Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Non–ST-Elevation Coronary Syndromes and Multivessel Disease: A Systematic Review and Meta-Analysis
2023; Elsevier BV; Volume: 195; Linguagem: Inglês
10.1016/j.amjcard.2023.03.005
ISSN1879-1913
AutoresHala Kakar, Frederik T.W. Groenland, Jacob J Elscot, Riccardo Rinaldi, Alessandra Scoccia, Isabella Kardys, Rutger Nuis, Jeroen Wilschut, Wijnand K. den Dekker, Joost Daemen, Felix Zijlstra, Nicolas M. Van Mieghem, Roberto Diletti,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoThere is lack of evidence regarding the optimal revascularization strategy in patients with non–ST-elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD). This systematic review and meta-analysis compares the clinical impact of percutaneous coronary intervention (PCI) with that of coronary artery bypass graft surgery (CABG) in this subset of patients. EMBASE, MEDLINE, and Web of Knowledge were searched for studies including patients with NSTE-ACS and MVD who underwent PCI or CABG up to September 1, 2021. The primary end point of the meta-analysis was all-cause mortality at 1 year. The secondary end points were myocardial infarction (MI), stroke, or repeat revascularization at 1 year. The analysis was conducted using the Mantel-Haenszel random-effects model to calculate the odds ratio (OR) with 95% confidence interval (CI). Four prospective observational studies met the inclusion criteria, including 1,542 patients who underwent CABG and 1,630 patients who underwent PCI. No significant differences were found in terms of all-cause mortality (OR 0.91, 95% CI 0.68 to 1.21, p = 0.51), MI (OR 0.78, 95% CI 0.40 to 1.51, p = 0.46), or stroke (OR 1.54, 95% CI 0.55 to 4.35, p = 0.42) between PCI and CABG. Repeat revascularization was significantly lower in the CABG group (OR 0.21, 95% CI 0.13 to 0.34, p <0.00001). In patients presenting with NSTE-ACS and MVD, 1-year mortality, MI, and stroke were similar between patients treated with either PCI or CABG, but the repeat revascularization rate was higher after PCI. There is lack of evidence regarding the optimal revascularization strategy in patients with non–ST-elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD). This systematic review and meta-analysis compares the clinical impact of percutaneous coronary intervention (PCI) with that of coronary artery bypass graft surgery (CABG) in this subset of patients. EMBASE, MEDLINE, and Web of Knowledge were searched for studies including patients with NSTE-ACS and MVD who underwent PCI or CABG up to September 1, 2021. The primary end point of the meta-analysis was all-cause mortality at 1 year. The secondary end points were myocardial infarction (MI), stroke, or repeat revascularization at 1 year. The analysis was conducted using the Mantel-Haenszel random-effects model to calculate the odds ratio (OR) with 95% confidence interval (CI). Four prospective observational studies met the inclusion criteria, including 1,542 patients who underwent CABG and 1,630 patients who underwent PCI. No significant differences were found in terms of all-cause mortality (OR 0.91, 95% CI 0.68 to 1.21, p = 0.51), MI (OR 0.78, 95% CI 0.40 to 1.51, p = 0.46), or stroke (OR 1.54, 95% CI 0.55 to 4.35, p = 0.42) between PCI and CABG. Repeat revascularization was significantly lower in the CABG group (OR 0.21, 95% CI 0.13 to 0.34, p <0.00001). In patients presenting with NSTE-ACS and MVD, 1-year mortality, MI, and stroke were similar between patients treated with either PCI or CABG, but the repeat revascularization rate was higher after PCI. Coronary artery bypass grafting (CABG) is currently the treatment of choice for stable patients with multivessel disease (MVD), particularly in patients with diabetes or an intermediate-to-high SYNTAX score. This is mainly due to a reduction in repeat revascularizations compared with percutaneous coronary intervention (PCI).1Daemen J Boersma E Flather M Booth J Stables R Rodriguez A Rodriguez-Granillo G Hueb WA Lemos PA Serruys PW. Long-term safety and efficacy of percutaneous coronary intervention with stenting and coronary artery bypass surgery for multivessel coronary artery disease: a meta-analysis with 5-year patient-level data from the ARTS, ERACI-II, MASS-II, and SoS trials.Circulation. 