Percutaneous coronary intervention versus optimal medical therapy for stable coronary artery disease: An umbrella
David R Soriano-Moreno1, Daniel Fernandez-Guzman2, Kimberly G Tuco1
1Unidad de Investigación Clínica y Epidemiológica, Escuela de Medicina, Universidad Peruana Unión, Lima, Peru.
Insights
Systematic reviews on percutaneous coronary intervention (PCI) versus optimal medical therapy (OMT) for stable coronary artery disease lack high methodological quality. Results are inconsistent, necessitating a high-quality review to clarify PCI benefits and harms.
Area of Science:
- Cardiology
- Interventional Cardiology
- Evidence Synthesis
Background:
- Stable coronary artery disease management remains controversial.
- Percutaneous coronary intervention (PCI) versus optimal medical therapy (OMT) is a key debate.
- Existing systematic reviews (SRs) on this topic require critical evaluation.
Purpose of the Study:
- To synthesize existing systematic reviews (SRs) evaluating PCI versus OMT for stable coronary artery disease.
- To assess the benefits and harms of invasive versus conservative management strategies.
- To identify gaps and limitations in the current evidence base.
Main Methods:
- Conducted an umbrella review of SRs with meta-analyses of randomized controlled trials (RCTs).
- Searched major databases (PubMed, Embase, CENTRAL) from 2018 to August 2022.
- Assessed SR methodological quality using AMSTAR-2 and evaluated RCT overlap with corrected covered area (CCA).
Main Results:
- Included 10 SRs, with high overlap (CCA > 15%) among their constituent RCTs.
- Nine out of 10 SRs possessed critically low methodological quality; none used the GRADE system.
- Heterogeneous results reported for mortality, myocardial infarction, revascularization, and angina; no differences found for cardiovascular mortality and stroke.
Conclusions:
- Current SRs on PCI versus OMT for stable coronary artery disease suffer from low methodological quality and inconsistent findings.
- The variability in evidence quality and results may lead to divergent clinical decision-making.
- A high-quality SR employing the GRADE approach is essential to definitively assess the risk-benefit profile of PCI.
Background:
Invasive management of stable coronary artery disease is still a controversial topic. The purpose of this umbrella review was to synthesize systematic reviews (SRs) that evaluate the benefits and harms of percutaneous coronary intervention (PCI) versus optimal medical therapy (OMT) in patients with stable coronary artery disease.
Methods:
We systematically searched PubMed/MEDLINE, Embase, and CENTRAL from 2018 to August 7, 2022. We included SRs with meta-analyses of randomized controlled trials (RCTs) that evaluated the question of interest. We assessed the methodological quality of the SRs with the AMSTAR-2 tool. We summarized the results of the outcomes for each SR. We calculated the degree of overlap of the RCTs included in the SRs using the corrected covered area (CCA).
Results:
We found 10 SRs with meta-analyses. The SRs included 3 to 15 RCTs. The degree of overlap among the SRs was very high (CCA > 15%). No SR evaluated the certainty of the evidence using the GRADE system and 9 out of 10 had critically low methodological quality. The SRs reported heterogeneous results for the outcomes of all-cause mortality, myocardial infarction, revascularization, and angina. On the other hand, for the outcomes of cardiovascular mortality and stroke, all SRs agreed that there were no differences between PCI and OMT alone.
Conclusions:
We found 10 SRs on the use of PCI compared to OMT alone for patients with stable coronary artery disease. However, none had high methodological quality, none evaluated the certainty of the evidence using the GRADE approach, and the results were inconsistent for several outcomes. This variability in evidence may result in divergent clinical decisions for the management of stable coronary artery disease among healthcare professionals. It is necessary to perform a high-quality SR using the GRADE approach to clarify the balance of benefits and harms of PCI.
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