Existing American guidelines developed more than 5 years ago recommend coronary artery bypass grafting over percutaneous coronary intervention in patients with diabetes, particularly for multivessel disease.
1
Despite these recommendations, one third of patients with diabetes and multivessel coronary artery disease undergoing revascularization received coronary artery bypass grafting.- Levine G.N.
- Bates E.R.
- Blankenship J.C.
- et al.
2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.
J Am Coll Cardiol. 2011; 58: e44-e122
2
We conducted a rapid review according to a protocol developed a priori to examine the most current evidence on the comparative effectiveness and safety of coronary artery bypass grafting and percutaneous coronary intervention for revascularization in patients with diabetes and multivessel coronary artery disease.- Pandey A.
- McGuire D.K.
- de Lemos J.A.
- et al.
Revascularization trends in patients with diabetes mellitus and multivessel coronary artery disease presenting with non-ST elevation myocardial infarction: insights from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines (NCDR ACTION Registry-GWTG).
Circulation. 2016; 9: 197-205
What Is the Clinical Question?
What are the comparative effectiveness and safety of coronary artery bypass grafting and percutaneous coronary intervention for revascularization in patients with diabetes and multivessel coronary artery disease?
What Does the Evidence Conclude?
Tabled
1
| Intervention | Quality of Evidence ∗ Quality of Evidence scale (Grading of Recommendations, Assessment, Development and Evaluations): high, moderate, low, and very low. For more information on the Grading of Recommendations, Assessment, Development, and Evaluations rating system, see http://gdt.guidelinedevelopment.org/app/handbook/handbook.html. | Balance Between Benefits and Harms |
|---|---|---|
| Percutaneous coronary intervention vs coronary artery bypass grafting | Low | Trade-off between benefits and harms coronary artery bypass grafting improves mortality and quality of life, and reduces the risk of revascularization but increases the risk of stroke, specifically in patients with high baseline risk for stroke and renal insufficiency |
∗ Quality of Evidence scale (Grading of Recommendations, Assessment, Development and Evaluations): high, moderate, low, and very low. For more information on the Grading of Recommendations, Assessment, Development, and Evaluations rating system, see http://gdt.guidelinedevelopment.org/app/handbook/handbook.html.
† The Guideline Elements Model: http://gem.med.yale.edu/default.htm.
What Are the Parameters for Our Evidence Search and Basis for Our Conclusions?
Population
The patient population included adults with diabetes and multivessel coronary artery disease (angiographic diagnosis). Patient characteristics contributing to treatment effect included demographics; risk factors for coronary artery disease, including hypertension, smoking and hyperlipidemia; duration of coronary artery disease; duration of diabetes; type of diabetes; and hemoglobin A1c.
Intervention
Intervention was percutaneous coronary intervention, including the number and type of stents.
Comparator
The comparator was coronary artery bypass grafting.
Primary Outcomes
The primary outcomes were mortality, all-cause mortality, disease-specific mortality, quality of life, incident myocardial infarction, incident stroke, and need for subsequent revascularization.
What Do the Clinical Guidelines Say?
American College of Cardiology Foundation/American Heart Association/Society for Cardiovascular Angiography and Interventions guideline for percutaneous coronary intervention. A report of the American College of Cardiology Foundation, the American Heart Association Task Force on Practice Guidelines, and the Society for Cardiovascular Angiography and Interventions, 2011 (Appraisal of Guidelines for Research and Evaluation II score: 74%).
1
- Levine G.N.
- Bates E.R.
- Blankenship J.C.
- et al.
2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.
J Am Coll Cardiol. 2011; 58: e44-e122
- •This guideline states that coronary artery bypass grafting probably is recommended in preference to percutaneous coronary intervention to improve survival in patients with multivessel coronary artery disease and diabetes mellitus, particularly if a left internal mammary artery graft can be anastomosed to the left anterior descending artery (level of evidence: B, limited population evaluated in single randomized controlled trials [RCTs] or nonrandomized studies).