2008; 118: 1146-1154Crossref PubMed Scopus (257) Google Scholar, 2Thuijs DJFM Kappetein AP Serruys PW Mohr FW Morice MC Mack MJ Holmes Jr, DR Curzen N Davierwala P Noack T Milojevic M Dawkins KD da Costa BR Jüni P Head SJ SYNTAX Extended Survival Investigators. Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial.Lancet. 2019; 394: 1325-1334Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar, 3Collet JP Thiele H Barbato E Barthélémy O Bauersachs J Bhatt DL Dendale P Dorobantu M Edvardsen T Folliguet T Gale CP Gilard M Jobs A Jüni P Lambrinou E Lewis BS Mehilli J Meliga E Merkely B Mueller C Roffi M Rutten FH Sibbing D Siontis GCM ESC Scientific Document Group2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.Eur Heart J. 2021; 42: 1289-1367Crossref PubMed Scopus (1963) Google Scholar, 4Neumann FJ Sousa-Uva M Ahlsson A Alfonso F Banning AP Benedetto U Byrne RA Collet JP Falk V Head SJ Jüni P Kastrati A Koller A Kristensen SD Niebauer J Richter DJ Seferovic PM Sibbing D Stefanini GG Windecker S Yadav R Zembala MO ESC Scientific Document Group2019 ESC/EACTS Guidelines on myocardial revascularization.Eur Heart J. 2018; 40: 87-165Crossref Scopus (3735) Google Scholar Conversely, PCI has been the recommended treatment strategy in patients with acute coronary syndrome (ACS) given the need for an immediate or urgent revascularization.3Collet JP Thiele H Barbato E Barthélémy O Bauersachs J Bhatt DL Dendale P Dorobantu M Edvardsen T Folliguet T Gale CP Gilard M Jobs A Jüni P Lambrinou E Lewis BS Mehilli J Meliga E Merkely B Mueller C Roffi M Rutten FH Sibbing D Siontis GCM ESC Scientific Document Group2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.Eur Heart J. 2021; 42: 1289-1367Crossref PubMed Scopus (1963) Google Scholar,5Patel MR Calhoon JH Dehmer GJ Grantham JA Maddox TM Maron DJ Smith PK ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes: a Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society of Thoracic Surgeons.J Am Coll Cardiol. 2017; 69: 570-591Crossref PubMed Scopus (132) Google Scholar In particular, in patients presenting with ST-elevation myocardial infarction (STEMI), primary PCI of the culprit lesion has emerged as a highly effective treatment because there is a mortality benefit related to time until therapy,6Ibanez B James S Agewall S Antunes MJ Bucciarelli-Ducci C Bueno H Caforio ALP Crea F Goudevenos JA Halvorsen S Hindricks G Kastrati A Lenzen MJ Prescott E Roffi M Valgimigli M Varenhorst C Vranckx P Widimský P ESC Scientific Document Group2018 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).Eur Heart J. 2017; 39: 119-177Crossref Scopus (5768) Google Scholar, 7Keeley EC Boura JA Grines CL. Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials.Lancet. 2006; 367: 579-588Abstract Full Text Full Text PDF PubMed Scopus (465) Google Scholar, 8Boersma E Primary Coronary Angioplasty vs. Thrombolysis GroupDoes time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients.Eur Heart J. 2006; 27: 779-788Crossref PubMed Scopus (554) Google Scholar, 9Steg PG James SK Atar D Badano LP Blömstrom-Lundqvist C Borger MA Di Mario C Dickstein K Ducrocq G Fernandez-Aviles F Gershlick AH Giannuzzi P Halvorsen S Huber K Juni P Kastrati A Knuuti J Lenzen MJ Mahaffey KW Valgimigli M van 't Hof A Widimsky P Zahger D Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology (ESC)ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.Eur