本文選題：我國(guó) + 復(fù)雜　； 參考：《北京協(xié)和醫(yī)學(xué)院》2016年博士論文

【摘要】：冠心病三支病變和左主干病變的自然預(yù)后差。血運(yùn)重建治療(CABG或PCI)是其主要治療方式。既往研究顯示,歐美國(guó)家存在血運(yùn)重建技術(shù)使用過度和使用不足的問題。我國(guó)冠心病發(fā)病率逐年增加,PCI和CABG迅速普及,但兩者的手術(shù)量之比為12～15：1,遠(yuǎn)高于發(fā)達(dá)國(guó)家水平(3：1)。我國(guó)目前尚無(wú)公認(rèn)的血運(yùn)重建指南和合理性評(píng)價(jià)標(biāo)準(zhǔn),�？漆t(yī)生培養(yǎng)體系有待健全,目前醫(yī)務(wù)工作的報(bào)償仍以醫(yī)療服務(wù)規(guī)模而非醫(yī)療質(zhì)量為依據(jù),因此我們有必要評(píng)價(jià)目前臨床事件中復(fù)雜冠心病治療策略選擇的合理性。中國(guó)復(fù)雜冠心病醫(yī)療結(jié)果評(píng)價(jià)研究(China PEACE-3VD)是由我國(guó)24家同時(shí)具備CABG和PCI治療能力的教學(xué)醫(yī)院聯(lián)合開展的前瞻性觀察性研究,共入選了超過4000例接受擇期冠脈造影被診斷為復(fù)雜冠心病(三支病變或左主干病變)的患者。我們利用國(guó)際指南評(píng)價(jià)該隊(duì)列患者治療策略的合理性,分析治療合理性與臨床預(yù)后的相關(guān)性,并探究治療策略選擇過程中的不合理環(huán)節(jié),為將來的臨床路徑優(yōu)化提供依據(jù)。主要的的研究結(jié)果如下：第一部分：復(fù)雜冠心病治療的合理性評(píng)價(jià)目的：利用一項(xiàng)在我國(guó)進(jìn)行的前瞻性觀察性研究隊(duì)列評(píng)價(jià)冠心病三支病變和/或左主干病變治療策略的合理性。方法：我們?cè)?4家單位連續(xù)入選了超過4000例在該中心接受擇期冠脈造影并被診斷為冠心病三支和/或左主干病變的患者,并利用2014年版歐洲心臟病協(xié)會(huì)/歐洲心胸外科醫(yī)師協(xié)會(huì)發(fā)布的冠心病血運(yùn)重建指南評(píng)價(jià)治療合理性。結(jié)果：?jiǎn)沃行暮投嘀行年?duì)列中接受合理治療的患者占比分別為68%和57.3%,各單位(23%-74.5%)、同一單位的各個(gè)病房(50%-78%)和冠脈造影醫(yī)生(48%-82%)間治療策略合理性差異顯著。患者的手術(shù)危險(xiǎn)性(SinoSCORE、慢性腎功能不全、年齡)和解剖病變復(fù)雜程度(SYNTAX評(píng)分、左主干病變)是治療策略合理性的獨(dú)立危險(xiǎn)因素,治療策略合理性與單位、科室或醫(yī)師的接診量無(wú)關(guān)(單位間Pearson相關(guān)系數(shù)0.278,p=0.222；醫(yī)師Pearson相關(guān)系數(shù)0.216,科室Pearson相關(guān)系數(shù)0.455,p0.05)。結(jié)論：我國(guó)復(fù)雜冠心病治療策略的合理性有待提高,單位間差異顯著,提示較大的質(zhì)量改善空間。第二部分：復(fù)雜冠心病治療合理性對(duì)預(yù)后的影響目的：我們發(fā)現(xiàn)復(fù)雜冠心病患者中大約40%接受了與指南指征不符的治療,合理性欠佳。本研究旨在進(jìn)一步評(píng)價(jià)治療合理性對(duì)患者臨床預(yù)后的影響,以驗(yàn)證指南對(duì)我國(guó)患者的適用性。方法：我們通過隨訪獲得前述隊(duì)列患者的重要臨床事件發(fā)生情況。我們利用COX回歸模型、傾向性積分匹配COX回歸模型來比較不同指征分層下各類治療策略與患者預(yù)后的相關(guān)性。結(jié)果：共有3213例患者(保守治療485例,CABG治療1104例,PCI治療1199例)納入本次分析。COX回歸模型分析發(fā)現(xiàn),保守治療的MACCE發(fā)生率(14% vs 5.9%, HR=2.004, p0.001)、全因死亡/心梗/腦卒中的發(fā)生率(8.9% vs 3.1%, HR=1.918, p=0001)明顯高于血運(yùn)重建組。我們根據(jù)患者的PCI治療指征將實(shí)際接受血運(yùn)重建的患者分成A組(符合CABG的Ⅰ類及PCI的Ⅰ類或Ⅱa類指征,1624例)和B組(符合CABG的Ⅰ類及PCI的Ⅲ類指征,1104例)。A組CABG的MACCE發(fā)生率(2.6% vs 5.7%, HR=2.563, p=0.008)明顯低于PCI組,死亡/心梗/腦卒中的發(fā)生率無(wú)統(tǒng)計(jì)學(xué)差異(1.4%vs 2.6%,HR=2.009,p=0.159)。B組CABG的MACCE發(fā)生率(3.8% vs 10%, HR=2.532, p=0.002)和死亡/心梗/腦卒中的發(fā)生率(2.5% vs 5.6%, HR=1.997)都明顯低于PCI,其中死亡/心梗/腦卒中的發(fā)生率在兩種治療策略間出現(xiàn)了接近統(tǒng)計(jì)學(xué)意義的差異。采用傾向性積分匹配的方法獲得的結(jié)果與未匹配的COX模型結(jié)果類似。結(jié)論：對(duì)于指南推薦血運(yùn)重建的患者,僅接受保守治療的預(yù)后不佳。接受不合理的血運(yùn)重建治療也將影響患者預(yù)后。歐洲血運(yùn)重建指南評(píng)價(jià)的治療合理性與患者預(yù)后具有明顯的相關(guān)性。第三部分：復(fù)雜冠心病治療方式選擇過程的合理性評(píng)價(jià)目的：復(fù)雜冠心病的治療策略選擇過程常需要內(nèi)外科醫(yī)師、患者和家屬參與。本研究旨在探討治療策略選擇過程中各個(gè)關(guān)鍵環(huán)節(jié)的合理性及其對(duì)預(yù)后的影響。方法：我們通過病案回顧確認(rèn)患者接受ad hoc PCI(造影后直接PCI)、外科會(huì)診,以及拒絕醫(yī)師治療建議的比例,并利用COX回歸模型、傾向性積分匹配COX回歸模型評(píng)價(jià)這些關(guān)鍵環(huán)節(jié)與患者臨床預(yù)后的關(guān)系。結(jié)果：3213例患者被納入本次分析,ad hoc PCI使用率、外科會(huì)診率和患者拒絕的比例分別為49%,36.3%和16.6%。與接受分期血運(yùn)重建治療相比,ad hocPCI患者治療合理性降低(57.9%vs 87.7%,p0.01),MACCE發(fā)生率(8.6% vs 4.9%, HR=0.543, p=0.002)更高。與獲得外科會(huì)診的患者相比,無(wú)外科會(huì)診的患者治療策略合理性降低(56.6%vs 77.8%,p0.01),預(yù)后不佳(7.7%vs 6.3%,p=0.017)。與依從醫(yī)師建議的患者相比,拒絕醫(yī)師建議的患者實(shí)際接受治療的合理性不佳(19.6%vs 74.2%,p0.01),影響預(yù)后(MACCE:12.2% vs 6.2%, HR=0.579, p0.001)。