Effects of Percutaneous Coronary Intervention on Death and Myocardial Infarction Stratified by Stable and Unstable Coronary Artery Disease

Abstract

Background: In patients presenting with ST-segment–elevation myocardial infarction, percutaneous coronary intervention (PCI) reduces mortality when compared with fibrinolysis. In other forms of coronary artery disease (CAD), however, it has been controversial whether PCI reduces mortality. In this meta-analysis, we examine the benefits of PCI in (1) patients post–myocardial infarction (MI) who did not receive immediate revascularization; (2) patients who have undergone primary PCI for ST-segment–elevation myocardial infarction but have residual coronary lesions; (3) patients who have suffered a non–ST-segment–elevation acute coronary syndrome; and (4) patients with truly stable CAD with no recent infarct. This analysis includes data from the recently presented International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) and Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI (COMPLETE) trials. Methods and Results: We systematically identified all randomized trials of PCI on a background of medical therapy for the treatment of CAD. The ISCHEMIA trial, presented in November 2019, was eligible for inclusion. Data were combined using a random-effects meta-analysis. The primary end point was all-cause mortality. Forty-six trials, including 37 757 patients, were eligible. In the 3 unstable scenarios, PCI had the following effects on mortality: unrevascularized post-MI relative risk (RR) 0.68 (95% CI, 0.45–1.03); P =0.07; multivessel disease following ST-segment–elevation myocardial infarction (RR, 0.84 [95% CI, 0.69–1.04]; P =0.11); non–ST-segment–elevation acute coronary syndrome (RR, 0.84 [95% CI, 0.72–0.97]; P =0.02). Overall, in these unstable scenarios PCI was associated with a significant reduction in mortality (RR, 0.84 [95% CI, 0.75–0.93]; P =0.02). In unstable CAD, PCI also reduced cardiac death (RR, 0.69 [95% CI, 0.53–0.90]; P =0.007) and MI (RR, 0.74 [95% CI, 0.62–0.90]; P =0.002). For stable CAD, PCI did not reduce mortality (RR, 0.98 [95% CI, 0.87–1.11]), cardiac death (RR, 0.89 [95% CI, 0.71–1.12]; P =0.33), or MI (RR, 0.96 [95% CI, 0.86–1.08]; P =0.54). Conclusions: PCI prevents death, cardiac death, and MI in patients with unstable CAD. For patients with stable CAD, PCI shows no evidence of an effect on any of these outcomes.

Sex Differences in the Incidence and Outcomes of Acute Myocardial Infarction in Spain, 2016–2018: A Matched-Pair Analysis

“…This is a relevant issue, since women may be more vulnerable than men to long-standing untreated ischemia [ 20 ]. The reason for the lower use of coronary revascularization in women is unclear, since the use of CABG or PCI has been associated with a lower IHM in previous research works [ 16 , 21 ]. This less invasive pattern in women has been formerly discussed by other investigators [ 6 , 16 , 21 , 22 ].…”

“…The reason for the lower use of coronary revascularization in women is unclear, since the use of CABG or PCI has been associated with a lower IHM in previous research works [ 16 , 21 ]. This less invasive pattern in women has been formerly discussed by other investigators [ 6 , 16 , 21 , 22 ]. Older studies speculated that women are less likely to receive timely in-hospital reperfusion therapy due to prehospital delays in hospital presentation [ 19 ], but the influence of this circumstance on PCI or CABG should be lower than on pharmacologic thrombolysis.…”

Invasive therapy versus conservative therapy for patients with stable coronary artery disease: An updated meta‐analysis

“…Although the field of coronary interventions has come a long way in PCI techniques and equipment, multiple prior meta‐analyses have either shown limited 30‐34 or no difference in outcomes between PCI and conservative therapy 35,36 . There have been several postulations as to why that is.…”

Coronary Revascularization and Long-Term Survivorship in Chronic Coronary Syndrome

“…A recent meta-analysis based on available data from randomized controlled trials has emphasized that PCI revascularization in addition to OMT had no evident effect on all-cause mortality, cardiac mortality, or myocardial infarction [ 49 ]. Randomized trials have also been performed to compare the safety and efficacy of CABG vs. PCI in patients with CCS.…”

“…In synthesis, by the 2010s indisputable evidence showing prolonged survival after PCI in acute coronary syndrome (ACS) [ 49 ] had still not been replicated in CCS patients ( Figure 1 ) and the interpretation of results derived from trials carried out throughout the previous three decades was still questionable [ 55 ]. Beyond a certain superiority of CABG over PCI and OMT alone in patients with extensive coronary disease (especially those with diabetes) and of PCI over OMT alone in terms of soft events (unplanned procedures and symptom improvement), no significant reduction in mortality by revascularization in CCS patients was reported.…”