Revascularization or Optimal Medical Therapy for Stable Ischemic Heart Disease: A Bayesian Meta-Analysis of Contemporary Trials

Ashish Kumar; Rajkumar Doshi; Safi U Khan; Mariam Shariff; Jeswin Baby; Monil Majmundar; Anmar Kanaa'N; David P Hedrick; Rishi Puri; Grant Reed; Roxana Mehran; Samir Kapadia; Umesh N Khot; Ankur Kalra

doi:10.1016/j.carrev.2021.12.005

Revascularization or Optimal Medical Therapy for Stable Ischemic Heart Disease: A Bayesian Meta-Analysis of Contemporary Trials

Cardiovasc Revasc Med. 2022 Jul:40:42-47. doi: 10.1016/j.carrev.2021.12.005. Epub 2021 Dec 9.

Authors

Ashish Kumar¹, Rajkumar Doshi², Safi U Khan³, Mariam Shariff⁴, Jeswin Baby⁵, Monil Majmundar⁶, Anmar Kanaa'N⁷, David P Hedrick⁸, Rishi Puri⁹, Grant Reed⁹, Roxana Mehran¹⁰, Samir Kapadia⁹, Umesh N Khot⁹, Ankur Kalra¹¹

Affiliations

¹ Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA.
² Department of Cardiology, St. Joseph's Medical Centre, Paterson, NJ, USA.
³ Department of Internal Medicine, West Virginia University, Morgantown, WV, USA.
⁴ Department of General Surgery, Mayo Clinic, Rochester, MN, USA.
⁵ Division of Epidemiology and Biostatistics, St John's Research Institute, Bangalore, India; Department of Statistical Sciences, Kannur University, Kerala, India.
⁶ Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, NYC, USA.
⁷ Heart, Vascular and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA.
⁸ Heart, Vascular and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
⁹ Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
¹⁰ The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
¹¹ Heart, Vascular and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address: kalraa@ccf.org.

PMID: 35210188
DOI: 10.1016/j.carrev.2021.12.005

Abstract

Background: The role of revascularization in patients with stable ischemic heart disease (SIHD) has been controversial, more so in the present era of drug-eluting stents.

Aims: To examine the absolute risk difference (ARD) between revascularization plus optimal medical therapy (OMT) versus OMT alone among patients with SIHD using Bayesian approach.

Methods: PubMed/MEDLINE and Cochrane citation indices were utilized to identify randomized controlled trials (RCTs) through March 31, 2020. Among trials comparing initial revascularization plus OMT with initial OMT alone, revascularization arm must have comprised >50% of patients receiving either percutaneous or surgical revascularization, and >50% of patients must have received aspirin and statin as OMT in both arms.

Results: Seven RCTs (12,494) were included in the final analysis. The ARD of all-cause mortality for revascularization with respect to OMT was centred at -0.002 (95% CrI: -0.01; 0.01, Tau: 0.01, 67% probability of ARD of revascularization vs. OMT < 0). The ARD for cardiac mortality was centred at -0.0025 (95%CrI: -0.01; 0.01, Tau: 0.01, 77% probability of ARD of revascularization vs. OMT < 0). The ARD for MI was -0.02 (95% CrI: -0.06; 0.00, Tau: 0.02, 97% probability of ARD for revascularization vs. OMT < 0). There was 96% probability of ARD for unstable angina with revascularization vs. OMT < 0, 4.5% probability of ARD for freedom from angina with revascularization vs. OMT < 0, and 6% probability of ARD for stroke with revascularization vs. OMT < 0.

Conclusions: Bayesian analysis demonstrated minimal probability of difference in all-cause mortality and cardiac mortality in patients with SIHD who underwent revascularization compared with OMT alone. However, revascularization was associated with lower probability of MI, unstable angina, and increased freedom from angina, but a higher risk of stroke compared with OMT alone.

Prospero: The protocol of this systematic review and meta-analysis was registered in PROSPERO [CRD42020160540].

Keywords: Optimal medical therapy; Revascularization; Stable angina.

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Angina Pectoris
Angina, Unstable
Bayes Theorem
Coronary Artery Disease*
Drug-Eluting Stents*
Humans
Myocardial Ischemia* / therapy
Percutaneous Coronary Intervention*
Stroke* / therapy
Treatment Outcome