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

Abstract

Background Heart disease remains the leading cause of death in the United States. Although there are clear indications for revascularization in patients with acute coronary syndromes, there is debate regarding the benefits of revascularization in stable ischemic heart disease. We sought to perform a comprehensive meta‐analysis to assess the role of revascularization compared to conservative medical therapy alone in patients with stable ischemic heart disease. Hypothesis There is no significant difference in all‐cause mortality or cardiovascular mortality between invasive and medical arms. Methods We performed a systematic literature search from January 2000 to June 2020. Our literature search yielded seven randomized controlled trials. We analyzed a total of 12 013 patients (6109 in revascularization arm and 5904 in conservative medical therapy arm). Primary outcome was all‐cause mortality. Secondary outcomes included major adverse cardiac events (MACE) (death, myocardial infarction [MI], or stroke), cardiovascular mortality, MI, and stroke. Additional subgroup analysis for all‐cause mortality was performed comparing percutaneous coronary intervention (PCI) with bare metal stent versus conservative therapy; and PCI with drug eluting stent versus conservative therapy. Results There was no statistically significant difference in primary outcome of all‐cause mortality between either arm (odds ratio [OR] = 0.95; 95% CI [confidence interval], 0.83 to 1.08; p = .84). There were statistically significant lower rates of MACE (death, MI or stroke) in the revascularization arm when compared to conservative arm. Conclusions Our analysis did not show any survival advantage of an initial invasive strategy over conservative medical therapy in patients with stable coronary artery disease (CAD).

Variability of pulmonary nodule volumetry on coronary CT angiograms

“…[1,2] CCTA has replaced invasive coronary angiography in diagnosing CAD and improved clinical outcomes for these patients. [3–8] However, the increasing number of CCTA scans performed led to an increase in reported incidental extracardiac findings, with pulmonary nodules (PNs) being the most common (up to 28% of scans). [9–11]…”

“…[1,2] CCTA has replaced invasive coronary angiography in diagnosing CAD and improved clinical outcomes for these patients. [3][4][5][6][7][8] However, the increasing number of CCTA scans performed led to an increase in reported incidental extracardiac findings, with pulmonary nodules (PNs) being the most common (up to 28% of scans). [9][10][11] The Fleischner Society recommends low-dose chest CT (LD-CT) follow-up of incidental solid, noncalcified PNs measuring between 5 and 8mm since the growth rate is a better marker for malignancy than size, calcifications, and morphological characteristics.…”

IACTS position statement on “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization”: section 7.1—a consensus document

“…Hence, this meta-analysis was essentially a comparison of PCI plus medical therapy versus medical therapy [27]. Despite running the risk of sounding repetitive, it has to be highlighted that yet another meta-analysis quoted by the authors provides the same picture-4 out of 7 RCTs did not have a single patient undergoing CABG [26]. Thus, with only a minority of patients receiving CABG, and the majority getting PCI, it is only logical to conclude that the primary driver for outcomes in the revascularization group was PCI.…”

“…The accumulated wisdom over the years, scientifically documented and peer reviewed [10,[20][21][22][23][24], was unceremoniously dismissed as outdated and antiquated under the euphemism of being ">20 to 40 years ago" and pitted against "new evidence" from the ISCHEMIA trial [6] and a few other studies [19,[25][26][27][28]. However, the downgrade seems to be supported not so much by "new evidence," but by a facetious "new definition" for "revascularization," that included both CABG and PCI [6,13,[25][26][27].…”

Three Technologies That Will Guide Revascularization of Chronic Coronary Syndrome Patients into the 21st Century: A Review

“…alleviating symptoms, has not consistently translated into reduced MACE. The major CCS trials, which are well summarized in recent statistically sophisticated meta-analyses, 9,10 tell a story of equivalence, at the very least with regard to allcause mortality, of revascularization as compared with MT.…”