The ISCHEMIA trial found no significant difference between an invasive vs. a conservative strategy in patients with chronic coronary syndromes and moderate to severe ischemia at a mean of 3.2 years. However, the cumulative difference in the estimates of cardiac death between the invasive and conservative strategies tended to increase numerically over time (e.g., 0.3% in favor of the invasive strategy at 2 years and 1.3% at 5 years). Because the ISCHEMIA trial was not powered for cardiac mortality and did not focus on long-term follow-up, the rationale for a meta-analysis emerged.
At EuroPCR 2021, Navarese and colleagues present the results of a new meta-analysis of revascularization plus medical therapy versus medical therapy alone. A total of 19,806 patients with chronic coronary syndromes undergoing elective revascularization from 25 randomized trials were pooled, and outcomes were extracted at the longest available follow-up. The primary endpoint was cardiac death. Secondary endpoints were all-cause death, spontaneous myocardial infarction, any myocardial infarction and stroke.
The authors found a statistically significant 21% relative risk reduction in cardiac death with revascularization plus medical therapy (risk ratio 0.79, 95% confidence interval 0.67 to 0.93, p
There was a parallel significant reduction in spontaneous myocardial infarction with revascularization plus medical therapy (risk ratio 0.74, 95% confidence interval 0.64 to 0.86, p
Overall, this meta-analysis suggests that the benefits of revascularization and optimized medical therapy are additive and their combination is required to achieve maximal and durable prevention of adverse events.