Stable coronary artery disease: CABG reduces the risk of death, myocardial infarction, and subsequent revascularisation compared with medical treatment


It has been investigated whether revascularisation improves prognosis compared with medical treatment among patients with stable coronary artery disease.

A large number of trials compared the different revascularisation strategies, including coronary artery bypass grafting, balloon angioplasty, and percutaneous coronary intervention with bare metal stents or with various FDA approved drug eluting stents [ early generation Paclitaxel eluting stent, Sirolimus eluting stent, and Zotarolimus eluting ( Endeavor ) stent, and new generation Everolimus eluting stent, and Zotarolimus eluting ( Resolute ) stent ] against medical treatment, as well as different revascularisation strategies head to head.

Data sources were randomised trials comparing medical treatment with revascularisation from 1980 to 2013.

The primary endpoint was all cause mortality.

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.

In 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.
The results provide evidence for improved survival with new generation drug eluting stents but no other percutaneous revascularisation technology compared with medical treatment. ( Xagena )

Windecker S et al, BMJ 2014;348:g3859

XagenaMedicine_2014



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