title: Survival Benefits of Invasive Versus Conservative Strategies in Heart Failure in Patients With Reduced Ejection Fraction and Coronary Artery Disease: A Meta-Analysis.
abstract: BACKGROUND
  Heart failure with reduced ejection fraction caused by ischemic heart disease is associated with increased morbidity and mortality. It remains unclear whether revascularization by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) carries benefits or risks in this group of stable patients compared with medical treatment.
  
  
  RESULTS
  We performed a meta-analysis of available studies comparing different methods of revascularization (PCI or CABG) against each other or medical treatment in patients with coronary artery disease and left ventricular ejection fraction ≤40%. The primary outcome was all-cause mortality; myocardial infarction, revascularization, and stroke were also analyzed. Twenty-one studies involving a total of 16 191 patients were included. Compared with medical treatment, there was a significant mortality reduction with CABG (hazard ratio, 0.66; 95% confidence interval, 0.61-0.72; P<0.001) and PCI (hazard ratio, 0.73; 95% confidence interval, 0.62-0.85; P<0.001). When compared with PCI, CABG still showed a survival benefit (hazard ratio, 0.82; 95% confidence interval, 0.75-0.90; P<0.001).
  
  
  CONCLUSIONS
  The present meta-analysis indicates that revascularization strategies are superior to medical treatment in improving survival in patients with ischemic heart disease and reduced ejection fraction. Between the 2 revascularization strategies, CABG seems more favorable compared with PCI in this particular clinical setting.
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.).
authors.forename: Georg
authors.initials: G
authors.lastname: Wolff
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.).
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Dimitroulis
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.).
authors.forename: Felicita
authors.initials: F
authors.lastname: Andreotti
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.).
authors.forename: Michalina
authors.initials: M
authors.lastname: Kołodziejczak
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.).
authors.forename: Christian
authors.initials: C
authors.lastname: Jung
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.).
authors.forename: Pietro
authors.initials: P
authors.lastname: Scicchitano
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.).
authors.forename: Fiorella
authors.initials: F
authors.lastname: Devito
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.).
authors.forename: Annapaola
authors.initials: A
authors.lastname: Zito
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.).
authors.forename: Michele
authors.initials: M
authors.lastname: Occhipinti
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.).
authors.forename: Battistina
authors.initials: B
authors.lastname: Castiglioni
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.).
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Calveri
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.).
authors.forename: Francesco
authors.initials: F
authors.lastname: Maisano
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.).
authors.forename: Marco M
authors.initials: MM
authors.lastname: Ciccone
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.).
authors.forename: Stefano
authors.initials: S
authors.lastname: De Servi
authors.affiliation: From the Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Milan, Italy (G.W., D.D., F.A., M.K., C.J., P.S., F.D., A.Z., M.O., M.M.C., S.D.S., E.P.N.); Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany (G.W., D.D., C.J.); Institute of Cardiology, Catholic University, Rome, Italy (F.A.); Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus, Toruń, Poland (M.K.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (P.S., F.D., A.Z.); Department of Heart Science, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (M.O., B.C., G.C.); Department of Cardiosurgery, University of Zurich, Switzerland (F.M.); Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, School of Medicine, University of Bari, Italy (M.M.C.); and Department of Cardiology, Multimedica IRCCS, Milan, Italy (S.D.S., E.P.N.). elianonavarese@gmail.com.
authors.forename: Eliano P
authors.initials: EP
authors.lastname: Navarese
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000150:complications / Q000628:therapy*; D005260:Female; D006333:Heart Failure / Q000209:etiology / Q000503:physiopathology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000628:therapy*; D017202:Myocardial Ischemia / Q000150:complications; D062645:Percutaneous Coronary Intervention; D018570:Risk Assessment; D013318:Stroke Volume / Q000502:physiology; D016019:Survival Analysis
keywords: coronary artery bypass; coronary artery disease; heart failure; meta-analysis; myocardial infarction