与长期预后
2019年08月31日 时讯速递, 进展交流 暂无评论

ORIGINAL ARTICLE

Myocardial Viability and Long-Term Outcomes in Ischemic Cardiomyopathy

Julio A. Panza, Alicia M. Ellis, Hussein R. Al-Khalidi, et al

N Engl J Med 2019; 381:739-748
DOI: 10.1056/NEJMoa1807365

Abstract

BACKGROUND 背景

The role of assessment of myocardial viability in identifying patients with ischemic cardiomyopathy who might benefit from surgical revascularization remains controversial. Furthermore, although improvement in left ventricular function is one of the goals of revascularization, its relationship to subsequent outcomes is unclear.

为鉴别从再血管化手术中获益的缺血性心肌病患者,评估心肌活性的作用尚存在争议。而且,尽管左室功能改善是再血管化的目标之一,但其与预后的相关性并不明确。

METHODS 方法学

Among 601 patients who had coronary artery disease that was amenable to coronary-artery bypass grafting (CABG) and who had a left ventricular ejection fraction of 35% or lower, we prospectively assessed myocardial viability using single-photon-emission computed tomography, dobutamine echocardiography, or both. Patients were randomly assigned to undergo CABG and receive medical therapy or to receive medical therapy alone. Left ventricular ejection fraction was measured at baseline and after 4 months of follow-up in 318 patients. The primary end point was death from any cause. The median duration of follow-up was 10.4 years.

研究入选了601名接受CABG手术且左室射血分数< 35%的冠心病患者,我们采用单光子发射断层扫描(SPECT)和(或)多巴酚丁胺心脏超声检查,前瞻性评估心肌活性。患者随机分组,分别接受CABG和内科治疗,或仅接受内科治疗。在基线状态下以及4个月后随访时对318名患者测定左室射血分数。主要预后终点为任何原因导致的死亡。中位随访期为10.4年。

RESULTS 结果

CABG plus medical therapy was associated with a lower incidence of death from any cause than medical therapy alone (182 deaths among 298 patients in the CABG group vs. 209 deaths among 303 patients in the medical-therapy group; adjusted hazard ratio, 0.73; 95% confidence interval, 0.60 to 0.90). However, no significant interaction was observed between the presence or absence of myocardial viability and the beneficial effect of CABG plus medical therapy over medical therapy alone (P=0.34 for interaction). An increase in left ventricular ejection fraction was observed only among patients with myocardial viability, irrespective of treatment assignment. There was no association between changes in left ventricular ejection fraction and subsequent death.

与单纯内科治疗相比,CABG和内科治疗伴随全因死亡风险降低(CABG组298名患者182例死亡,内科治疗组303名患者209名死亡;校正后风险比,0.73;95%可信区间,0.60 to 0.90)。然而,观察到的心肌存活情况与CABG和内科治疗获益之间不存在交互作用(交互作用P=0.34)。无论治疗分组如何,仅在心肌存活患者观察到左室射血分数增加。左室射血分数改变与后续死亡之间并不相关。

CONCLUSIONS 结论

The findings of this study do not support the concept that myocardial viability is associated with a long-term benefit of CABG in patients with ischemic cardiomyopathy. The presence of viable myocardium was associated with improvement in left ventricular systolic function, irrespective of treatment, but such improvement was not related to long-term survival. (Funded by the National Institutes of Health; STICH ClinicalTrials.gov number, NCT00023595. opens in new tab.)

本研究的发现不支持以下概念,即缺血性心肌病患者心肌存活情况与CABG的长期获益有关。存在存活心肌与左室射血分数改善相关,但这一改善与长期存活无关。

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