European Society of Cardiology guidelines on diabetes, prediabetes, and cardiovascular diseases, developed in collaboration with the European Association for the Study of Diabetes. The Task Force on Diabetes, Prediabetes, and Cardiovascular Diseases of the European Society of Cardiology in collaboration with the European Association for the Study of Diabetes, 2013 (Appraisal of Guidelines for Research and Evaluation II score: 53%).
3
- Ryden L.
- Grant P.J.
- et al.
Authors/Task Force Members
ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD).
ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD).
Eur Heart J. 2013; 34: 3035-3087
- •This guideline recommends coronary artery bypass grafting in patients with diabetes mellitus and multivessel or complex (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery score >22) coronary artery disease to improve survival free from major cardiovascular events (level of evidence: A, strong recommendation based on high-quality evidence from RCTs).
- •This guideline recommends that in patients with diabetes mellitus who received percutaneous coronary intervention, drug-eluting stents rather than bare-metal stents are recommended to reduce the risk of target vessel revascularization (level of evidence: A, strong recommendation based on high-quality evidence from RCTs).
Author Commentary
Our comprehensive search in PubMed, Cochrane Library, EMBASE, and clinicaltrials.gov identified 2 individual patient data and 24 aggregate data meta-analyses of RCTs, unpublished data from 3 RCTs, 2 post hoc analyses of 2 RCTs, and 5 observational studies.
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, - Sipahi I.
- Akay M.H.
- Dagdelen S.
- Blitz A.
- Alhan C.
Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease: meta-analysis of randomized clinical trials of the arterial grafting and stenting era.
JAMA Intern Med. 2014; 174: 223-230
6
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, NCT00326196. Coronary Artery Revascularization in Diabetes. 2006. Available at: https://clinicaltrials.gov/ct2/show/NCT00326196.
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, - Morice M.C.
- Serruys P.W.
- Kappetein A.P.
- et al.
Five-year outcomes in patients with left main disease treated with either percutaneous coronary intervention or coronary artery bypass grafting in the synergy between percutaneous coronary intervention with TAXUS and cardiac surgery trial.
Circulation. 2014; 129: 2388-2394
42
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, - Soares P.R.
- Hueb W.A.
- Lemos P.A.
- et al.
Coronary revascularization (surgical or percutaneous) decreases mortality after the first year in diabetic subjects but not in nondiabetic subjects with multivessel disease: an analysis from the medicine, angioplasty, or surgery study (MASS II).
Circulation. 2006; 114: I420-I424
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, - Flather M.
- Rhee J.W.
- Boothroyd D.B.
- et al.
The effect of age on outcomes of coronary artery bypass surgery compared with balloon angioplasty or bare-metal stent implantation among patients with multivessel coronary disease. A collaborative analysis of individual patient data from 10 randomized trials.
J Am Coll Cardiol. 2012; 60: 2150-2157
54
, - Ariyaratne T.V.
- Ademi Z.
- Yap C.H.
- et al.
Prolonged effectiveness of coronary artery bypass surgery versus drug-eluting stents in diabetics with multi-vessel disease: an updated meta-analysis.
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- Patvardhan E.
- Gajulapalli R.D.
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- Kapadia S.R.
Late stroke: comparison of percutaneous coronary intervention versus coronary artery bypass grafting in patients with multivessel disease and unprotected left main disease: a meta-analysis and review of literature.
Stroke. 2014; 45: 185-193
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, - Fanari Z.
- Weiss S.A.
- Zhang W.
- Hadid M.
- Weintraub W.S.
Meta-analysis of three randomized controlled trials comparing coronary artery bypass grafting with percutaneous coronary intervention using drug-eluting stenting in patients with diabetes. Conference abstract: American Heart Association 2013 Scientific Sessions and Resuscitation Science Symposium, Dallas, TX, United States.
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, - Hakeem A.
- Garg N.
- Bhatti S.
- Rajpurohit N.
- Ahmed Z.
- Uretsky B.F.
Effectiveness of percutaneous coronary intervention with drug-eluting stents compared with bypass surgery in diabetics with multivessel coronary disease: comprehensive systematic review and meta-analysis of randomized clinical data.