結(jié)論：我國(guó)復(fù)雜冠心病患者的外科會(huì)診率低,ad hoc PCI使用率偏高,尚有一部分患者拒絕醫(yī)師的治療策略建議,三個(gè)關(guān)鍵指標(biāo)都影響治療策略的合理性和臨床預(yù)后。第四部分：中國(guó)冠心病血運(yùn)重建適宜使用標(biāo)準(zhǔn)的驗(yàn)證目的：中國(guó)冠心病血運(yùn)重建適宜標(biāo)準(zhǔn)(中國(guó)AUC)已經(jīng)發(fā)布,我們利用單中心隊(duì)列數(shù)據(jù)比較該標(biāo)準(zhǔn)與歐洲指南對(duì)合理性評(píng)價(jià)的一致性。方法：我們根據(jù)中國(guó)AUC制定合理性評(píng)價(jià)方法,利用該方法評(píng)價(jià)本研究單中心隊(duì)列患者的治療合理性。我們通過比較兩種合理性評(píng)價(jià)方法評(píng)價(jià)治療策略合理性的一致程度來驗(yàn)證中國(guó)AUC的適用性。結(jié)果：利用中國(guó)AUC建立評(píng)價(jià)標(biāo)準(zhǔn),發(fā)現(xiàn)本研究單中心隊(duì)列中有65%接受合理的治療,該比例與歐洲指南類似。中國(guó)AUC可以區(qū)分各病房(50%-73.6%)和冠脈造影醫(yī)生(47.6%-81.8%)間治療策略合理性差異。該標(biāo)準(zhǔn)與歐洲指南的合理性評(píng)價(jià)一致性為96.4%。結(jié)論：根據(jù)中國(guó)AUC建立的評(píng)價(jià)標(biāo)準(zhǔn)與歐洲指南具有較好的一致性,可以用于評(píng)價(jià)復(fù)雜冠心病治療的合理性及其單位間差異。
[Abstract]:The natural prognosis of three branches of coronary heart disease and left main artery disease is poor. Blood revascularization (CABG or PCI) is the main treatment method. Previous studies have shown that there is a problem of excessive use and insufficient use of blood transport reconstruction in European and American countries. The incidence of coronary heart disease in China is increasing year by year, and PCI and CABG are rapidly popularized, but the ratio of the amount of operation is 12 15:1, far higher than the level of developed countries (3:1). There is no recognized guidelines for blood transportation and the standard of rational evaluation in China. The training system of specialist doctors remains to be improved. At present medical service is still based on the scale of medical service rather than medical quality. Therefore, it is necessary for us to evaluate the treatment of complex coronary heart disease in the current clinical events. The rationality of the choice of therapeutic strategies. The Chinese complex coronary heart disease medical results evaluation study (China PEACE-3VD) is a prospective observational study conducted jointly by 24 Chinese teaching hospitals with the ability to treat CABG and PCI. More than 4000 patients with selective coronary angiography were diagnosed with complex coronary artery disease (three or left main coronary arteries). We use the international guidelines to evaluate the rationality of the patients' treatment strategy in this cohort, analyze the correlation between the rationality of the treatment and the clinical prognosis, and explore the irrational links in the course of the treatment strategy selection, and provide the basis for the optimization of the future clinical pathway. The main results are as follows: complex coronary heart disease Objective: To evaluate the reasonableness of a prospective observational cohort of three coronary lesions and / or left main coronary artery disease in China. Methods: more than 4000 patients received selective coronary angiography and diagnosed as three coronary artery disease and / or coronary artery disease in 24 units. The patients with left main disease were treated with the guidelines of the 2014 edition of the European Heart Association / European Cardiology surgeon Association for coronary artery