Revascularization or Optimal Medical Therapy for Stable Ischemic Heart Disease: A Bayesian Meta-Analysis of Contemporary Trials

Why percutaneous revascularisation might not reduce the risk of myocardial infarction and mortality in patients with stable CAD?

“…6 Aiming at reconciling the discrepancies between previous studies and increasing the statistical power of available estimates, a number of meta-analyses have been performed. [7][8][9][10][11][12] Pooling 14 trials and nearly 15 000 patients, Bangalore et al 7 showed no difference in terms of survival and MI, although the latter finding resulted from a reduced risk of spontaneous MI in the face of higher frequency of periprocedural events. Soares et al 10 showed benefit of CABG (but not PCI) on MI, with no benefit of revascularisation on mortality, and this was confirmed by a Bayesian meta-analysis from Kumar et al 8 In contrast, Navarese et al 9 found lower cardiac death in the revascularisation arm but of note, at meta-regression, the prognostic benefit of revascularisation was linearly correlated with follow-up length, but also with the prevalence of three-vessel disease, supporting the hypothesis that survival benefit may be more evident in patients with an extensive burden of disease, in whom CABG (rather than PCI) may be more effective in reducing both spontaneous MI and mortality in the long-term.…”

“…Soares et al 10 showed benefit of CABG (but not PCI) on MI, with no benefit of revascularisation on mortality, and this was confirmed by a Bayesian meta-analysis from Kumar et al . 8 In contrast, Navarese et al 9 found lower cardiac death in the revascularisation arm but of note, at meta-regression, the prognostic benefit of revascularisation was linearly correlated with follow-up length, but also with the prevalence of three-vessel disease, supporting the hypothesis that survival benefit may be more evident in patients with an extensive burden of disease, in whom CABG (rather than PCI) may be more effective in reducing both spontaneous MI and mortality in the long-term. Notably, a broad proportion of studies included by Navarese et al enrolled CABG-treated patients, with CABG being the only strategy tested against OMT in a significant proportion of cases.…”

Angiographic complete revascularization versus incomplete revascularization in patients with diabetes mellitus

“…Routine invasive therapy has been shown to reduce adverse events in acute coronary syndrome patients [ 9 ]. Recent Bayesian analyses demonstrated that coronary revascularization was associated with a lower probability of future cardiac events and relief of angina compared to medical therapy [ 10 , 11 ]. In clinical practice, completeness of coronary revascularization after PCI is generally of interest as it was reported to be associated with better cardiovascular outcomes [ 12 – 16 ].…”