Network meta-analysis of treatment strategies in patients with coronary artery disease and low left ventricular ejection fraction.

OBJECTIVE: The optimal treatment strategy in patients with coronary artery disease (CAD) and low left ventricular ejection fraction (LVEF) remains controversial. Herein, we conducted a network meta-analysis comparing coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), and optimal medical therapy (OMT) in patients with CAD and low LVEF. METHODS: MEDLINE and EMBASE were searched through March, 2021 to identify randomized controlled trials (RCTs) and propensity-score matched (PSM) studies comparing CABG, PCI, and OMT. We extracted hazard ratios (HRs) of the outcomes. RESULTS: A total of three RCTs and 10 PSM trials were identified, yielding a total of 18,855 patients with CAD with low EF who were treated with CABG (n = 9241), PCI (n = 8771), or OMT (n = 1003). All-cause mortality was significantly lower in patients with CABG compared with those with PCI or OMT (HR [95% confidence interval (CI)] = 0.72 [0.62-0.82], p < .001, HR [95% CI] = 0.65 [0.51-0.82], p = .004, respectively), while no difference was observed between PCI and OMT. The rates of MI were significantly lower in patients treated with CABG compared to those treated with PCI or OMT. However, the subgroup analysis by limiting the PCI group to patients who received drug-eluting stent (DES) showed similar all-cause mortality between CABG and PCI, while both CABG and PCI were associated with lower all-cause mortality compared with OMT. CONCLUION: The present study demonstrated that CABG was the appropriate treatment strategy in patients with CAD and low LVEF. Further long-term trials were warranted to investigate outcomes of PCI with DES compared with CABG.