Abstract 8562: Lower Survival after Drug-eluting Stents than Coronary Artery Bypass Grafting for Unprotected Left Main and/or Multivessel Disease: A Meta-analysis of Randomized Trials and Risk-adjusted Observational Comparative Studies
Backgrounds: Previous meta-analyses of raw data from randomized trials and observational comparative studies have demonstrated no significant difference in survival between drug-eluting stents (DES) and coronary artery bypass grafting (CABG) for patients with unprotected left main (ULMD) and/or multivesssel disease (MVD) (double-vessel [2VD] and triple-vessel disease [3VD]). Raw data from observational studies, however, are unadjusted and susceptible to confounding.
Methods: To attempt to control for confounding in observational studies, we performed a meta-analysis of randomized trials and risk-adjusted observational comparative studies (providing adjusted hazard ratios [HRs] using propensity score and/or multivariate Cox proportional hazards regression analyses) of DES versus CABG for survival in patients with ULMD and/or MVD. Study-specific estimates were combined in a random-effects model.
Results: Our comprehensive search identified 3 randomized trials and 21 risk-adjusted observational comparative studies. Pooled analysis of 32 HRs for all-cause death from all studies (36,574 patients) demonstrated a significantly higher mortality with DES than CABG (HR, 1.22; 95% confidence interval [CI], 1.04-1.42; P=0.01). Exclusion of any single HR from the analysis did not substantively alter the overall results of our analysis. When data were pooled separately in MVD (both 2VD and 3VD)-studies (31,325 patients) and ULMD-studies (4,214 patients), DES were associated with a significantly higher mortality than CABG for MVD (HR, 1.34; 95% CI, 1.11-1.61; P=0.002), not for ULMD (HR, 0.93; 95% CI, 0.69-1.25; P=0.74). Separately pooled analysis of 3VD-studies (14,196 patients) and 2VD-studies (15,137 patients) demonstrated a significantly higher mortality with DES than CABG for 3VD (HR, 1.49; 95% CI, 1.17-1.89; P=0.001), not for 2VD (HR, 1.25; 95% CI, 0.82-1.89; P=0.29).
Conclusions: The present meta-analysis of randomized trials and risk-adjusted observational comparative studies suggests that DES are associated with lower survival than CABG for high-risk (ULMD and/or MVD) patients, mainly due to lower survival for patients with 3VD.
- © 2011 by American Heart Association, Inc.