Adult: Coronary
Difference in spontaneous myocardial infarction and mortality in percutaneous versus surgical revascularization trials: A systematic review and meta-analysis

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Abstract

Objectives

It has been hypothesized that the survival benefit of coronary artery bypass (CABG) compared with percutaneous interventions (PCI) may be associated with the reduction in spontaneous myocardial infarction (SMI) achieved by surgery. This, however, has not been formally investigated. The present meta-analysis aims to evaluate the association between the difference in SMI and in survival in PCI versus CABG randomized controlled trials (RCTs).

Methods

A systematic search was performed to identify all RCTs comparing PCI with CABG for the treatment of coronary artery disease and reporting SMI outcomes. Generic inverse variance method was used to pool outcomes as natural logarithms of the incident rate ratios across studies. Subgroup analysis and interaction test were used to compare the difference of the primary outcome among trials that did and did not report a significant reduction in SMI- in the patients treated by CABG. Primary outcome was all-cause mortality; secondary outcome was SMI.

Results

Twenty RCTs were included in the meta-analysis. A statistically significant difference in SMI in favor of CABG was found in 7 of the included trials (35%). Overall, PCI was associated with significantly greater all-cause mortality (incident rate ratio, 1.13; 95% confidence interval, 1.01-1.28). At subgroup analysis, a significant difference in survival in favor of CABG was seen only in trials that reported a significant reduction in SMI in the surgical arm (P for interaction 0.02).

Conclusions

In the published PCI versus CABG trials, the reduction in all-cause mortality in the surgical arm is associated with the protective effect of CABG against SMI.

Graphical abstract

Summary of the findings of the study. SMI, Spontaneous myocardial infarction; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; RCT, randomized clinical trial; CAD, coronary artery disease; IRR, incidence rate ratio; CI, confidence interval.

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Section snippets

Methods

A medical librarian performed comprehensive searches to identify all randomized controlled trials (RCTs) comparing PCI versus CABG. Searches were run in November 2019 in the following databases: Ovid MEDLINE (1946 to present); Ovid EMBASE (1974 to present); and The Cochrane Library (Wiley). The full search strategy for Ovid MEDLINE is available in Appendix E1. Institutional review committee approval was not required, as this is a meta-analysis of published data.

Trials were considered for

Results

Searches retrieved 4916 results. Following de-duplication, 4411 citations were screened; a total of 20 RCTs met the inclusion criteria and were included in the meta-analysis (Table 1).6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Flowchart outlining the study selection process is reported in Figure 1.

A total of 12,334 patients were included (PCI: 6190; CABG: 6144). The number of patients

Discussion

In this meta-analysis of 20 RCTs comparing PCI with CABG, we have found that surgery was associated with lower mortality at a weighted mean follow-up of 3.9 years. The survival benefit in the surgical arm was found only in the trials that reported a significant reduction of SMI in the surgical arm.

Recently, a study level meta-analysis of 14 randomized trials comparing routine revascularization with conservative strategy in patients with stable CAD found that, at a follow-up of 4.5 years,

Full Search Strategy

Ovid MEDLINE ALL - 1946 to November 21, 2019

Searched on November 24, 2019

Limited to RCTs via BMJ's study design search filter available from: https://bestpractice.bmj.com/info/toolkit/learn-ebm/study-design-search-filters/

Line # | Search

  • 1

    Percutaneous Coronary Intervention/

  • 2

    (percutaneous coronary intervention∗ or percutaneous coronary revascularization∗ or PCI or percutaneous coronary angioplasty or stent or stents or stenting).tw.

  • 3

    Angioplasty, Balloon, Coronary/

  • 4

    (coronary balloon angioplasties or

References (33)

  • P.E. Buszman et al.

    Left main stenting in comparison with surgical revascularization: 10-year outcomes of the (Left Main Coronary Artery Stenting) LE MANS trial

    JACC Cardiovasc Interv

    (2016)
  • N.R. Holm et al.

    Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non-inferiority NOBLE trial

    Lancet

    (2020)
  • J.-M. Ahn et al.

    Randomized trial of stents versus bypass surgery for left main coronary artery disease: 5-year outcomes of the PRECOMBAT study

    J Am Coll Cardiol

    (2015)
  • J.-J. Goy et al.

    10-year follow-up of a prospective randomized trial comparing bare-metal stenting with internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis the SIMA (Stenting versus Internal Mammary Artery grafting) trial

    J Am Coll Cardiol

    (2008)
  • F.W. Mohr et al.

    Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial

    Lancet

    (2013)
  • D.J.F.M. Thuijs et al.

    Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial

    Lancet

    (2019)
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