Heart J. 2012; 33: 2569-2619Crossref PubMed Scopus (4575) Google Scholar with subsequent percutaneous revascularization appearing to be a reasonable option.10Bravata DM Gienger AL McDonald KM Sundaram V Perez MV Varghese R Kapoor JR Ardehali R Owens DK Hlatky MA. Systematic review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery.Ann Intern Med. 2007; 147: 703-716Crossref PubMed Scopus (262) Google Scholar, 11Kornowski R Mehran R Dangas G Nikolsky E Assali A Claessen BE Gersh BJ Wong SC Witzenbichler B Guagliumi G Dudek D Fahy M Lansky AJ Stone GW HORIZONS-AMI Trial InvestigatorsPrognostic impact of staged versus "one-time" multivessel percutaneous intervention in acute myocardial infarction: analysis from the HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trial.J Am Coll Cardiol. 2011; 58: 704-711Crossref PubMed Scopus (222) Google Scholar, 12Politi L Sgura F Rossi R Monopoli D Guerri E Leuzzi C Bursi F Sangiorgi GM Modena MG. A randomised trial of target-vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up.Heart. 2010; 96: 662-667Crossref PubMed Scopus (309) Google Scholar, 13Di Mario C Mara S Flavio A Imad S Antonio M Anna P Emanuela P Stefano DS Angelo R Stefania C Anna F Carmelo C Antonio C Monzini N Bonardi MA Single vs multivessel treatment during primary angioplasty: results of the multicentre randomised HEpacoat for cuLPrit or multivessel stenting for acute myocardial infarction (HELP AMI) Study.Int J Cardiovasc Intervent. 2004; 6: 128-133Crossref PubMed Scopus (230) Google Scholar In particular, in the scenario in which there is MVD STEMI, CABG is rarely advised, even though complex coronary artery disease is a frequent finding.14Rodríguez-Olivares R López-Menéndez J Barca LV Hycka JM Hernández-Antolín R Rodríguez-Roda Stuart J Zamorano Gómez JL Identification of candidates for coronary artery bypass grafting admitted with STEMI and multivessel Disease.Cardiovasc Revasc Med. 2018; 19: 21-26Crossref PubMed Scopus (4) Google Scholar In patients with non–ST-elevation ACS (NSTE-ACS), the prevalence of MVD ranges between 20% and 40%.15Muller DW Topol EJ Ellis SG Sigmon KN Lee K Califf RM. Multivessel coronary artery disease: a key predictor of short-term prognosis after reperfusion therapy for acute myocardial infarction. Thrombolysis and angioplasty in myocardial infarction (TAMI) study group.Am Heart J. 1991; 121: 1042-1049Crossref PubMed Scopus (174) Google Scholar,16Goldstein JA Demetriou D Grines CL Pica M Shoukfeh M O'Neill WW Multiple complex coronary plaques in patients with acute myocardial infarction.N Engl J Med. 2000; 343: 915-922Crossref PubMed Scopus (896) Google Scholar Complete revascularization seems the preferred strategy,5Patel MR Calhoon JH Dehmer GJ Grantham JA Maddox TM Maron DJ Smith PK ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes: a Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society of Thoracic Surgeons.J Am Coll Cardiol. 2017; 69: 570-591Crossref PubMed Scopus (132) Google Scholar but the optimal treatment modality remains unclear.17Stettler C Wandel S Allemann S Kastrati A Morice MC Schömig A Pfisterer ME Stone GW Leon MB de Lezo JS Goy JJ Park SJ Sabaté M Suttorp MJ Kelbaek H Spaulding C Menichelli M Vermeersch P Dirksen MT Cervinka P Petronio AS Nordmann AJ Diem P Meier B Zwahlen M Reichenbach S Trelle S Windecker S Jüni P. Outcomes associated with drug-eluting and bare-metal stents: a collaborative network meta-analysis.Lancet. 