The Impact of Revascularization on Mortality in Patients with Nonacute Coronary Artery Disease
Article Outline
Abstract
Background
Although early revascularization improves outcomes for patients with acute coronary syndromes, the role of revascularization for patients with nonacute coronary artery disease is controversial. The objective of this meta-analysis was to compare surgical or percutaneous revascularization with medical therapy alone to determine the impact of revascularization on death and nonfatal myocardial infarction in patients with coronary artery disease.
Methods
The Medline and Cochrane Central Register of Controlled Trials databases were searched to identify randomized trials of coronary revascularization (either surgical or percutaneous) versus medical therapy alone in patients with nonacute coronary disease reporting the individual outcomes of death or nonfatal myocardial infarction reported at a minimum follow-up of 1 year. A random effects model was used to calculate odds ratios (OR) for the 2 prespecified outcomes.
Results
Twenty-eight studies published from 1977 to 2007 were identified for inclusion in the analysis; the revascularization modality was percutaneous coronary intervention in 17 studies, coronary bypass grafting in 6 studies, and either strategy in 5 studies. Follow-up ranged from 1 to 10 years with a median of 3 years. The 28 trials enrolled 13,121 patients, of whom 6476 were randomized to revascularization and 6645 were randomized to medical therapy alone. The OR for revascularization versus medical therapy for mortality was 0.74 (95% confidence interval [CI], 0.63-0.88). A stratified analysis according to revascularization mode revealed both bypass grafting (OR 0.62; 95% CI, 0.50-0.77) and percutaneous intervention (OR 0.82; 95% CI, 0.68-0.99) to be superior to medical therapy with respect to mortality. Revascularization was not associated with a significant reduction in nonfatal myocardial infarction compared with medical therapy (OR 0.91; 95% CI, 0.72-1.15).
Conclusion
Revascularization by coronary bypass surgery or percutaneous intervention in conjunction with medical therapy in patients with nonacute coronary artery disease is associated with significantly improved survival compared with medical therapy alone.
Keywords: Angioplasty, Bypass surgery, Coronary artery disease, Stents
Whereas timely coronary artery revascularization significantly reduces the incidence of death and nonfatal myocardial infarction in the setting of acute coronary syndromes,1 data regarding the impact of revascularization on patients with nonacute coronary artery disease are scarce.2, 3, 4 Early randomized trials comparing surgical revascularization (coronary artery bypass grafting) with medical therapy found that mortality was reduced by bypass surgery only in specific high-risk subsets of patients, such as those with severe left main coronary artery stenosis or 3-vessel coronary artery disease with reduced left ventricular systolic function.5 However, these trials consistently demonstrated that coronary bypass grafting was more effective than medical therapy at relieving angina.6, 7 Similarly, randomized clinical trials comparing percutaneous coronary intervention with medical therapy demonstrated a reduction in anginal symptoms and anti-anginal medication without a major impact on mortality after coronary intervention.8, 9, 10
<.001), indicating a significant mortality reduction with coronary revascularization.
However, prior studies of revascularization versus medical therapy alone were powered inadequately to detect significant mortality differences. Even the relatively large Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial10 was vastly underpowered to demonstrate a mortality difference between the 2 arms.
Prior meta-analyses have compared a single form of revascularization (surgical or percutaneous) with medical therapy and have not included recently completed trials.4, 11 Repeatedly, both forms of revascularization have been found to be equivalent in preventing death or myocardial infarction in patients with coronary artery disease.12, 13, 14, 15, 16, 17, 18 Consequently, we conducted a systematic review and meta-analysis of all randomized clinical trials that compared the effect of coronary revascularization by either percutaneous intervention or bypass grafting with medical therapy alone on outcomes of patients with nonacute coronary artery disease.
