Compliance With Guideline-Directed Medical Therapy in Contemporary Coronary Revascularization Trials
Key result
PCI achieves significantly higher GDMT compliance than CABG, though adherence drops to ~53% at 5 years.
- n=5
Why the study?
The importance of concurrent guideline-directed medical therapy in clinical trials comparing PCI and CABG is often overlooked despite its established benefits in secondary cardiovascular prevention.
Does compliance with guideline-directed medical therapy differ between patients undergoing PCI versus CABG in clinical trials?
Key Points
- To assess adherence to guideline-directed medical therapy in clinical trials comparing percutaneous coronary intervention with coronary artery bypass grafting and evaluate its influence on comparative clinical endpoints.
- Systematic review searching Cochrane Central Register of Controlled Trials and MEDLINE (2005 to August 2017) alongside trial registries for randomized controlled trials comparing PCI using drug-eluting stents versus CABG.
- Extracted post-revascularization compliance with two guideline-directed medical therapy tiers: GDMT1 (antiplatelet, beta-blocker, statin) and GDMT2 (GDMT1 plus ACE inhibitor or ARB) using Cochrane Collaboration methodology.
- Across 5 included randomized trials, GDMT1 compliance fell from 67% at 1 year to 53% at 5 years, while GDMT2 compliance fell from 40% at 1 year to 38% at 5 years.
- Compliance with both GDMT1 and GDMT2 was significantly higher in PCI arms than in CABG arms across all evaluated time points.
- Meta-regression demonstrated an association between lower GDMT1 utilization and increased adverse clinical outcomes in PCI versus CABG at 5-year follow-up.
Study Design
Type
Meta-Analysis (n=5)
Structured PICO
Does compliance with guideline-directed medical therapy differ between patients undergoing PCI versus CABG in clinical trials?
P
Population
5 randomized controlled trials comparing PCI with drug-eluting stents versus CABG and reporting medical therapy after revascularization.
I
Intervention
Percutaneous coronary intervention (PCI) with drug-eluting stents
C
Comparator
Coronary artery bypass grafting (CABG)
O
Outcome
Compliance with guideline-directed medical therapy (GDMT1: any antiplatelet agent plus beta-blocker plus statin; GDMT2: any antiplatelet agent plus beta-blocker plus statin plus angiotensin-converting enzyme inhibitor/angiotensin receptor blocker)
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Whenever a patient comes for coronary revascularization, we need to be as focused on what happens after the patient leaves the hospital as on what happens in the lab or in the OR. If we call ourselves interventionalists or surgeons we need to align with all the interventions that work, and that includes many of the medical interventions or even nonmedical interventions such as exercise, smoking cessation, and beyond.”
“It's dramatic and interesting how little progress we've made with drugs that we know have fairly substantial mortality and acute coronary events benefits.”
APAna-Catarina Pinho-GomesResearcher, Oxford University Hospitals NHS Trust
“What we can infer is that the difference [in outcomes] between CABG and PCI—if compliance was the same—would... favor CABG even more in comparison to PCI.”
Implication
Compliance with guideline-directed medical therapy in contemporary revascularization trials is suboptimal and significantly lower after CABG than after PCI, which may confound the comparison of clinical endpoints between these strategies.
Abstract
BACKGROUND: Despite the well-established benefits of secondary cardiovascular prevention, the importance of concurrent medical therapy in clinical trials of coronary revascularization is often overlooked. OBJECTIVES: The goal of this study was to assess compliance with guideline-directed medical therapy (GDMT) in clinical trials and its potential impact on the comparison between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). METHODS: The Cochrane Central Register of Controlled Trials and MEDLINE were searched from 2005 to August 2017. Clinical trial registries and reference lists of relevant studies were also searched. Randomized controlled trials comparing PCI with drug-eluting stents versus CABG and reporting medical therapy after revascularization were included. The study outcome was compliance with GDMT, defined as the following: 1) any antiplatelet agent plus beta-blocker plus statin (GDMT1); and 2) any antiplatelet agent plus beta-blocker plus statin plus angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (GDMT2). Data collection and analysis were performed according to the methodological recommendations of The Cochrane Collaboration. RESULTS: From a total of 439 references, 5 trials were included based on our inclusion and exclusion criteria. Overall, compliance with GDMT1 was low and decreased over time from 67% at 1 year to 53% at 5 years. Compliance with GDMT2 was even lower and decreased from 40% at 1 year to 38% at 5 years. Compliance with both GDMT1 and GDMT2 was higher in PCI than in CABG at all time points. Meta-regression suggested an association between lower use of GDMT1 and adverse clinical outcomes in PCI versus CABG at 5 years. CONCLUSIONS: Compliance with GDMT in contemporary clinical trials remains suboptimal and is significantly lower after CABG than after PCI, which may influence the comparison of clinical trial endpoints between those study groups.
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Cite This Study
Pinho‐Gomes et al. (2018) conducted a meta-analysis in Coronary revascularization (n=5). Percutaneous coronary intervention (PCI) with drug-eluting stents vs. Coronary artery bypass grafting (CABG) was evaluated on Compliance with guideline-directed medical therapy (GDMT1 and GDMT2). Compliance with guideline-directed medical therapy in revascularization trials was low (decreasing to 53% at 5 years for GDMT1) and significantly lower after CABG than after PCI.