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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.
Insights
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.
Abstract:
The optimal management strategy for stable coronary artery disease (CAD) remains contentious. While revascularization benefits acute coronary syndromes, its role in stable CAD compared with medical therapy (MT) is less clear. This systematic review and meta-analysis evaluated the safety and efficacy of coronary revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) versus MT in patients with stable CAD. A systematic search identified randomized trials comparing revascularization with optimal MT in stable CAD. Trials included documented CAD via angiography and excluded acute coronary syndromes. The primary safety endpoint was all-cause mortality, non-fatal myocardial infarction (MI), and stroke. The primary efficacy endpoint also included unplanned revascularization, cardiac hospitalization, and major bleeding. The secondary endpoint included the percentage free from angina. Relative risk (RR) was calculated using random-effects models. Ten trials with 14,171 participants were included. There was no difference in the primary safety endpoint (RR 0.96 [0.90-1.03], p = 0.23). The primary efficacy endpoint favored revascularization (RR 0.81 [0.69-0.96], p = 0.01), primarily driven by unplanned revascularization (RR 0.5 [0.29-0.85], p = 0.01), though with increased procedural MI risk (RR 2.21 [1.44-3.39], p < 0.001). More patients had freedom from angina with revascularization compared with MT (71.8% vs. 62.9%, p < 0.001). In stable CAD, initial revascularization did not improve outcomes for the primary safety endpoint; however, it did reduce unplanned revascularization compared with MT. More patients had freedom from angina in the revascularization arm, at the cost of increased procedural MI. Decision regarding optimal management strategy for stable CAD remains a patient-centered discussion, recognizing the largely symptomatic rather than prognostic benefit that patients derive from early revascularization.
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