Materials and Methods
Search Strategy and Inclusion Criteria
This meta-analysis considered randomized clinical trials comparing coronary revascularization by percutaneous coronary intervention or bypass grafting in combination with medical therapy with medical therapy alone for the treatment of patients with nonacute coronary artery disease. Comprehensive searches of the Medline and Cochrane Central Register of Controlled Trials databases were performed using Web-based engines (PubMed and OVID) for studies published between 1977 and January 2008. Search terms included coronary revascularization, balloon angioplasty, stent, coronary artery bypass grafting, medical therapy, angina, stable, coronary artery disease, and combinations. In addition, bibliographies of retrieved articles were searched for other relevant studies.
For inclusion, studies were required to be prospective, randomized trials of coronary revascularization versus medical therapy alone in patients with stable coronary disease with the individual outcomes of death or nonfatal myocardial infraction reported at a minimum follow-up of 1 year. Multiple study designs were accepted, including trials with 2 arms in which patients were randomized to percutaneous intervention versus medical therapy or bypass grafting versus medical therapy; trials with 2 arms in which patients were randomized to any revascularization strategy versus medical therapy alone; and trials with 3 arms in which patients were randomized to percutaneous intervention or bypass grafting or medical therapy alone. Although studies randomizing patients with acute coronary syndromes were excluded from the analysis, studies of stable patients after a completed myocardial infraction were included. Studies were included irrespective of the presence of documented ischemia or any functional assessment of the hemodynamic significance of a coronary stenosis. Study eligibility was assessed by 2 authors; disagreements were resolved by consensus with a third author.
End Points
End point definitions were those used in the individual trials. All-cause mortality was death from any cause (cardiac or noncardiac) and preferentially used unless only cardiac deaths were reported. Myocardial infarction was generally defined as an elevation of serum markers of myocardial necrosis more than 3 times the upper limit of normal or electrocardiographic changes. End points were extracted from each trial at the primary prespecified follow-up. The follow-up periods for each trial are provided in Table 1. Event rates at the end of the follow-up period for each study were those used for the analysis.
Table 1. Randomized Trials of Revascularization versus Medical Therapy in Patients with Stable Coronary Artery Disease
| Revascularization Therapy Modality | No. Enrolled Revascularization Therapy/Medical Therapy | Publication Year | Follow-up (y) | Enrollment Criteria | |
|---|---|---|---|---|---|
| Mathur and Guinn28 | CABG | 56/60 | 1977 | 3 | Stable angina |
| Kloster et al29 | CABG | 51/49 | 1979 | 3 | Disabling angina |
| ECSS6 | CABG | 395/373 | 1979 | 2 | Stable angina |
| Norris et al30 | CABG | 50/50 | 1981 | 4.5 | No symptoms |
| CASS7 | CABG | 390/390 | 1984 | 5 | Mild stable angina or free of angina post-MI |
| VA Cooperative Study31 | CABG | 332/354 | 1984 | 5 | Stable angina |
| ACME-132, 33 | PCI | 112/115 | 1992 | 2.4 | Exercise-induced ischemia |
| TOPS34 | PCI | 42/45 | 1992 | 1 | 4-14 d post-thrombolytic therapy for MI |
| Sievers et al35 | PCI | 44/44 | 1993 | 2 | Asymptomatic single-vessel CAD |
| MASS I (CABG)20 | CABG | 70/72 | 1995 | 3 | Stable angina |
| MASS I (PCI)20 | PCI | 72/72 | 1995 | 3 | Stable angina |
| ACME-236 | PCI | 51/50 | 1997 | 3 | Exercise-induced ischemia |
| DANAMI3 | Mixed | 503/505 | 1997 | 2.4 | Inducible ischemia post-MI |
| ACIP2 | Mixed | 192/366 | 1997 | 2 | Exercise-induced ischemia in asymptomatic patients |
| RITA-28 | PCI | 504/514 | 1997 | 2.7 | Stable angina |
| Dakik et al37 | PCI | 19/22 | 1998 | 1 | Inducible ischemia post-MI |
