Abstract 2448: The Effect of Revascularization on Outcomes of Patients with Stable Coronary Artery Disease
Background: Whereas early revascularization results in improved outcomes among patients with acute coronary syndromes, the role of revascularization for patients with stable coronary artery disease is controversial. We therefore conducted a meta-analysis of randomized clinical trials comparing surgical or percutaneous revascularization with medical therapy to determine the impact of revascularization on outcomes.
Methods: Medline and Cochrane databases were searched to identify relevant trials. Twenty-two studies published from 1977–2007 were identified for inclusion in the analysis. Follow-up ranged from 1 to 7 years. A random effects model was used to calculate risk ratios (RR) for the 2 primary outcomes of interest: death and nonfatal myocardial infarction.
Results: The 22 trials enrolled 10,201 patients of whom 5,026 were randomized to revascularization and 5,175 were randomized to medical therapy. The RR for revascularization versus medical therapy for mortality was 0.78 (95% Confidence Interval (CI), 0.67 to 0.91, P=0.001). The P value for heterogeneity was nonsignificant. To control for changes in medical therapy over time and the shift in the predominant revascularization modality evaluated in trials from surgical to percutaneous, the impact of revascularization was assessed among studies performed before and after 1995. The RR for revascularization in studies completed before 1995 was 0.69 (95% CI, 0.56 to 0.86, P=0.001) whereas in studies performed after 1995 the RR for revascularization was 0.82 (95% CI, 0.72 to 1.05, P= 0.14). The difference in RR between the 2 time periods was not significant (P=0.27 by ANOVA). Similarly, there was no significant difference in RR (P=0.27 by ANOVA) if the revascularization modality was surgical (RR=0.67), percutaneous (RR=0.90) or a combination (RR=0.77). Revascularization was not associated with a significant reduction in risk of nonfatal myocardial infarction (RR= 0.90, 95% CI, 0.75 to 1.06, P= 0.21).
Conclusion: This analysis suggests that revascularization in patients with stable coronary artery disease results in significantly improved survival without reducing the risk of nonfatal myocardial infarction.