J Am Heart Assoc. 2013; 2: e000354
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, - Lang C.
- Shim H.G.
- Arora R.
Aggregate Bayesian meta-analysis of percutaneous coronary intervention versus coronary artery bypass grafting in patients with diabetes. Conference abstract, American Heart Association 2013 Scientific Sessions and Resuscitation Science Symposium, Dallas, TX, United States.
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, NCT00006305. Bypass angioplasty revascularization investigation in type 2 diabetes. 2000. Available at: https://clinicaltrials.gov/ct2/show/NCT00006305?term=NCT00006305&rank=1.
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, NCT00086450. Comparison of two treatments for multivessel coronary artery disease in individuals with diabetes (FREEDOM). 2004. Available at: https://clinicaltrials.gov/ct2/show/NCT00086450?term=NCT00086450&rank=1.
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We graded the quality of evidence according to the criteria from the Grading of Recommendations, Assessment, Development, and Evaluations Working Group.Low-quality evidence suggests that when compared with percutaneous coronary intervention with drug-eluting stents, coronary artery bypass grafting reduces mortality and the need for subsequent revascularizations and improves quality of life but increases the risk for stroke (Table 1). Reduction in mortality after coronary artery bypass grafting versus percutaneous coronary intervention was largest in people with diabetes aged more than 59 years of age in a meta-analysis of individual patient data from 10 RCTs (adjusted relative risk, 0.61; 95% confidence interval [CI], 0.44-0.85).
53
Observational studies confirmed better survival after coronary artery bypass grafting but rarely reported stroke as an outcome in adults with diabetes undergoing revascularization for coronary artery disease (Appendix Table 1, available online). Only 1 observational study examining the risk of stroke did not find a statistically significant association between coronary artery bypass grafting and the risk of stroke in Japanese adults with diabetes (Appendix Table 1, available online).- Flather M.
- Rhee J.W.
- Boothroyd D.B.
- et al.
The effect of age on outcomes of coronary artery bypass surgery compared with balloon angioplasty or bare-metal stent implantation among patients with multivessel coronary disease. A collaborative analysis of individual patient data from 10 randomized trials.
J Am Coll Cardiol. 2012; 60: 2150-2157
16
Table 1GRADE Summary—Percutaneous Coronary Intervention With Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Adults With Diabetes and Multivessel Coronary Artery Disease
| Population: Adults with diabetes and multivessel CAD | ||||||
| Settings: Inpatient | ||||||
| Intervention: PCI with drug-eluting stents | ||||||
| Comparator: CABG | ||||||
| Outcome | Risk With Intervention Per 1000 | Risk With Comparator Per 1000 | Relative Measure of Association (95% CI) | No. of Participants (Studies) | Quality of Evidence (GRADE) | Comment |
|---|---|---|---|---|---|---|
| All-cause mortality, 1- to 5-y follow-up | 142 | 90 Attributable events per 1000 treated, 40 (8-73) | OR 1.4 (1.1-1.9) NNT 25 (14-125) | 3516 (7 RCTs) 4 , 5
Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease: meta-analysis of randomized clinical trials of the arterial grafting and stenting era. JAMA Intern Med. 2014; 174: 223-230 | Low | Favors CABG |
| All-cause mortality, 5-y follow-up | 169 | 112 Attributable events per 1000 treated, 63 (19-107) | RR 1.5 (1.1-2.1) NNT 16 (9-53) | 2588 (4 RCTs) 6 | Very low | Favors CABG |
| Death/MI/stroke events | 214 | 165 Attributable events per 1000 treated, 49 (23-76) | HR 1.4 (1.2-1.7) NNT 20 (13-43) | 3443 (individual participant data meta-analysis of 3 RCTs) 7 , 8 , 9 , 10 | Moderate | Favors CABG |