| Horie et al38 | PCI | 44/39 | 1998 | 5 | Q-wave anterior MI with persistent coronary occlusion>24 h after the event |
| AVERT39 | PCI | 177/164 | 1999 | 1.5 | Asymptomatic or mild-to-moderate angina |
| TIME9, 40 | Mixed | 153/148 | 2001 | 4.1 | Chronic angina of at least Canadian Cardiac Society class II despite at least 2 anti-anginal drugs |
| Bech et al41 | PCI | 90/91 | 2001 | 2 | Patients with ischemia excluded |
| TOAT22 | PCI | 32/34 | 2002 | 1 | Q-wave anterior MI with persistent occlusion of the LAD and absence of chest pain |
| ALKK42 | PCI | 149/151 | 2003 | 1 | No or minor angina post-MI |
| MASS II (CABG)43 | CABG | 203/203 | 2004 | 1 | Stable angina |
| MASS II (PCI)21 | PCI | 205/203 | 2004 | 5 | Stable angina |
| Hambrecht et al27 | PCI | 50/51 | 2004 | 1 | Stable angina |
| DECOPI23 | PCI | 109/103 | 2004 | 3 | First Q-wave MI, no ischemia, and total occlusion of the infarct-related artery |
| OAT24 | PCI | 1082/1084 | 2006 | 4 | Total occlusion of the infarct-related artery 3 to 28 d after MI |
| INSPIRE44 | Mixed | 104/101 | 2006 | 1 | Inducible ischemia |
| COURAGE10 | PCI | 1149/1138 | 2007 | 4.6 | Inducible ischemia |
| SWISSI-II45 | PCI | 96/105 | 2007 | 10.2 | Recent MI with silent ischemia |
Statistical Analysis
Because individual patient-level data from each trial were not available, a meta-analysis of summary statistics from individual trials was performed using Comprehensive Meta Analysis software (Biostat, Englewood, NJ). Data were analyzed according to the intention-to-treat principle. Methods based on odds ratios (OR) (Peto's method) were used to calculate the OR for the 2 primary outcomes of interest: death and nonfatal myocardial infarction. Although the Q statistic failed to indicate statistical heterogeneity (P=.15), given the heterogeneous nature of the included studies, a random-effects model was used to calculate a summary OR from the ORs and 95% confidence interval (CI) for each end point in each study. Cumulative meta-analysis was performed by sequentially adding studies one at a time according to date of publication (from earliest to latest). As each trial is added, a new summary OR incorporating the new and earlier trial(s) is calculated. Sensitivity analyses were performed for each outcome to assess the contribution of each study to the pooled estimate by excluding individual trials 1 at a time and recalculating the combined OR for the remaining studies. To assess publication bias, a funnel plot of the logarithm of effect size versus the standard error for each trial was generated. In addition, the classic fail-safe N method was used to detect a potential publication bias by the inadvertent omission of studies that, if included, would nullify the observed effect. This method determines the number of studies that are required to nullify the significant differences in mortality between the revascularization versus the medical therapy alone groups.19
To control for a potential differential benefit from bypass grafting versus percutaneous intervention when compared with medical therapy alone, a stratified analysis was performed on the basis of revascularization modality. Similarly, a stratified analysis was performed for patients after myocardial infarction versus stable coronary artery disease.
Results
Study Characteristics
Twenty-eight studies published from 1977 to 2007 were included in the analysis. Of these, the revascularization modality was percutaneous intervention in 17 studies, bypass grafting in 6 studies, either percutaneous intervention or bypass grafting (nonrandomized) in 3 studies, and percutaneous intervention or bypass grafting (randomized) in 2 studies. The ORs for the latter 2 trials were calculated using the single medical therapy arm as the comparator for both the percutaneous intervention and bypass grafting arms (resulting in 30 direct comparisons). Details of each study are provided in Table 1. Follow-up ranged from 1 to 10 years with a median of 3 years. The 28 trials enrolled 13,121 patients, of whom 6476 were randomized to revascularization therapy and 6645 were randomized to medical therapy alone.
