Title : To stent or to operate in heart failure with reduced ejection fraction patients
Abstract:
Background: Coronary artery disease (CAD) continues to be a leading cause of global mortality despite advances in cardiovascular medicine. The choice between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for CAD treatment depends on various factors, including left ventricular ejection fraction (LVEF). This systematic review and meta-analysis aim to compare these two revascularization methods in patients with heart failure and reduced LVEF (HFrEF).
Objectives/Aims: The primary objectives were to assess differences in mortality, repeat revascularization, new postoperative myocardial infarction (MI), and cerebrovascular accidents (CVA/stroke) between PCI and CABG in HFrEF patients, stratified by the degree of LVEF reduction.
Methods: A comprehensive search of electronic databases was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria comprised clinical trials or observational cohort studies with ≥20 patients per group, comparing long-term outcomes in HFrEF patients (LVEF <50%) who underwent PCI or CABG. Data was extracted, and quality was assessed using the New Castle Ottawa (NOS) Risk of Bias tool. Hazard ratios (HRs) were pooled for time-to-event outcomes, with subgroup analysis based on LVEF. Heterogeneity was assessed, sensitivity analysis conducted, and publication bias evaluated.
Results: Twenty studies involving 25,031 patients met the inclusion criteria. In the severe LVEF reduction group (<35%), CABG was associated with significantly higher long-term survival (p<0.01), reduced repeat revascularization (p<0.01), and fewer postoperative MIs (p<0.01) compared to PCI. In patients with moderate LVEF reduction (<40%), there was no difference in long-term survival (p=0.53), but repeat revascularization was lower in the CABG group (p<0.01). In the mild LVEF reduction group (<50%), CABG was associated with superior long-term survival (p<0.01) and reduced repeat revascularization (p<0.01). Stroke rates were similar between PCI and CABG in all groups.
Discussion: This meta-analysis supports CABG as the preferred revascularization method in HFrEF patients, especially those with severe LVEF reduction. CABG exhibited better long-term survival and fewer complications, including repeat revascularization and postoperative MIs, compared to PCI. Stroke rates were similar for both interventions.
Conclusion: Individualized patient care should consider the degree of LVEF reduction when selecting between PCI and CABG, with CABG generally favored for improved outcomes in HFrEF patients. However, clinical presentation, patient characteristics, and cost-effectiveness should also