| Myocardial infarction, 1- to 5-y follow-up | 103 | 60 | OR 1.3 (0.9-2.0) | 3516 (7 RCTs) 4 | Very low | No difference |
| Nonfatal myocardial infarction at 5-y follow-up | 125 | 67 | RR 1.5 (0.8-2.8) | 2620 (4 RCTs) 6 | Very low | No difference |
| Need for subsequent revascularization, 1- to 5-y follow-up | 263 | 113 Attributable events per 1000 treated, 107 (41-174) | OR 2.4 (1.7-3.1) NNT 9 (6-24) | 3516 (7 RCTs) 4 | Low | Favors CABG |
| Stroke, 1- to 5-y follow-up | 24 | 41 Attributable avoided events per 1000 treated, 15 (3-27) | RR 0.6 (0.4-0.8) NNTp 67 (37-333) | 3516 (7 RCTs) 4 | Low | Favors PCI |
| Quality of life at 2-y follow-up, Seattle Angina Questionnaire, total score | NR | NR | MD −2.2 (−3.8 to −0.7) | 1900 (1 RCT) 11 | Very low | Favors CABG |
| Total, nonserious adverse events | 69 | 690 Attributable avoided events per 1000 treated 621 (517-726) | RR 0.10 (0.05-0.21) NNTp 2 (1-2) | 198 (1 RCT) 12 NCT00326196. Coronary Artery Revascularization in Diabetes. 2006. Available at: https://clinicaltrials.gov/ct2/show/NCT00326196. | Very low | Favors PCI |
| Total, serious adverse events | 227 | 474 Attributable avoided events per 1000 treated 247 (118-375) | RR 0.48 (0.32-0.73) NNTp 4 (3-8) | 198 (1 RCT) 12 NCT00326196. Coronary Artery Revascularization in Diabetes. 2006. Available at: https://clinicaltrials.gov/ct2/show/NCT00326196. | Very low | Favors PCI |
CABG = coronary artery bypass grafting; CAD = coronary artery disease; CI = confidence interval; GRADE = Grading of Recommendations Assessment, Development, and Evaluation; MD = mean difference; NNT = number needed to treat; NNTp = number needed to treat to prevent 1 event; NR = not reported; OR = odds ratio; PCI = percutaneous coronary intervention; RCT = randomized controlled trial; RR = relative risk.
∗ ORs from Bayesian network meta-analysis with 95% Credible Intervals.
Low-quality evidence suggests that when compared with percutaneous coronary intervention with bare-metal stents, coronary artery bypass grafting reduces mortality and the need for subsequent revascularization (Table 2).
Table 2GRADE Summary—Percutaneous Coronary Intervention With Bare-Metal Stents Versus Coronary Artery Bypass Grafting for Adults With Diabetes and Multivessel Coronary Artery Disease
| Population: Adults with diabetes and multivessel CAD | ||||||
| Settings: Inpatient | ||||||
| Intervention: PCI with bare-metal stents | ||||||
| Comparator: CABG | ||||||
| Outcome | Risk With Intervention Per 1000 | Risk With Comparator Per 1000 | Relative Measure of Association (95% CI) | No. of Participants (Studies) | Quality of Evidence (GRADE) | Comment |
|---|---|---|---|---|---|---|
| All-cause mortality, 5-y follow-up | 127 | 82 Attributable events per 1000 treated, 54 (5-102) | RR 1.4 (0.8-2.5) NNT 19 (10-200) | 543 (4 RCTs) 6 | Low | Favors CABG |
| Nonfatal myocardial infarction, 5-y follow-up | 89 | 88 | RR 1.0 (0.4-2.5) | 350 (2 RCTs) 6 | Low | No difference |
| Myocardial infarction, 1- to 5-y follow-up | 100 | 58 | OR 1.9 (1.2-2.9) | 752 (4 RCTs) 4 | Low | Favors CABG |
| Need for subsequent revascularization, 1- to 5-y follow-up | 328 | 72 Attributable events per 1000 treated, 216 (144-287) | OR 5.2 (3.7-7.4) NNT 5 (3-7) | 896 (5 RCTs) 4 | Low | Favors CABG |
| Need for subsequent revascularization, 5-y follow-up | 361 | 82 Attributable events per 1000 treated, 261 (135-387) | RR 4.2 (2.5-7.2) NNT 4 (3-7) | 350 (2 RCTs) 6 | Very low | Favors CABG |
CABG = coronary artery bypass grafting; CAD = coronary artery disease; CI = confidence interval; GRADE = Grading of Recommendations Assessment, Development, and Evaluation; NNT = number needed to treat; OR = odds ratio; PCI = percutaneous coronary intervention; RCT = randomized controlled trial; RR = relative risk.
