Revascularization in stable coronary artery disease

摘要

IMPORTANCE Recent trials of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) for multivessel disease were not designed to detect a difference in mortality and therefore were underpowered for this outcome. Consequently, the comparative effects of these 2 revascularization methods on long-term mortality are still unclear. In the absence of solid evidence for mortality difference, PCI is oftentimes preferred over CABG in these patients, given its less invasive nature. OBJECTIVES To determine the comparative effects of CABG vs PCI on long-term mortality and morbidity by performing a meta-analysis of all randomized clinical trials of the current era that compared the 2 treatment techniques in patients with multivessel disease. DATA SOURCES Asystematic literature searchwas conducted for all randomized clinical trials directly comparingCABGwith PCI. STUDY SELECTION To reflect current practice, we included randomized trials with 1 or more arterial grafts used in at least 90%, and 1 or more stents used in at least 70% of the cases that reported outcomes in patients with multivessel disease. DATA EXTRACTION Numbers of events at the longest possible follow-up and sample sizes were extracted. DATA SYNTHESIS Atotal of 6 randomized trials enrolling a total of 6055 patientswere included, with aweighted average follow-up of 4.1 years. Therewas a significant reduction in total mortality withCABGcompared with PCI (I2 = 0%; risk ratio [RR],0.73 [95%CI,0.62-0.86]) (P >.001). Therewere also significant reductions inmyocardial infarction (I2 = 8.02%; RR, 0.58 [95%CI,0.48-0.72]) (P >.001) and repeat revascularization (I2 = 75.6%; RR,0.29 [95%CI,0.21-0.41]) (P >.001) with CABG. Therewas a trend toward excess strokes withCABG(I2 = 24.9%; RR, 1.36 [95%CI,0.99-1.86]), but thiswas not statistically significant (P =.06). For reduction in total mortality, therewas no heterogeneity between trials thatwere limited to and not limited to patients with diabetes or whether stentswere drug eluting or not. Owing to lack of individual patient-level data, additional subgroup analyses could not be performed. CONCLUSIONS AND RELEVANCE In patients with multivessel coronary disease, compared with PCI, CABG leads to an unequivocal reduction in long-term mortality andmyocardial infarctions and to reductions in repeat revascularizations, regardless of whether patients are diabetic or not. These findings have implications for management of such patients.