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Lancet:在冠状动脉旁路移植术和经皮冠状动脉介入术之间由个体患者的解剖特征与临床特征指导临床决策:SYNTAX评分II 的发展与验证

2014-06-27 Farooq V等 柳叶刀中文网

背 景:欧洲和美国的指南均推荐解剖学SYNTAX评分作为工具,帮助临床医生为复杂冠状动脉疾病患者选择最佳的血运重建方法。但由于其并未纳入患者个体信息,而且缺乏在冠状动脉旁路移植术(CABG)和经皮冠状动脉介入术(PCI)之间指导决策的临床变量,因此SYNTAX评分的使用受到限制。SYNTAX评分Ⅱ旨在克服这些缺陷。方 法:SYNTAX评分Ⅱ是根据SYNTAX试验全部随机参与者(n=1800)的结果

背 景:


欧洲和美国的指南均推荐解剖学SYNTAX评分作为工具,帮助临床医生为复杂冠状动脉疾病患者选择最佳的血运重建方法。但由于其并未纳入患者个体信息,而且缺乏在冠状动脉旁路移植术(CABG)和经皮冠状动脉介入术(PCI)之间指导决策的临床变量,因此SYNTAX评分的使用受到限制。SYNTAX评分Ⅱ旨在克服这些缺陷。

方 法:

SYNTAX评分Ⅱ是根据SYNTAX试验全部随机参与者(n=1800)的结果,利用Cox比例风险模型开发出来的。无论是采用CABG还是PCI术(交互效应),或者二者均有(预测精确性),患者的基线特征与4年病死率均具有很强的相关性,因此将其添加到解剖学SYNTAX评分中。每例患者都进行4年病死率的预测,并比较CABG或PCI治疗患者的预测结果。判定结果的差异通过一致性检验来定量,并采用Bootstrap法再抽样进行内部验证。外部验证利用多国DELTA注册研究的全部受试者(n=2891)资料进行分析,这一多样化的受试者人群均为接受CABG或PCI治疗的患者,包括三支血管病变(26%)和复杂冠状动脉血管病变(SYNTAX评分≥33分,30%)。SYNTAX试验在ClinicalTrial.gov的注册编号为NCT00114972。

结 果:

SYNTAX评分Ⅱ包括8个预测因子:解剖学SYNTAX评分、年龄、肌酐清除率、左室射血分数(LVEF)、存在无保护的左主干(ULMCA)病变、有外周血管疾病、女性、有慢性阻塞性肺疾病(COPD)。SYNTAX评分Ⅱ可有效预测患者行CABG与行PCI后4年病死率的差异(P交互=0.003
7)。为了使CABG或PCI术后患者有相近的4年病死率,年轻患者、女性患者和LVEF降低的患者需要更低的SYNTAX评分,而老龄患者、ULMCA病变患者和COPD患者需要更高的SYNTAX评分。是否患糖尿病对于CABG或PCI的选择并不重要(P交互=0.67)。SYNTAX评分Ⅱ可有效区分所有CABG或PCI的患者,内部验证(SYNTAX试验)的一致性指数为0.725,外部验证(DELTA注册研究)的指数为0.716,均显著高于单独的解剖学SYNTAX评分(一致性指数分别为0.567和0.612)。为了更准确地个体化预测4年病死率,对拟行CABG或PCI的患者绘制预测列线图。

结 论:

复杂冠状动脉疾病的患者长期病死率(4年)可通过使用SYNTAX评分Ⅱ结合患者的解剖特征和临床特征进行良好预测。SYNTAX评分Ⅱ比经典的SYNTAX评分更有助于医生决定患者是进行CABG还是PCI。

原始出处:

Farooq V1, van Klaveren D, Steyerberg EW, Meliga E, Vergouwe Y, Chieffo A, Kappetein AP, Colombo A, Holmes DR Jr, Mack M, Feldman T, Morice MC, Ståhle E, Onuma Y, Morel MA, Garcia-Garcia HM, van Es GA, Dawkins KD, Mohr FW, Serruys PW.Anatomical and clinical characteristics to guide decision making between coronary artery bypass surgery and percutaneous coronary intervention for individual patients: development and validation of SYNTAX score II.Lancet. 2013 Feb 23;381(9867):639-50. doi: 10.1016/S0140-6736(13)60108-7.

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CST 2014, time=2014-06-29, status=1, ipAttribution=)]
  5. 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CST 2014, time=2014-06-29, status=1, ipAttribution=)]
  6. 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CST 2014, time=2014-06-29, status=1, ipAttribution=)]
    2015-01-23 cy0324
  7. 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  8. 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  9. 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