Surgical versus percutaneous revascularization in multivessel non-ST-elevation acute coronary syndrome: a meta-analysis of 77 989 patients

Multivessel coronary artery disease (MVD) significantly complicates the management of patients with non-ST-elevation acute coronary syndrome, worsening their clinical and angiographic outcomes. However, the optimal revascularization strategy in this subset of patients is still controversial. Our systematic review and meta-analysis aimed to compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with MVD and non-ST-elevation acute coronary syndrome . We performed a comprehensive search of four electronic databases (PubMed, Scopus, WOS, and Cochrane) from inception till 15 December 2024. The outcomes were reported as a relative risk (RR) and 95% confidence interval (CI) in the random-effect model. Our primary outcome was all-cause mortality, while the secondary outcomes were major adverse cardiovascular events (MACCE), myocardial infarction (MI), cardiac death, repeated revascularization, and stroke. Fourteen studies, comprising 77 989 patients, were included. CABG was associated with lower risk of all-cause mortality (RR: 0.80, 95% CI: 0.68-0.93), MACCE (RR: 0.70, 95% CI: 0.59-0.83), MI (RR: 0.53, 95% CI: 0.42-0.67), cardiac death (RR: 0.77, 95% CI: 0.68-0.89), and repeated revascularization (RR: 0.41, 95% CI: 0.33-0.51) in long-term follow-up. However, stroke incidence was higher with CABG in long-term follow-up (RR: 1.36, 95% CI: 1.07-1.73). CABG and PCI showed no significant difference in clinical outcomes at 30-day follow-up. This meta-analysis showed that CABG was associated with favorable long-term outcomes compared to PCI, including lower mortality, MACCE, MI, and repeated revascularization. Time-dependent hazard ratio showed that CABG was associated with better survival over a 16-year follow-up period. perioperative outcomes were comparable in both CABG and PCI.