Revascularization fails to improve survival in stable ischemic heart disease
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In a meta-analysis of 14 randomized trials of patients with stable ischemic heart disease, revascularization did not reduce risk for mortality but did improve certain other outcomes, researchers reported at the virtual PCR e-Course.
Compared with patients assigned medical therapy alone, those assigned revascularization (PCI or CABG) plus medical therapy had reduced risk for nonprocedural MI and unstable angina and increased risk for procedural MI, according to the researchers, who simultaneously published the findings in Circulation.
“Even with the publication of the ISCHEMIA trial, there was this lingering debate” over how to treat patients with stable ischemic heart disease, presenter Sripal Bangalore, MD, MHA, FACC, FAHA, FSCAI, professor of medicine at the NYU Grossman School of Medicine, director of the cardiac catheterization lab at Bellevue Hospital, director of research of the cardiac catheterization lab at NYU Langone Health and a Cardiology Today Editorial Board Member, told Healio. “We wanted to look at the individual endpoints of all the stable ischemic heart disease trials to see if there is consistency in the results.”
Bangalore and colleagues analyzed 14 trials of 14,877 patients with stable ischemic heart disease who were followed for a weighted mean of 4.5 years, or a total of 64,678 patient-years.
Compared with medical therapy alone, revascularization plus medical therapy did not reduce the risk for death (RR = 0.99; 95% CI, 0.9-1.09) and a trial sequential analysis showed revascularization was unlikely to reduce mortality risk by 10% or more, according to the researchers.
There was no difference between the groups in overall MI (RR = 0.93; 95% CI, 0.83-1.03), but the revascularization group had reduced risk for nonprocedural MI (RR = 0.76; 95% CI, 0.67-0.85) and increased risk for procedural MI (RR = 2.48; 95% CI, 1.86-3.31) compared with the medical therapy group, Bangalore said during the presentation.
The revascularization group also had reduced risk for unstable angina (RR = 0.64; 95% CI, 0.45-0.92) and an increased rate of freedom from angina (RR = 1.1; 95% CI, 1.05-1.15), he said.
Risk for HF (RR = 1.03; 95% CI, 0.71-1.49) and stroke (RR = 1.26; 95% CI, 0.98-1.62) did not differ between the groups, according to the researchers.
“It was very reassuring that the overall analyses were very similar to what we saw in the ISCHEMIA trial,” Bangalore said in an interview.
Although ISCHEMIA and ISCHEMIA-CKD accounted for more than 40% of the patients in the meta-analysis, “we performed an 'influence' analysis, where we removed one study at a time to address whether any one study, including ISCHEMIA, is unduly influencing the results of the meta-analysis. The results were consistent without any undue influence of any single trial, including ISCHEMIA. This shows the robustness of the data for stable ischemic heart disease,” he said.
“Many people still believed even after ISCHEMIA that there may be a survival benefit of revascularization,” Bangalore told Healio. “If you look at all the data, we clearly show that there isn’t one. It makes decisions on these patients more clear. There isn’t a survival difference, but there are other differences, and you have to weigh the risks and the benefits.”
Reference:
- Bangalore S, et al. PCR e-Course 2020 Late-Breaking Trials - part 2. Presented at: PCR e-Course: June 25-27, 2020 (virtual meeting).
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