Patients enrolled in the studies were predominately men at relatively young ages, except for the Trial of Invasive versus Medical Therapy,9 which focused on the elderly (mean age, 80 years). Saphenous vein grafts were used exclusively in the bypass grafting arm of most surgical trials, except for Medicine, Angioplasty or Surgery Study I20 and II,21 in which the internal thoracic artery was used in the majority of cases. Most percutaneous coronary intervention trials compared medical therapy with balloon angioplasty without stenting, except for The Open Artery Trial,22 Medicine, Angioplasty, or Surgery Study II,21 DEsobstruction COronaire en Post-Infarctus,23 Occluded Artery Trial,24 and Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation,10 in which bare metal stents were implanted in 72% to 100% of cases. Baseline characteristics of the study populations are provided in Table 2. The annual mortality rates of the medically treated patients ranged from 0% to 16.3%. A meta-regression revealed no relationship between the year of study and the mortality rate.
Table 2. Patient Baseline Characteristics of Eligible Trials
| Mean Age (y) | Men, % | DM, % | Extent of CAD (No. of Vessels) | No. of Vessels Revascularized | Annual Mortality Rate in Control Group, % | Stents Used, % | Arterial Conduit Used, % | |
|---|---|---|---|---|---|---|---|---|
| Mathur and Guinn28 | 54 | — | 13-19 | 1/2/3 | — | 7.2 | NA | 0 |
| Kloster et al29 | 51-52 | 88-90 | — | 1/2/3 | 2.2 | 5.4 | NA | 0 |
| Norris et al30 | 51 | — | — | 2/3 | 2.8 | 2.2 | NA | 0 |
| ECSS6 | 49 | 100 | 6 | 2/3 | 2.2 | 8.5 | NA | 13.7 |
| CASS7 | 51-52 | 90-91 | 8-9 | 1/2/3 | 2.7 | 1.6 | NA | 0 |
| VA Cooperative Study31 | 51 | 100 | 14-15 | 1/2/3 | 2.0 | 4.5 | NA | 0 |
| ACME-132, 33 | 62-63 | — | 17-19 | 1 | 1 | 5.4 | 0 | NA |
| TOPS34 | 56-58 | 82-86 | 20-21 | 1 | 1 | 2.2 | 0 | NA |
| Sievers et al35 | 56 | — | 0 | 1 | 1 | 1.2 | 0 | NA |
| MASS I (CABG)20 | 58 | 58-59 | 18-20 | 1 | 1 | 2.8 | NA | 100 |
| MASS I (PCI)20 | 54-58 | 58-59 | 15-20 | 1 | 1 | 2.8 | 0 | NA |
| ACME-236 | — | — | — | 1/2 | — | 6.7 | 0 | NA |
| DANAMI3 | 56 | 82-83 | 31-39 | 1/2/3 | — | 1.8 | 0 | — |
| ACIP2 | 61 | 86 | 16 | 1/2/3 | — | 2.8 | 0 | — |
| RITA-28 | 58 | 82 | 9 | 1/2/3 | 1.4 | 3.1 | 9.3 | NA |
| Dakik et al37 | 52-55 | 53-64 | — | 1/2 | 1.1 | 4.5 | 28.6 | NA |
| Horie et al38 | 62 | 74-77 | 15-16 | 1/2/3 | 1 | 2.6 | 0 | NA |
| AVERT39 | 58-59 | 79-89 | 26-28 | 1/2 | 1.3 | 0.4 | 30.0 | NA |
| TIME9, 40 | 80 | 56 | 33-35 | 1/2/3 | — | 9.0 | — | 83 |
| Bech et al41 | 61 | 65-67 | 9-15 | 1/2/3 | — | 2.2 | 46 | NA |
| TOAT22 | 58-59 | 80-81 | 9-19 | 1 | 1 | 2.9 | 100 | NA |
| ALKK42 | 58 | 84-89 | 15-17 | 1 | 1 | 11.3 | 17 | NA |
| MASS II43 (CABG) | 60 | 67-69 | 29-36 | 2/3 | 3.3 | 16.3 | NA | 92 |
| MASS II (PCI)21 | 60 | 69-72 | 23-36 | 2/3 | 2.1 | 3.3 | 72 | NA |
| Hambrecht et al27 | 60-62 | 100 | 11-12 | 1/2/3 | 1 | 0.0 | — | NA |
| DECOPI23 | 56-58 | 85-95 | 11-21 | 1/2/3 | 1 | 2.9 | 80.4 | NA |
| OAT24 | 59 | 78 | 18-23 | 1/2 | 1 | 1.9 | 87 | NA |
| INSPIRE44 | 63-64 | 73-78 | 26-31 | 1/2/3 | 1.5 | 1.0 | 94 | 92 |
| COURAGE10 | 61 | 85 | 32-35 | 1/2/3 | 1.6 | 1.4 | 94 | NA |
| SWISSI-II45 | 54-56 | 86-89 | 9-14 | 1/2 | 2 | 2.1 | — | NA |
