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Meta-analysis: Effects of Percutaneous Coronary Intervention Versus Medical Therapy on Angina Relief

Harindra C. Wijeysundera, MD; Brahmajee K. Nallamothu, MD, MPH; Harlan M. Krumholz, MD, SM; Jack V. Tu, MD, PhD; and Dennis T. Ko, MD, MSc
[+] Article and Author Information

From Sunnybrook Health Sciences Centre, University of Toronto, and the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan; and Yale University School of Medicine, New Haven, Connecticut.


Grant Support: By the University of Toronto Department of Medicine Clinician Scientist Training Program and a research fellowship award from the Canadian Institutes of Health Research (Dr. Wijeysundera); a Heart and Stroke Foundation of Ontario Clinician Scientist Award and a Canadian Institutes of Health Research New Investigator Award (Dr. Ko); and a Canada Research Chair in Health Services Research and a Career Investigator Award from the Heart and Stroke Foundation of Ontario (Dr. Tu). This analysis of the study was funded in part by operating grants by a Canadian Institutes of Health Research (MOP 82747) and a Canadian Institutes of Health Research Team Grant in Cardiovascular Outcomes Research.

Potential Conflicts of Interest: Dr. Wijeysundera has disclosed the following: Grants received/pending (money to institution): Canadian Institutes of Health Research. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-0753.

Requests for Single Reprints: Dennis T. Ko, MD, Institute for Clinical Evaluative Sciences, Room G1-06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; e-mail, dennis.ko@ices.on.ca.

Current Author Addresses: Dr. Wijeysundera: Sunnybrook Health Sciences Center, Room A209D, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.

Dr. Nallamothu: Cardiovascular Center, CVC Cardiovascular Medicine, University of Michigan Medical School, SPC 5869, 1500 East Medical Center Drive, Ann Arbor, MI 48109.

Dr. Krumholz: Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, PO Box 208088, New Haven, CT 06520.

Drs. Tu and Ko: Institute for Clinical Evaluative Sciences, Room G1-06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.

Author Contributions: Conception and design: H.C. Wijeysundera, D.T. Ko.

Analysis and interpretation of the data: H.C. Wijeysundera, H.M. Krumholz, B.K. Nallamothu, H.M. Krumholz, J.V. Tu, D.T. Ko.

Drafting of the article: H.C. Wijeysundera, D.T. Ko.

Critical revision of the article for important intellectual content: H.C. Wijeysundera, B.K. Nallamothu, H.M. Krumholz, J.V. Tu, D.T. Ko.

Final approval of the article: H.C. Wijeysundera, B.K. Nallamothu, H.M. Krumholz, J.V. Tu, D.T. Ko.

Statistical expertise: H.C. Wijeysundera, D.T. Ko.

Obtaining of funding: D.T. Ko.

Collection and assembly of data: H.C. Wijeysundera, D.T. Ko.


Ann Intern Med. 2010;152(6):370-379. doi:10.7326/0003-4819-152-6-201003160-00007
Text Size: A A A

Background: Several meta-analyses have evaluated the efficacy of percutaneous coronary intervention (PCI) compared with medical therapy, but none has focused on angina relief.

Purpose: To summarize the evidence on the degree of angina relief from PCI compared with medical therapy in patients with stable coronary artery disease.

Data Sources: The Cochrane Library (1993 to June 2009), EMBASE (1980 to June 2009), and MEDLINE (1950 to June 2009), with no language restrictions.

Study Selection: Two independent reviewers screened citations to identify randomized, controlled trials of PCI versus medical therapy in patients with stable coronary artery disease.

Data Extraction: Two independent reviewers abstracted data on patient characteristics, study conduct, and outcomes. A random-effects model was used to combine data on freedom from angina and to perform stratified analyses based on duration of follow-up, inclusion of patients with recent myocardial infarction, coronary stent utilization, recruitment period, and utilization of evidence-based medications.

Data Synthesis: A total of 14 trials, enrolling 7818 patients, met the inclusion criteria. Although PCI was associated with an overall benefit on angina relief (odds ratio, 1.69 [95% CI, 1.24 to 2.30]), important heterogeneity across trials was observed. The incremental benefit of PCI observed in older trials (odds ratio, 3.38 [CI, 1.89 to 6.04]) was substantially less and possibly absent in recent trials (odds ratio, 1.13 [CI, 0.76 to 1.68]). An inverse relationship between use of evidence-based therapies and the incremental benefit of PCI was observed.

Limitations: Information about the long-term use of medication was incomplete in most trials. Few trials used drug-eluting stents. Meta-regression analyses used aggregated study-level data from few trials.

Conclusion: Percutaneous coronary intervention was associated with greater freedom from angina compared with medical therapy, but this benefit was largely attenuated in contemporary studies. This observation may be related to greater use of evidence-based medications in contemporary trials.

Primary Funding Source: Canadian Institutes of Health Research.

Figures

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Figure 1.
Study flow diagram.

CABG = coronary artery bypass graft; PCI = percutaneous coronary intervention.

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Figure 2.
Summary OR of freedom from angina.

OR = odds ratio; PCI = percutaneous coronary intervention.

* See Table 1 for definitions of study abbreviations.

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Figure 3.
Summary ORs, stratified by duration of follow-up and recruitment period.

OR = odds ratio; PCI = percutaneous coronary intervention.

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Appendix Figure.
Meta-regression, restricted to non–myocardial infarction trials.

OR = odds ratio.

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Figure 4.
Meta-regression of freedom from angina with evidence-based medications.

OR = odds ratio.

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