A meta-analysis of optimal medical therapy with or without percutaneous coronary intervention in patients with stable coronary artery disease

Abstract

Background Whether percutaneous coronary intervention (PCI) improves clinical outcomes in patients with chronic angina and stable coronary artery disease (CAD) has been a continuing area of investigation for more than two decades. The recently reported results of the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches, the largest prospective trial of optimal medical therapy (OMT) with or without myocardial revascularization, provides a unique opportunity to determine whether there is an incremental benefit of revascularization in stable CAD patients.Methods Scientific databases and websites were searched to find randomized clinical trials (RCTs). Pooled risk ratios were calculated using the random-effects model. ResultsData from 10 RCTs comprising 12 125 patients showed that PCI, when added to OMT, were not associated with lower all-cause mortality (risk ratios, 0.96; 95% CI, 0.87-1.08), cardiovascular mortality (risk ratios, 0.91; 95% CI, 0.79-1.05) or myocardial infarction (MI) (risk ratios, 0.90; 95% CI, 0.78-1.04) as compared with OMT alone. However, OMT+PCI was associated with improved anginal symptoms and a lower risk for revascularization (risk ratios, 0.52; 95% CI, 0.37-0.75). ConclusionsIn patient with chronic stable CAD (without left main disease or reduced ejection fraction), PCI in addition to OMT did not improve mortality or MI compared to OMT alone. However, this strategy is associated with a lower rate of revascularization and improved anginal symptoms.

Percutaneous coronary intervention versus optimal medical therapy for stable coronary artery disease: An umbrella review

“…After eliminating duplicate articles, we evaluated 194 records by title and abstract, of which 23 were reviewed in full text, and finally included 10 SRs with meta-analyses of RCTs [ 6 , 7 , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] ] ( Fig. 1 ).…”

“…Of the 10 included SRs, 9 conducted their literature search between April 2018 and November 2021, and one did not mention its search period [ 15 ]. Only 2 SRs had a protocol registered in PROSPERO [ 13 , 18 ].…”

“…The number of meta-analyzed RCTs was 3–15. Seven SRs evaluated the risk of bias: 6 with the Cochrane tool [ 6 , 14 , 15 , [17] , [18] , [19] , [20] ] and 1 with the Jadad score [ 7 , 13 ]. None of the SRs used the GRADE approach to evaluate the certainty of the evidence.…”

Percutaneous coronary intervention prevents spontaneous myocardial infarction in patients with stable coronary artery disease

“…In the recently reported International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial, PCI when added to optimal medical therapy (OMT), did not improve the major adverse cardiovascular event (MACE) rate [1]. Similarly a recent meta-analysis in this field, including data from ISCHEMIA trial, concluded that when PCI was added to medical therapy, risk of myocardial infarction (MI) rate did not decrease [2]. However, in this meta-analysis and other previous meta-analyses, total MI rate included both spontaneous and periprocedural MI [3].…”

Temporal trends in the efficacy of revascularization in stable ischaemic heart disease: A cumulative meta-analysis

“…The meta-analysis by Shah et al. is also a good example of homogeneous pooling of studies to answer this specific research question [5] .…”