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
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Article info
Footnotes
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).
Identification
Copyright
© 2009 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
