TCT-847 Strut Level Optical Coherence Tomography Evaluation of Coronary Stent Strut Coverage Temporal Trends: A Systematic Review

Abstract

Background: Recent randomized controlled trials (RCTs) have called into question whether percutaneous coronary intervention (PCI) reduces death or myocardial infarction in patients with stable ischemic heart disease (SIHD). However, several of these trials randomized an unselected group of patients, including those with and without objective ischemia. Methods: We performed a meta-analysis of RCTs comparing PCI with medical therapy (MT) in pts with either ischemia (identified on non-invasive testing) or abnormal fractional flow reserve (FFR), to determine whether PCI reduces all-cause mortality in this high-risk SIHD cohort. Results: Four RCTs comparing PCI vs. MT in pts with objective ischemia (or FFRequivalent) were found; these trials randomized a total of 1,769 pts with f/u from 7 months to 10 years. The point estimate of the hazard ratio (HR) for mortality following PCI vs. MT varied from 0.33-0.73, with no trial heterogeneity (I2¼0%). Of note, the documented ischemia cohort of the COURAGE trial (Am Heart J 2012) comprised 48% of the weight of the included studies. Overall, 28/871 (3.2%) PCI pts died compared with 54/898 MT pts (6.0%), consistent with a significant reduction in allcause mortality with PCI (HR 0.56; 95% confidence interval (CI): 0.34-0.93, p¼0.02, Figure), which remained significant when 3 other ineligible RCTs were added which included a PCI vs MT arm (HR 0.61 [0.42,0.89], p¼0.01).Conclusions: Despite conventional conclusions drawn from existing RCT data that PCI and MT result in comparable survival in SIHD, when analyses are restricted to pts with objective ischemia (or the FFR equivalent), PCI is associated with a significant and consistent 44% reduction in all-cause mortality compared with MT.