20-Year Meta-Analysis Studies PCI for Nonacute CAD

March 14, 2009—In The Lancet, Thomas A. Trikalinos, MD, et al published a quantitative 20-year synopsis and a network meta-analysis of percutaneous coronary interventions for nonacute coronary artery disease (2009;373:911-918). The US National Institutes of Health funded the study.

As noted in the background of the study, during the past 20 years, percutaneous transluminal balloon coronary angioplasty (PTCA), bare-metal stents (BMS), and drug-eluting stents (DES) succeeded each other as catheter-based treatments for coronary artery disease. The investigators undertook a systematic overview of randomized trials comparing these interventions with each other and with medical therapy in patients with nonacute coronary artery disease.

As detailed in The Lancet, the investigators searched Medline for trials contrasting at least two of the four interventions (PTCA, BMS, DES, and medical therapy). Eligible outcomes were death, myocardial infarction (MI), coronary artery bypass grafting, target lesion or vessel revascularization, and any revascularization. Random effects meta-analyses summarized head-to-head (direct) comparisons, and network meta-analyses integrated direct and indirect evidence. Sixty-one eligible trials (25,388 patients) investigated four of six possible comparisons between the four interventions; no trials directly compared DES with medical therapy or PTCA. In all direct or indirect comparisons, succeeding advancements in percutaneous coronary intervention did not produce detectable improvements in deaths or MI. The risk ratio (RR) for indirect comparisons between DES and medical therapy was 0.96 (95% confidence interval, 0.60–1.52) for death and 1.15 (95% confidence interval, 0.73–1.82) for MI. In contrast, the investigators recorded sequential significant reductions in target lesion or vessel revascularization with BMS compared with PTCA (RR, 0.68 [0.6–0.77]) and with DES compared with BMS (RR, 0.44 [0.35–0.56]). The RR for the indirect comparison between DES and PTCA for target lesion or vessel revascularization was 0.3 (0.17–0.51).

From these data, the investigators found that sequential innovations in the catheter-based treatment of nonacute coronary artery disease showed no evidence of an effect on death or MI when compared with medical therapy. These results lend support to present recommendations to optimize medical therapy as an initial management strategy in patients with this disease, the investigators concluded.