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Meta-analysis of randomised trials comparing coronary angioplasty with bypass surgery
S J Pocock1, R A Henderson, A F Rickards
1London School of Hygiene and Tropical Medicine, UK.
Insights
Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) show similar long-term survival for severe angina. However, PCI patients more frequently require repeat procedures and experience higher rates of angina symptoms.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Severe angina often presents patients with a choice between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG).
- Clinical decisions require a clear understanding of the comparative long-term outcomes and procedural requirements of these revascularization strategies.
Purpose of the Study:
- To conduct a meta-analysis comparing the long-term efficacy and safety of PCI versus CABG in patients with severe angina.
- To evaluate differences in mortality, major adverse cardiac events, need for repeat interventions, and symptom relief between the two treatment groups.
Main Methods:
- A collaborative meta-analysis was performed, combining data from eight randomized trials involving 3371 patients (1661 undergoing CABG, 1710 undergoing PCI).
- Mean follow-up was 2.7 years, with analyses stratified by disease severity (single-vessel vs. multivessel).
Main Results:
- No significant difference was observed in overall mortality (RR 1.08) or the combined endpoint of cardiac death/non-fatal myocardial infarction (RR 1.10) between CABG and PCI groups.
- Patients treated with PCI had a significantly higher rate of requiring additional CABG within the first year (17.8%) compared to those initially randomized to CABG (3.3%).
- The prevalence of angina was higher in the PCI group at one year (RR 1.56), though this difference diminished by three years (RR 1.22).
Conclusions:
- Percutaneous coronary intervention and coronary artery bypass grafting demonstrate comparable long-term prognostic outcomes for severe angina.
- Treatment choice should consider the marked differences in the need for subsequent revascularization procedures and the impact on angina symptom relief.
- These findings provide crucial evidence to guide future revascularization strategy selection for patients with angina.
Abstract:
A patient with severe angina will often be eligible for either angioplasty (PTCA) or bypass surgery (CABG). Results from eight published randomised trials have been combined in a collaborative meta-analysis of 3371 patients (1661 CABG, 1710 PTCA) with a mean follow-up of 2.7 years. The total deaths in the CABG and PTCA groups were 73 and 79, respectively, with a relative risk (RR) of 1.08 (95% CI 0.79-1.50). The combined endpoint of cardiac death and non-fatal myocardial infarction occurred in 169 PTCA patients and 154 CABG patients (RR 1.10 [0.89-1.37]). Amongst patients randomised to PTCA 17.8% required additional CABG within a year, while in subsequent years the need for additional CABG was around 2% per annum. The rate of additional non-randomised interventions (PTCA and/or CABG) in the first year of follow-up was 33.7% and 3.3% in patients randomised to PTCA and CABG, respectively. The prevalence of angina after one year was considerably higher in the PTCA group (RR 1.56 [1.30-1.88]) but at 3 years this difference had attenuated (RR 1.22 [0.99-1.54]). Overall there was substantial similarity in outcome across the trials. Separate analyses for the 732 single-vessel and 2639 multivessel disease patients were largely compatible, though the rates of mortality, additional intervention, and prevalent angina were slightly lower in single vessel disease. The combined evidence comparing PTCA with CABG shows no difference in prognosis between these two initial revascularisation strategies. However, the treatments differ markedly in the subsequent requirement for additional revascularisation procedures and in the relief of angina. These results will influence the choice of revascularisation procedure in future patients with angina.