Outcomes After Complete Versus Incomplete Revascularization of Patients With Multivessel Coronary Artery Disease: A Meta-Analysis of 89,883 Patients Enrolled in Randomized Clinical Trials and Observational Studies

Study Questions:

Compared to incomplete revascularization (IR) of coronary artery disease (CAD), is complete revascularization (CR) associated with improved clinical outcomes?

Methods:

This was a meta-analysis of observational studies and randomized clinical trials published from 1970 through September 2012 (post-hoc analyses were included). Patients with multivessel CAD undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction were excluded. Eligible studies enrolled patients with multivessel CAD referred for CR with coronary artery bypass grafting (CABG) or PCI, compared the outcomes of CR versus IR, and reported the long-term mortality rates. Main outcome measures were total mortality, myocardial infarction, and repeat revascularization procedures.

Results:

Thirty-five studies, including 89,883 patients, were included. Mean follow-up time was 4.6 (±4) years. IR was more common after PCI than CABG (56% vs. 25%, p < 0.001). Relative to IR, CR was associated with lower long-term mortality (risk ratio [RR], 0.71; 95% confidence interval [CI], 0.65-0.77; p < 0.001), myocardial infarction (RR, 0.78; 95% CI, 0.68-0.90; p = 0.001), and repeat coronary revascularization (RR, 0.74; 95% CI, 0.65-0.83; p < 0.001). SYNTAX score was higher in IR patients, compared to those with CR (31.4 ± 11 vs. 26.2 ± 10; p < 0.01). Mortality benefit (~30%) with CR was similar, irrespective of revascularization strategy.

Conclusions:

The authors concluded that in this meta-analysis, CR was associated with lower risk for subsequent cardiovascular events and mortality, when compared to IR.

Perspective:

In this large meta-analysis, the authors present evidence that may suggest CR is the optimal revascularization strategy in patients with multivessel CAD. The limitations of the analysis aside, and while IR may be a proxy for more advanced CAD not amenable to revascularization, these results do suggest, as the authors indicate, that ‘the likelihood of achieving CR with either revascularization modality’ should guide the selection of CABG or PCI. The authors also advocate for consensus for a definition of IR, highlighting the value of a definition based on both anatomic and physiologic data.

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

Keywords: Outcome Assessment (Health Care), Odds Ratio, Risk, Coronary Artery Disease, Myocardial Infarction, Follow-Up Studies, Cardiovascular Diseases, Confidence Intervals, Coronary Artery Bypass, Angioplasty, Consensus, Percutaneous Coronary Intervention


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