Clinician Article
Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis.
PMID: 24958153
-
CardiologyRelevance - 6/7
Newsworthiness - 6/7 -
Family Medicine (FM)/General Practice (GP)Relevance - 6/7
Newsworthiness - 5/7 -
General Internal Medicine-Primary Care(US)Relevance - 6/7
Newsworthiness - 5/7 -
Internal MedicineRelevance - 6/7
Newsworthiness - 5/7 -
Surgery - CardiacRelevance - 6/7
Newsworthiness - 5/7
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.
Clinical Comments
Cardiology
This is a classic meta-analysis and the best documentation of the benefits of revascularization ever assembled!
Internal Medicine
The devil's in the details. The fact that the results have CIs overlapping 1 in analyses restricted to later trials probably means that, when you separate out the patients who have a known survival advantage with revascularization, there may be no mortality benefit to CABG or PCI.
Internal Medicine
I`m not sure this is really adding anything since the patients are grouped in categories more coarse than are considered in clinical decisions (e.g., What is the anatomy? What are the comorbidities?, etc.). There also is the issue of what is going to constitute non-revascularization therapy. Highly compliant patients may be able to do a COURAGE-like medical therapy option, other patients may not. The basic story that CABG, on average, likely has a survival advantage and has less revascularization is not something likely to be considered "new" by primary care physicians.
Internal Medicine
This is an important meta-analysis. Many clinicians have relied on the COURAGE trial results to guide their therapeutic approach (i.e. medical therapy first, then intervention if it fails). Also, many consider the stents as a type of palliative therapy. This meta-analysis suggests that the newer devices have clear mortality benefits. Obviously, there are many assumptions underlying the network meta-analysis, but this study challenges previous practice. Whether the data are strong enough to truly change practice is not clear, but I think clinicians should be made aware of the findings.
Surgery - Cardiac
Excellent analysis. The information should lead to the use of the latest stents or coronary bypass grafting in this group of patients. At the same time, this will not change the present decision-making at all. Some meta-analysis is not the same as a randomized study.
Register for free access to all Professional content
RegisterOur Content
About
Support for the Portal is largely provided by the Labarge Optimal Aging Initiative. AGE-WELL is a contributing partner. Help us to continue to provide direct and easy access to evidence-based information on health and social conditions to help you stay healthy, active and engaged as you grow older. Donate Today.
