Difference in spontaneous myocardial infarction and mortality in percutaneous versus surgical revascularization
Mario Gaudino1, Antonino Di Franco1, Cristiano Spadaccio2
1Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
Insights
Coronary artery bypass grafting (CABG) reduces spontaneous myocardial infarction (SMI), contributing to improved survival compared to percutaneous coronary intervention (PCI). This meta-analysis confirms CABG
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Surgical Outcomes Research
Background:
- The survival advantage of coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) is debated.
- A potential mechanism is CABG's reduction of spontaneous myocardial infarction (SMI), which requires formal investigation.
Approach:
- A meta-analysis of randomized controlled trials (RCTs) comparing CABG and PCI was conducted.
- The association between SMI reduction and survival benefit in CABG versus PCI was evaluated.
- All-cause mortality and SMI were primary and secondary outcomes, respectively.
Key Points:
- Twenty RCTs were analyzed, with 35% showing significantly lower SMI with CABG.
- Overall, PCI was linked to higher all-cause mortality (IRR 1.13).
- A survival benefit for CABG was observed only in trials demonstrating a significant SMI reduction.
Conclusions:
- The survival benefit of CABG over PCI is associated with its protective effect against spontaneous myocardial infarction.
- This finding highlights the importance of SMI reduction in surgical outcomes for coronary artery disease.
Objectives:
It has been hypothesized that the survival benefit of coronary artery bypass (CABG) compared with percutaneous interventions (PCI) may be associated with the reduction in spontaneous myocardial infarction (SMI) achieved by surgery. This, however, has not been formally investigated. The present meta-analysis aims to evaluate the association between the difference in SMI and in survival in PCI versus CABG randomized controlled trials (RCTs).
Methods:
A systematic search was performed to identify all RCTs comparing PCI with CABG for the treatment of coronary artery disease and reporting SMI outcomes. Generic inverse variance method was used to pool outcomes as natural logarithms of the incident rate ratios across studies. Subgroup analysis and interaction test were used to compare the difference of the primary outcome among trials that did and did not report a significant reduction in SMI- in the patients treated by CABG. Primary outcome was all-cause mortality; secondary outcome was SMI.
Results:
Twenty RCTs were included in the meta-analysis. A statistically significant difference in SMI in favor of CABG was found in 7 of the included trials (35%). Overall, PCI was associated with significantly greater all-cause mortality (incident rate ratio, 1.13; 95% confidence interval, 1.01-1.28). At subgroup analysis, a significant difference in survival in favor of CABG was seen only in trials that reported a significant reduction in SMI in the surgical arm (P for interaction 0.02).
Conclusions:
In the published PCI versus CABG trials, the reduction in all-cause mortality in the surgical arm is associated with the protective effect of CABG against SMI.
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