Death and Myocardial Infarction Following Initial Revascularization Versus Optimal Medical Therapy in Chronic Coronary Syndromes With Myocardial Ischemia: A Systematic Review and Meta-Analysis of Contemporary Randomized Controlled Trials

Abstract

Background In chronic coronary syndromes, myocardial ischemia is associated with a greater risk of death and nonfatal myocardial infarction (MI). We sought to compare the effect of initial revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) plus optimal medical therapy (OMT) with OMT alone in patients with chronic coronary syndrome and myocardial ischemia on long-term death and nonfatal MI. Methods and Results Ovid Medline, Embase, Scopus, and Cochrane Library databases were searched for randomized controlled trials of PCI or CABG plus OMT versus OMT alone for patients with chronic coronary syndromes. Studies were screened and data were extracted independently by 2 authors. Random-effects models were used to generate pooled treatment effects. The search yielded 7 randomized controlled trials that randomized 10 797 patients. Median follow-up was 5 years. Death occurred in 640 of the 5413 patients (11.8%) randomized to revascularization and in 647 of the 5384 patients (12%) randomized to OMT (odds ratio [OR], 0.97; 95% CI, 0.86-1.09; P=0.60). Nonfatal MI was reported in 554 of 5413 patients (10.2%) in the revascularization arms compared with 627 of 5384 patients (11.6%) in the OMT arms (OR, 0.75; 95% CI, 0.57-0.99; P=0.04). In subgroup analysis, nonfatal MI was significantly reduced by CABG (OR, 0.35; 95% CI, 0.21-0.59; P<0.001) but was not reduced by PCI (OR, 0.92; 95% CI, 0.75-1.13; P=0.43) (P-interaction <0.001). Conclusions In patients with chronic coronary syndromes and myocardial ischemia, initial revascularization with PCI or CABG plus OMT did not reduce long-term mortality compared with OMT alone. CABG plus OMT reduced nonfatal MI compared with OMT alone, whereas PCI did not.

Keywords: coronary artery bypass grafting; coronary artery disease; myocardial ischemia; percutaneous coronary intervention.

Figure 1. Study selection.

Flow diagram depicts study selection for inclusion in the meta‐analysis, according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement for reporting systematic reviews and meta‐analyses.

Figure 2. Comparison of revascularization and optimal medical therapy vs optimal medical therapy alone in patients with chronic coronary syndromes, obstructive coronary artery disease, and myocardial ischemia for all‐cause mortality during follow‐up.

All included studies are shown by name along with point estimates of the odds ratios and respective 95% CIs. The size of the squares denoting the point estimate in each study is proportional to the weight of the study. BARI 2D indicates Bypass Angioplasty Revascularization Investigation 2 Diabetes; CABG, coronary artery bypass grafting; COURAGE, Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation; FAME 2, Fractional Flow Reserve vs Angiography for Multivessel Evaluation 2; ISCHEMIA, International Study of Comparative Health Effectiveness With Medical and Invasive Approaches; ISCHEMIA‐CKD, International Study of Comparative Health Effectiveness With Medical and Invasive Approaches–Chronic Kidney Disease; MASS II, Medicine, Angioplasty, or Surgery Study II; PCI, percutaneous coronary intervention; and STICH, Surgical Treatment for Ischemic Heart Failure.

Figure 3. Comparison of revascularization and optimal medical therapy vs optimal medical therapy alone in patients with chronic coronary syndromes, obstructive coronary artery disease, and myocardial ischemia for nonfatal myocardial infarction (MI) during follow‐up.

All included studies are shown by name along with point estimates of the odds ratios and respective 95% CIs. The size of the squares denoting the point estimate in each study is proportional to the weight of the study. A, Comparison of revascularization and optimal medical therapy vs optimal medical therapy alone in patients with chronic coronary syndromes, obstructive coronary artery disease, and myocardial ischemia for nonfatal MI using the primary definition of MI from the ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) ¹² and ISCHEMIA‐CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches–Chronic Kidney Disease) ²³ trials. B, Subgroup comparison of nonfatal MI where revascularization was performed exclusively or predominantly with percutaneous coronary intervention vs studies in which revascularization was exclusively by coronary artery bypass grafting. Nonfatal MI was defined using the primary definition in the ISCHEMIA ¹² and ISCHEMIA‐CKD ²³ trials. C, Comparison of revascularization and optimal medical therapy vs optimal medical therapy alone in patients with chronic coronary syndromes, obstructive coronary artery disease, and myocardial ischemia for nonfatal MI using the secondary definition of MI in the ISCHEMIA ¹² and ISCHEMIA‐CKD ²³ trials. D, Subgroup comparison of nonfatal MI where revascularization was performed exclusively or predominantly with percutaneous coronary intervention vs studies in which revascularization was exclusively by coronary artery bypass grafting. Nonfatal MI was defined using the secondary definition in the ISCHEMIA ¹² and ISCHEMIA‐CKD ²³ trials. BARI 2D indicates Bypass Angioplasty Revascularization Investigation 2 Diabetes; CABG, coronary artery bypass grafting; COURAGE, Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation; FAME 2, Fractional Flow Reserve vs Angiography for Multivessel Evaluation 2; MASS II, Medicine, Angioplasty, or Surgery Study II; PCI, percutaneous coronary intervention; and STICH, Surgical Treatment for Ischemic Heart Failure.