The majority of trials tested the hypothesis that coronary revascularization improved outcomes in patients with stable angina or documented myocardial ischemia compared with medical therapy alone. However, several trials randomized patients with completed myocardial infraction who were free of angina and had no or minimal myocardial ischemia to revascularization or medical therapy alone days to weeks after the infarct.22, 23, 24 Details of the inclusion criteria for each trial are provided in Table 1.
Quantitative Outcomes
There were 511 deaths among the 6476 patients in the revascularization group (7.9%) compared with 649 deaths among the 6645 participants in the medical therapy group (9.8%). The OR for revascularization versus medical therapy for mortality was 0.74 (95% CI, 0.63-0.88) (Figure 1). Sensitivity analysis to assess the potential impact of qualitative differences in study design and patient selection showed that exclusion of any single trial from the analysis did not alter the overall finding of this analysis.
Figure 1.
Comparison of coronary revascularization versus medical therapy for overall mortality. All included studies are shown by name along with point estimates of the OR and respective 95% CIs. The size of the squares denoting the point estimate in each study is proportional to the weight of the study. The study by Hambrecht et al27 is not included because there were no mortalities in either the revascularization or medical therapy groups.
Computation of the cumulative OR revealed that a statistically significant reduction in total mortality (OR 0.47; 95% CI, 0.32-0.68) was achieved by revascularization after completion of the first 3 trials that randomized 984 patients. The results of the 25 subsequent trials, which enrolled an additional 12,137 patients, increased the precision of the point estimate without changing the overall finding (Figure 2).
Figure 2.
Cumulative OR for overall mortality with coronary revascularization versus medical therapy.
The OR for mortality with bypass grafting versus medical therapy alone was 0.62 (95% CI, 0.50-0.77) (Figure 3A), whereas the OR for percutaneous coronary intervention versus medical therapy alone was 0.82 (95% CI, 0.68-0.99) (Figure 3B). There was no significant difference in the ORs between the 2 revascularization modalities by analysis of variance (P=.33).
Figure 3.
Comparison of coronary revascularization versus medical therapy for overall mortality, stratified by revascularization modality: coronary artery bypass surgery (A) and percutaneous coronary intervention (B). Interpretation of OR plot as in Figure 1.
When studies evaluating the benefit of coronary revascularization in patients post-myocardial infarction were excluded (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte, Dakik et al,37 DANish trial in Acute Myocardial Infarction, DEsobstruction COronaire en Post-Infarctus, Horie et al,38 Occluded Artery Trial, Swiss Interventional Study on Silent Ischemia Type II, The Open Artery Trial, Treatment of Post-Thrombolytic Stenoses), the OR for mortality with revascularization in patients with stable coronary artery disease was 0.77 (95% CI, 0.65-0.91).
Nonfatal Myocardial Infarction
The nonfatal myocardial infarction rate was reported in 26 trials that randomized 11,768 patients. Revascularization was not associated with a significant reduction in risk of nonfatal myocardial infarction: The myocardial infarction rate was 8.4% in the revascularization group and 8.9% in the medical therapy group (OR=0.91; 95% CI, 0.72-1.15) (Figure 4).