∗ ORs from Bayesian network meta-analysis with 95% Credible Intervals.
Low-quality evidence suggests that percutaneous coronary intervention with drug-eluting stents, when compared with percutaneous coronary intervention with bare-metal stents, reduces the risk for myocardial infarction and revascularization (Table 3). A single observational study reported that people with diabetes with prior percutaneous coronary intervention had poorer long-term outcomes after coronary artery bypass grafting revascularization compared with those who had no prior percutaneous coronary intervention.
14
Table 3GRADE Summary—Percutaneous Coronary Intervention With Bare-Metal Stents Versus Drug-Eluting Stents for Adults With Diabetes and Multivessel Coronary Artery Disease
| Population: Adults with diabetes and multivessel CAD | ||||||
| Settings: Inpatient | ||||||
| Intervention: PCI with bare-metal stents | ||||||
| Comparator: PCI with drug-eluting stents | ||||||
| Outcome | Risk with Intervention per 1000 | Risk with Comparator per 1000 Attributable Events per 1000 Treated (95% CI) | Relative Measure of Association (95% CI) NNT (95% CI) | No. of Participants (RCTs) | Quality of Evidence (GRADE) | Comment |
|---|---|---|---|---|---|---|
| All-cause mortality, 1- to 5-y follow-up | 94 | 79 | OR 0.9 (0.7-1.2) | 3470 (14 RCTs) 4 | Low | No difference |
| Myocardial infarction, 1- to 5-y follow-up | 94 | 57 Attributable events per 1000 treated, 26 (7-46) | OR 1.4 (1.0-2.0) NNT 38 (22-143) | 3131 (10 RCTs) 4 | Low | Favors PCI with drug-eluting stents |
| Need for subsequent revascularization, 1- to 5-y follow-up | 329 | 190 Attributable events per 1000 treated, 151 (101-202) | OR 2.2 (1.7-3.0) NNT 7 (5-10) | 2444 (6 RCTs) 4 | Moderate | Favors PCI with drug-eluting stents |
CAD = coronary artery disease; CI = confidence interval; GRADE = Grading of Recommendations Assessment, Development, and Evaluation; NNT = number needed to treat; OR = odds ratio; PCI = percutaneous coronary intervention; RCT = randomized controlled trial.
∗ ORs from Bayesian network meta-analysis with 95% Credible Intervals.
All published meta-analyses reported better survival after coronary artery bypass grafting but a higher risk for stroke when compared with percutaneous coronary intervention.
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, 61
, 62
, 63
, - Hakeem A.
- Garg N.
- Bhatti S.
- Rajpurohit N.
- Ahmed Z.
- Uretsky B.F.
Effectiveness of percutaneous coronary intervention with drug-eluting stents compared with bypass surgery in diabetics with multivessel coronary disease: comprehensive systematic review and meta-analysis of randomized clinical data.
J Am Heart Assoc. 2013; 2: e000354
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Post hoc analysis of the largest RCTs of diabetic patients revealed that levels of low-density lipoprotein >105 mg/dL (adjusted hazard ratio [HR], 3.28; 95% CI, 1.19-9.02) and renal insufficiency (adjusted HR, 3.57; 95% CI, 1.01-12.64) were associated with more than a 200% increase in relative risk for later stroke.78
In contrast, and for unclear reasons, each 1 mm Hg increase in diastolic blood pressure was associated with a 5% relative reduction in the risk for stroke (adjusted HR, 0.95; 95% CI, 0.91-0.99).78
We downgraded the quality of evidence because of risk of bias in the body of evidence, small number of events, and inconsistency in treatment effects. We also downgraded the quality of evidence from indirect comparisons in the network meta-analysis.
