A head-to-head comparison of physiology versus angiography-guided coronary artery bypass grafting

Abstract Introduction While invasive coronary angiography is considered the gold standard for the diagnosis of coronary artery disease (CAD) involving the epicardial coronary vessels, coronary physiology-guided revascularization represents a contemporary gold-standard practice for the invasive management of patients with intermediate CAD. Nevertheless, the long-term results of assessing the severity of stenosis through physiology compared to the angiogram as the guide to bypass surgery – coronary artery bypass grafting (CABG) are still uncertain. Methods We searched Medline, EMBASE, and the Cochrane Library until December 2023, including all previous studies. We aimed to assess the clinical outcomes of a physiology-guided CABG compared to the angiography-guided CABG. A pooled odds-ratio meta-analysis was conducted focusing on five main outcomes: all-cause death, myocardial infarction (MI), target vessel revascularization (TVR), major adverse cardiovascular events (MACE), and postoperative angina. A pooled effect estimates meta-analysis was performed with MetaXL 2.0. Results We identified six studies that included a total of 18,849 patients. The follow-up ranged from 6 months to 6 years. A pooled meta-analysis showed no significant difference between physiology and angiography-guided strategies in all-cause death (odds ratio OR = 0.80; 95%CI = 0.50–1.28; I2 = 20%; p = 0.28), MACE (OR = 0.78; 95%CI = 0.55–1.09; I2 = 0%; p = 0.99), MI (OR = 0.95; 95%CI, 0.70–1.29; I2 = 0%; p = 0.61), and TVR (OR = 1.17; 95%CI = 0.91–1.51; I2 = 0%; p = 0.67). The rates of postoperative angina were also similar in both approaches (OR = 1.71; 95%CI = 0.39-7.38; I2 = 0%; p = 0.32). Conclusion This meta-analysis suggests that physiology-guided and angiography-guided CABG strategies exhibit comparable clinical outcomes, questioning the role of coronary physiology in surgical patients. Further research is needed to address this clinical concern.