Abstract 13660: Initial Revascularization in Chronic Coronary Syndromes With Myocardial Ischemia

Introduction: Ischemic heart disease is the leading cause of death worldwide. It is unknown whether initial revascularization using percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG) plus optimal medical therapy (OMT) in patients with chronic coronary syndromes (CCS), obstructive coronary artery disease (CAD) and myocardial ischemia improves hard clinical outcomes compared to OMT alone. Hypothesis: In CCS patients with obstructive CAD and documented myocardial ischemia, initial revascularization plus OMT does not reduce death or nonfatal myocardial infarction (MI) compared to OMT alone. Methods: We searched Ovid Medline, Embase, Scopus, and Cochrane Library databases from inception to March 2020 for randomized controlled trials (RCTs) of PCI or CABG and OMT vs OMT alone for CCS patients in whom stents and statins were used in more than 50% of patients. Random-effects models were used to estimate average treatment effects across trials. The co-primary outcomes were all-cause death and nonfatal MI at 5 years. Results: Six RCTs were identified that randomized 10,020 CCS patients. At 5 years, among 5,025 CCS patients assigned to revascularization plus OMT, there were 492 deaths (9.8%) compared to 482 deaths among 4,995 patients (9.6%) assigned to OMT (OR, 1.01, 95% CI: 0.88-1.16; P=0.87). There were 521 nonfatal MIs (10.3%) in those assigned to revascularization plus OMT compared with 593 MIs (11.9%) in those assigned to OMT arms (OR, 0.78, 95% CI: 0.58-1.05; P=0.10). In subgroup analysis, nonfatal MI was not reduced by PCI plus OMT (OR, 0.95, 95% CI: 0.74-1.23, P=0.71) but was significantly reduced in studies of CABG plus OMT compared to OMT alone (OR, 0.38, 95% CI: 0.23-0.64, P<0.001). The overall effect of CABG on reducing nonfatal MI was significantly greater than that of PCI (P=0.002). Conclusions: In patients with CCS and myocardial ischemia, initial revascularization with PCI or CABG plus OMT was not associated with a reduction in death at 5 years compared to OMT alone. CABG plus OMT reduced nonfatal MI compared to OMT alone whereas PCI did not. These findings suggest important differences in MI outcomes between those who undergo CABG vs. PCI, but no overall difference in mortality compared with OMT alone.