Anatomic vs ischemia-driven strategies for percutaneous coronary revascularization in chronic coronary syndrome: a network meta-analysis

Abstract Background In patients with chronic coronary syndrome (CCS), percutaneous coronary intervention (PCI) stands out as an alternative to optimal medical therapy (OMT). The decision to perform a PCI may be driven either by angiographic evaluation or ischemia assessment, thus depicting different potential strategies which have not yet been compared. Purpose To compare different strategies of percutaneous revascularization (angiography, non-invasive ischemia and coronary physiology (FFR or iFR) guided) in order to identify a potential benefit of PCI depending on the guidance chosen in CCS. Methods Randomized controlled trials (RCTs) comparing OMT vs. PCI-angio guided or vs. PCI guided by non-invasive or invasive ischemia assessment were included and compared via network metanalysis. Major adverse clinical events (MACE), as defined by each included trial, were the primary end point, while cardiovascular (CV) death, myocardial infarction and subsequent revascularization the secondary ones. Results 18 studies, encompassing 17512 patients, were included followed up for a weighted mean of 3,5 years. PCI guided by non-invasive assessment of ischemia entailed a reduced risk of myocardial infarction compared with OMT (HR 0.61:0.37-0.94, CI 95%). This strategy ranked best in preventing CV death. In addition, PCI guided by ischemia defined either invasively or not was associated with a reduced risk of MACE as compared with OMT. iFR and FFR guided approaches showed the highest probability of performing best. Finally, physiology guided PCI ranked best in reducing subsequent urgent revascularizations. Conclusions For patients with CCS, ischemia-guided PCI, either by invasive or noninvasive assessment, resulted in a reduced risk of MACE as compared with OMT. PCI guided by a non-invasive assessment of ischemia reduced risk of myocardial infarction compared to OMT, while PCI guided by iFR or FFR showed the highest probability of reducing the need of subsequent revascularization. These strategies showed the highest probability of reducing MACE and CV death.Bar plot of best treatmentPRISMA diagram and Network Plot