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Abstract：
OBJECTIVE: This article presents a comprehensive review of coronary revascularization versus optimal medical therapy (OMT) in patients with severe ischemic left ventricular dysfunction.
RESULTS: The REVIVED-BCIS2 trial randomized 700 patients with extensive coronary artery disease and left ventricular (LV) ejection fraction (LVEF) ≤ 35% and viability in more than four dysfunctional myocardial segments to percutaneous coronary intervention (PCI) plus OMT versus OMT alone. Over a median duration of 41 months, there was no difference in the composite of all-cause mortality, heart failure hospitalization, or improvement in LVEF with PCI plus OMT versus OMT alone at 6 and 12 months, quality of life scores at 24 months, or fatal ventricular arrhythmia. The STICH randomized trial was conducted between 2002 and 2007, involving patients with LV dysfunction and coronary artery disease. The patients were assigned to either CABG plus medical therapy or medical therapy alone. At the 5-year follow-up, the trial showed that CABG plus medical therapy reduced cardiovascular disease-related deaths and hospitalizations but no reduction in all-cause mortality. However, a 10-year follow-up showed a significant decrease in all-cause mortality with CABG. The currently available evidence showed no apparent benefit of PCI in severe ischemic cardiomyopathy as compared to OMT, but that CABG improves outcomes in this patient population. The paucity of data on the advantages of PCI in this patient population underscores the critical need for optimization of medical therapy for better survival and quality of life until further evidence from RCTs is available.
RESULTS: The REVIVED-BCIS2 trial randomized 700 patients with extensive coronary artery disease and left ventricular (LV) ejection fraction (LVEF) ≤ 35% and viability in more than four dysfunctional myocardial segments to percutaneous coronary intervention (PCI) plus OMT versus OMT alone. Over a median duration of 41 months, there was no difference in the composite of all-cause mortality, heart failure hospitalization, or improvement in LVEF with PCI plus OMT versus OMT alone at 6 and 12 months, quality of life scores at 24 months, or fatal ventricular arrhythmia. The STICH randomized trial was conducted between 2002 and 2007, involving patients with LV dysfunction and coronary artery disease. The patients were assigned to either CABG plus medical therapy or medical therapy alone. At the 5-year follow-up, the trial showed that CABG plus medical therapy reduced cardiovascular disease-related deaths and hospitalizations but no reduction in all-cause mortality. However, a 10-year follow-up showed a significant decrease in all-cause mortality with CABG. The currently available evidence showed no apparent benefit of PCI in severe ischemic cardiomyopathy as compared to OMT, but that CABG improves outcomes in this patient population. The paucity of data on the advantages of PCI in this patient population underscores the critical need for optimization of medical therapy for better survival and quality of life until further evidence from RCTs is available.
摘要：
目的：本文对严重缺血性左心室功能障碍患者的冠状动脉血运重建与最佳药物治疗（OMT）进行了全面综述。
结果：REVIVED-BCIS2试验将700名患有广泛性冠状动脉疾病且左心室（LV）射血分数（LVEF）≤35％且四个以上功能失调的心肌节段的患者随机分配到经皮冠状动脉介入治疗（PCI）加OMT与单独OMT。中位持续时间为41个月，全因死亡率的复合没有差异，心力衰竭住院，或在6个月和12个月时PCI加OMT与单独OMT的LVEF改善，24个月时的生活质量评分，或者致命的室性心律失常.STICH随机试验于2002年至2007年进行，涉及患有LV功能障碍和冠状动脉疾病的患者。患者被分配到CABG加药物治疗或单独药物治疗。在5年的随访中，试验显示,CABG+药物治疗减少了心血管疾病相关死亡和住院,但全因死亡率没有降低.然而,10年的随访显示,CABG的全因死亡率显著降低.目前可用的证据表明，与OMT相比，PCI在严重缺血性心肌病中没有明显的益处。但CABG改善了该患者人群的预后.关于PCI在该患者人群中的优势的数据很少，强调了在获得RCT的进一步证据之前，迫切需要优化药物治疗以提高生存率和生活质量。
结果：REVIVED-BCIS2试验将700名患有广泛性冠状动脉疾病且左心室（LV）射血分数（LVEF）≤35％且四个以上功能失调的心肌节段的患者随机分配到经皮冠状动脉介入治疗（PCI）加OMT与单独OMT。中位持续时间为41个月，全因死亡率的复合没有差异，心力衰竭住院，或在6个月和12个月时PCI加OMT与单独OMT的LVEF改善，24个月时的生活质量评分，或者致命的室性心律失常.STICH随机试验于2002年至2007年进行，涉及患有LV功能障碍和冠状动脉疾病的患者。患者被分配到CABG加药物治疗或单独药物治疗。在5年的随访中，试验显示,CABG+药物治疗减少了心血管疾病相关死亡和住院,但全因死亡率没有降低.然而,10年的随访显示,CABG的全因死亡率显著降低.目前可用的证据表明，与OMT相比，PCI在严重缺血性心肌病中没有明显的益处。但CABG改善了该患者人群的预后.关于PCI在该患者人群中的优势的数据很少，强调了在获得RCT的进一步证据之前，迫切需要优化药物治疗以提高生存率和生活质量。
