Complete myocardial revascularization confers a larger clinical benefit when performed with state‐of‐the‐art techniques in high‐risk patients with multivessel coronary artery disease: A meta‐analysis of randomized and observational studies

OBJECTIVES: To test whether a strategy of complete revascularization (CR) as compared with incomplete myocardial revascularization (IR)-both performed with current "state-of-the-art" percutaneous coronary interventions (PCI) or coronary artery bypass graft (CABG)-would provide a clinical benefit in patients with multivessel coronary artery disease (MVCAD). BACKGROUND: The "optimal" extent of myocardial revascularization remains to be determined. METHODS: We performed a meta-analysis of studies reporting on clinical outcomes of MVCAD patients treated with CR and IR, with extensive (>80%) use of stents for PCI or arterial conduits in CABG. Relative risk (RR) and 95% confidence intervals (CIs) for all-cause mortality were assessed as primary endpoint, myocardial infarction (MI) and repeat revascularization as secondary endpoints. RESULTS: A total of 28 studies were identified, including 83,695 patients with 4.7 ± 4.3 years of follow-up. Compared with IR, CR was associated with reduced mortality (RR: 0.73; 95% CI 0.66-0.81) both after CABG (RR: 0.76; 95% CI 0.63-0.90) and PCI (RR: 0.73; 95% CI 0.64-0.82). The risks of MI (RR: 0.74; 95% CI 0.64-0.85) and repeat revascularization (RR: 0.77; 95% CI 0.66-0.88) were also lower after CR as compared with IR. Metaregression showed a significant RR reduction of MI associated with more recent publication (P = 0.021) and increasing prevalence of diabetes (P = 0.033). CONCLUSIONS: In MVCAD, as compared with IR, CR confers a clinical benefit that seems larger in cohorts of patients enrolled in more recent studies and with a higher prevalence of diabetes.