2007; 370: 937-948Abstract Full Text Full Text PDF PubMed Scopus (1306) Google Scholar No randomized controlled trials (RCTs) have yet compared PCI with CABG in NSTE-ACS. Therefore, current guidelines do not address which treatment strategy is preferable, but a revascularization strategy based on the patient's clinical status, co-morbidities, and coronary disease severity is recommended.3Collet JP Thiele H Barbato E Barthélémy O Bauersachs J Bhatt DL Dendale P Dorobantu M Edvardsen T Folliguet T Gale CP Gilard M Jobs A Jüni P Lambrinou E Lewis BS Mehilli J Meliga E Merkely B Mueller C Roffi M Rutten FH Sibbing D Siontis GCM ESC Scientific Document Group2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.Eur Heart J. 2021; 42: 1289-1367Crossref PubMed Scopus (1963) Google Scholar,5Patel MR Calhoon JH Dehmer GJ Grantham JA Maddox TM Maron DJ Smith PK ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes: a Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society of Thoracic Surgeons.J Am Coll Cardiol. 2017; 69: 570-591Crossref PubMed Scopus (132) Google Scholar,10Bravata DM Gienger AL McDonald KM Sundaram V Perez MV Varghese R Kapoor JR Ardehali R Owens DK Hlatky MA. Systematic review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery.Ann Intern Med. 2007; 147: 703-716Crossref PubMed Scopus (262) Google Scholar,18Hlatky MA Boothroyd DB Bravata DM Boersma E Booth J Brooks MM Carrié D Clayton TC Danchin N Flather M Hamm CW Hueb WA Kähler J Kelsey SF King SB Kosinski AS Lopes N McDonald KM Rodriguez A Serruys P Sigwart U Stables RH Owens DK Pocock SJ. Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials.Lancet. 2009; 373: 1190-1197Abstract Full Text Full Text PDF PubMed Scopus (602) Google Scholar In this systematic review and meta-analysis, we compared clinical outcome after CABG or PCI in patients with ACS and MVD. This meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane Collaboration recommendations.19Bramer WM de Jonge GB Rethlefsen ML Mast F Kleijnen J. A systematic approach to searching: an efficient and complete method to develop literature searches.J Med Libr Assoc. 2018; 106: 531-541Crossref PubMed Google Scholar,20Rethlefsen ML Kirtley S Waffenschmidt S Ayala AP Moher D Page MJ Koffel JB PRISMA-S GroupPRISMA-S: an extension to the PRISMA Statement for Reporting Literature Searches in Systematic Reviews.Syst Rev. 2021; 10: 39Crossref PubMed Scopus (566) Google Scholar The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used (Supplementary Data 1 ). From inception to September 1, 2021, the following databases were searched by the medical library specialist of the Erasmus Medical Center, Rotterdam, The Netherlands: EMBASE, MEDLINE, and Web of Knowledge. Search terms included "multivessel disease," "'percutaneous coronary intervention," "coronary artery bypass graft," and "acute coronary syndromes" (Supplementary Data 2 ). After removal of duplicates, 2 reviewers (HK and RR) independently screened all search results and identified potentially eligible studies (Figure 1). Subsequently, full-text evaluation was independently performed (HK and RR). Abstracts from conferences were not considered, nor were publications in languages other than English. In addition, the authors of 1 study21Freitas P Madeira M Raposo L Madeira S Brito J Brízido C Gama F Vale N Ranchordás S Magro P Braga A Gonçalves PA Gabriel HM Nolasco T Boshoff S Marques M Bruges L Calquinha J Sousa-Uva M Abecasis M Almeida M Neves JP Mendes M. Coronary artery bypass grafting versus percutaneous coronary intervention in patients with non-ST-elevation myocardial infarction and left main or multivessel coronary disease.Am J Cardiol. 