Optimal medical therapy vs. coronary revascularization for patients presenting with chronic total occlusion: A meta‐analysis of randomized controlled trials and propensity score adjusted studies

Iannaccone, Mario; D’Ascenzo, Fabrizio; Piazza, Fabio Di; Benedictis, Michele De; Doronzo, Baldassarre; Behnes, Michael; Garbo, Roberto; Mashayekhi, Kambis

doi:10.1002/ccd.28037

Cited by 22 publications

(19 citation statements)

References 30 publications

(49 reference statements)

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“…Additionally, the incidence of MACE-although defined differently in the studies-did not differ significantly at several time points during follow-up. This was also demonstrated in a previous meta-analysis by Iannaccone et al [21], but observational studies were also included which could have distorted the results. It is noteworthy that both mortality rate and MACE incidence are low, even after 4 years of follow-up.…”

Section: Clinical Endpointsmentioning

confidence: 66%

Percutaneous coronary intervention versus medical therapy for chronic total coronary occlusions: a systematic review and meta-analysis of randomised trials

et al. 2020

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Background The results of chronic total occlusion percutaneous coronary intervention (CTO-PCI) trials are inconclusive. Therefore, we studied whether CTO-PCI leads to improvement of clinical endpoints and patient symptoms when combining all available randomised data. Methods and results This meta-analysis was registered in PROSPERO prior to starting. We performed a literature search and identified all randomised trials comparing CTO-PCI to optimal medical therapy alone (OMT). A total of five trials were included, comprising 1790 CTO patients, of whom 964 were randomised to PCI and 826 to OMT. The all-cause mortality was comparable between groups at 1‑year [risk ratio (RR) 1.70, 95% confidence interval (CI) 0.50–5.80, p = 0.40] and at 4‑year follow-up (RR 1.14, 95% CI 0.38–3.40, p = 0.81). There was no difference in the incidence of major adverse cardiac events (MACE) between groups at 1 year (RR 0.69, 95% CI 0.36–1.33, p = 0.27) and at 4 years (RR 0.85, 95% CI 0.60–1.22, p = 0.38). Left ventricular function and volumes at follow-up were comparable between groups. However, the PCI group had fewer target lesion revascularisations (RR 0.28, 95% CI 0.15–0.52, p < 0.001) and was more frequently free of angina at 1‑year follow-up (RR 0.65, 95% CI 0.50–0.84, p = 0.001), although the scores on the subscales of the Seattle Angina Questionnaire were comparable. Conclusion In conclusion, in this meta-analysis of 1790 CTO patients, CTO-PCI did not lead to an improvement in survival or in MACE as reported at long-term follow-up of up to 4 years, or to improvement of left ventricular function. However, CTO-PCI resulted in less angina and fewer target lesion revascularisations compared to OMT.

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Section: Clinical Endpointsmentioning

confidence: 66%

Percutaneous coronary intervention versus medical therapy for chronic total coronary occlusions: a systematic review and meta-analysis of randomised trials

et al. 2020

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“…Por último, en un metanálisis se estudiaron los 4 ensayos aleatorizados descritos previamente y 3 estudios observacionales, y no se encontraron diferencias en el objetivo compuesto primario analizado (muerte cardiovascular, infarto de miocardio y reintervención coronaria). El análisis independiente de cada uno de los componentes observó que el intervencionismo tuvo un mejor resultado en cuanto a muerte cardiovascular (OR = 0,52; IC95%, 0,33-0,81; p < 0,01), fundamentalmente a expensas de los resultados favorables en los estudios observacionales 26 .…”

