Meta-Analysis Looks at Impact of Revascularization Plus MT in Patients With CCS

Noncardiac mortality in late follow-up in patients with chronic coronary syndrome (CCS) was similar for revascularization plus medical therapy (MT) when compared with MT alone, according to results presented at EuroPCR 2023 in Paris, France, and simultaneously published May 19 in JACC: Cardiovascular Interventions.

Eliano P. Navarese, MD, PhD, FACC, et al., conducted a large-scale meta-analysis of 18 existing trials, which included 16,908 patients, to compare elective coronary revascularization plus MT vs. MT alone in patients with CCS to see if revascularization has any impact on noncardiac mortality at the longest follow-up. The prespecified endpoint of the study was noncardiac mortality, and treatment effects were measured by rate ratios (RR) with 95% CIs using random-effect models.

The researchers compared their findings to data from the ISCHEMIA-EXTENDED trial, which reported relative excess in noncardiac-related mortality in revascularization. The ISCHEMIA-EXTENDED trial is the largest and most recent randomized comparison of coronary revascularization plus MT vs. MT alone in patients with CCS and moderate or severe inducible myocardial ischemia.

Results showed there was no significant difference in noncardiac mortality with revascularization plus MT compared with MT alone between the assigned treatment groups (RR, 1.09; 95% CI, 0.94-1.26; p=0.26), with absent heterogeneity (I2= 0%). The results were consistent without the ISCHEMIA-EXTENDED trial (RR, 1.00; 95% CI, 0.84-1.18; p=0.97). Additionally, the follow-up duration did not affect noncardiac death rates for revascularization plus MT vs. MT alone (p=0.52).

The authors note that, to their knowledge, this is the “first large-scale meta-analysis designed to systematically evaluate potential differences in noncardiac mortality between treatment strategies for CCS,” and that results support the hypothesis that “noncardiac mortality excess risk found in a single large trial is likely due to a statistical type I error.”

In an accompanying editorial comment, Harvey D. White, MB CHB, DSc, writes that the results of the meta-analysis “seem to dispel concerns about increases in noncardiac and cardiovascular deaths seen in some revascularization trials,” and has brought forward the need to analyze the cause of deaths more carefully in trials.

Keywords: Follow-Up Studies, Ischemia, Cardiovascular System, Heart, ACC International

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