Compared with medical therapy alone, revascularization also provided greater freedom from angina, but revascularization did not improve survival or MI risk and showed increased risk of procedural MI.
A meta-analysis shows that routine revascularization for stable angina was associated with a lower risk of non-procedural myocardial infarction (MI) and unstable angina, and greater freedom from angina. However, routine revascularization did not improve survival at a mean follow-up of 4.5 years, according to late-breaking trial results presented Friday at the PCR e-Course.
Sripal Bangalore, MD, MHA, of the New York University Grossman School of Medicine presented the study at. Bangalore and colleagues also reported their findings in a manuscript that was simultaneously published online in Circulation.
Clinical trials have shown that routine revascularization is associated with improved survival in patients with ischemic cardiomyopathy and in acute coronary syndromes. However, studies have shown mixed results in terms of survival with routine revascularization. Thus, the authors performed an updated meta-analysis to evaluate the outcomes of routine revascularization vs. medical therapy in patients with stable ischemic heart disease (SIHD).
This meta-analysis included 14 randomized clinical trials with a total of 14,877 patients who were followed for a mean of 4.5 years. Revascularization was performed in 87% of patients (percutaneous coronary intervention [PCI] in 71% and coronary artery bypass grafting [CABG] in 16%). Drug-eluting stents were used in three trials: FAME 2, ISCHEMIA and ISCHEMIA-CKD. Revascularization was performed in 32% of patients in the medical therapy group during the follow-up period. Most of the trials excluded patients with left main disease.
At 4.5 years’ follow-up, routine revascularization was not associated with reduced risk of death in comparison with medical therapy alone (relative risk [RR], 0.99; 95% confidence interval [CI], 0.90-1.09). No significant differences in cardiovascular death were noted between revascularization and medical therapy alone. The results were similar when analyzed by stent era status.
Routine revascularization did decrease non-procedural MI (RR, 0.76; 95% CI, 0.67-0.85) and unstable angina (RR, 0.64; 95% CI, 0.45-0.92) as compared with medical therapy alone, and revascularization was associated with greater symptomatic benefit. However, revascularization also resulted in increased procedural MI (RR, 2.48; 95% CI, 1.86-3.31), and did not reduce the risk of death (RR, 0.99; 95% CI, 0.90-1.09) or overall MI (RR, 0.93; 95% CI, 0.83-1.03) in comparison with medical therapy alone. These results were similar with a sensitivity analysis.
The authors noted some limitations of the meta-analysis. They said their study did not account for the type of stent, the dosage of medications, patient compliance with the medication regimen, and differences in trial designs and patient population.
Bangalore concluded that routine revascularization was not associated with improved survival but was associated with lower risk of non-procedural MI and greater freedom from angina. He recommended longer-term follow-up of trials to evaluate whether the reduction in non-fatal spontaneous events improves survival.
PCR e-Course is the virtual meeting being held in place of the annual in-person EuroPCR congress, which was canceled because of the COVID-19 pandemic.
Bangalore S, Maron DJ, Stone GW, et al. Routine Revascularization versus Initial Medical Therapy for Stable Ischemic Heart Disease: A Systematic Review and Meta-Analysis of Randomized Trials. Circulation 2020 Jun 26. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.048194