ABC | Volume 112, Nº5, May 2019

Original Article Andrade et al Stent versus CABG: a meta-analysis Arq Bras Cardiol. 2019; 112(5):511-523 Figure 3 – Stent versus CABG: Acute myocardial infarct at one year (top) and after three or more years (bottom). The size of each box is proportional to the number of patients of the trial. The bars represent 95% confidence interval. The diamond represents the syntheses of results. DES: trials of the drug-eluting stent era; BMS: trials of the bare-metal stent trials era; CABG: coronary artery bypass grafting; ARTS: Arterial Revascularization Therapies Study; AWESOME: Angina with extremely severe outcomes; ERACI II: Argentine randomized study: coronary angioplasty with stenting versus coronary bypass surgery in patients with multi-vessel disease; MASS II: Medicine, Angioplasty, or Surgery Study; SOS: Stent or Surgery trial; BEST: Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multi-vessel Coronary Artery; Boldriot, trial of Boldriot et al: J Am Coll Cardiol. 2011; 57: 538-545. CARDia: Coronary artery revascularization in diabetic; LE MANS: Left main coronary artery stenting; EXCEL: Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization; FREEDOM: Future Revascularization Evaluation in Patients with Diabetes Mellitus; NOBLE: Nordic-Baltic-British Left Main Revascularization Study; PRECOMBAT: Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease; SYNTAX: Synergy between PCI with Taxus and Cardiac Surgery; Va-Cards: Coronary Artery Revascularization in Diabetes in VA Hospitals. –0.2 –0.1 0.1 0.2 0 –0.2 –0.1 0.1 0.2 0 Favours stent Favours CABG Favours stent Favours CABG 5417 5386 100.0% 0.01 [0.00, 0.02] 4624 4629 100.0% 0.02 [0.01, 0.03] 5 8 16 225 4.9% 2001 2001 2004 2008 2009 2011 2012 2015 2016 13.9% 4.4% 1.1% 19.5% 6.5% 20.5% 9.5% 20.6% 605 203 53 897 300 947 442 957 39 17 6 93 5 48 12 77 225 600 205 52 903 300 953 438 948 51 23 5 123 6 98 21 72 407 313 15 25 14 4 52 28 14 3 4 42 13 12 62 30 34 18 52 43 25 4 3 62 3 21 47 347 288 225 225 2001 2001 2002 2004 2008 2009 2010 2011 2011 2012 2013 2015 2016 4.2% –0.04 [–0.08, –0.01] 0.01 [–0.01, –0.03] 0.04 [0.01, 0.07] 0.07 [0.02, 0.11] 0.00 [–0.04, 0.04] 0.02 [–0.00, 0.03] 0.04 [–0.00, 0.09] 0.00 [–0.01, 0.02] –0.01 [–0.06, 0.04] 0.02 [0.00, 0.04] 0.03 [–0.01, 0.07] –0.02 [–0.04, 0.01] –0.04 [–0.08, 0.01] 0.02 [–0.01, 0.05] 0.03 [–0.03, 0.09] –0.02 [–0.13, 0.10] 0.03 [0.00, 0.06] 0.00 [–0.02, 0.02] 0.05 [0.03, 0.08] 0.02 [–0.00, 0.05] –0.00 [–0.03, 0.02] –0.10 [–0.18, –0.03] 11.2% 9.1% 3.8% 1.0% 16.1% 4.7% 5.6% 1.9% 17.6% 1.8% 5.6% 17.5% 605 500 203 52 849 254 300 101 953 97 300 947 600 488 205 52 891 254 300 100 953 101 300 948 Total (95% Cl) Total events Test for overall effect: Z = 2.57 (p = 0.01) Heterogeneity: Chi 2 = 41.05, df = 12 (p < 0.0001); I 2 = 71% Total (95% Cl) Total events Test for overall effect: Z = 3.67 (p = 0.0002) Heterogeneity: Chi 2 = 21.45, df = 8 (p = 0.006); I 2 = 63% Non fatal MI (one year) Non fatal MI (late results) ERACI II 2001 ARTS 2001 SOS 2002 MASS II 2004 LE MANS 2008 SYNTAX 2009 CARDIA 2010 PRECOMBAT 2011 Boudriot et al 2011 FREEDOM 2012 VA-CARDIS 2013 BEST 2015 EXCEL 2016 ERACI II 2001 ARTS 2001 MASS II 2004 LE MANS 2008 SYNTAX 2009 PRECOMBAT 2011 FREEDOM 2012 BEST 2015 EXCEL 2016 Study or Subgroup Stent CABG Risk Difference Risk Difference Events Total Events Total Weight Year M-H, Fixed, 95% Cl M-H, Fixed, 95% Cl Benedetto et al excluded LMCAD (that presented similar results of mortality with the two methods of revascularization) and BMS trials (that involved patients with less complex CAD), did not include AWESOME and included two years results of VaCards. Another reason for the significant worse comparative results of PCI-stent in the meta‑analysis of Benedetto et al. was that diabetics represented 66% of their population. Recently a pooled analysis of an individual database from 11 trials was published by Head et al. 35 and their overall results are similar to ours. Small differences can be explained by the fact that they included late results of VACards and did not include AWESOME, CARDia, Boldriot and LEMANS. LMCAD was, for a long time, an indication type III for PCI, but this concept began to change after four trials showed similar results in mortality. 11,12,16,17 However, AHA/ACC guidelines have accepted PCI only as class IIA or IIB indication for LMCAD and yet, only for patients at high surgical risk. In the present study, we found results similar in mortality, while the incidence of stroke was lower, favouring PCI. Our findings are similar to the collaborative study of Head et al and to the meta-analysis of Palmerini et al. 32 This study provided also mortality results in subgroups, showing that in patients with low SYNTAX SCORE there was a trend to higher long-term mortality with CABG (HR, 0.68, CI 0.43‑1.08; p = 0.09); intermediate SYNTAX score patients had similar 517