Revascularization or Medical Therapy for Stable Ischemic Heart Disease

Quick Takes

  • This meta-analysis reports that a routine revascularization approach was not associated with reduced risks of death, cardiovascular death, overall MI, heart failure, or stroke.
  • Of note, freedom from angina was greater with a revascularization strategy.
  • These observations along with the results of the contemporary ISCHEMIA trial should be used in shared decision making to individualize the initial treatment approach in patients with stable ischemic heart disease.

Study Questions:

What are the outcomes of a routine revascularization strategy compared with initial treatment with medical therapy alone in patients with stable ischemic heart disease (SIHD)?

Methods:

The investigators conducted PUBMED/EMBASE/CENTRAL searches for randomized trials comparing routine revascularization versus an initial conservative strategy in patients with SIHD. The primary outcome was death. Secondary outcomes were cardiovascular death, myocardial infarction (MI), heart failure, stroke, unstable angina, and freedom from angina. Trials were stratified by percent stent use and by percent statin use to evaluate outcomes in contemporary trials. Meta-analysis was performed using both a random-effects model (DerSimonian and Laird) and a fixed-effect model.

Results:

Fourteen randomized controlled trials that enrolled 14,877 patients followed up for a weighted mean of 4.5 years with 64,678 patient-years of follow-up fulfilled the inclusion criteria. Most trials enrolled patients with preserved left ventricular systolic function and low symptom burden, and excluded patients with left main disease. Revascularization compared with medical therapy alone was not associated with a reduced risk of death (relative risk [RR], 0.99; 95% confidence interval [CI], 0.90-1.09). Trial sequential analysis showed that the cumulative z-curve crossed the futility boundary indicating firm evidence for lack of a 10% or greater reduction in death. Revascularization was associated with a reduced nonprocedural MI (RR, 0.76; 95% CI, 0.67-0.85), but also with increased procedural MI (RR, 2.48; 95% CI, 1.86-3.31), with no difference in overall MI (RR, 0.93; 95% CI, 0.83-1.03). A significant reduction in unstable angina (RR, 0.64; 95% CI, 0.45-0.92) and increase in freedom from angina (RR, 1.10; 95% CI, 1.05-1.15) was also observed with revascularization. There were no treatment-related differences in the risk of heart failure or stroke.

Conclusions:

The authors concluded that in patients with SIHD, routine revascularization was not associated with improved survival, but was associated with a lower risk of nonprocedural MI and unstable angina with greater freedom from angina at the expense of higher rates of procedural MI.

Perspective:

This meta-analysis reports that a routine revascularization approach was not associated with reduced risks of death, cardiovascular death, overall MI, heart failure, or stroke. However, revascularization was associated with reduced risks of nonprocedural MI and unstable angina, at the cost of an increased risk of procedural MI. In addition, freedom from angina was greater with revascularization. Additional longer-term follow-up from clinical trials is warranted to determine whether the observed reduction in nonprocedural MI with routine revascularization improves long-term survival. These observations along with the results of the contemporary ISCHEMIA trial should be used in shared decision making to individualize the initial treatment approach in patients with SIHD.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Acute Heart Failure, Interventions and Coronary Artery Disease

Keywords: Angina Pectoris, Angina, Unstable, Coronary Artery Disease, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Medical Futility, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Risk, Secondary Prevention, Stents, Stroke


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