Bayesian Methods Affirm the Use of Percutaneous Coronary Intervention to Improve Survival in Patients with Unprotected Left Main Coronary Artery Disease
Background—Several randomized clinical trials (RCTs) support the use of coronary artery bypass grafting (CABG) for patients with unprotected left main coronary artery disease (ULMCAD). Studies suggesting the equivalence of percutaneous coronary intervention (PCI) with CABG for this indication indirectly support the 2011 American College of Cardiology Foundation/American Heart Association Class IIa recommendation for PCI to improve survival in patients with ULMCAD. We tested whether Bayesian approaches uphold the new recommendation.
Methods and Results—We performed a Bayesian cross-design and network meta-analysis of 12 studies (4 RCTs and 8 observational studies) comparing CABG with PCI (N=4,574 patients) and of 7 studies (2 RCTs and 5 observational studies) comparing CABG with medical therapy (MT, N=3,224 patients). The odds ratios (ORs) of 1-year mortality after PCI compared with CABG using Bayesian cross-design meta-analysis were not different among RCTs (OR 0.99, 95% Bayesian credible interval [BCI] 0.67-1.43), matched cohort studies (OR 1.10, 95% BCI 0.76-1.73), and other types of cohort studies (OR 0.93, 95% BCI 0.58-1.35). A network meta-analysis suggested that MT is associated with higher 1-year mortality than the use of PCI for patients with ULMCAD (OR 3.22, 95% BCI 1.96-5.30).
Conclusions—Bayesian methods support the current guidelines, which were based on traditional statistical methods and have proposed that PCI like CABG, as compared with MT, improves survival for patients with ULMCAD. An integrated approach using both direct and indirect evidence may yield new insights to enhance the translation of clinical-trial data into practice.
- Bayesian analysis
- left main coronary artery stenosis
- angioplasty and stenting
- bypass surgery
- randomized controlled trial
- Received December 13, 2012.
- Revision received April 3, 2013.
- Accepted April 12, 2013.