Preferred Revascularization Strategies in Patients with Ischemic Heart Failure: A Meta-Analysis

Abstract

Clinically, coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) is generally used to treat patients with ischemic heart failure. However, the optimal treatment strategy remains unknown. This study examined the efficacy of the two coronary revascularization strategies for severe ischemic heart failure by using a meta-analysis. Studies comparing the efficacy of CABG and PCI were obtained from PubMed, EMBASE, Google Scholar and Cochrane Central Register of Controlled Trials (CENTRAL). The quality of each eligible article was evaluated by Newcastle-Ottawa Quality Assessment Scale (NOS), and the meta-analysis was performed using Stata version 12.0 software. Eventually, 12 studies involving 9248 patients (n=4872 in CABG group; n=4376 in PCI group) were subject to the meta-analysis for subsequent pooling calculation. The pooled hazard ratio (HR) [HR=0.83, 95% CI (0.76, 0.90), P<0.001; heterogeneity, P=0.218, I²=22.9%] of CABG compared with that of PCI revealed a statistical superiority of CABG to PCI in terms of the long-term mortality. Furthermore, CABG showed more advantages over PCI with respect to the incidence of myocardial infarction [HR=0.51, 95% CI (0.39, 0.67), P<0.001; heterogeneity, P=0.707, I²=0%] and repeat revascularization [HR=0.40, 95% CI (0.27, 0.59), P<0.001; heterogeneity, P<0.001, I²=80.1%]. It was concluded that CABG appears to be more advantageous than PCI for the treatment of ischemic heart failure in the given clinical setting.

Keywords

coronary artery disease / ischemic heart failure / left ventricular ejection fraction / coronary artery bypass grafting / percutaneous coronary intervention

References

[1] Lancet, 2015, 385(9963):

[2] LeeMS, YangT, DhootJ, et al.. Meta-analysis of studies comparing coronary artery bypass grafting with drug-eluting stenting in patients with diabetes mellitus and multivessel coronary artery disease. Am J Cardiol, 2010, 105(11): 1540-1544

[3] GhaliJK. Ischemic heart failure. J La State Med Soc, 1995, 147(5): 202-207

[4] BolliR, MarbanE. Molecular and cellular mechanisms of myocardial stunning. Physiol Rev, 1999, 79(2): 609-634

[5] RamanathanK, AbelJ, ParkJ, et al.. Surgical versus percutaneous coronary revascularization in patients with diabetes and acute coronary syndromes. J Am Coll Cardiol, 2017, 70(24): 2995-3006

[6] KulikA. Quality of life after coronary artery bypass graft surgery versus percutaneous coronary intervention: what do the trials tell us. Curr Opin Cardiol, 2017, 32(6): 707-714

[7] FortierJ, ShawR, GlineurD, et al.. Percutaneous coronary intervention versus coronary artery bypass grafting: where are we after NOBLE and EXCEL. Curr Opin Cardiol, 2017, 32(6): 699-706

[8] WellsGA, SheaBJ, O'ConnellD, et al.. The Newcastle–Ottawa Scale (NOS) for assessing the quality of non-randomized studies in meta-analysis, 2014

[9] MoherD, LiberatiA, TetzlaffJ, et al.. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ, 2009, 339: b2535

[10] AhnJM, OhJH, SunBJ, et al.. AS-230 comparisons of drug-eluting stents vs. coronary-artery bypass grafting for patients with multi-vessel disease and severely compromised ventricular dysfunction. Am J Cardiol, 2011, 107: 87A

[11] BangaloreS, GuoY, SamadashviliZ, et al.. Revascularization in patients with multivessel coronary artery disease and severe left ventricular systolic dysfunction: Everolimus-eluting stents versus coronary artery bypass graft surgery. Circulation, 2016, 133(22): 2132-2140

[12] BuszmanP, SzkrobkaI, GruszkaA, et al.. Comparison of effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention in patients with ischemic cardiomyopathy. Am J Cardiol, 2007, 99(1): 36-41

[13] ClelandJG, CalvertM, FreemantleN, et al.. The Heart Failure Revascularisation Trial (HEART). Eur J Heart Fail, 2011, 13(2): 227-233

[14] GioiaG, MatthaiW, GillinK, et al.. Revascularization in severe left ventricular dysfunction: outcome comparison of drug-eluting stent implantation versus coronary artery by-pass grafting. Catheter Cardiovasc Interv, 2007, 70(1): 26-33

