title: Percutaneous coronary intervention versus optimal medical therapy in stable coronary artery disease: a systematic review and meta-analysis of randomized clinical trials.
abstract: BACKGROUND
  The role of percutaneous coronary intervention (PCI) in the management of stable coronary artery disease remains controversial. Given advancements in medical therapies and stent technology over the last decade, we sought to evaluate whether PCI, when added to medical therapy, improves outcomes when compared with medical therapy alone.
  
  
  RESULTS
  We performed a systematic review and meta-analysis, searching PubMed, EMBASE, and CENTRAL databases, until January 2012, for randomized clinical trials comparing revascularization with PCI to optimal medical therapy (OMT) in patients with stable coronary artery disease. The primary outcome was all-cause mortality, and secondary outcomes included cardiovascular death, nonfatal myocardial infarction, subsequent revascularization, and freedom from angina. Primary analyses were based on longest available follow-up with secondary analyses stratified by trial duration, with short-term (≤1 year), intermediate (1-5 years), and long-term (≥5 years) time points. We identified 12 randomized clinical trials enrolling 7182 participants who fulfilled our inclusion criteria. For the primary analyses, when compared with OMT, PCI was associated with no significant improvement in mortality (risk ratio [RR], 0.85; 95% CI, 0.71-1.01), cardiac death (RR, 0.71; 95% CI, 0.47-1.06), nonfatal myocardial infarction (RR, 0.93; 95% CI, 0.70-1.24), or repeat revascularization (RR, 0.93; 95% CI, 0.76-1.14), with consistent results over all follow-up time points. Sensitivity analysis restricted to studies in which there was >50% stent use showed attenuation in the effect size for all-cause mortality (RR, 0.93; 95% CI, 0.78-1.11) with PCI. However, for freedom from angina, there was a significant improved outcome with PCI, as compared with the OMT group (RR, 1.20; 95% CI, 1.06-1.37), evident at all of the follow-up time points.
  
  
  CONCLUSIONS
  In this most rigorous and comprehensive analysis in patients with stable coronary artery disease, PCI, as compared with OMT, did not reduce the risk of mortality, cardiovascular death, nonfatal myocardial infarction, or revascularization. PCI, however, provided a greater angina relief compared with OMT alone, larger studies with sufficient power are required to prove this conclusively.
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Seema
authors.initials: S
authors.lastname: Pursnani
authors.forename: Frederick
authors.initials: F
authors.lastname: Korley
authors.forename: Ravindra
authors.initials: R
authors.lastname: Gopaul
authors.forename: Pushkar
authors.initials: P
authors.lastname: Kanade
authors.forename: Newry
authors.initials: N
authors.lastname: Chandra
authors.forename: Richard E
authors.initials: RE
authors.lastname: Shaw
authors.forename: Sripal
authors.initials: S
authors.lastname: Bangalore
mesh_terms: D060050:Angina, Stable / Q000188:drug therapy* / Q000401:mortality*; D015906:Angioplasty, Balloon, Coronary / Q000401:mortality*; D003324:Coronary Artery Disease / Q000188:drug therapy* / Q000401:mortality*; D016208:Databases, Factual / Q000706:statistics & numerical data; D006801:Humans; D016032:Randomized Controlled Trials as Topic