Percutaneous coronary revascularization versus medical therapy in chronic coronary syndromes: An updated
Giuseppe Panuccio1,2, Nicole Carabetta3, Daniele Torella1
1Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy.
Insights
Percutaneous coronary intervention (PCI) significantly reduces cardiovascular death and angina in chronic coronary syndromes (CCS) patients compared to optimal medical therapy (OMT). Benefits are greater in younger patients without chronic total occlusions and with longer follow-up.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Coronary artery disease (CAD) remains a leading cause of mortality globally.
- The role of coronary revascularization versus optimal medical therapy (OMT) in chronic coronary syndromes (CCS) is an ongoing area of research.
- Recent trials suggest potential benefits of percutaneous coronary intervention (PCI) in improving angina and quality of life.
Purpose of the Study:
- To conduct an updated meta-analysis on the impact of PCI versus OMT in CCS patients.
- To evaluate the effects of PCI on cardiovascular (CV) mortality, myocardial infarction (MI), and angina severity.
- To identify patient subgroups and follow-up durations associated with greater benefits from PCI.
Main Methods:
- Systematic screening of randomized controlled trials (RCTs) in PubMed/Medline until January 2024.
- Inclusion of RCTs comparing PCI to OMT in CCS patients.
- Primary outcome: CV death. Secondary outcomes: MI, all-cause mortality, stroke, bleeding, and angina severity.
Main Results:
- Nineteen RCTs with 8616 patients were analyzed, with a median follow-up of 3.3 years.
- PCI significantly reduced CV death (OR=0.77; p=0.02) compared to OMT.
- PCI led to lower angina severity (SAQ and CCS classification, p<0.05) but showed no significant differences in other secondary outcomes.
Conclusions:
- PCI offers significant reductions in CV mortality and angina severity for CCS patients compared to OMT.
- Benefits of PCI are more pronounced in patients without chronic total occlusions (CTOs), those under 65 years, and with follow-up exceeding 3 years.
- PCI improves quality of life in CCS patients, supported by reduced angina symptoms.
Introduction:
Coronary artery disease (CAD) is a main cause of morbidity and mortality. The effectiveness of coronary revascularization in chronic coronary syndromes (CCS) is still debated. Our recent study showed the superiority of coronary revascularization over optimal medical therapy (OMT) in reducing cardiovascular (CV) mortality and myocardial infarction (MI). The recent publication of the ORBITA-2 trial suggested superiority of percutaneous coronary revascularization (PCI) in reducing angina and improving quality of life. Therefore, we aimed to provide an updated meta-analysis evaluating the impact of PCI on both clinical outcomes and angina in CCS.
Methods:
Relevant studies were screened in PubMed/Medline until 08/01/2024. Randomized controlled trials (RCTs) comparing PCI to OMT in CCS were selected. The primary outcome was CV death. Secondary outcomes were MI, all-cause mortality, stroke, major bleeding and angina severity.
Results:
Nineteen RCTs involving 8616 patients were included. Median follow-up duration was 3.3 years. Revascularization significantly reduced CV death (4.2% vs. 5.5%; OR = .77; 95% CI .62-.96, p = .02). Subgroup analyses favoured revascularization in patients without chronic total occlusions (CTOs) (p = .052) and those aged <65 years (p = .02). Finally, a follow-up duration beyond 3 years showed increased benefit of coronary revascularization (p = .04). Secondary outcomes analyses showed no significant differences, except for a lower angina severity in the revascularization group according to the Seattle Angina Questionnaire (SAQ) (p = .04) and to the Canadian Cardiovascular Society (CCS) classification (p = .005).
Conclusions:
PCI compared to OMT significantly reduces CV mortality and angina severity, improving quality of life in CCS patients. This benefit was larger without CTOs, in patients aged <65 years and with follow-up duration beyond 3 years.
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