[15] HannanEL, WuC, WalfordG, et al.. Drugeluting stents vs. coronary-artery bypass grafting in multivessel coronary disease. N Engl J Med, 2008, 358(4): 331-341

[16] LaBarberaM, HuiP, ShawR. Coronary artery disease in patients with reduced left ventricular systolic function treated with medicine, surgery, or percutaneous coronary intervention: a retrospective review of outcomes within a multicenter healthcare system. J Am Coll Cardiol, 2012, 60(17): B107

[17] MaruiA, KimuraT, NishiwakiN, et al.. Comparison of five-year outcomes of coronary artery bypass grafting versus percutaneous coronary intervention in patients with left ventricular ejection fractions</=50% versus >50% (from the CREDO-Kyoto PCI/CABG Registry Cohort-2). Am J Cardiol, 2014, 114(7): 988-996

[18] NagendranJ, NorrisCM, GrahamMM, et al.. Coronary revascularization for patients with severe left ventricular dysfunction. Ann Thorac Surg, 2013, 96(6): 2038-2044

[19] FortunaD, NicoliniF, GuastarobaP, et al.. Coronary artery bypass grafting vs percutaneous coronary intervention in a 'real-world' setting: a comparative effectiveness study based on propensity scorematched cohorts. Eur J Cardio-Thorac Sur, 2013, 44(1): E16-E24

[20] TodaK, MackenzieK, MehraMR, et al.. Revascularization in severe ventricular dysfunction (15% < OR = LVEF < OR = 30%): a comparison of bypass grafting and percutaneous intervention. Ann Thorac Surg, 2002, 74(6): 2082-2087

[21] YangJH, ChoiSH, SongYB, et al.. Long-term outcomes of drug-eluting stent implantation versus coronary artery bypass grafting for patients with coronary artery disease and chronic left ventricular systolic dysfunction. Am J Cardiol, 2013, 112(5): 623-629

[22] BarnesE, DutkaDP, KhanM, et al.. Effect of repeated episodes of reversible myocardial ischemia on myocardial blood flow and function in humans. Am J Physiol Heart Circ Physiol, 2002, 282(5): H1603-H1608

[23] CamiciPG, PrasadSK, RimoldiOE. Stunning, hibernation, and assessment of myocardial viability. Circulation, 2008, 117(1): 103-114

[24] LangRM, BierigM, DevereuxRB, et al.. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr, 2005, 18(12): 1440-1463

[25] MorrisonDA, SethiG, SacksJ, et al.. Percutaneous coronary intervention versus coronary artery bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass: a multicenter, randomized trial. Investigators of the Department of Veterans Affairs Cooperative Study #385, the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME). J Am Coll Cardiol, 2001, 38(1): 143-149

[26] AldermanEL, AndrewsK, BostJ, et al.. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med, 1996, 335(4): 217-225

[27] BundhunPK, PursunM, TeeluckAR, et al.. Adverse cardiovascular outcomes associated with coronary artery bypass surgery and percutaneous coronary intervention with everolimus eluting stents: A metaanalysis. Sci Rep, 2016, 6: 35869

[28] FihnSD, BlankenshipJC, AlexanderKP, et al.. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation, 2014, 130(19): 1749-1767

[29] WindeckerS, KolhP, AlfonsoF, et al.. 2014 ESC/ EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J, 2014, 35(37): 2541-2619

[30] SchwannTA, EngorenM, BonnellM, et al.. Comparison of late coronary artery bypass graft survival effects of radial artery versus saphenous vein grafting in male and female patients. Ann Thorac Surg, 2012, 94(5): 1485-1491

[31] MosesJW, LeonMB, PopmaJJ, et al.. Sirolimuseluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med, 2003, 349(14): 1315-1323

[32] MaslowAD, ReganMM, PanzicaP, et al.. Precardiopulmonary bypass right ventricular function is associated with poor outcome after coronary artery bypass grafting in patients with severe left ventricular systolic dysfunction. Anesth Analg, 2002, 95(6): 1507-1518

[33] CaoC, ManganasC, HortonM, et al.. Angiographic outcomes of radial artery versus saphenous vein in coronary artery bypass graft surgery: a meta-analysis of randomized controlled trials. J Thorac Cardiovasc Surg, 2013, 146(2): 255-261