Revascularisation strategies for non-acute myocardial ischaemic syndromes

Clinical Snapshot

Key Findings

• P Value: Not reported (Bayesian analysis uses credible intervals)

• Effect Size: CABG+OMT vs OMT: HR 0.84; PCI+OMT vs OMT: HR 0.93; CABG+OMT vs PCI+OMT: HR 0.91

• Primary Outcome: All-cause mortality at maximum follow-up

• Nnt Or Sensitivity: SUCRA scores: CABG+OMT 88.1% probability of being optimal for mortality, 99.7% for MI prevention, 17.5% for stroke, 99.5% for re-revascularisation

• Confidence Interval: CABG+OMT vs OMT: 95% CrI 0.68-1.07; PCI+OMT vs OMT: 95% CrI 0.79-1.16; CABG+OMT vs PCI+OMT: 95% CrI 0.71-1.13

Clinical Application

Both CABG and PCI are established procedures in Australian practice, though patient selection and timing remain critical Relevant to Australian cardiothoracic surgery and interventional cardiology practice. Both procedures are PBS-funded. Results support current CSANZ and RACGP guidelines emphasising individualised treatment decisions Patients with stable coronary artery disease or non-acute ischaemic syndromes suitable for revascularisation

Abstract

BACKGROUND: Contemporary guidelines by the European Society for Cardiology and American College of Cardiology/American Heart Association for the treatment of non-acute myocardial ischaemic syndromes dispute the value of revascularisation and differ in their recommendation to perform revascularisation. A Bayesian network meta-analysis was performed, evaluating the strength of evidence for the comparative incremental effectiveness of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) over medical therapy on long-term outcomes. METHODS: A hierarchical Bayesian network meta-analysis was designed (PROSPERO CRD42024541215, date 20 May 2024), including randomised controlled trials (RCTs) published between 2005 and 10 June 2025, which consisted of three initial treatment modalities: optimal medical therapy (OMT), PCI+OMT and CABG+OMT. The primary outcome was all-cause mortality at maximum follow-up; secondary outcomes were trates of the rates of myocardial infarction, stroke and re-revascularisation at maximum follow-up, expressed in HRs and 95% credible intervals (CrIs), accompanied by surface under the cumulative ranking curve (SUCRA) scores. RESULTS: 10 RCTs, comprising 10 742 patients, were included. For all-cause mortality, the estimated median HR of CABG+OMT versus OMT was 0.84 (95% CrI 0.68-1.07); the HR of PCI+OMT versus OMT was 0.93 (0.79-1.16); and the HR of CABG+OMT versus PCI+OMT was 0.91 (0.71-1.13). The SUCRAs of a CABG+OMT strategy ranking as the optimal revascularisation treatment regarding mortality, myocardial infarction, stroke and re-revascularisation were 88.1%, 99.7%, 17.5% and 99.5%, respectively. Results were consistent across sensitivity analyses, including in the node-splitting models. CONCLUSIONS: This Bayesian network meta-analysis found that an initial CABG (+OMT) revascularisation strategy was associated with higher probabilities of optimal outcomes, with the exception of stroke, compared with an initial PCI (+OMT) revascularisation strategy, although CrIs overlapped, suggesting that some uncertainty remains. PROSPERO REGISTRATION NUMBER: CRD42024541215.

References

1. 1.Kawczynski, M. J., Barili, F., Brophy, J. M., De Caterina, R., Biondi Zoccai, G., Anselmi, A., Boden, W. E., Parolari, A., & Heuts, S. (2026). Revascularisation strategies for non-acute myocardial ischaemic syndromes. Heart. https://doi.org/10.1136/heartjnl-2025-326101