Revascularization or medical therapy for stable coronary artery disease patients with different degrees of ischemia: a systematic review and meta-analysis of the role of myocardial perfusion

OBJECTIVE: This study explored the best treatment strategies for stable coronary artery disease (SCAD) patients with differing levels of ischemic severity. METHODS: We conducted a comprehensive search of the PubMed, EMBASE, and Cochrane databases – searching for relevant articles through 4 February 2021. We selected studies comparing different treatments for patients with SCAD who had received ischemia assessments. The primary outcome was death. The secondary outcomes were major adverse cardiovascular events (MACEs) and myocardial infarction (MI). RESULTS: A total of 11 studies, including 35,607 subjects, were selected for this meta-analysis. Results showed that, compared with medical therapy, revascularization could reduce MACE incidence (odds ratio (OR) 0.73, 95% confidence interval (CI): 0.57–0.94, p < 0.05) in SCAD patients with myocardial ischemia, but that it was not effective for patients without ischemia. For mild ischemia, the incidence of death (OR 0.78, 95% CI: 0.59–1.01, p = 0.063), MACE (OR 0.91, 95% CI: 0.48–1.70, p = 0.762), or MI (OR 1.44, 95% CI: 0.94–2.19, p = 0.093) was the same whether they were treated with revascularization or medical therapy. For moderate to severe ischemia, revascularization reduced the incidence of MACE (OR 0.59, 95% CI: 0.42–0.83, p < 0.05) and MI (OR 0.83, 95% CI: 0.71–0.98, p < 0.05), but the incidence of death (OR 0.73, 95% CI: 0.47–1.12, p = .145) was similar. For SCAD patients with severe ischemia, revascularization may confer survival benefits (OR 0.46, 95% CI: 0.21–1.00, p = 0.05). CONCLUSION: For SCAD patients with moderate to severe ischemia, revascularization reduces the MACE and MI incidences, but does not change the incidence of death. Evaluation for myocardial ischemia is vital when selecting a therapeutic strategy.