Elective revascularization combined with medication may bring long-term benefits to patients with stable coronary heart disease

 Editor's note: There has been debate as to whether the benefit of revascularization therapy should be routinely observed in patients with stable coronary artery disease, and recently, the EuroPCR 2021 announced a large meta-analysis of randomized trials of patients with stable coronary artery disease to explore the association between combination medical therapy and medical therapy alone for elective revascularization, We invited to the study by a special interview with Prof. Eliano P. Navarese.

《International Circulation》: At this conference, you introduced the results of a meta-analysis study. Would you please share us the characteristics of the patients selected for this study?

 

Professor Eliano P. Navarese: Thank you very much. We conducted a large scale meta-analysis of randomized trials comparing coronary elective revascularization versus medical therapy alone in stable patients with documented coronary artery disease. The findings are really important, significant and robust, showing a cardiac mortality reduction with revascularization plus medical therapy versus medical therapy alone. This significant cardiac mortality reduction persisted in all sensitivity analyses conducted. Moreover, similarly, we found a significant reduction in spontaneous myocardial infarctions that were related to cardiac mortality. Remarkably, there was a linear association between cardiac mortality reduction and the length of follow-up. So, the magnitude of cardiac mortality reduction is a function of revascularization and duration of follow-up, with increasing follow-up portending a higher reduction in cardiac mortality with revascularization. With these findings, there are important implications for the management of patients with coronary artery disease.

《International Circulation》: What are the effects of elective revascularization and optimized drug therapy (MT) on the long-term adverse events of patients with stable coronary heart disease?

 

Professor Eliano P. Navarese: Exactly as you said, it is important to point out that the synergism between revascularization and medical therapy means combining these therapies versus medical therapy alone can provide longer standing benefits over time. It is accruing over time. For each four-year follow-up, it is possible to predict a 19% reduction in cardiac mortality. Therefore, we should not wait to treat patients in order to allow the accrual of benefits of treatment over time. It is very important to say that the benefits are incremental with time.

《International Circulation》: There is still controversy about whether patients with stable coronary heart disease should be implant a stent. What guiding significance does this meta-analysis bring to clinical diagnosis and treatment?

 

Professor Eliano P. Navarese: Thank you for the question. All trials comparing revascularization versus medical therapy alone were underpowered to draw conclusions about cardiac mortality. In contrast, this large scale meta-analysis, as shown also by a trial sequential analysis, is very robust and definitive in showing this benefit. With regard to the ISCHEMIA trial, the recent large trial that was negative for cardiac mortality, no benefit was seen for the primary endpoint at a median follow-up of 3.2 years. However, at five years of follow-up, there were fewer cardiovascular deaths in favor of revascularization. But the trial could not demonstrate a significant benefit because it was underpowered. The analyses that we conducted included studies with the longest available follow-ups and allowed us to show a very robust and sound reduction in cardiovascular mortality. This has implications, because based on these findings, it is unethical not to offer revascularization to these stable patients with coronary artery disease.

《International Circulation》: At present, what are the recommended treatment strategies for patients with stable coronary heart disease in relevant guidelines? Which patients can undergo revascularization?

Professor Eliano P. Navarese: The current guideline recommendations were mainly based on previous studies, either single studies or meta-analyses, that were underpowered. The recommendations were based on the possibility of improving angina symptoms in patients with coronary artery disease. However, based on this new analysis, revascularization can offer a solid and robust reduction of mortality and an increased chance of survival. So it is expected that an update of the recommendations would account for these new findings.

You can imagine that if we don’t treat these patients, there would be thousands of deaths per year in every country. Based on this analysis, we could predict thousands of deaths. This is something that we also see in the COVID era. Many patients who are treated at home are developing spontaneous myocardial infarction that can lead to increased mortality. Mortality can jump just because we are not treating patients in the hospital with revascularization.