Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis

Abstract

Objective To investigate whether revascularisation improves prognosis compared with medical treatment among patients with stable coronary artery disease.Design Bayesian network meta-analyses to combine direct within trial comparisons between treatments with indirect evidence from other trials while maintaining randomisation.Eligibility criteria for selecting studies A strategy of initial medical treatment compared with revascularisation by coronary artery bypass grafting or Food and Drug Administration approved techniques for percutaneous revascularization: balloon angioplasty, bare metal stent, early generation paclitaxel eluting stent, sirolimus eluting stent, and zotarolimus eluting (Endeavor) stent, and new generation everolimus eluting stent, and zotarolimus eluting (Resolute) stent among patients with stable coronary artery disease. Data sources ConclusionAmong patients with stable coronary artery disease, coronary artery bypass grafting reduces the risk of death, myocardial infarction, and subsequent revascularisation compared with medical treatment. All stent based coronary revascularisation technologies reduce the need for revascularisation to a variable degree. Our results provide evidence for improved survival with new generation drug eluting stents but no other percutaneous revascularisation technology compared with medical treatment.

Safety and Efficacy of Resolute Zotarolimus-Eluting Stents Compared With Everolimus-Eluting Stents

“…TVR occurred in 556 patients (5.61%). The risk of TVR was similar in patients randomly allocated to treatment with R-ZES compared with patients randomly allocated to treatment with EES (6 Figure 3C). TV-MI was observed in 325 patients (3.28%).…”

“…Notwithstanding, there remains residual uncertainty whether the 2 devices differ with respect to individual safety and efficacy outcomes, notably the risk of stent thrombosis (ST). Although several network meta-analyses compared different DES, [6][7][8][9] there was an inconsistency between direct and indirect evidence with regard to the effectiveness of R-ZES and EES. 8 Therefore, we sought to perform a pairwise meta-analysis of randomized clinical trials with direct comparisons of FDAapproved new-generation DES to evaluate the safety and efficacy of R-ZES and EES in patients undergoing PCI.…”

“…Indeed, new-generation DES have become the standard of care among patients undergoing PCI because of improved clinical outcomes in all patient and lesion subsets. 6 Thin strut, durable polymer-based, Resolute zotarolimuseluting stent (R-ZES) and everolimus-eluting stent (EES) are the 2 only approved new-generation DES by the US Food and Drug Administration (FDA). R-ZES and EES have been directly compared in several randomized trials powered for noninferiority with respect to composite clinical end points.…”

ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease

“…3,4 These trials include studies not only on the use of percutaneous coronary intervention (PCI), but also on coronary artery bypass graft surgery (CABG), medical therapy, and diagnostic technologies such as fractional flow reserve (FFR) to guide revascularization. [5][6][7][8] Additional studies, some based on data from the National Cardiovascular Data Registry (NCDR), have been published providing insights into practice patterns and information around clinical scenarios and patient features not previously addressed. [9][10][11][12][13] Improvements in our understanding of the variables affecting patient outcomes before and after coronary revascularization, continued emphasis on the role of medical therapy for coronary artery disease (CAD), and an increasing emphasis on shared decision making and patient preferences also make a revision of the coronary revascularization AUC timely.…”

Diagnostic usefulness of myocardial perfusion imaging in patients reluctant to undergo angiography

“…The authors showed improved survival with newer generation of drug-eluting stents when compared to medical therapy. 18 On the other hand, two additional meta-analyses comprising 7,200 and 8,000 patients found no difference in mortality in patients treated with PCI compared to optimal medical therapy. 19,20 The Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 2 (FAME 2) trial examined patients with stable CAD for whom PCI was being considered.…”