Table 2.
Updated Meta-Analysis of RCTs of PCI With DES vs CABG for LMCA Disease
| Giacoppo et al43 | Palmerini et al44 | Head et al45 | Ahmad et al46 | Kuno et al49 | D’Ascenzo et al50 | Sabatine et al51 | |
|---|---|---|---|---|---|---|---|
| Publication year | 2017 | 2017 | 2018 | 2020 | 2020 | 2021 | 2021 |
| Number of RCTs | 4 | 6 | 11 | 5 | 4 | 4 | 4 |
| Number of participants, (PCI/CABG) | 4,394 (2,197/2,197) | 4,686 (2,347/2,339) | 4,478 of 11,518 (38.9%) had LMCA disease (2,233/2,245) |
4612 (2,303/2,309) | 4,394 (not reported specific numbers for PCI/CABG) | 4,394 (2,197/2,197) | 4,394 (2,197/2,197) |
| Mean follow-up duration | Not reported (1 RCT had a 3-y follow-up; 3 RCTs reported 5-y follow-up) | 39 months | 3.4 y | 67.1 months | Not reported (included trials with at least a 5-y follow-up) | Not reported (included trials with at least a 5-y follow-up) | Not reported (included trials with at least a 5-y follow-up) |
| Primary outcome | A composite of all-cause death, MI, or stroke | All-cause mortality | All-cause mortality | All-cause mortality | All-cause mortality | All-cause mortality | All-cause mortality |
| Pooled estimate for primary outcome | HR: 1.06; 95% CI: 0.85-1.32; P = 0.60 | HR: 0.99; 95% CI: 0.76-1.30; P = 0.74 | HR 1.07; 95% CI: 0.87-1.33; P = 0.52 | RR: 1.03; 95% CI: 0.81-1.32; P = 0.78 | HR: 1.11; 95% CI: 0.91–1.35; P = 0.30 | ORa: 0.93; 95% CI 0.71-1.21; P = 0.58 | HR: 1.10; 95% CI: 0.91-1.32; P = 0.33 |
| Additional analyses and secondary outcomes | Primary outcome in patients with low to intermediate SYNTAX score: HR: 1.02; 95% CI: 0.74-1.41; P = 0.89 Repeat revascularization: HR: 1.70; 95% CI 1.42-2.05; P < 0.001 All cause-death: HR: 1.04; 95% CI: 0.81-1.31; P = 0.77 Cardiac death: HR: 1.00; 95% CI: 0.72-1.31; P = 0.77 MI: HR: 1.48; 95% CI: 0.85-2.58; P = 0.17 Stroke: HR: 0.87; 95% CI: 0.39-1.92; P = 0.72 |
Cardiac mortality: HR: 1.01; 95% CI: 0.72-1.42; P = 0.83 Significant interaction for cardiac mortality between treatment and SYNTAX score: P for interaction = 0.03 MI: HR: 1.33; 95% CI: 0.84-2.11; P = 0.11 Stroke: HR: 0.71; 95% CI: 0.34-1.49; P = 0.31 Unplanned revascularization: HR: 1.74; 95% CI: 1.47-2.07; P < 0.001 All-cause death, MI, or stroke: HR: 1.06; 95% CI: 0.82-1.37; P = 0.39 |
In diabetic patients with LMCA disease: HR: 1.34; 95% CI 0.93-1.91; P = 0.11 For nondiabetic patients with LMCA disease: HR: 0.94; 95% CI: 0.72-1.23; P = 0.65; P for interaction = 0.13 LMCA disease with SYNTAX score 0-22: HR: 0.91; 95% CI: 0.60-1.36; P = 0.64 SYNTAX score 23-32: HR: 0.92; 95% CI: 0.65-1.30; P = 0.65 SYNTAX score ≥33: HR: 1.39; 95% CI: 0.94-2.06; P = 0.10; P for interaction = 0.38 |
Cardiac mortality: RR: 1.03; 95% CI: 0.79-1.34; P = 0.82 Stroke: RR: 0.74; 95% CI: 0.35-1.50; P = 0.40 MI: RR: 1.22; 95% CI: 0.96-1.56; P = 0.11 Unplanned revascularization: RR: 1.73; 95% CI: 1.49-2.02; P < 0.001 |
Cardiac mortality: HR: 1.13; 95% CI: 0.88-1.44; P = 0.34 MI: HR: 1.48; 95% CI: 0.88-2.48; P = 0.14 Stroke: HR: 0.81; 95% CI: 0.42–1.53; P = 0.53 Repeat revascularization: HR: 1.80; 95% CI: 1.52-2.13; P < 0.01 |
Cardiac mortality: ORa: 0.95; 95% CI: 0.68-1.32; P = 0.75 MACCEs (including repeat revascularization): ORa: 0.69; 95% CI: 0.60-0.79; P < 0.00001 MI: ORa: 0.48; 95% CI: 0.36-0.65; P < 0.0001 Repeat revascularization: ORa: 0.53; 95% CI: 0.45-0.64; P < 0.0001 Stroke: ORa: 1.17; 95% CI: 0.59-2.31; P = 0.66 |
Cardiac mortality: HR: 1.07; 95% CI: 0.83-1.37; P = 0.61 MI: HR: 2.35; 95% CI:1.71-3.23; P < 0.0001 Stroke: HR: 0.84; 95% CI: 0.59-1.21; P = 0.36 Repeat revascularization: HR: 1.78; 95% CI: 1.51-2.10; P < 0.0001 Bayesian analysis: 85.7% probability that death at 5 years was greater with PCI than with CABG (probably <1.0%; <0.2%/y) |
| Key findings | PCI and CABG showed comparable outcomes at 3-5 y of follow-up. | PCI had a similar risk of mortality compared with CABG, with an interaction effect suggesting relatively lower mortality with PCI in patients with low SYNTAX scores and relatively lower mortality with CABG in patients with high SYNTAX scores. | Patients with LMCA disease had similar survival with PCI and CABG, regardless of diabetes and SYNTAX score. | PCI with DES showed similar long-term mortality compared with CABG in patients with LMCA disease. | PCI with DES showed similar long-term mortality compared with CABG in patients with LMCA disease. | PCI with DES showed similar long-term mortality compared with CABG in patients with LMCA disease. | PCI with DES showed similar long-term mortality compared with CABG in patients with LMCA disease. |
LMCA = left main coronary artery; MACCE = major adverse cardiac or cerebrovascular event; MI = myocardial infraction; OR = odds ratio; RCT = randomized clinical trial; RR = relative risk; other abbreviations as in Table 1.
a
ORs for CABG as compared with PCI.