Comparative-effectiveness of revascularization versus routine medical therapy for stable ischemic heart disease: a
Harindra C Wijeysundera1, Maria C Bennell, Feng Qiu
1Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite A202, Toronto, ON, M4N3M5, Canada, harindra.wijeysundera@sunnybrook.ca.
Insights
Revascularization (PCI/CABG) in stable ischemic heart disease (IHD) patients showed better real-world outcomes than optimal medical therapy. This suggests revascularization improves effectiveness, possibly due to undertreatment in the medical therapy group.
Area of Science:
- Cardiology
- Interventional Cardiology
- Public Health
Background:
- Randomized trials indicate optimal medical therapy (OMT) is as effective as revascularization for stable ischemic heart disease (IHD).
- Real-world effectiveness of OMT versus revascularization in stable IHD remains unclear.
Purpose of the Study:
- To compare the real-world effectiveness of OMT versus revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) in stable IHD patients.
- To assess outcomes including death, myocardial infarction (MI), and repeat revascularization.
Main Methods:
- Observational cohort study of 39,131 stable IHD patients in Ontario, Canada (2008-2011).
- Revascularization defined as PCI/CABG within 90 days of angiography.
- Comparative analysis using multivariable Cox models and propensity score matching.
- Follow-up averaged 2.5 years, with a longer follow-up of 4.1 years in the matched analysis.
Main Results:
- Revascularization was associated with significantly lower rates of death, MI, and repeat PCI/CABG compared to medical therapy.
- In propensity-matched analysis (12,362 pairs), revascularized patients had fewer deaths (8.6% vs. 12.7%), MIs (11.7% vs. 14.4%), and repeat procedures (17.4% vs. 24.1%).
- Revascularized patients showed higher adherence to clopidogrel, beta-blockers, and statins post-angiography.
Conclusions:
- Revascularization in stable IHD patients is associated with improved risk-adjusted clinical outcomes in real-world practice.
- Potential under-treatment of medical therapy in some patients may contribute to observed differences.
- Findings highlight the importance of revascularization strategies in managing stable IHD.
Background:
Randomized studies have shown optimal medical therapy to be as efficacious as revascularization in stable ischemic heart disease (IHD). It is not known if these efficacy results are reflected by real-world effectiveness.
Objective:
To evaluate the comparative effectiveness of routine medical therapy versus revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in stable IHD.
Design:
Observational cohort study.
Patients:
Stable IHD patients from 1 October 2008 to 30 September 2011, identified using a Registry of all angiography patients in Ontario, Canada.
Intervention:
Revascularization, defined as PCI/CABG within 90 days after index angiography.
Main Measures:
Death, myocardial infarction (MI) or repeat PCI/CABG. Revascularization was compared to medical therapy using a) multivariable Cox-proportional hazard models with therapy strategy treated as a time-varying covariate; and b) a propensity score matched analysis. Post-angiography medication use was determined.
Key Results:
We identified 39,131 stable IHD patients, of whom 15,139 were treated medically, and 23,992 were revascularized (PCI = 15,604; CABG = 8,388). Mean follow-up was 2.5 years. Revascularization was associated with fewer deaths (HR 0.76; 95 % CI 0.68-0.84; p < 0.001) ,MIs (HR 0.78; 95 % CI 0.72-0.85; p < 0.001) and repeat PCI/CABG (HR 0.59; 95 % CI 0.50-0.70; p < 0.001) than medical therapy. In the propensity-matched analysis of 12,362 well-matched pairs of revascularized and medical therapy patients, fewer deaths (8.6 % vs 12.7 %; HR 0.75; 95 % CI 0.69-0.81; p < 0.001) , MIs (11.7 % vs 14.4 %; HR 0.84; 95 % CI 0.77-0.93 p < 0.001) and repeat PCI/CABG ( 17.4 % vs 24.1 %;HR 0.67; 95 % 0.63-0.71; p < 0.001) occurred in revascularized patients, over the 4.1 years of follow-up. The revascularization patients had higher uptake of clopidogrel (70.3 % vs 27.2 %; p < 0.001), β-blockers (78.2 % vs 76.7 %; p = 0.010), and statins (94.7 % vs 91.5 %, p < 0.001) in the 1-year post-angiogram.
Conclusions:
Stable IHD patients treated with revascularization had improved risk-adjusted outcomes in clinical practice, potentially due to under-treatment of medical therapy patients.
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