Section: Estudios Observacionalesunclassified

Actualizaci�n del intervencionismo percut�neo en la oclusi�n total cr�nica

Cuevas¹,

Elorriaga²,

Sagredo³

2021

RECIC

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Palabras clave: Enfermedad arterial coronaria. Oclusión total crónica. Intervención coronaria percutánea. Cardiopatía isquémica estable. RESUMENEl tratamiento de la oclusión total coronaria (OTC) sigue siendo uno de los grandes retos de la cardiología. La complejidad del procedimiento de angioplastia de una OTC, unida a cierta controversia en cuanto al beneficio clínico, han generado resistencias en la comunidad de cardiólogos para desarrollar programas de intervención coronaria en los laboratorios de hemodinámica. Sin embargo, la evidencia proveniente de estudios observacionales indica que el intervencionismo con éxito puede aumentar de manera significativa la calidad de vida del paciente, mejorar la función ventricular izquierda, reducir la necesidad de una posterior cirugía y, posiblemente, prolongar la supervivencia. Deben tenerse en cuenta varios factores en la selección de los pacientes para el intervencionismo, como la extensión de la isquemia que rodea a la oclusión, la viabilidad miocárdica, la ubicación coronaria de la OTC y la probabilidad de éxito del procedimiento. Esta revisión proporciona una descripción general de la anatomía y de la histopatología de las OTC, la evidencia sobre el beneficio clínico del intervencionismo, el uso de sistemas de puntuación que pueden ser útiles para evaluar de forma más objetiva la probabilidad de éxito, y un resumen de las técnicas actuales para la realización del procedimiento. AbreviaturasEAC: enfermedad arterial coronaria. ICP: intervencionismo coronario percutáneo. IVUS: ecografía intravascular. MACE: evento adverso cardiovascular mayor. MDL: microcatéter de doble luz. OTC: oclusión total coronaria. Update on percutaneous coronary intervention in the management of chronic total occlusions ABSTRACTThe management of chronic total coronary occlusions (CTO) is still today one of the greatest challenges of cardiology. The complexity of the angioplasty procedure of a CTO added to its controversial clinical benefits has generated certain skepticism in the community of cardiologists when developing CTO intervention programs at the catheterization laboratory. However, the evidence from observational studies indicates that if the intervention is successful it can significantly increase the patient's quality of life, improve the left ventricular function, reduce the need for a subsequent coronary artery bypass graft, and possibly improve survival. Several factors must be taken into consideration in the selection of patients elective for an intervention, including the extent of ischemia surrounding the occlusion, the myocardial viability, the coronary location of the CTO, and the chances of being successful with the procedure. This review provides a general description of the anatomy and histopathology of the CTOs, the evidence surrounding the clinical benefit of these procedures, the use of useful scoring systems to assess more objectively the probability of success, and a summary of the latest techniques available today to perform this procedure.

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“…Previous meta-analyses on the present context were restricted to studies with propensity-matched analysis and only reported the pooled hazard ratio and often did not separately report outcomes of PCI and coronary artery bypass grafting (CABG) in comparison to OMT. 8 , 9 , 10 To overcome the lacunae of evidence, we reported the first meta-analysis incorporating both randomized and observational studies. 11 The aim of the present study was to conduct a meta-analysis of published data of observational as well as randomized studies comparing long term outcomes of PCI with OMT versus OMT alone in patients with CTO ( Online supplemental material, Supplement 1, PICO strategy ).…”

Section: Introductionmentioning

confidence: 99%

Percutaneous coronary intervention provided better long term results than optimal medical therapy alone in patients with chronic total occlusion: A meta-analysis

Khanra

Mishra

Jain

et al. 2020

Indian Heart Journal

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Aims Studies comparing the outcome of percutaneous coronary intervention (PCI) along with optimal medical therapy (OMT) versus OMT alone in treatment of chronic total occlusion (CTO) are limited by observational design, variable follow-up period, diverse clinical outcomes, high drop-out and cross-over rates. This study aims to conduct a meta-analysis of published data of observational as well as randomized studies comparing long term outcomes of PCI+OMT versus OMT alone. Methods and results PubMed, Embase and Cochrane databases were systematically reviewed. 15 studies meeting criteria were included in the meta-analysis. The New-castle Ottawa scale was used to appraise the overall quality of the studies. Random-effects model with inverse variance method was undertaken. Major adverse cardiovascular events (MACE) which comprises of cardiac death, myocardial infarction, stroke, and un-planned revascularization were significantly lower in the PCI+OMT group (RR:0.76; 95% CI:0.61 to 0.95; P=<0.00001; I 2 = 85%). All-cause mortality and cardiac death were significantly lower in the PCI+OMT group (P=<0.00001 in both). Myocardial infarction and stroke rates were lower in the PCI+OMT group, however they did not reach statistical significance (P = 0.24, P = 0.15 respectively). Unplanned revascularizations (of any vessel) were also similar in both the groups (P = 0.78, I 2 = 88%). Conclusion PCI of CTO is rewarded with better long term outcome, in terms of MACE, all-cause mortality and cardiac death with similar rates of un-planned revascularization.

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Optimal medical therapy vs. coronary revascularization for patients presenting with chronic total occlusion: A meta‐analysis of randomized controlled trials and propensity score adjusted studies

Cited by 22 publications

References 30 publications

Percutaneous coronary intervention versus medical therapy for chronic total coronary occlusions: a systematic review and meta-analysis of randomised trials

Percutaneous coronary intervention versus medical therapy for chronic total coronary occlusions: a systematic review and meta-analysis of randomised trials

Actualizaci�n del intervencionismo percut�neo en la oclusi�n total cr�nica

Percutaneous coronary intervention provided better long term results than optimal medical therapy alone in patients with chronic total occlusion: A meta-analysis

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