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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.