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Cardiac Mortality With Revascularization vs. Medical Therapy Alone
Quick Takes
- The present meta-analysis reports a significantly lower risk of cardiac death among patients randomized to revascularization plus medical therapy compared with medical therapy alone.
- The cardiac survival benefit of revascularization plus medical therapy increased progressively over time, with an incremental relative risk reduction of 19% for every 4 years of follow-up extension.
- The ISCHEMIA-EXTEND study, with >5,000 participants, will assess all-cause mortality to provide robust evidence regarding survival following revascularization plus medical therapy compared with medical therapy over the long term (~10 years).
Study Questions:
Does revascularization in addition to medical therapy affect cardiac mortality at longest follow-up?
Methods:
The investigators searched MEDLINE, EMBASE, Google Scholar, and other databases from inception through November 2020 for randomized trials comparing revascularization against medical therapy alone in clinically stable coronary artery disease patients. Treatment effects were measured by rate ratios (RRs) with 95% confidence intervals (CIs), using random-effects models. Cardiac mortality was the prespecified primary endpoint. Spontaneous myocardial infarction (MI) and its association with cardiac mortality were secondary endpoints. Further endpoints included all-cause mortality, any MI, and stroke. Longest follow-up data were abstracted. The study is registered with PROSPERO (CRD42021225598).
Results:
Twenty-five trials involving 19,806 patients (10,023 randomized to revascularization plus medical therapy and 9,783 to medical therapy alone) were included. Compared with medical therapy alone, revascularization yielded a lower risk of cardiac death (RR, 0.79; 95% CI, 0.67–0.93; p < 0.01) and spontaneous MI (RR, 0.74; 95% CI, 0.64–0.86; p < 0.01). By meta-regression, the cardiac death risk reduction after revascularization, compared with medical therapy alone, was linearly associated with follow-up duration (RR per 4-year follow-up, 0.81; 95% CI, 0.69–0.96; p = 0.008), spontaneous MI absolute difference (p = 0.01) and percentage of multivessel disease at baseline (p = 0.004). Trial sequential and sensitivity analyses confirmed the reliability of the cardiac mortality findings. All-cause mortality (RR, 0.94; 95% CI, 0.87–1.01; p = 0.11), any MI (p = 0.14), and stroke risk (p = 0.30) did not differ significantly between strategies.
Conclusions:
The authors concluded that in stable coronary artery disease patients, randomization to elective coronary revascularization plus medical therapy led to reduced cardiac mortality compared with medical therapy alone.
Perspective:
The present meta-analysis reports a significantly lower risk of cardiac death among patients randomized to revascularization plus medical therapy compared with medical therapy alone. The cardiac survival benefit of revascularization plus medical therapy increased progressively over time, with an incremental relative risk reduction of 19% for every 4 years of follow-up extension. In addition, there was an association between the reduced risk of cardiac death and the difference between treatment arms in spontaneous MI. It should be noted that the meta-analysis included trials over four decades, a time when medical therapy was evolving and interventional techniques also improved. Longer-term results from more contemporary trials are key to ascertaining if the suggested reduction in cardiac death is indeed true. To that end, the ISCHEMIA-EXTEND study, with >5,000 participants, will assess all-cause mortality to provide robust evidence regarding survival following revascularization plus medical therapy compared with medical therapy over the long term (~10 years).
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease
Keywords: Cardiac Surgical Procedures, Cardiology Interventions, Coronary Artery Disease, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Risk, Risk Reduction Behavior, Secondary Prevention, Stroke
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