Long-term outcomes of treatment strategies for ischemic cardiomyopathy, a network meta-analysis

Introduction Ischemic heart disease is the leading cause of heart failure (HF), with a poor prognosis despite advances in pharmacological and interventional therapies. Current guidelines assign Class IIa and IIb recommendations to coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in ischemic cardiomyopathy, respectively, reflecting the limited evidence available and an ongoing knowledge gap regarding the optimal treatment strategy. Purpose This study compares long-term outcomes of medical therapy (MT), PCI and CABG in ischemic cardiomyopathy using a network meta-analysis. Methods A systematic search of the Cochrane Library, EMBASE and MEDLINE was conducted for English-language studies published from January 2000 to February 2025. Eligible studies compared MT, PCI and CABG in ischemic cardiomyopathy. Data were analyzed using a frequentist network meta-analysis with a multivariate random-effects model. The primary endpoint was all-cause mortality, while secondary endpoints included myocardial infarction (MI), any revascularization, HF hospitalization and stroke. Outcomes were assessed at the longest available follow-up. Results Thirty studies (4 randomized controlled trials and 26 adjusted observational studies) met inclusion criteria, comprising 4809 patients in the MT group, 18034 in the PCI group, and 20739 in the CABG group. The median follow-up was 60 months (IQR: 36-120). Median age was 62.5 years (62-66.8) for MT, 66 years (65-68.8) for PCI, and 65 years (63-65.8) for CABG. 34.5% (29.8-58.8) of MT, 36% (20.8-43.3) of PCI and 48% (36.5-56) of CABG presented NYHA Class III-IV. Median left ventricular ejection fraction was 27% (26-30) for MT, 29.5% (26.8- 37.7) for PCI and 29.5% (26.8- 33.8) for CABG. Left main disease was present in 14% (4-33.5) of MT, 17% (13-29) of PCI, and 30% of CABG (19-44), while three- vessel disease was found in 51% (39-59) of MT, 51% (41.5-59) of PCI and 62% (47.8-72.8) CABG patients. Complete revascularization was achieved in 45% (24.5-55) of PCI patients and 84% (68-92) of CABG patients. MT and PCI were associated with a higher risk of all-cause mortality compared to CABG. Additionally, both MT and PCI were linked with an increased risk of MI and revascularization, while PCI was associated to a higher risk of HF hospitalization compared to CABG. No significant differences were observed in stroke among the treatment groups. Findings remained consistent in an analysis restricted to studies published between 2010- 2025. Conclusions In this network meta-analysis, CABG was associated with a lower risk of all-cause mortality compared to MT and PCI, along with a reduced risk of MI, revascularization and HF hospitalization. No significant differences in stroke incidence were observed. While these findings suggest potential benefits of CABG in ischemic cardiomyopathy, further randomized trials are needed to confirm the optimal treatment strategy and guide clinical decision-making.