2019; 123: 717-724Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar were contacted to obtain 1-year follow-up data (instead of only the cumulative 60-month clinical outcomes). The inclusion criteria we used for the studies were (1) patients with NSTE-ACS and MVD, (2) comparison of PCI with CABG for revascularization, (3) use of drug-eluting stents (DES), (4) prospective studies or RCTs, and (5) at least 1 year follow-up. The primary end point was all-cause mortality at 1 year. Secondary end points included myocardial infarction (MI), stroke, and repeat revascularization at 1 year. Trial-level qualitative assessment was performed (by HK and JE) using the Risk of Bias In Non-randomized Studies-1 assessment tool for nonrandomized studies. The risk of bias in 7 domains, including confounding, selection of studies, classification of intervention, deviation from intended intervention, missing data, measurement of outcome, and selection of reported results, was classified as low, moderate, serious, critical, or no information. Sensitivity analysis was used to investigate whether the overall results were affected by the individual studies. Each study was separately excluded from the meta-analyses to analyze its effect on the overall results owing to overlap of included cases. Mantel-Haenszel random-effects models using trial-level and pooled estimates are reported as odds ratio (OR) and 95% confidence interval (CI); risk distribution is presented by forest plots with weighting according to random-effects models. We assessed heterogeneity across trials using between-study variance chi-square and I2 statistics.22von Hippel PT. The heterogeneity statistic I(2) can be biased in small meta-analyses.BMC Med Res Methodol. 2015; 15: 35Crossref PubMed Scopus (510) Google Scholar Formal testing was performed for uniform effect size across trials, with significance set at p <0.05. Review Manager (Rev-Man, version 5.4.1. the Nordic Cochrane Centre, The Cochrane Collaboration, 2020) was used for statistical analysis and to acquire forest plots. A p <0.05 (2-sided) was considered statistically significant. The initial search strategy resulted in 4,199 records. After full-text evaluation of 20 potentially eligible records, 4 studies were included in the meta-analysis, as shown in Figure 1.21Freitas P Madeira M Raposo L Madeira S Brito J Brízido C Gama F Vale N Ranchordás S Magro P Braga A Gonçalves PA Gabriel HM Nolasco T Boshoff S Marques M Bruges L Calquinha J Sousa-Uva M Abecasis M Almeida M Neves JP Mendes M. Coronary artery bypass grafting versus percutaneous coronary intervention in patients with non-ST-elevation myocardial infarction and left main or multivessel coronary disease.Am J Cardiol. 2019; 123: 717-724Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,23Chang M Lee CW Ahn JM Cavalcante R Sotomi Y Onuma Y Han M Park DW Kang SJ Lee SW Kim YH Park SW Serruys PW Park SJ. Comparison of outcome of coronary artery bypass grafting versus drug-eluting stent implantation for non-ST-elevation acute coronary syndrome.Am J Cardiol. 2017; 120: 380-386Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 24Ben-Gal Y Moses JW Mehran R Lansky AJ Weisz G Nikolsky E Argenziano M Williams MR Colombo A Aylward PE Stone GW. Surgical versus percutaneous revascularization for multivessel disease in patients with acute coronary syndromes: analysis from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial.JACC Cardiovasc Interv. 2010; 3: 1059-1067Crossref PubMed Scopus (62) Google Scholar, 25Ben-Gal Y Mohr R Feit F Ohman EM Kirtane A Xu K Mehran R Stone GW. Surgical versus percutaneous coronary revascularization for multivessel disease in diabetic patients with non-ST-segment-elevation acute coronary syndrome: analysis from the Acute Catheterization and Early Intervention Triage Strategy trial.Circ Cardiovasc Interv. 