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Revascularization or Optimal Medical Therapy for Stable Ischemic Heart Disease: A Bayesian Meta-Analysis of
Ashish Kumar1, Rajkumar Doshi2, Safi U Khan3
1Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA.
Insights
Revascularization in stable ischemic heart disease (SIHD) shows minimal impact on mortality but reduces myocardial infarction and unstable angina. However, it may increase stroke risk compared to optimal medical therapy alone.
Area of Science:
- Cardiology
- Interventional Cardiology
- Evidence-Based Medicine
Background:
- The role of revascularization in stable ischemic heart disease (SIHD) remains debated, particularly with advancements in drug-eluting stents.
- Optimal medical therapy (OMT) is the cornerstone of SIHD management, but the added benefit of revascularization is unclear.
Purpose of the Study:
- To evaluate the absolute risk difference (ARD) between revascularization plus OMT versus OMT alone in patients with SIHD.
- To utilize a Bayesian approach for a robust statistical analysis of outcomes.
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials (RCTs) identified through PubMed/MEDLINE and Cochrane.
- Included trials compared initial revascularization (percutaneous or surgical) plus OMT against OMT alone, with >50% of patients receiving aspirin and statins in both arms.
- Data were analyzed using a Bayesian approach to determine ARDs and probabilities.
Main Results:
- Seven RCTs involving 12,494 patients were analyzed.
- Revascularization showed minimal ARD for all-cause mortality (ARD: -0.002) and cardiac mortality (ARD: -0.0025).
- Significant reductions were observed in myocardial infarction (MI) (ARD: -0.02) and unstable angina, with increased freedom from angina, but a higher risk of stroke.
Conclusions:
- Revascularization in SIHD offers limited benefit for mortality reduction when compared to OMT alone.
- Revascularization is associated with a lower incidence of MI and unstable angina, and improved angina relief.
- The findings suggest a careful consideration of revascularization in SIHD due to potential increased stroke risk and minimal mortality benefit.
Background:
The role of revascularization in patients with stable ischemic heart disease (SIHD) has been controversial, more so in the present era of drug-eluting stents.
Aims:
To examine the absolute risk difference (ARD) between revascularization plus optimal medical therapy (OMT) versus OMT alone among patients with SIHD using Bayesian approach.
Methods:
PubMed/MEDLINE and Cochrane citation indices were utilized to identify randomized controlled trials (RCTs) through March 31, 2020. Among trials comparing initial revascularization plus OMT with initial OMT alone, revascularization arm must have comprised >50% of patients receiving either percutaneous or surgical revascularization, and >50% of patients must have received aspirin and statin as OMT in both arms.
Results:
Seven RCTs (12,494) were included in the final analysis. The ARD of all-cause mortality for revascularization with respect to OMT was centred at -0.002 (95% CrI: -0.01; 0.01, Tau: 0.01, 67% probability of ARD of revascularization vs. OMT < 0). The ARD for cardiac mortality was centred at -0.0025 (95%CrI: -0.01; 0.01, Tau: 0.01, 77% probability of ARD of revascularization vs. OMT < 0). The ARD for MI was -0.02 (95% CrI: -0.06; 0.00, Tau: 0.02, 97% probability of ARD for revascularization vs. OMT < 0). There was 96% probability of ARD for unstable angina with revascularization vs. OMT < 0, 4.5% probability of ARD for freedom from angina with revascularization vs. OMT < 0, and 6% probability of ARD for stroke with revascularization vs. OMT < 0.
Conclusions:
Bayesian analysis demonstrated minimal probability of difference in all-cause mortality and cardiac mortality in patients with SIHD who underwent revascularization compared with OMT alone. However, revascularization was associated with lower probability of MI, unstable angina, and increased freedom from angina, but a higher risk of stroke compared with OMT alone.
Prospero:
The protocol of this systematic review and meta-analysis was registered in PROSPERO [CRD42020160540].
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