Network meta‐analysis of treatment strategies in patients with coronary artery disease and low left ventricular ejection fraction

Abstract

Objective: The optimal treatment strategy in patients with coronary artery disease (CAD) and low left ventricular ejection fraction (LVEF) remains controversial. Herein, we conducted a network meta-analysis comparing coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), and optimal medical therapy (OMT) in patients with CAD and low LVEF.Methods: MEDLINE and EMBASE were searched through March, 2021 to identify randomized controlled trials (RCTs) and propensity-score matched (PSM) studies comparing CABG, PCI, and OMT. We extracted hazard ratios (HRs) of the outcomes.Results: A total of three RCTs and 10 PSM trials were identified, yielding a total of 18,855 patients with CAD with low EF who were treated with CABG (n = 9241), PCI (n = 8771), or OMT (n = 1003). All-cause mortality was significantly lower in patients with CABG compared with those with PCI or OMT (HR [95% confidence interval (CI)] = 0.72 [0.62-0.82], p < .001, HR [95% CI] = 0.65 [0.51-0.82], p = .004, respectively), while no difference was observed between PCI and OMT. The rates of MI were significantly lower in patients treated with CABG compared to those treated with PCI or OMT. However, the subgroup analysis by limiting the PCI group to patients who received drug-eluting stent (DES) showed similar all-cause mortality between CABG and PCI, while both CABG and PCI were associated with lower allcause mortality compared with OMT. Concluion:The present study demonstrated that CABG was the appropriate treatment strategy in patients with CAD and low LVEF. Further long-term trials were warranted to investigate outcomes of PCI with DES compared with CABG.

Effects of Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting on Clinical Outcomes in Patients with Reduced Ejection Fraction Heart Failure and Coronary Heart Disease: A Meta-Analysis

“…At three years of follow up, PCI reduced ACM or readmission rates [Brophy 2021]. A network meta-analysis of treatment strategies in patients with CHD and left ventricular dysfunction by Yokoyama et al showed that ACM was similar between CABG and PCI after adjustment for stenting in the PCI group [Yokoyama 2021]. From the above studies, it can be concluded that PCI can be used to treat CHD complicated with HFrEF, and its efficacy may be like that of CABG.…”

Coronary artery bypass grafting is superior to percutaneous coronary intervention in patients with left ventricular dysfunction

“…Furthermore, Ono et al 15 just a few days ago highlight in this extended follow‐up of the SYNTAX trial 16 that there were no significant differences at 10 years in all‐cause death and estimated life expectancy between PCI and CABG in the elderly (>70 years). These latest studies do not specifically address ventricular function as the current meta‐analysis does 11 . In the end, it is all about statistics?…”

“…These latest studies do not specifically address ventricular function as the current meta-analysis does. 11 In the end, it is all about statistics? Is everybody trying to squeeze data as much as possible aiming at convincing the others by defending a specific hypothesis?…”

“…In this issue of the Journal, Yokoyama et al address one of those controversies, which the optimal treatment for patients with CAD and reduced left ventricular ejection fraction (LVEF) is 11 . They have conducted a network meta‐analysis comparing CABG, PTCA, and optimal medical therapy (OMT) in patients with CAD and low LVEF.…”

Prognostic Value of Preoperative Assessment of Left Ventricular Function in Patients Undergoing Percutaneous Coronary Intervention

“…Lack of evaluation of the LV function before PCI may result in the failure to select the optimal revascularization protocol. In a 2021 network meta-analysis by Yujiro Yokoyama et al [9], coronary-artery bypass grafting (CABG) remained the treatment of choice in patients with coronary artery disease and low LV ejection fraction (LVEF). Studies have shown that approximately one-third of patients who undergo PCI [10][11][12] suffered from LV dysfunction-an important predictor of post PCI death and major adverse cardiac events (MACE) [13,14].…”