2015; 8e002032Crossref PubMed Scopus (21) Google Scholar, 26Desperak P Hawranek M Gąsior P Desperak A Lekston A Gąsior M. Long-term outcomes of patients with multivessel coronary artery disease presenting non-ST-segment elevation acute coronary syndromes.Cardiol J. 2019; 26: 157-168PubMed Google Scholar Table 1 shows an overview of patients' baseline characteristics and main study characteristics for CABG versus PCI. The baseline characteristics are derived by calculating the mean value of each variable from all studies and weighting them according to the study population. All studies were prospective and observational. All-cause mortality was assessed in all 4 studies, whereas MI and stroke were only measured in 3 studies. A total of 1,542 patients underwent CABG, and 1,630 patients underwent PCI. The use of imaging and coronary physiology was negligible throughout the study population.Table 1Main characteristics of the included studiesCABG vs PCIStudyYearDesignPrimary endpointFollow-upNumber of patients (n)Age (years)Male (%)Number of vessel disease (mean (n))Ben-Gal2010Prospective observationalMACE, composite of all-cause mortality, myocardial infarction, repeat revascularization1 year528/ 52864.3/ 63.878.5/ 74.32.61/ 2.61Freitas2017Prospective observationalAll-cause mortality5 years159/ 15968/ 6673/ 702.63/ 2.59Chang2018Prospective observationalComposite of all-cause mortality, myocardial infarction, stroke1 year634/ 61265.1/ 64.173.3/ 69.82.78/ 2.80Desperak2019Prospective observationalAll-cause mortality2 year91/ 9173/ 73.668.1/ 65.92.55/ 2.60 Open table in a new tab All-cause mortality (OR 0.91, 95% CI 0.68 to 1.21, p = 0.51), MI (OR 0.78, 95% CI 0.40 to 1.51, p = 0.46), or stroke (OR 1.54, 95% CI 0.55 to 4.35, p = 0.42) did not differ significantly between PCI and CABG (Figure 2). Repeat revascularization (OR 0.21, 95% CI 0.13 to 0.34, p 50%). The sensitivity analysis showed no effect on the primary and secondary end points.21Freitas P Madeira M Raposo L Madeira S Brito J Brízido C Gama F Vale N Ranchordás S Magro P Braga A Gonçalves PA Gabriel HM Nolasco T Boshoff S Marques M Bruges L Calquinha J Sousa-Uva M Abecasis M Almeida M Neves JP Mendes M. Coronary artery bypass grafting versus percutaneous coronary intervention in patients with non-ST-elevation myocardial infarction and left main or multivessel coronary disease.Am J Cardiol. 2019; 123: 717-724Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,23Chang M Lee CW Ahn JM Cavalcante R Sotomi Y Onuma Y Han M Park DW Kang SJ Lee SW Kim YH Park SW Serruys PW Park SJ. Comparison of outcome of coronary artery bypass grafting versus drug-eluting stent implantation for non-ST-elevation acute coronary syndrome.Am J Cardiol. 2017; 120: 380-386Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 24Ben-Gal Y Moses JW Mehran R Lansky AJ Weisz G Nikolsky E Argenziano M Williams MR Colombo A Aylward PE Stone GW. Surgical versus percutaneous revascularization for multivessel disease in patients with acute coronary syndromes: analysis from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial.JACC Cardiovasc Interv. 2010; 3: 1059-1067Crossref PubMed Scopus (62) Google Scholar, 25Ben-Gal Y Mohr R Feit F Ohman EM Kirtane A Xu K Mehran R Stone GW. Surgical versus percutaneous coronary revascularization for multivessel disease in diabetic patients with non-ST-segment-elevation acute coronary syndrome: analysis from the Acute Catheterization and Early Intervention Triage Strategy trial.Circ Cardiovasc Interv. 2015; 8e002032Crossref PubMed Scopus (21) Google Scholar, 26Desperak P Hawranek M Gąsior P Desperak A Lekston A Gąsior M. Long-term outcomes of patients with multivessel coronary artery disease presenting non-ST-segment elevation acute coronary syndromes.Cardiol J. 2019; 26: 157-168PubMed Google Scholar Overall risk of bias was scored as moderate in all studies (Supplementary Figures 3 and 4 ). No studies were classified to have a critical risk of bias. To the best of our knowledge, this systematic review and meta-analysis is the first to compare PCI with CABG in patients presenting with NSTE-ACS and MVD. The main findings are (1) there was no difference in all-cause mortality, MI, or stroke, and (2) multivessel PCI was associated with more repeat revascularizations. Given the limited available evidence, the European Society of Cardiology guidelines