Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for the Treatment of Coronary Artery Disease: A Meta-Analysis of Randomized and Nonrandomized Studies

Study Questions:

What is the comparative safety and efficacy of drug-eluting stents (DES) with coronary artery bypass grafting (CABG) for patients with coronary artery disease?

Methods:

Twenty-five eligible comparative studies (1 randomized and 24 nonrandomized) were assessed. Two reviewers independently appraised each study. A meta-analysis was performed by combining the results of reported incidence of morbidity, mortality, and repeat revascularization. In this study, both fixed- and random-effects models were tested.

Results:

In these 25 studies, 34,278 patients were compared, of whom 18,538 received DES and 15,740 underwent CABG. It must be acknowledged that this comparison represented a selected group of patients who received DES or underwent CABG. The accumulative incidences of all-cause mortality at 12 months (4.5% vs. 4.0%, p = 0.92) and 24 months (6.2% vs. 8.4%, p = 0.27), and 30-day myocardial infarction (1.4% vs. 2.0%, p = 0.60) were similar, respectively, between the DES and CABG groups. DES were associated with lower rates of all-cause mortality at 30 days (0.9% vs. 2.3%, p < 0.001), stroke (0.4% vs. 1.7%, p < 0.001), and 30-day major adverse cardiac and cerebrovascular events (MACCE) (3.6% vs. 5.5%, p < 0.04). However, the CABG group had a lower incidence of postprocedural myocardial infarction (5.5% vs. 4.7%, p = 0.03), repeat revascularization (22.2% vs. 4.1%, p < 0.001), and 12-month MACCE (16.7% vs. 10.5%, p < 0.001). Subgroup analysis of patients with multivessel coronary artery disease showed similar results.

Conclusions:

The authors concluded that DES are associated with less periprocedural risks, but a higher incidence of postprocedural myocardial infarction, repeat revascularization, and 12-month MACCE compared with CABG.

Perspective:

The present meta-analysis suggests that the accumulative incidences of all-cause mortality at 12 and 24 months, and 30-day myocardial infarction, were similar between DES and CABG. DES were associated with lower rates of all-cause mortality at 30 days, stroke, and 30-day MACCE; however, the CABG group had a lower incidence of overall myocardial infarction at last follow-up, repeat revascularization, and 12-month MACCE. It should be noted that the data included in the present meta-analysis were mostly extrapolated from nonrandomized studies, which are subject to selection bias, and this comparison also represented a subset of patients who were initially enrolled or screened for treatments. Large-scale randomized clinical trials with long-term follow-up are indicated to compare revascularization modalities and optimal medical therapy strategy for patients with coronary artery disease.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease

Keywords: Coronary Artery Disease, Myocardial Infarction, Stroke, Follow-Up Studies, Drug-Eluting Stents, Coronary Artery Bypass


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