目的：在伴左主干和（或）三支血管病变的糖尿病和非糖尿病患者中，对比目前外科血运重建（冠状动脉旁路移植手术[CABG]）与TAXUS Express（Boston Scientific）紫杉醇洗脱支架（PES）。
    背景：尽管糖尿病的患病率不断升高，对于复杂多支血管病变的糖尿病患者的最佳冠状动脉血运重建策略仍有争议。
    方法：SYNTAX（应用TAXUS的PCI治疗与心脏外科的协同作用）研究将1800例患者（452例为接受药物治疗的糖尿病患者）随即分配，接受PES或CABG治疗。
    结果：与接受CABG治疗的糖尿病患者相比，接受PES者1年总的主要心脑血管不良事件发生率更高。但对于非糖尿病患者（6.8% CABG vs. 6.8% PES，P=0.97）或糖尿病患者（10.3% CABG vs. 10.1% PES，P=0.96），血运重建的方法不影响死亡、卒中及心肌梗死的发生率。无论接受哪种血运重建治疗，糖尿病与致死率显著升高相关。在非糖尿病患者接受CABG后，卒中的发生率更高（CABG 2.2% vs. PES 0.5%，P=0.006）。在伴高度复杂病变的糖尿病患者应用PES治疗后的死亡率高于CABG组（4.1% vs. 13.5%，P=0.04）。非糖尿病患者（5.7% vs. 11.1%，P<0.001）和糖尿病患者（6.4% vs. 20.3%，P<0.001）选择PES后的再次血运重建率均更高。
    结论：亚组分析提示，与CABG相比，应用PES的左主干和（或）三支血管病变的糖尿病患者由于再次血运重建增加，因此1年主要不良心脑血管事件率更高。然而，在糖尿病和非糖尿病患者，两种治疗选择的复合安全性终点（死亡、卒中、心肌梗死）均相似。尽管需要进一步研究，这些初步结果可能增加了PES在选择性患者（不太复杂的左主干和/或三支血管病变）中应用的证据。

J Am Coll Cardiol 2010; 55:1067-1075

点评

    Jeffrey W. Moses， MD. Center for Interventional Vascular Therapy， New York-Presbyterian Hospital / Columbia University Medical Center
    his study goes further to dispel the myth that patients with multivessel disease and diabetes are best treated with CABG. The overall outcome in this group yields a similar outcomes in terms of death and MI in diabetes treated with stents and CABG. The gradient effect of diabetes in terms of mortality extends equally to both treatment options. While target lesion revascularization(TLR) is clearly higher with the stent strategy， the mortality differences seem to be confined exclusively to the most complex disease group and， more specifically， in those with Insulin-requiring diabetes. Given the fact that the PES used in this trial has been demonstrated to be clearly inferior to current generation DES (ie Xience V/Promus) in terms of TLR and combined hard outcomes of death， MI， and stroke， in other randomized trials these newer technologies clearly present us more opportunity to expand the cohort of patients with multivessel disease that can be safely treated with multivessel stenting even in patients with diabetes. While we await the results of the fully enrolled FREEDOM trial of 1900 with diabetes comparing surgery with a variety of DES， most practitioners can feel safe in recommending percutaneous therapy to those with moderate or lowest SYNTAX who are non insulin-dependent for their glucose control.