revascularization. Results: 68% and 57.3% of patients received reasonable treatment in single center and multicenter cohort, each unit (23%-74.5%), each unit of the same unit (50% There were significant differences in the rationality of treatment strategies between -78%) and coronary angiography (48%-82%). Surgical risk (SinoSCORE, chronic renal insufficiency, age) and the complexity of anatomical lesions (SYNTAX score, left main disease) were independent risk factors for the rationality of the treatment strategy, the rational and unit of the treatment strategy, the number of departments or doctors' visits. It was not related (Pearson correlation coefficient 0.278, p=0.222; physician Pearson correlation coefficient 0.216, Pearson correlation coefficient 0.455, P0.05). Conclusion: the rationality of the treatment strategy of complex coronary heart disease in our country needs to be improved, the difference between units is significant and the greater quality is improved. The second part: the rationality of the treatment of complex coronary heart disease is the prognosis. Objective: we have found that about 40% of patients with complex coronary heart disease have been treated with incompatible treatment with guidelines. The purpose of this study is to further evaluate the effect of treatment rationality on the patient's clinical prognosis in order to verify the applicability of the guide to the patients in our country. We used the COX regression model and the tendency integral matching COX regression model to compare the correlation between the different treatment strategies under different indications and the patients' prognosis. Results: 3213 patients (485 cases of conservative treatment, 1104 cases with CABG, 1199 cases with PCI) were included in the analysis of the.COX regression model. The incidence of MACCE (14% vs 5.9%, HR=2.004, p0.001), the incidence of all causes of death / myocardial infarction / stroke (8.9% vs 3.1%, HR=1.918, p=0001) was significantly higher than that in the revascularization group. We divided the patients who actually received the revascularization according to the PCI treatment indications of the patients into the A group (class I and PCI of CABG and PCI, 1624 or class II indications, 1624 The incidence of MACCE (2.6% vs 5.7%, HR=2.563, p=0.008) in group.A was significantly lower than that of the PCI group in group B and group B (class I and PCI). There was no significant difference in the incidence of death / myocardial infarction / stroke (1.4%vs 2.6%, HR=2.009, 10%) and death / myocardial infarction. The incidence of stroke (2.5% vs 5.6%, HR=1.997) was significantly lower than that of PCI, and the incidence of death / myocardial infarction / stroke occurred close to statistical difference between the two treatments. The results obtained by the tendency integral matching method were similar to those of the unmatched COX model. Patients received poor prognosis only with conservative treatment. Receiving irrational revascularization will also affect the patient's prognosis. The rationality of the European guidelines for revascularization has a significant correlation with the prognosis of the patients. The third