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Meta-analyses find little benefit for PCI vs. CABG, medical therapy
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A meta-analysis has shown that PCI plus medical therapy does not lead to a reduction in clinical events in patients with stable CAD and objectively documented ischemia compared with medical therapy alone, whereas another meta-analysis has found that CABG reduces long-term mortality, MI and repeat revascularization vs. PCI.
Both analyses were published online recently by JAMA: Internal Medicine.
CABG outperforms PCI in complex disease
To determine the comparative effects of CABG vs. PCI on long-term mortality and morbidity, Ilke Sipahi, MD, with Acibadem University Medical School and
Acibadem Maslak Hospital in Istanbul, and colleagues performed a meta-analysis of all randomized clinical trials of the current era that compared PCI with CABG in patients with multivessel disease. The researchers included randomized trials with one or more arterial grafts used in at least 90% and one or more stents used in at least 70% of the cases.
The analysis included six randomized trials that enrolled 6,055 patients.
During follow-up (weighted mean, 4.1 years), patients treated with CABG had a significant reduction in mortality (RR=0.73; 95% CI, 0.62-0.86), MI (RR=0.58; 95% CI, 0.48-0.72) and repeat revascularization (RR=0.29; 95% CI, 0.21-0.41) when compared with PCI, regardless of whether patients had diabetes.
There was, however, a trend of excess strokes in the CABG group, although this did not reach statistical significance (RR=1.36;95%CI, 0.99-1.86).
“Our results strongly suggest that CABG should be the revascularization method in patients with multivessel CAD, regardless of their diabetic status,” Sipahi and colleagues wrote. “However, it should be remembered that the included trials enrolled patients mostly with stable or unstable angina and excluded patients with acute MI. Therefore, our findings do not apply to the type of patients who were systematically excluded from these trials.”
MT comparable to PCI plus MT
In a separate analysis, Kathleen Stergiopoulos, MD, PhD, with State University of New York – Stony Brook School of Medicine, and colleagues examined randomized clinical trials of PCI and medical therapy (MT) vs. MT alone for stable CAD; stents and statins were used in more than 50% of patients.
From the five trials that enrolled 5,286 patients who were included in the analysis, myocardial ischemia was documented in 4,064 patients via exercise testing, nuclear or echocardiographic stress imaging, or fractional flow reserve.
Researchers followed patients for a median of 5 years and found the following event rates:
- Death: PCI, 6.5% vs. MT, 7.3% (OR=0.9; 95%CI, 0.71-1.16);
- Nonfatal MI: PCI, 9.2% vs. MT, 7.6% (OR=1.24; 95% CI, 0.99-1.56);
- Unplanned revascularization: PCI, 18.3% vs. MT, 28.4% (OR=0.64; 95% CI, 0.35-1.17);
- Angina: PCI, 20.3% vs. MT, 23.3% (OR=0.91; 95% CI, 0.57-1.44).
“These findings underscore existing clinical practice guidelines that recommend an initial approach of contemporary MT for patients with stable CAD and ischemia rather than proceeding directly to ischemia-guided PCI,” Stergiopoulos and colleagues concluded.
For more information:
Sipahi I. JAMA Intern Med. 2013;doi:10.1001/jamainternmed.2013.12844.
Stergiopoulos K. JAMA Intern Med. 2013;doi:10.1001/jamainternmed.2013.12855.
Disclosure: Sipahi and colleagues report no relevant financial disclosures. One researcher in the Stergiopoulos et al study reports receiving lecture fees from Boston Scientific Germany and another researcher reports receiving lecture fees from Berlin-Chemie, Eli Lilly, Merck Sharp & Dohme, and Pohl-Boskamp.
Perspective
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Sripal Bangalore, MD
The findings of the PCI vs. MT meta-analysis are consistent with the COURAGE and BARI-2D trials. However, the PCI therapy has evolved since these trials, as the newer-generation stents are much better and have a lower risk of stent thrombosis, even compared with bare-metal stents. As a result, we don’t know what the applicability of these findings is to contemporary PCI practice. One of the important things to keep in mind with meta-analyses is that the balance of baseline characteristics we see in randomized trials is lost. This is why we are doing the ISCHEMIA trial, an 8,000-patient trial that will help prove whether there is benefit for revascularization in high-risk patients with moderate-to-severe ischemia.
In the CABG meta-analysis, we see findings that are consistent with some of the signals we saw in the FREEDOM trial, pointing toward a mortality benefit with CABG. I’m not surprised by the findings because when you look at CABG, the procedure is beneficial because it bypasses a lot more territory than PCI. But again, the flip side is there is no way to know whether these results would hold up if you were to use newer-generation stents. That being said, I would not think there would be a superiority of newer-generation stents, but maybe the mortality gap between PCI and CABG would be reduced. So the jury with the newer-generation stents is still out, and we need to have more trials to figure out if there is a mortality benefit with CABG.
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