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Stenting versus surgical bypass grafting for coronary artery disease: systematic overview and meta-analysis of
Giuseppe G L Biondi-Zoccai1, Antonio Abbate, Pierfrancesco Agostoni
1Istituto di Cardiologia Università Cattolica del Sacro Cuore Policlinico A. Gemelli Largo A. Gemelli, 8 00168 Roma. gbiondizoccai@tiscali.it
Insights
Coronary artery bypass grafting (CABG) and stenting offer similar survival rates for coronary artery disease. However, CABG results in significantly less repeat revascularization and fewer symptoms compared to conventional stenting.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Surgery
Background:
- Coronary artery disease (CAD) management involves angioplasty with stenting and coronary artery bypass grafting (CABG).
- CABG is traditionally linked to lower rates of repeat revascularization.
- Conflicting evidence exists regarding survival outcomes between stenting and CABG.
Purpose of the Study:
- To systematically review randomized trials comparing stenting versus CABG for CAD.
- To analyze comparative effectiveness regarding mortality, myocardial infarction, stroke, repeat revascularization, and symptomatic angina.
Main Methods:
- Systematic overview of randomized trials published between January 1986 and February 2003.
- Searched multiple databases including MEDLINE, Current Contents, Cochrane, and LILACS.
- Calculated random-effect odds ratios for key clinical outcomes with longest available follow-up.
Main Results:
- Nine trials (3283 patients) with a mean follow-up of 28 months were analyzed; no studies used drug-eluting stents.
- Stenting versus CABG showed similar rates for death, myocardial infarction, or stroke (OR 0.82, p=0.3).
- Stenting was associated with significantly higher rates of repeat revascularization (OR 4.6, p<0.00001) and symptomatic angina (OR 2.3, p<0.00001).
Conclusions:
- Conventional stenting and CABG demonstrate comparable overall and event-free survival in CAD patients.
- CABG remains superior in reducing the incidence of repeat revascularization and symptoms.
- Future research should evaluate next-generation drug-eluting stents in comparison to CABG.
Background:
Coronary angioplasty and coronary artery bypass grafting (CABG) are both major techniques for the management of coronary artery disease, but CABG is associated with a lower incidence of repeat revascularization. Recent studies comparing angioplasty with stenting vs CABG have yielded conflicting results, with some suggesting improved survival with stenting, and others the opposite. We thus undertook a systematic overview of the randomized trials comparing stenting vs CABG in coronary artery disease.
Methods:
MEDLINE (January 1986-February 2003), ISI Current Contents, the Cochrane Controlled Trial Register, LILACS and the American Heart Association, American College of Cardiology, European Society of Cardiology, and Transcatheter Cardiovascular Therapeutics conference proceedings were among the databases we searched. Abstraction was performed in a non-blinded manner on pre-specified forms. The random-effect odds ratios for death, myocardial infarction, stroke, repeat revascularization, and symptomatic angina were computed for the longest available follow-up.
Results:
Nine randomized trials (3283 patients, representing only 6% of all screened subjects) with an average follow-up of 28 months were included in the analysis, while four studies were excluded because they were still unpublished, ongoing, or with non-systematic stenting. No study used drug-eluting stents. The odds ratios for stenting vs CABG were 0.82 (95% confidence interval-CI 0.57-1.18, p = 0.3) for the occurrence of death, non-fatal myocardial infarction or stroke, 4.6 (95% CI 3.5-5.9, p < 0.00001) for repeat revascularization, and 2.3 (95% CI 1.8-2.8, p < 0.00001) for symptomatic angina. Heterogeneity tests were not statistically significant. The results of sensitivity analysis were similar even after stratification for single vessel, off-pump, single center or high-quality studies.
Conclusions:
Overall and event-free survival after conventional stenting for coronary artery disease are similar to those after CABG, but surgery is still associated with a significantly lower incidence of repeat revascularization and symptoms. The role of next-generation drug-eluting stents in widening the indications for stenting and overcoming restenosis will need to be assessed in future observational and randomized studies comparing stenting vs CABG.
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