Figure 4.
Comparison of coronary revascularization versus medical therapy for nonfatal myocardial infarction. Interpretation of OR plot as in Figure 1.
Publication Bias
There was no evidence of significant publication bias by the analysis of the funnel plot (results not shown). The classic fail-safe N was 96, indicating that 96 “null” studies were needed to be added to the analysis for the combined 2-tailed P value to exceed .05.
Discussion
This analysis demonstrates that, compared with medical therapy alone, coronary artery revascularization by either bypass grafting or percutaneous intervention for nonacute coronary artery disease is associated with a significant reduction in mortality without a decrease in the rate of nonfatal myocardial infarction. Although previous meta-analyses have compared one form of revascularization (bypass grafting or percutaneous intervention) with medical therapy alone, the unique aspect of the current study is the incorporation of both forms of revascularization into a comparison with medical therapy alone.
Combining surgical and percutaneous therapies is supported by numerous randomized trials that have found them to be equivalent in terms of late mortality.12, 25 A recent meta-analysis of 23 randomized, controlled trials comparing surgical with percutaneous revascularization demonstrated similar survivals at 10 years.18 This finding also was confirmed in a subpopulation of patients with diabetes mellitus. In this analysis, both bypass grafting and percutaneous intervention were associated with a significant reduction in overall mortality when compared with medical therapy alone, indicating that either revascularization therapy is superior to conservative management. Furthermore, the realities of clinical decision-making support the combined analysis of both revascularization strategies. Patients with coronary artery disease are triaged for revascularization therapy after extensive analysis of the potential risks and benefits. The type of revascularization strategy is selected by patient and physician on the basis of a careful risk–benefit calculation depending on the number of vessels with flow-limiting stenoses, location of the stenoses, degree of left ventricular dysfunction, myocardial viability, presence of chronic total occlusions, and comorbidities.26 Thus, in practice, percutaneous intervention and bypass grafting are complementary. It is artificial and of little use to the physician or patient to consider the merits of these revascularization procedures independently of each other.
The failure of revascularization to reduce the risk of nonfatal myocardial infarction strongly suggests that revascularization does not prevent plaque rupture. Thus, the additional survival benefit derived from revascularization when combined with medical therapy is likely to be explained by mechanisms other than plaque stabilization or creation of a conduit that bypasses the vulnerable plaque in native coronary arteries.
This study has several limitations. First, this is a meta-analysis of the pooled results reported from each individual trial because we did not have access to individual patient-level data. Therefore, stratification of patients according to high-risk features such as diabetes mellitus and left ventricular dysfunction was not possible. Second, data were extracted only from randomized clinical trials. Patients enrolled in such trials may not be representative of patients actually seen in clinical practice, as clearly demonstrated by the large number of patients screened that were not deemed to be eligible.10 Third, our pooled analysis combines studies performed over a span of 30 years, during which rapid improvements in both medical and revascularization therapy occurred, including the use of the internal thoracic artery for bypass grafting and coronary stents. However, despite these technical and pharmacologic advancements, the results of early studies, such as the Coronary Artery Surgery Study,7 remain relevant and, in fact, form the basis for contemporary management decisions, such as the preference of bypass grafting over medical therapy for significant left main coronary artery disease.26 Nevertheless, it is possible that the benefit of revascularization is somewhat mitigated in the presence of optimal medical therapy, and more contemporary data are required to address this important question. Finally, despite the statistical failure to demonstrate heterogeneity among the included studies, it is obvious from the wide range of studies used for this analysis that the population was not homogenous. In fact, this is the largest and most comprehensive meta-analysis to date comparing revascularization versus medical therapy in a broad range of patients with coronary artery disease. This includes patients with stable angina, patients with chronic total occlusions after myocardial infarction, and patients with and without myocardial ischemia. Although it would be possible to evaluate each of these subgroups separately, the goal of this analysis was to assess the utility of revascularization by any means (including percutaneous intervention and bypass grafting) in the broadest possible population with coronary artery disease. However, given the heterogeneous nature of studies included in this analysis, the results have to be interpreted with caution and might not apply to an individual patient.