4
Current clinical practice guidelines recommend coronary artery bypass grafting over percutaneous coronary intervention for diabetic patients with multivessel disease.
1
, - Levine G.N.
- Bates E.R.
- Blankenship J.C.
- et al.
2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.
J Am Coll Cardiol. 2011; 58: e44-e122
3
However, the choice of treatment always should be individualized depending on the baseline risk for stroke, renal function, and anticoagulant use. Future research is needed to examine the role of patient characteristics and provider skills and the quality of provided care on patient survival and quality of life in patients undergoing these procedures.- Ryden L.
- Grant P.J.
- et al.
Authors/Task Force Members
ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD).
ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD).
Eur Heart J. 2013; 34: 3035-3087
Acknowledgment
The authors thank David Goldmann, MD, for his contribution to the development of the clinical question, review protocol, and preliminary analysis of the evidence.
Appendix
Appendix Table 1GRADE Summary—Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Adults With Diabetes and Multivessel Coronary Artery Disease: Results From Observational Studies
| Population: Adults with diabetes and multivessel CAD | ||||||
| Settings: Inpatient | ||||||
| Intervention: PCI | ||||||
| Comparator: CABG | ||||||
| Outcome | Risk With Intervention Per 1000 | Risk With Comparator Per 1000 | Adjusted Relative Measure of Association (95% CI) | No. of Participants (Studies) | Quality of Evidence (GRADE) | Comment |
|---|---|---|---|---|---|---|
| Registry of 8 community hospitals, US | ||||||
| Mortality, 5-8 y | NR | NR | OR 1.67 (1.08-2.56) | 1082 (1 study) 17 | Very low | Favors CABG |
| MACE (mortality, nonfatal myocardial infarction, or revascularization), 5-8 y | NR | NR | OR 1.75 (1.43-3.23) | 1082 (1 study) 17 | Very low | Favors CABG |
| Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2, Japan | ||||||
| Mortality, 5 y | NR | NR | HR 1.31 (1.01-1.70) | 1998 (1 study) 16 | Very low | Favors CABG |
| Cardiac death, 5 y | NR | NR | HR 1.45 (1.00-2.51) | 1998 (1 study) 16 | Very low | Favors CABG |
| MI, 5 y | NR | NR | HR 2.31 (1.31-4.08) | 1998 (1 study) 16 | Very low | Favors CABG |
| Any coronary revascularization), 5 y | NR | NR | HR 3.70 (2.91-4.69) | 1998 (1 study) 16 | Very low | Favors CABG |
| Stroke, 5 y | NR | NR | HR 1.07 (0.72-1.59) | 1998 (1 study) 16 | Very low | No difference |
| Elderly in a single center in Japan | ||||||
| Mortality, 3.5 y | NR | NR | HR 1.37 (0.72-2.50) | 483 (1 study) 15 | Very low | No difference |
| Single-center study in China | ||||||
| All-cause death, 3 y | NR | NR | HR 1.10 (0.70-1.75) | 1154 (1 study) 13 | Very low | No difference |
| Death, MI, and stroke, 3 y | NR | NR | HR 0.66 (0.51-0.87) | 1154 (1 study) 13 | Very low | Favors PCI |
| Repeat revascularization, 3 y | NR | NR | HR 6.74 (4.38-10.37) | 1154 (1 study) 13 | Very low | Favors CABG |
CABG = coronary artery bypass grafting; CAD = coronary artery disease; CI = confidence interval; GRADE = Grading of Recommendations Assessment, Development, and Evaluation; HR = hazard ratio; NR = not reported; OR = odds ratio; MACE = major adverse cardiac events; MI = myocardial infarction; PCI = percutaneous coronary intervention.
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Article info
Publication history
Published online: May 26, 2017
Footnotes
Funding: Elsevier Evidence-Based Medicine Center.
Conflict of Interest: TAS is employed by Elsevier.
Authorship: Both authors had access to the data and played a role in writing this manuscript.
