Objectives

It is unclear whether coronary artery bypass grafting (CABG) improves survival compared to medical therapy (MT) in patients with stable coronary artery disease (CAD). The aim of this analysis was to perform an individual patient data pooled meta-analysis of contemporary randomized controlled trials (RCTs) that compared CABG and MT in patients with stable CAD.

Methods

A systematic search was performed in January 2021 to identify RCTs enrolling adult patients with stable CAD, randomized to CABG or MT. Only trials using at least aspirin, beta-blockers, and statins in the MT arm were included. Individual patient data were obtained from all eligible studies and pooled. The primary outcome was all-cause mortality.

Results

Four trials involving 2523 patients (1261 CABG; 1262 MT) were included with a median follow-up of 5.6 (4.0-9.2) years. CABG was associated with increased risk of all-cause mortality within 30 days (hazard ratio [HR] 4.81, 95% confidence interval [CI] 1.95-11.83), but subsequent reduction in the long-term risk of death (HR 0.79, 95%CI 0.69-0.89). As such, the cumulative 10-year mortality rate was lower in patients treated with CABG compared with MT (45.1% vs 51.7% respectively; odds ratio 0.70, 95%CI 0.58-0.85). Age and race were significant treatment effect modifier (interaction p=0.003 for both).

Conclusions

In patients with stable CAD, initial allocation to CABG was associated with higher periprocedural risk of death but improved long-term survival compared with MT. The survival advantage for CABG became significant after the fourth postoperative year and was particularly pronounced in younger and non-white patients.

中文翻译：

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稳定性冠状动脉疾病患者的冠状动脉搭桥术与药物治疗：随机试验的个体患者数据汇总荟萃分析

 目标

对于稳定性冠状动脉疾病 (CAD) 患者，与药物治疗 (MT) 相比，冠状动脉旁路移植术 (CABG) 是否可以提高生存率尚不清楚。本分析的目的是对当代随机对照试验 (RCT) 进行个体患者数据汇总荟萃分析，比较稳定型 CAD 患者的 CABG 和 MT。

 方法

2021 年 1 月进行了一项系统性检索，以确定纳入稳定型 CAD 成年患者的随机对照试验，并随机接受 CABG 或 MT。仅纳入 MT 组中至少使用阿司匹林、β 受体阻滞剂和他汀类药物的试验。从所有符合条件的研究中获得个体患者数据并进行汇总。主要结局是全因死亡率。

 结果

四项试验涉及 2523 名患者（1261 名 CABG；1262 名 MT），中位随访时间为 5.6（4.0-9.2）年。 CABG 与 30 天内全因死亡风险增加相关（风险比 [HR] 4.81，95% 置信区间 [CI] 1.95-11.83），但随后长期死亡风险降低（HR 0.79，95） %CI 0.69-0.89）。因此，与 MT 治疗相比，接受 CABG 治疗的患者的 10 年累积死亡率较低（分别为 45.1% 和 51.7%；比值比 0.70，95%CI 0.58-0.85）。年龄和种族是显着的治疗效果调节因素（两者的交互作用 p=0.003）。

 结论

在稳定型 CAD 患者中，初始分配至 CABG 与围手术期死亡风险较高相关，但与 MT 相比，长期生存率有所提高。 CABG 的生存优势在术后第四年后变得显着，并且在年轻和非白人患者中尤其明显。