Clinical research study
The Impact of Revascularization on Mortality in Patients with Nonacute Coronary Artery Disease

https://doi.org/10.1016/j.amjmed.2008.07.027Get rights and content

Abstract

Background

Although early revascularization improves outcomes for patients with acute coronary syndromes, the role of revascularization for patients with nonacute coronary artery disease is controversial. The objective of this meta-analysis was to compare surgical or percutaneous revascularization with medical therapy alone to determine the impact of revascularization on death and nonfatal myocardial infarction in patients with coronary artery disease.

Methods

The Medline and Cochrane Central Register of Controlled Trials databases were searched to identify randomized trials of coronary revascularization (either surgical or percutaneous) versus medical therapy alone in patients with nonacute coronary disease reporting the individual outcomes of death or nonfatal myocardial infarction reported at a minimum follow-up of 1 year. A random effects model was used to calculate odds ratios (OR) for the 2 prespecified outcomes.

Results

Twenty-eight studies published from 1977 to 2007 were identified for inclusion in the analysis; the revascularization modality was percutaneous coronary intervention in 17 studies, coronary bypass grafting in 6 studies, and either strategy in 5 studies. Follow-up ranged from 1 to 10 years with a median of 3 years. The 28 trials enrolled 13,121 patients, of whom 6476 were randomized to revascularization and 6645 were randomized to medical therapy alone. The OR for revascularization versus medical therapy for mortality was 0.74 (95% confidence interval [CI], 0.63-0.88). A stratified analysis according to revascularization mode revealed both bypass grafting (OR 0.62; 95% CI, 0.50-0.77) and percutaneous intervention (OR 0.82; 95% CI, 0.68-0.99) to be superior to medical therapy with respect to mortality. Revascularization was not associated with a significant reduction in nonfatal myocardial infarction compared with medical therapy (OR 0.91; 95% CI, 0.72-1.15).

Conclusion

Revascularization by coronary bypass surgery or percutaneous intervention in conjunction with medical therapy in patients with nonacute coronary artery disease is associated with significantly improved survival compared with medical therapy alone.

Section snippets

Search Strategy and Inclusion Criteria

This meta-analysis considered randomized clinical trials comparing coronary revascularization by percutaneous coronary intervention or bypass grafting in combination with medical therapy with medical therapy alone for the treatment of patients with nonacute coronary artery disease. Comprehensive searches of the Medline and Cochrane Central Register of Controlled Trials databases were performed using Web-based engines (PubMed and OVID) for studies published between 1977 and January 2008. Search

Study Characteristics

Twenty-eight studies published from 1977 to 2007 were included in the analysis. Of these, the revascularization modality was percutaneous intervention in 17 studies, bypass grafting in 6 studies, either percutaneous intervention or bypass grafting (nonrandomized) in 3 studies, and percutaneous intervention or bypass grafting (randomized) in 2 studies. The ORs for the latter 2 trials were calculated using the single medical therapy arm as the comparator for both the percutaneous intervention and

Discussion

This analysis demonstrates that, compared with medical therapy alone, coronary artery revascularization by either bypass grafting or percutaneous intervention for nonacute coronary artery disease is associated with a significant reduction in mortality without a decrease in the rate of nonfatal myocardial infarction. Although previous meta-analyses have compared one form of revascularization (bypass grafting or percutaneous intervention) with medical therapy alone, the unique aspect of the

Conclusions

The findings of this analysis suggest that coronary artery revascularization by either bypass grafting or percutaneous intervention in conjunction with medical therapy results in prolonged survival compared with medical management alone in patients with nonacute coronary artery disease. Furthermore, both bypass grafting and percutaneous intervention are independently associated with a statistically significant reduction in mortality when compared with medical therapy alone in this population.

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    Funding: None.

    Conflict of Interest: None of the authors have any conflicts of interest associated with the work presented in this article.

    Authorship: All authors had access to the data and were involved as follows: Conception (AJ, TKR, LG, DLB); statistical analysis (AJ, SK, DLB); writing of article (AJ, DLB); critical review (AJ, SK, TKR, LG, DLB).

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