NEJM：糖尿病患者的血运重建评价：多支冠脉病变更佳治疗策略

　　背景  在一些比较糖尿病患者血运重建策略的随机试验中，冠状动脉旁路移植术（CABG）的转归优于经皮冠脉介入术（PCI）。我们尝试探索积极药物治疗和用药物洗脱支架治疗是否可改变糖尿病合并多支冠状动脉疾病患者的血运重建方法。

　　方法  在这项随机试验中，我们将糖尿病合并多支冠状动脉疾病患者分为两组，第一组接受药物洗脱支架PCI治疗，第二组接受CABG 治疗。患者最少被随访2年（在生存者中的中位数3.8年）。所有患者均被开具当前建议的药物治疗以控制低密度脂蛋白胆固醇、收缩压和糖化血红蛋白。主要转归指标是任何原因所致死亡、非致死性心肌梗死或非致死性卒中的复合。

　　结果  从2005～2010年，我们在140家国际中心纳入了1900例患者。患者的平均年龄为（63.1±9.1）岁，29%为女性，83%有三支血管疾病。PCI 组主要转归发生更频繁（P＝0.005），PCI 组（主要转归）5 年发生率为26.6% ，CABG 组为18.7%。CABG的益处体现在该组患者心肌梗死（P＜0.001）和任何原因所致死亡（P=0.049）的发生率较低。CABG 组卒中发生更频繁，PCI 组（卒中）5 年发生率为2.4%，CABG组为5.2%（P＝0.03）。

　　结论  对于糖尿病和进展期冠状动脉疾病患者，CABG 优于PCI。CABG显著降低了死亡和心肌梗死发生率，但卒中发生率较高。

Strategies for Multivessel Revascularization in Patients with Diabetes

BACKGROUND

In some randomized trials comparing revascularization strategies for patients with diabetes, coronary-artery bypass grafting (CABG) has had a better outcome than percutaneous coronary intervention (PCI). We sought to discover whether aggressive medical therapy and the use of drug-eluting stents could alter the revascularization approach for patients with diabetes and multivessel coronary artery disease.

METHODS

In this randomized trial, we assigned patients with diabetes and multivessel coronary artery disease to undergo either PCI with drug-eluting stents or CABG. The patients were followed for a minimum of 2 years (median among survivors, 3.8 years). All patients were prescribed currently recommended medical therapies for the control of low-density lipoprotein cholesterol, systolic blood pressure, and glycated hemoglobin. The primary outcome measure was a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke.

RESULTS

From 2005 through 2010, we enrolled 1900 patients at 140 international centers. The patients' mean age was 63.1±9.1 years, 29% were women, and 83% had three-vessel disease. The primary outcome occurred more frequently in the PCI group (P=0.005), with 5-year rates of 26.6% in the PCI group and 18.7% in the CABG group. The benefit of CABG was driven by differences in rates of both myocardial infarction (P<0.001) and death from any cause (P=0.049). Stroke was more frequent in the CABG group, with 5-year rates of 2.4% in the PCI group and 5.2% in the CABG group (P=0.03).

CONCLUSIONS

For patients with diabetes and advanced coronary artery disease, CABG was superior to PCI in that it significantly reduced rates of death and myocardial infarction, with a higher rate of stroke. (Funded by the National Heart, Lung, and Blood Institute and others; FREEDOM ClinicalTrials.gov number, NCT00086450.)