Journal Club 30 July 2014

Paper

Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis

Presenter

MD

Summary

Objective

To investigate whether revascularisation improves prognosis
compared with medical treatment among patients with stable coronary
artery disease.

Design

Bayesian network meta-analyses to combine direct within trial
comparisons between treatments with indirect evidence from other trials
while maintaining randomisation.
Eligibility criteria for selecting studies A strategy of initial medical
treatment compared with revascularisation by coronary artery bypass
grafting or Food and Drug Administration approved techniques for
percutaneous revascularization: balloon angioplasty, bare metal stent,
early generation paclitaxel eluting stent, sirolimus eluting stent, and
zotarolimus eluting (Endeavor) stent, and new generation everolimus
eluting stent, and zotarolimus eluting (Resolute) stent among patients
with stable coronary artery disease.
Data sources Medline and Embase from 1980 to 2013 for randomised
trials comparing medical treatment with revascularisation.
Main outcome measure All cause mortality.

Results

100 trials in 93 553 patients with 262 090 patient years of
follow-up were included. Coronary artery bypass grafting was associated
with a survival benefit (rate ratio 0.80, 95% credibility interval 0.70 to
0.91) compared with medical treatment. New generation drug eluting
stents (everolimus: 0.75, 0.59 to 0.96; zotarolimus (Resolute): 0.65, 0.42
to 1.00) but not balloon angioplasty (0.85, 0.68 to 1.04), bare metal
stents (0.92, 0.79 to 1.05), or early generation drug eluting stents
(paclitaxel: 0.92, 0.75 to 1.12; sirolimus: 0.91, 0.75 to 1.10; zotarolimus
(Endeavor): 0.88, 0.69 to 1.10) were associated with improved survival
compared with medical treatment. Coronary artery bypass grafting
reduced the risk of myocardial infarction compared with medical treatment
(0.79, 0.63 to 0.99), and everolimus eluting stents showed a trend
towards a reduced risk of myocardial infarction (0.75, 0.55 to 1.01). The
risk of subsequent revascularisation was noticeably reduced by coronary
artery bypass grafting (0.16, 0.13 to 0.20) followed by new generation
drug eluting stents (zotarolimus (Resolute): 0.26, 0.17 to 0.40;
everolimus: 0.27, 0.21 to 0.35), early generation drug eluting stents
(zotarolimus (Endeavor): 0.37, 0.28 to 0.50; sirolimus: 0.29, 0.24 to 0.36;
paclitaxel: 0.44, 0.35 to 0.54), and bare metal stents (0.69, 0.59 to 0.81)
compared with medical treatment.

Conclusion

Among patients with stable coronary artery disease,
coronary artery bypass grafting reduces the risk of death, myocardial
infarction, and subsequent revascularisation compared with medical
treatment. All stent based coronary revascularisation technologies reduce
the need for revascularisation to a variable degree. Our results provide
evidence for improved survival with new generation drug eluting stents
but no other percutaneous revascularisation technology compared with
medical treatment.

Supplmentary Material

Visualization of the revascularization strategies by end-point sensitivity analysis that is tabulated in the paper is available here.

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