part: the objective of rational evaluation of the selection process of complex coronary heart disease: the treatment of complex coronary heart disease The strategy selection process often requires the participation of internal and external physicians, patients and family members. The purpose of this study is to explore the rationality of each key link in the process of treatment strategy selection and its impact on the prognosis. Methods: We reviewed the patient's acceptance of ad hoc PCI (direct PCI after contrast), surgical consultation, and the rejection of the physician's advice. The COX regression model and the tendency integral matching COX regression model were used to evaluate the relationship between these key links and the patient's clinical prognosis. Results: 3213 patients were included in this analysis, the rate of ad hoc PCI use, the rate of surgical consultation and the rejection rate of patients were 49%, 36.3% and 16.6%. were compared with the reconstructive therapy for ad hocPCI. The patient's treatment reasonableness decreased (57.9%vs 87.7%, P0.01), the incidence of MACCE (8.6% vs 4.9%, HR=0.543, p=0.002) was higher. Compared with the patients who received surgical consultation, the treatment strategy of patients without surgical consultation was lower (56.6%vs 77.8%, P0.01), and the prognosis was poor (7.7%vs 6.3%, p=0.017). The reasonableness of the patient's treatment was not reasonable (19.6%vs 74.2%, P0.01), affecting the prognosis (MACCE:12.2% vs 6.2%, HR=0.579, p0.001). Conclusion: the surgical consultation rate of the patients with complex coronary heart disease is low, the ad hoc PCI use rate is high, there are some patients who refuse the doctor's treatment strategy advice, and the three key indexes all affect the treatment strategy. The fourth part: the fourth part: China's coronary artery revascularization suitable standard test objective: the Chinese coronary artery revascularization suitable standard (China AUC) has been published, we use the single center queue data to compare the consistency between the standard and the European guide to the rationality evaluation. Methods: we are based on the Chinese AUC system. This method is used to evaluate the rationality of the treatment of the patients in the single center of this study. We compare the consistency of the two rational evaluation methods to verify the applicability of the Chinese AUC. Results: the evaluation criteria of Chinese AUC are established, and there are 65% connections in the single center queue of this study. The ratio is similar to the European guide. China's AUC can distinguish the differences in the rationality of the treatment strategy between the wards (50%-73.6%) and the coronary angiography (47.6%-81.8%). The consistency of the standard with the European guide is 96.4%. conclusion: the evaluation standards built according to China's AUC are in good agreement with the European guide. It can be used to evaluate the rationality of the treatment of complex coronary heart disease and its differences among units.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R541.4

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