Conclusions
The findings of this analysis suggest that coronary artery revascularization by either bypass grafting or percutaneous intervention in conjunction with medical therapy results in prolonged survival compared with medical management alone in patients with nonacute coronary artery disease. Furthermore, both bypass grafting and percutaneous intervention are independently associated with a statistically significant reduction in mortality when compared with medical therapy alone in this population. Coronary artery revascularization does not have an impact on nonfatal myocardial infarction rates. Given the exploratory nature of this analysis, an adequately powered, prospective study comparing coronary artery revascularization therapy by any modality with medical therapy alone in patients with nonacute coronary artery disease will be necessary to confirm the present results.
References
- ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction—summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. 2002;40:1366–1374
- Asymptomatic Cardiac Ischemia Pilot (ACIP) study two-year follow-up: outcomes of patients randomized to initial strategies of medical therapy versus revascularization. Circulation. 1997;95:2037–2043
- Danish multicenter randomized study of invasive versus conservative treatment in patients with inducible ischemia after thrombolysis in acute myocardial infarction (DANAMI) (DANish trial in Acute Myocardial Infarction). Circulation. 1997;96:748–755
- Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet. 1994;344:563–570
- Ten-year follow-up of survival and myocardial infarction in the randomized Coronary Artery Surgery Study. Circulation. 1990;82:1629–1646
- . Coronary-artery bypass surgery in stable angina pectoris: survival at two years. Lancet. 1979;1:889–893
- Myocardial infarction and mortality in the coronary artery surgery study (CASS) randomized trial. N Engl J Med. 1984;310:750–758
- Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial (RITA-2 trial participants). Lancet. 1997;350:461–468
- Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME): a randomised trial. Lancet. 2001;358:951–957
- Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356:1503–1516
- . Percutaneous coronary intervention versus conservative therapy in nonacute coronary artery disease: a meta-analysis. Circulation. 2005;111:2906;2612
- Percutaneous transluminal coronary angioplasty with stents versus coronary artery bypass grafting for people with stable angina or acute coronary syndromes. Cochrane Database Syst Rev. 2005;CD004588
- Coronary angioplasty versus coronary artery bypass surgery: the Randomized Intervention Treatment of Angina (RITA) trial. Lancet. 1993;341:573–580
- A randomized study of coronary angioplasty compared with bypass surgery in patients with symptomatic multivessel coronary disease (German Angioplasty Bypass Surgery Investigation (GABI)). N Engl J Med. 1994;331:1037–1043
- A randomized trial comparing coronary angioplasty with coronary bypass surgery (Emory Angioplasty versus Surgery Trial (EAST)). N Engl J Med. 1994;331:1044–1050
- . Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med. 1996;335:217–225
- Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease. N Engl J Med. 2001;344:1117–1124
- Systematic review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass surgery. Ann Intern Med. 2007;147:703–716
- . The file-drawer problem revisited: a general weighted method for calculating fail-safe numbers in meta-analysis. Int J Org Evol. 2005;59:464–468
- The Medicine, Angioplasty or Surgery Study (MASS): a prospective, randomized trial of medical therapy, balloon angioplasty or bypass surgery for single proximal left anterior descending artery stenoses. J Am Coll Cardiol. 1995;26:1600–1605
- Five-year follow-up of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease. Circulation. 2007;115:1082–1089
- Late intervention after anterior myocardial infarction: effects on left ventricular size, function, quality of life, and exercise tolerance: results of the Open Artery Trial (TOAT Study). J Am Coll Cardiol. 2002;40:869–876
- DECOPI (DEsobstruction COronaire en Post-Infarctus): a randomized multi-centre trial of occluded artery angioplasty after acute myocardial infarction. Eur Heart J. 2004;25:2187–2194
- Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med. 2006;355:2395–2407
- Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel disease: the final analysis of the Arterial Revascularization Therapies Study (ARTS) randomized trial. J Am Coll Cardiol. 2005;46:575–581
- ACC/AHA 2002 guideline update for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina). J Am Coll Cardiol. 2003;41:159–168
- Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation. 2004;109:1371–1378
- . Prospective randomized study of the surgical therapy of stable angina. Cardiovasc Clin. 1977;8:131–144
- Coronary bypass for stable angina: a prospective randomized study. N Engl J Med. 1979;300:149–157
- Coronary surgery after recurrent myocardial infarction: progress of a trial comparing surgical with nonsurgical management for asymptomatic patients with advanced coronary disease. Circulation. 1981;63:785–792
- . Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina. N Engl J Med. 1984;311:1333–1339
- . A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease (Veterans Affairs ACME Investigators). N Engl J Med. 1992;326:10–16
- . Two- to three-year follow-up of patients with single-vessel coronary artery disease randomized to PTCA or medical therapy (results of a VA cooperative study) (Veterans Affairs Cooperative Studies Program ACME Investigators. Angioplasty Compared to Medicine). Am J Cardiol. 1998;82:1445–1450
- Randomized trial of late elective angioplasty versus conservative management for patients with residual stenoses after thrombolytic treatment of myocardial infarction (Treatment of Post-Thrombolytic Stenoses (TOPS) Study Group). Circulation. 1992;86:1400–1406
- . Medical therapy versus PTCA: a prospective, randomized trial in patients with asymptomatic coronary single-vessel disease. Circulation. 1993;88:I-297;(abstract)
- . Percutaneous transluminal coronary angioplasty versus medical therapy for stable angina pectoris: outcomes for patients with double-vessel versus single-vessel coronary artery disease in a Veterans Affairs Cooperative randomized trial (Veterans Affairs ACME Investigators). J Am Coll Cardiol. 1997;29:1505–1511
- Intensive medical therapy versus coronary angioplasty for suppression of myocardial ischemia in survivors of acute myocardial infarction: a prospective, randomized pilot study. Circulation. 1998;98:2017–2023
- Long-term beneficial effect of late reperfusion for acute anterior myocardial infarction with percutaneous transluminal coronary angioplasty. Circulation. 1998;98:2377–2382
- Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease (Atorvastatin versus Revascularization Treatment Investigators). N Engl J Med. 1999;341:70–76
- Influence of revascularization on long-term outcome in patients>or =75 years of age with diabetes mellitus and angina pectoris. Am J Cardiol. 2005;96:193–198
- Fractional flow reserve to determine the appropriateness of angioplasty in moderate coronary stenosis: a randomized trial. Circulation. 2001;103:2928–2934
- Randomized comparison of percutaneous transluminal coronary angioplasty and medical therapy in stable survivors of acute myocardial infarction with single vessel disease: a study of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte. Circulation. 2003;108:1324–1328
- The medicine, angioplasty, or surgery study (MASS-II): a randomized, controlled clinical trial of three therapeutic strategies for multivessel coronary artery disease: one-year results. J Am Coll Cardiol. 2004;43:1743–1751
- An initial strategy of intensive medical therapy is comparable to that of coronary revascularization for suppression of scintigraphic ischemia in high-risk but stable survivors of acute myocardial infarction. J Am Coll Cardiol. 2006;48:2458–2467
- Effects of percutaneous coronary interventions in silent ischemia after myocardial infarction: the SWISSI II randomized controlled trial. JAMA. 2007;297:1985–1991
Funding: None.
Conflict of Interest: None of the authors have any conflicts of interest associated with the work presented in this article.
Authorship: All authors had access to the data and were involved as follows: Conception (AJ, TKR, LG, DLB); statistical analysis (AJ, SK, DLB); writing of article (AJ, DLB); critical review (AJ, SK, TKR, LG, DLB).
PII: S0002-9343(08)00955-8
doi:10.1016/j.amjmed.2008.07.027
© 2009 Elsevier Inc. All rights reserved.
