Elective coronary revascularization with medical therapy among patients with stable coronary artery disease was associated with superior clinical outcomes compared with medical therapy alone, according to results of a systematic review and meta-analysis published in the European Heart Journal.

Researchers searched publication databases for randomized trials of revascularization and medical therapies among patients with stable coronary artery disease. A total of 25 randomized trials comprising 19,806 patients were included.

Patients received medical therapy alone (n=9783) or with elective revascularization (n=10,023). Patients were followed for an average of 5.7 (95% CI, 3.60-7.76) years.


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Cardiac-related mortality occurred among 5.09% of the revascularization and 6.20% of the medical therapy cohorts (I2, 21%), indicating a decreased risk for cardiac mortality (risk ratio [RR], 0.79; 95% CI, 0.67-0.93; P <.01).

Decreased cardiac mortality risk was observed among studies of patients who had post-acute coronary syndrome (RR, 0.82; 95% CI, 0.73-0.94; P <.01), chronic total occlusions (RR, 0.80; 95% CI, 0.67-0.95; P <.01), and coronary artery bypass grafting (RR, 0.83; 95% CI, 0.71-0.98; P =.03).

Follow-up duration was observed to be a significant factor for cardiac death. Mortality decreased as follow-up increased (b, -0.05; P =.008), accounting for a 19% decrease (RR, 0.81; 95% CI, 0.69-0.96) in risk for every additional 4 years of follow-up time.

All-cause mortality occurred among 12.66% of the revascularization and 13.41% of the medical therapy cohorts (I2, 0%). No significant effect was observed among all studies (RR, 0.94; 95% CI, 0.87-1.01; P =.11); however, removing 1 study with high risk for publication bias resulted in a significant association between revascularization and all-cause mortality (RR, 0.90; 95% CI, 0.83-0.99; P =.03).

Myocardial infarctions and stroke occurred among 6.57% and 2.24% of the revascularization and 8.81% and 1.80% of the medical therapy cohorts (I2, 21%; I2, 27%), respectively. Revascularization was associated with a decreased risk for myocardial infarction (RR, 0.74; 95% CI, 0.64-0.86; P <.01) but not for stroke (RR, 1.18; 95% CI, 0.86-1.60; P =.30).

This study was limited by the differences of patient characteristics and the heterogeneity for type of coronary stents and high amount of missing patient data.

The study authors concluded elective coronary revascularization with medical therapy was associated with decreased cardiac mortality and myocardial infarction among patients with stable coronary artery disease.

Disclosure: Some authors declared affiliations with biotech, pharmaceutical, and/or device companies.  Please see the original reference for a full list of authors’ disclosures.

Reference

Navarese EP, Lansky AJ, Kereiakes DJ, et al. Cardiac mortality in patients randomised to elective coronary revascularisation plus medical therapy or medical therapy alone: a systematic review and meta-analysis. Eur Heart J. Published online May 18, 2021. doi:10.1093/eurheartj/ehab246