In people with stable coronary artery disease, coronary artery bypass grafting reduces risk of death and heart attack

Windecker S, Stortecky S, Stefanini GG, et al. Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis. BMJ. 2014 Jun 23;348:g3859.

Review question

In people with stable coronary artery disease, does revascularization reduce risk of death or acute myocardial infarction (heart attack) more than medication alone?

Background

Coronary artery disease is a narrowing of the blood vessels (coronary arteries) that supply oxygen and blood to the heart. This can cause shortness of breath, chest pain, heart attacks and death.

Coronary artery disease can be treated with medications, such as statins, aspirin and beta-blockers. Revascularization is a more invasive treatment that can restore blood flow through or around a blocked blood vessel. The 2 primary methods for revascularization are coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI or angioplasty).

• CABG is an open-heart surgery that uses a healthy blood vessel from another part of the body to bypass the blocked artery.
• Angioplasty is a nonsurgical procedure that inflates a small balloon within a partly blocked artery to open the artery. Often, stents (tiny tubes) are then placed in the artery to keep it open. Some of these stents are coated with medication that is slowly released (“eluted”) to further prevent the artery from closing up.

How the review was done

The researchers did a systematic review based on studies that were published up to June 2013.

They found 100 randomized controlled trials with 93,553 patients (average age 62 years).

All people had stable coronary artery disease—that is, they were not currently having a heart attack or increasing chest pain.

The revascularization treatments studied were CABG and angioplasty without stents, with paclitaxel-eluting stents (Taxus®), with sirolimus-eluting stents (Cypher®), with zotarolimus-eluting stents (Endeavor®), with zotarolimus-eluting stents (Resolute®), and with everolimus-eluting stents (Xience®/Promus®).

Revascularization treatments, which typically include medications as well, were compared with initial treatment with medication alone.

What the researchers found

The trials were generally of high quality.

Compared with medication alone:

• CABG and angioplasty with everolimus-eluting stents (Xience®/Promus®) reduced the risk of death;
• CABG reduced the risk of heart attack; and
• CABG and angioplasty with paclitaxel-eluting stents (Taxus®), sirolimus-eluting stents (Cypher®), zotarolimus-eluting stents (Endeavor®), zotarolimus-eluting stents (Resolute®) and everolimus-eluting stents (Xience®/Promus®) reduced the risk of later revascularization.

Conclusion

In people with stable coronary artery disease, coronary artery bypass grafting reduces risk of death and heart attack; use of everolimus-eluting stents (Xience®/Promus®) reduces risk of death but not heart attack.

Revascularization vs medication alone in people with coronary artery disease*