Medical Treatment, Percutaneous Coronary Intervention, or Coronary Artery Bypass Grafting for Stable CAD?
Howard C. Herrmann, MD
In meta-analyses of mortality and morbidity outcomes, CABG was better than PCI for multivessel disease, and PCI was not better than medical therapy in patients with ischemia.
Randomized trials of contemporary treatments for stable coronary artery disease (CAD) have been underpowered for hard endpoints such as mortality and myocardial infarction (MI). To derive statistically meaningful comparisons of these outcomes, two teams of investigators conducted meta-analyses of trial data.
Stergiopoulos and colleagues examined five randomized trials comparing percutaneous coronary intervention (PCI) and medical therapy with medical therapy alone in 4064 patients with stable CAD and documented ischemia. More than 90% of the patients were from three large trials (COURAGE, BARI 2D, and FAME 2). Follow-up duration was 5 years in four trials and 7 months in one (FAME 2). Use of drug-eluting stents varied from none to 95%, and diabetes prevalence varied from 22% to 100%; crossover was allowed in all studies (rates not given). No significant between-group differences were found in rates of death (about 7%), nonfatal MI (8%–9%), unplanned revascularization (18%–28%), or recurrent and persistent angina (20%–23%).
Sipahi and colleagues examined six trials comparing coronary artery bypass grafting (CABG) with PCI in 6055 patients with multivessel CAD. At an average follow-up of 4.1 years, CABG was associated with a reduction in mortality compared with PCI (risk ratio, 0.73; 95% confidence interval, 0.62–0.86; P<0.001). Rates of MI and repeat revascularization were also lower with CABG (RR, 0.58 and 0.29, respectively); however, the stroke rate trended higher (RR, 1.36; 95% CI, 0.99–1.86; P=0.06). In a sensitivity analysis, the benefits of CABG were similar in diabetic and nondiabetic patients.
Citation(s):
Stergiopoulos K et al. Percutaneous coronary intervention outcomes in patients with stable obstructive coronary artery disease and myocardial ischemia: A collaborative meta-analysis of contemporary randomized clinical trials. JAMA Intern Med 2013 Dec 2; [e-pub ahead of print].
Sipahi I et al. Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease: Meta-analysis of randomized clinical trials of the arterial grafting and stenting era. JAMA Intern Med 2013 Dec 2; [e-pub ahead of print].
Katz MH.Evolving treatment options in coronary artery disease. JAMA Intern Med 2013 Dec 2; [e-pub ahead of print].
