BMJ 2000;321:73-77 ( 8 July )

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Percutaneous transluminal coronary angioplasty versus medical treatment for non-acute coronary heart disease: meta-analysis of randomised controlled trials

Editorial by Lüscher

Heiner C Bucher, assistant professor, ^a Peter Hengstler, senior fellow, ^a Christian Schindler, statistician, ^b Gordon H Guyatt, professor. ^c

^a Medizinische Universitäts-Poliklinik, Kantonsspital Basel, CH-4031 Basle, Switzerland, ^b Institut für Sozial-und Präventivmedizin, Basle University, Switzerland, ^c Department for Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada L8N 3Z5

Correspondence to: H Bucher hbucher{at}uhbs.ch

Objective: To determine whether percutaneous transluminal coronary angioplasty (angioplasty) is superior to medical treatment in non-acute coronary artery disease.
Design: Meta-analysis of randomised controlled trials.
Setting: Randomised controlled trials conducted worldwide and published between 1979 and 1998.
Participants: 953 patients treated with angioplasty and 951 with medical treatment from six randomised controlled trials, three of which included patients with multivessel disease and pre-existing myocardial infarction.
Main outcome measures: Angina, fatal and non-fatal myocardial infarction, death, repeated angioplasty, and coronary artery bypass grafting.
Results: In patients treated with angioplasty compared with medical treatment the risk ratios were 0.70 (95% confidence interval 0.50 to 0.98; heterogeneity P<0.001) for angina; 1.42 (0.90 to 2.25) for fatal and non-fatal myocardial infarction, 1.32 (0.65 to 2.70) for death, 1.59 (1.09 to 2.32) for coronary artery bypass graft, and 1.29 (0.71 to 3.36; heterogeneity P<0.001) for repeated angioplasty. Differences in the methodological quality of the trials, in follow up, or in single versus multivessel disease did not explain the variability in study results in any analysis.
Conclusions: Percutaneous transluminal coronary angioplasty may lead to a greater reduction in angina in patients with coronary heart disease than medical treatment but at the cost of more coronary artery bypass grafting. Trials have not included enough patients for informative estimates of the effect of angioplasty on myocardial infarction, death, or subsequent revascularisation, though trends so far do not favour angioplasty.

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