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Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis

Stephan Windecker et al. BMJ. .

Erratum in

  • BMJ. 349:g4605. daCosta, Bruno R [corrected to da Costa, Bruno R]; Siletta, Maria G [corrected to Silletta, Maria G]; Juni, Peter [corrected to Jüni, Peter]

Abstract

Objective: To investigate whether revascularisation improves prognosis compared with medical treatment among patients with stable coronary artery disease.

Design: Bayesian network meta-analyses to combine direct within trial comparisons between treatments with indirect evidence from other trials while maintaining randomisation.

Eligibility criteria for selecting studies: A strategy of initial medical treatment compared with revascularisation by coronary artery bypass grafting or Food and Drug Administration approved techniques for percutaneous revascularization: balloon angioplasty, bare metal stent, early generation paclitaxel eluting stent, sirolimus eluting stent, and zotarolimus eluting (Endeavor) stent, and new generation everolimus eluting stent, and zotarolimus eluting (Resolute) stent among patients with stable coronary artery disease.

Data sources: Medline and Embase from 1980 to 2013 for randomised trials comparing medical treatment with revascularisation.

Main outcome measure: All cause mortality.

Results: 100 trials in 93,553 patients with 262,090 patient years of follow-up were included. Coronary artery bypass grafting was associated with a survival benefit (rate ratio 0.80, 95% credibility interval 0.70 to 0.91) compared with medical treatment. New generation drug eluting stents (everolimus: 0.75, 0.59 to 0.96; zotarolimus (Resolute): 0.65, 0.42 to 1.00) but not balloon angioplasty (0.85, 0.68 to 1.04), bare metal stents (0.92, 0.79 to 1.05), or early generation drug eluting stents (paclitaxel: 0.92, 0.75 to 1.12; sirolimus: 0.91, 0.75 to 1.10; zotarolimus (Endeavor): 0.88, 0.69 to 1.10) were associated with improved survival compared with medical treatment. Coronary artery bypass grafting reduced the risk of myocardial infarction compared with medical treatment (0.79, 0.63 to 0.99), and everolimus eluting stents showed a trend towards a reduced risk of myocardial infarction (0.75, 0.55 to 1.01). The risk of subsequent revascularisation was noticeably reduced by coronary artery bypass grafting (0.16, 0.13 to 0.20) followed by new generation drug eluting stents (zotarolimus (Resolute): 0.26, 0.17 to 0.40; everolimus: 0.27, 0.21 to 0.35), early generation drug eluting stents (zotarolimus (Endeavor): 0.37, 0.28 to 0.50; sirolimus: 0.29, 0.24 to 0.36; paclitaxel: 0.44, 0.35 to 0.54), and bare metal stents (0.69, 0.59 to 0.81) compared with medical treatment.

Conclusion: Among patients with stable coronary artery disease, coronary artery bypass grafting reduces the risk of death, myocardial infarction, and subsequent revascularisation compared with medical treatment. All stent based coronary revascularisation technologies reduce the need for revascularisation to a variable degree. Our results provide evidence for improved survival with new generation drug eluting stents but no other percutaneous revascularisation technology compared with medical treatment.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf. SW has received research grants to the institution from St Jude Medical and Biotronik. PJ is an unpaid steering committee or statistical executive committee member of trials funded by Abbott Vascular, Biosensors, Medtronic, and Johnson & Johnson. CTU Bern, which is part of the University of Bern, has a staff policy of not accepting honorariuma or consultancy fees. However, CTU Bern is involved in the design, conduct, or analysis of clinical studies funded by Abbott Vascular, Ablynx, Amgen, AstraZeneca, Biosensors, Biotronic, Boehrhinger Ingelheim, Eisai, Eli Lilly, Exelixis, Geron, Gilead Sciences, Nestlé, Novartis, Novo Nordisc, Padma, Roche, Schering-Plough, St Jude Medical, and Swiss Cardio Technologies. PS has received speakers’ honorariums from Medtronic, Biotronik, St Jude Medical, Impulse Dynamics, BioControl during the past five years. All other members of the writing committee declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Network of comparisons included in analyses. Circle size is proportional to number of randomised patients and reflects sample size, whereas line width is proportional to number of comparisons. CABG=coronary artery bypass grafting; PTCA=percutaneous transluminal coronary angioplasty; BMS=bare metal stents; PES=paclitaxel eluting stent; SES=sirolimus eluting stent; E-ZES=zotarolimus eluting (Endeavor) stent; R-ZES=zotarolimus eluting (Resolute) stent; EES=everolimus eluting stent
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Fig 2 Accumulation of randomised evidence according to comparison over time. Cumulative number of patients randomly assigned to different types of intervention according to start of patient enrolment in each trial is presented. CABG=coronary artery bypass grafting; PTCA=percutaneous transluminal coronary angioplasty; BMS=bare metal stent; DES=drug eluting stent
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Fig 3 Estimated rate ratios (95% credibility intervals) for mortality, myocardial infarction, the composite of death or myocardial infarction, and subsequent revascularisation from network meta-analyses for different revascularisation modalities compared with medical treatment—overall analyses. Square size is proportional to statistical precision of estimates. CABG=coronary artery bypass grafting; PTCA=percutaneous transluminal coronary angioplasty; BMS=bare metal stents; PES=paclitaxel eluting stent; SES=sirolimus eluting stent; E-ZES=zotarolimus eluting (Endeavor) stent; R-ZES=zotarolimus eluting (Resolute) stent; EES=everolimus eluting stent
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Fig 4 Estimated rate ratios (95% credibility intervals) for mortality, myocardial infarction, the composite of death or myocardial infarction, and subsequent revascularisation from network meta-analyses for different revascularisation modalities compared with medical treatment—secondary analyses of contemporary trials initiated in 1999 or later. Square size is proportional to statistical precision of estimates. CABG=coronary artery bypass grafting; PTCA=percutaneous transluminal coronary angioplasty; BMS=bare metal stents; PES=paclitaxel eluting stent; SES=sirolimus eluting stent; E-ZES=zotarolimus eluting (Endeavor) stent; R-ZES=zotarolimus eluting (Resolute) stent; EES=everolimus eluting stent
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