PCI vs. CABG – punkt widzenia lekarza i pacjenta

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Rewaskularyzacja przezskórna (PCI) czy operacyjne wszczepienie by-passów (CABG), która z tych metod powinna być preferowana w poszczególnych grupach pacjentów z chorobą niedokrwienną serca (CHD)? Takie pytanie zadają sobie kardiolodzy i kardiochirurdzy na całym świecie, a odpowiedź na przestrzeni lat wielokrotnie się zmieniała.

W ostatnim czasie ukazało się kolejne duże badanie[1], którego celem było porównanie śmiertelności u chorych po wielonaczyniowym CABG i PCI. Korzystając z danych zgromadzonych w systemie ubezpieczeniowym Medicare wyodrębniono 251 553 pacjentów spełniających kryteria włączenia, spośród których 194 223 przeszło operację kardiochirurgiczną, a 57 330 zabieg przezskórny w latach 1992 – 2008. Każdemu z chorych z grupy PCI przyporządkowano odpowiadającego mu pod względem charakterystyki klinicznej pacjenta po CABG, tak by charakterystyki obu grup nie różniły się statystycznie. Średni czas obserwacji wyniósł średnio 4,3 lat. Względne ryzyko zgonu z jakiejkolwiek przyczyny było istotnie statystycznie niższe w grupie osób poddanych zabiegowi kardiochirurgicznemu i wyniosło 0,92. Jeszcze większe różnice w śmiertelności ogólnej występowały u pacjentów z dodatkowymi obciążeniami, takimi jak cukrzyca, nikotynizm, niewydolność serca czy choroba naczyń obwodowych – każdy z tych czynników w istotny statystycznie sposób wiązał się z niższą częstością zgonów w grupie leczonej CABG. Ryzyko względne wynosiło odpowiednio 0,88 wśród chorych z cukrzycą, 0,82 u palaczy, 0,84 u osób z niewydolnością serca oraz 0,85 w przypadku pacjentów z współistniejącą miażdżycą naczyń obwodowych. Z drugiej strony, wśród osób wolnych od tych czynników ryzyka (41% osób badanych) PCI nie tylko nie było rozwiązaniem gorszym, ale wiązało się nawet z nieznacznie lepszym rokowaniem odległym.

Tak wygląda porównanie obu metod z perspektywy lekarza – najważniejszym czynnikiem wpływającym na wybór sposobu leczenia jest jego mierzalny efekt. Dla pacjenta proces decyzyjny jest o wiele bardziej złożony. Statystycznie lepsze efekty uzyskiwane przez kardiochirurgów niejednokrotnie okazują się mniej przekonywujące od strachu przed rozległą operacją, dłuższą rekonwalescencją po CABG, czy rozległością blizny na mostku. Ciekawe badanie[2] dokumentujące to zjawisko opublikowali niedawno naukowcy z USA.  585 osobom ze stabilną chorobą niedokrwienną serca przedstawiali przebieg operacji wszczepienia by-passu oraz rewaskularyzacji metodą przezskórną, następnie prezentowali statystyki powikłań związanych z obiema procedurami i pytali, jaką metodę wybrałby dla siebie pacjent. Informacje dotyczące PCI dla poszczególnych grup chorych różniły się od siebie, np.: ryzyko zgonu było przedstawiane jako 2, 4 lub 6 %, podczas gdy ryzyko zgonu związane z CABG podawano jako 3 %. Podobnie postępowano z danymi dotyczącymi ponownej rewaskularyzacji czy udaru mózgu związanego z procedurą. Miało to na celu sprawdzenie, czy, a jeśli tak, to przy jakim poziomie ryzyka zgonu, chorzy zaczną preferować operację kardiochirurgiczną. Okazało się, że chociaż wraz z „pogarszaniem się” podawanych statystyk, pacjenci mniej chętnie decydowali się na PCI, to jednak ta metoda była preferowana niemal we wszystkich grupach chorych. Podobny scenariusz zrealizowano pytając lekarzy, którą z metod wybraliby potencjalnie dla siebie i chociaż tu przewaga PCI była jeszcze mniejsza, to jednak była ona zachowana, mimo statystycznie gorszych efektów.

Podsumowując, widać wyraźnie, że lekarze i pacjenci patrzą na proces leczenia z różnej perspektywy. Mimo bardzo dobrze udokumentowanej wyższości CABG u osób z wielonaczyniową chorobą niedokrwienną, większość chorych wolałaby przejść rewaskularyzację przezskórną. Dotyczy to także wielu lekarzy, którzy sami stali się pacjentami.

1. Hlatky MA et al., Comparative effectiveness of multivessel coronary bypass surgery and multivessel percutaneous coronary intervention. Ann Intern Med 2013, 158:727-34

2. Kipp R et al., Patient preferences for coronary artery bypass graft surgery or percutaneous intervention in multivessel coronary disease. Catherization and Cardiovascular Interventions 2013, 82:212-8



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