Coronary revascularization for heart failure with coronary artery disease: A systematic review and meta‐analysis of randomized trials

• Published in: European journal of heart failure Vol. 25; no. 7; pp. 1094 - 1104
• Main Authors: Iaconelli, Antonio, Pellicori, Pierpaolo, Dolce, Pasquale, Busti, Matteo, Ruggio, Aureliano, Aspromonte, Nadia, D'Amario, Domenico, Galli, Mattia, Princi, Giuseppe, Caiazzo, Elisabetta, Rezig, Asma O.M., Maffia, Pasquale, Pecorini, Giovanni, Crea, Filippo, Cleland, John G.F.
• Format: Journal Article
• Language: English
• Published: Oxford, UK John Wiley & Sons, Ltd 01.07.2023
• Subjects: Coronary Artery Bypass - adverse effects; Coronary artery disease; Coronary Artery Disease - complications; Coronary Artery Disease - surgery; Female; Heart failure; Heart Failure - drug therapy; Humans; Male; Percutaneous Coronary Intervention - adverse effects; Randomized Controlled Trials as Topic; Revascularization; Stroke Volume; Treatment Outcome; Heart failure; Coronary artery disease; Revascularization
• ISSN: 1388-9842; 1879-0844
• DOI: 10.1002/ejhf.2911

Aims Coronary artery disease (CAD) is a common cause of heart failure (HF). Whether coronary revascularization improves outcomes in patients with HF receiving guideline‐recommended pharmacological therapy (GRPT) remains uncertain; therefore, we conducted a systematic review and meta‐analysis of relevant randomized controlled trials (RCTs). Methods and results We searched in public databases for RCTs published between 1 January 2001 and 22 November 2022, investigating the effects of coronary revascularization on morbidity and mortality in patients with chronic HF due to CAD. All‐cause mortality was the primary outcome. We included five RCTs that enrolled, altogether, 2842 patients (most aged <65 years; 85% men; 67% with left ventricular ejection fraction ≤35%). Overall, compared to medical therapy alone, coronary revascularization was associated with a lower risk of all‐cause mortality (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.79–0.99; p = 0.0278) and cardiovascular mortality (HR 0.80, 95% CI 0.70–0.93; p = 0.0024) but not the composite of hospitalization for HF or all‐cause mortality (HR 0.87, 95% CI 0.74–1.01; p = 0.0728). There were insufficient data to show whether the effects of coronary artery bypass graft surgery or percutaneous coronary intervention were similar or differed. Conclusions For patients with chronic HF and CAD enrolled in RCTs, the effect of coronary revascularization on all‐cause mortality was statistically significant but neither substantial (HR 0.88) nor robust (upper 95% CI close to 1.0). RCTs were not blinded, which may bias reporting of the cause‐specific reasons for hospitalization and mortality. Further trials are required to determine which patients with HF and CAD obtain a substantial benefit from coronary revascularization by either coronary artery bypass graft surgery or percutaneous coronary intervention. In patients with heart failure (HF) and coronary artery disease (CAD), coronary revascularization was associated with a lower risk of all‐cause mortality and cardiovascular mortality but not the composite of hospitalization for HF or all‐cause mortality. Further trials are required to determine which patients with HF and CAD may obtain a benefit from coronary revascularization. CABG, coronary artery bypass; CI, confidence interval; HR, hazard ratio; PCI, percutaneous coronary intervention; RCT, randomized controlled trial.