title: Coronary surgery is superior to drug eluting stents in multivessel disease. Systematic review and meta-analysis of contemporary randomized controlled trials.
abstract: OBJECTIVE
  Current randomized controlled trials (RCTs) comparing percutaneous coronary intervention with drug eluting stent (DES-PCI) with coronary artery bypass grafting (CABG) in multivessel disease are underpowered to detect a difference in hard clinical end-points such as mortality, myocardial infarction and stroke. We aimed to overcome this limitation by conducting a meta-analysis of contemporary RCTs.
  
  
  METHODS
  A systematic literature search was conducted for all RCTs comparing DES-PCI versus CABG in multivessel disease published through May 2015. Inverse variance weighting was used to pool data from individual studies (<1 favouring DES-PCI and >1 CABG favouring surgery).
  
  
  RESULTS
  A total of five randomized trials including 4563 subjects were analysed. After an average follow-up of 3.4 years, DES-PCI was associated with a significantly increased risk of overall mortality (HR 1.51; 95%CI 1.23-1.84; P<0.001), MI (HR 2.02; 95%CI 1.57-2.58; P<0.001) and repeat revascularization (HR 2.54; 95%CI 2.07-3.11; P=<0.001). CABG marginally increased the risk of stroke (HR 0.70; 95%CI 0.50-0.98; P=0.04). The absolute risk reduction for all-cause mortality (3.3%) and myocardial infarction (4.3%) with CABG was larger than the absolute risk reduction for stroke (0.9%) with DES-PCI.
  
  
  CONCLUSIONS
  In patients with multivessel coronary disease, CABG was found to be superior to DES-PCI by reducing the risk of mortality and subsequent myocardial infarction at the expense of a marginally increased risk of stroke.
authors.affiliation: Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, UK. Electronic address: umberto.benedetto@hotmail.com.
authors.forename: Umberto
authors.initials: U
authors.lastname: Benedetto
authors.affiliation: Division of Cardio-thoracic Surgery, Cornell University, New York, NY, USA.
authors.forename: Mario
authors.initials: M
authors.lastname: Gaudino
authors.affiliation: Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, UK.
authors.forename: Colin
authors.initials: C
authors.lastname: Ng
authors.affiliation: Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Eleonora Lorillard Spencer Cenci Foundation, Rome, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Biondi-Zoccai
authors.affiliation: Dipartimento di Scienze Mediche, Divisione di Cardiologia, Città della Salute e della Scienza, Turin, Italy.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: D'Ascenzo
authors.affiliation: Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Department of Angiocardioneurology, IRCCS Neuromed, Pozzilli, Italy.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Frati
authors.affiliation: Division of Cardio-thoracic Surgery, Cornell University, New York, NY, USA.
authors.forename: Leonard N
authors.initials: LN
authors.lastname: Girardi
authors.affiliation: Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, UK.
authors.forename: Gianni D
authors.initials: GD
authors.lastname: Angelini
authors.affiliation: Nuffield Department of Surgical Sciences, Oxford University Hospital, Oxford, UK.
authors.forename: David P
authors.initials: DP
authors.lastname: Taggart
mesh_terms: D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000379:methods; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000379:methods*; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000628:therapy*; D054855:Drug-Eluting Stents / Q000009:adverse effects; D006801:Humans; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000379:methods*; D016032:Randomized Controlled Trials as Topic / Q000379:methods*; D012307:Risk Factors; D016896:Treatment Outcome
keywords: CABG; Meta-analysis; PCI