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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Risk of stroke with coronary artery bypass graft surgery compared with percutaneous coronary intervention

T Palmerini, G Biondi-Zoccai, L Bacchi Reggiani, D Sangiorgi, L Alessi, S De Servi, A Branzi, and GW Stone.

Review published: 2012.

Link to full article: [Journal publisher]

CRD summary

The authors concluded that coronary revascularisation by coronary artery bypass grafting, compared with percutaneous coronary intervention, was associated with an increased risk of stroke at 30 days and midterm follow-up. With a small caveat regarding limitations of the evidence base, the authors' conclusions reflect the evidence and appear reliable.

Authors' objectives

To evaluate whether coronary artery bypass grafting surgery was associated with an increased risk of stroke, in comparison with percutaneous coronary intervention.

Searching

MEDLINE, EMBASE and The Cochrane Library were searched (search dates not reported). Search terms were provided.

Study selection

Randomised controlled trials (RCTs) that compared coronary artery bypass grafting versus percutaneous coronary intervention in patients with single vessel coronary artery disease, multivessel coronary artery disease and unprotected left main coronary artery disease were eligible for inclusion. The primary outcome of interest was rate of stroke at 30 days; the secondary eligible outcome was rate of stroke at midterm follow-up.

Included RCTs were published between 1993 and 2011. Where reported, the mean age of patients ranged from 59 to 69 years; proportions of male patients ranged from 60 to 83%. Just over half of the study populations had multivessel coronary artery disease; the remainder had equal numbers of populations with unprotected left main coronary artery disease or single vessel coronary artery disease. Definitions of stroke varied across studies.

Two reviewers independently selected studies for inclusion; any disagreements were resolved by consensus.

Assessment of study quality

The authors did not report whether any quality assessment was undertaken.

Data extraction

Data (number of stroke events) were extracted to calculate odds ratios and 95% confidence intervals, with data from RCTs as the primary data set and data from observational studies considered secondary. The authors did not report how many reviewers extracted data.

Methods of synthesis

Odds ratios and 95% confidence intervals were pooled using fixed-effect (inverse variance-weighted) and random-effects (DerSimonian and Laird) models. Median follow-up and number-needed-to-harm were calculated. Other analyses included possible interactions between revascularisation method and the extent of coronary artery disease, and sensitivity analyses according to study heterogeneity of effects, and publication bias (assessed by funnel plots and Peter's test).

Results of the review

Forty-six studies were included in the review and meta-analyses (44,924 patients): 19 RCTs (10,944 patients, from 102 to 1,829 per study) and 27 observational studies (33,980 patients, from 59 to 6,479 per study). Only RCT data were included in the meta-analyses.

At 30-days follow-up, coronary artery bypass grafting demonstrated statistically significantly higher rates of stroke than percutaneous coronary intervention (OR 2.94, 95% CI 1.69 to 5.09; 14 RCTs; Ι²=0%); results were identical for the fixed-effect and random-effects models. The number-needed-to-harm was 155, with an additional seven strokes for every 1,000 patients treated with coronary artery bypass grafting rather than percutaneous coronary intervention. No statistically significant interactions were reportedly observed between the revascularisation methods and the period within which these studies were performed (p=0.25), the extent of coronary artery disease in patients (p=0.57), and the use of stents instead of balloon angioplasty only (p=0.52).

After a median follow-up period of 12.1 months, coronary artery bypass grafting demonstrated statistically significantly higher rates of stroke than percutaneous coronary intervention using the fixed-effect model (OR 1.67, 95% CI 1.09 to 2.56; 12 RCTs; Ι²=4.8%) and the random-effects model (OR 1.69, 95% CI 1.07 to 2.67). No statistically significant interaction was observed between revascularisation method and the extent of coronary artery disease.

In observational studies, coronary artery bypass grafting demonstrated a statistically significantly increased risk of stroke over percutaneous coronary intervention, both at 30 days (27 studies) and at a median follow-up of 14.2 months (13 studies). Details reported in paper.

No statistically significant heterogeneity was observed across the RCTs or the observational studies overall, or within the subgroups analysed (Ι² range: 0 to 7.5%). No evidence of publication bias was found.

Authors' conclusions

Coronary revascularisation by coronary artery bypass grafting compared with percutaneous coronary intervention was associated with an increased risk of stroke at 30 days and midterm follow-up.

CRD commentary

The review question was clear and supported by sufficiently defined inclusion criteria. Relevant electronic databases were searched, but no attempts were made to locate further studies through other methods, such as handsearching of reference lists. All included studies were published, but no evidence of publication bias was reportedly found. Effort was made to minimise reviewer error and bias during study selection but this was unclear for the process of data extraction. Quality assessment was not reported, so the likelihood of biases within studies and the reliability of their findings could not be asserted.

Adequate study details were presented, which revealed some clinical diversity between the studies in definitions of stroke, and characteristics of study populations and the revascularisation method. The methods of synthesis seemed appropriate given the inclusion of both RCTs and observational studies, and very little statistical between-study heterogeneity was shown. The authors acknowledged that because follow-up was restricted to a year or less, the longer term differences in stroke rates between the coronary artery bypass grafting and percutaneous coronary intervention methods remained unknown. Another limitation of the evidence base was that definitions of stroke varied across the studies, and the nature of the data meant that the authors were unable to analyse the potential influence of classical risk factors for stroke (such as diabetes or prior stroke).

With a small caveat regarding limitations of the evidence base, the authors' conclusions reflect the evidence and appear reliable.

Implications of the review for practice and research

Practice: The authors stated that the findings of the meta-analysis were robust and scientifically valid, and could inform patients, their families, and physicians during decision-making for the optimal strategy of revascularisation

Research: The authors did not state any implications for further research.

Funding

Not stated.

Bibliographic details

Palmerini T, Biondi-Zoccai G, Bacchi Reggiani L, Sangiorgi D, Alessi L, De Servi S, Branzi A, Stone GW. Risk of stroke with coronary artery bypass graft surgery compared with percutaneous coronary intervention. Journal of the American College of Cardiology 2012; 60(9): 798-805. [PubMed: 22917004]

Indexing Status

Subject indexing assigned by NLM

MeSH

Angioplasty, Balloon, Coronary /adverse effects; Coronary Artery Bypass /adverse effects; Humans; Risk Assessment; Stroke /epidemiology /etiology

AccessionNumber

12012041779

Database entry date

04/04/2013

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 22917004