recommend that the same approach be applied in NSTE-ACS and in stable patients with heart-team consensus, especially for complex cases.3Collet JP Thiele H Barbato E Barthélémy O Bauersachs J Bhatt DL Dendale P Dorobantu M Edvardsen T Folliguet T Gale CP Gilard M Jobs A Jüni P Lambrinou E Lewis BS Mehilli J Meliga E Merkely B Mueller C Roffi M Rutten FH Sibbing D Siontis GCM ESC Scientific Document Group2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.Eur Heart J. 2021; 42: 1289-1367Crossref PubMed Scopus (1963) Google Scholar Our results support this recommendation. Our findings are therefore in line with the SYNTAX (Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease) trial, studying stable patients with MVD, in which no significant difference in all-cause mortality between patients who underwent PCI and those who underwent CABG was observed at 1-year follow-up27Serruys PW Morice MC Kappetein AP Colombo A Holmes DR Mack MJ Ståhle E Feldman TE van den Brand M Bass EJ Van Dyck N Leadley K Dawkins KD Mohr FW SYNTAX InvestigatorsPercutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.N Engl J Med. 2009; 360: 961-972Crossref PubMed Scopus (3352) Google Scholar and confirmed at very long term.2Thuijs DJFM Kappetein AP Serruys PW Mohr FW Morice MC Mack MJ Holmes Jr, DR Curzen N Davierwala P Noack T Milojevic M Dawkins KD da Costa BR Jüni P Head SJ SYNTAX Extended Survival Investigators. Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial.Lancet. 2019; 394: 1325-1334Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar However, the 5-year mortality in stable patients showed a benefit for CABG over PCI in patients with diabetes mellitus and MVD.28Head SJ Milojevic M Daemen J Ahn JM Boersma E Christiansen EH Domanski MJ Farkouh ME Flather M Fuster V Hlatky MA Holm NR Hueb WA Kamalesh M Kim YH Mäkikallio T Mohr FW Papageorgiou G Park SJ Rodriguez AE Sabik 3rd, JF Stables RH Stone GW Serruys PW Kappetein AP. Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data.Lancet. 2018; 391: 939-948Abstract Full Text Full Text PDF PubMed Scopus (408) Google Scholar Interestingly, the use of second-generation DES in more recent studies was associated with a limited improvement in terms of overall major adverse cardiac and cerebrovascular events (MACCEs) rate, which was still higher in the PCI group.18Hlatky MA Boothroyd DB Bravata DM Boersma E Booth J Brooks MM Carrié D Clayton TC Danchin N Flather M Hamm CW Hueb WA Kähler J Kelsey SF King SB Kosinski AS Lopes N McDonald KM Rodriguez A Serruys P Sigwart U Stables RH Owens DK Pocock SJ. Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials.Lancet. 2009; 373: 1190-1197Abstract Full Text Full Text PDF PubMed Scopus (602) Google Scholar,29Park SJ Ahn JM Kim YH Park DW Yun SC Lee JY Kang SJ Lee SW Lee CW Park SW Choo SJ Chung CH Lee JW Cohen DJ Yeung AC Hur SH Seung KB Ahn TH Kwon HM Lim DS Rha SW Jeong MH Lee BK Tresukosol D Fu GS Ong TK BEST Trial Investigators. Trial of everolimus-eluting stents or bypass surgery for coronary disease.N Engl J Med. 2015; 372: 1204-1212Crossref PubMed Scopus (364) Google Scholar Even though PCI offers a faster revascularization and recovery, it remains associated with a great number of repeat revascularizations compared with CABG, and in patients with ACS. Conversely, CABG might be associated with greater risk of stroke, periprocedural bleedings, acute renal injury, and blood transfusion.23Chang M Lee CW Ahn JM Cavalcante R Sotomi Y Onuma Y Han M Park DW Kang SJ Lee SW Kim YH Park SW Serruys PW Park SJ. Comparison of outcome of coronary artery bypass grafting versus drug-eluting stent implantation for non-ST-elevation acute coronary syndrome.Am J Cardiol. 2017; 120: 380-386Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 24Ben-Gal Y Moses JW Mehr
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