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Revascularization in Stable Coronary Disease: A Systematic Review and Meta-Analysis of Randomized Clinical Trials
Nushrat Sultana1, Francis J Ha1, Anthony White1,2
1Department of Cardiology, Victorian Heart Hospital, Monash Health, Melbourne, Australia.
Summary
For stable coronary artery disease (CAD), revascularization (PCI or CABG) showed no safety benefit over optimal medical therapy (MT). However, it reduced unplanned revascularization and improved angina relief, despite a higher risk of procedural myocardial infarction (MI).
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Optimal management for stable coronary artery disease (CAD) is debated, particularly the role of revascularization versus medical therapy (MT).
- Revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) is established for acute coronary syndromes but less clear for stable CAD.
Purpose of the Study:
- To systematically review and meta-analyze randomized trials comparing revascularization with optimal MT in stable CAD.
- To evaluate the safety and efficacy of revascularization strategies in patients with stable CAD.
Main Methods:
- Systematic search of randomized trials comparing revascularization (PCI/CABG) with optimal MT in stable CAD patients.
- Inclusion criteria: documented CAD via angiography, exclusion of acute coronary syndromes.
- Primary safety endpoint: all-cause mortality, non-fatal MI, stroke. Primary efficacy endpoint: included unplanned revascularization, cardiac hospitalization, major bleeding. Secondary endpoint: freedom from angina. Random-effects models used for relative risk (RR) calculation.
Main Results:
- Ten trials with 14,171 participants were analyzed. No significant difference in the primary safety endpoint (all-cause mortality, MI, stroke) between revascularization and MT (RR 0.96 [0.90-1.03], p=0.23).
- Revascularization favored the primary efficacy endpoint (RR 0.81 [0.69-0.96], p=0.01), driven by a reduction in unplanned revascularization (RR 0.5 [0.29-0.85], p=0.01).
- Increased risk of procedural MI with revascularization (RR 2.21 [1.44-3.39], p<0.001). Significantly more patients achieved freedom from angina with revascularization (71.8%) compared to MT (62.9%, p<0.001).
Conclusions:
- Initial revascularization in stable CAD does not improve safety outcomes (mortality, MI, stroke) compared to optimal MT.
- Revascularization reduces unplanned revascularization and improves symptom control (angina) but carries a higher risk of procedural MI.
- The decision for revascularization in stable CAD should be patient-centered, focusing on symptomatic relief rather than prognostic benefit.
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