Coronary revascularisation in people with multiple long-term conditions: a systematic review and meta-analysis

Introduction People presenting for multivessel coronary revascularisation commonly have multiple long-term conditions that influence prognosis. The aim of this study was to review the evidence for revascularisation choices in these groups. Methods Randomised trials of Coronary Artery Bypass Grafting (CABG) versus Percutaneous Coronary Intervention (PCI) reporting outcomes by pre-specified comorbidities were included. Treatment effects were estimated using inverse variance random effects models and presented as Risk Ratios (95% Confidence Intervals). The certainty of evidence for outcomes was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results 19 studies from nine RCTs with 10,594 participants were included. Reported baseline comorbidities included diabetes (49%), CKD (25%), LVSD (9%), female sex (14%), and older age (40%). Trials were unblinded, resulting in some bias concerns. For people with diabetes and CKD, CABG reduced the risks of all-cause death and repeat revascularisation, with no treatment effect on MI or stroke, versus PCI. There was no difference in mortality or stroke for female sex, or older age. No data was reported for people with peripheral vascular disease or frailty. Patient reported outcomes favoured CABG in people with diabetes. GRADE showed that the certainty of the evidence was generally Low to Very Low with the exception of people with diabetes (Moderate Certainty). Conclusion There is a knowledge gap with respect to the risks and benefits of CABG versus PCI in people with common comorbidities. Registration PROSPERO CRD420251032665