Percutaneous coronary intervention and medical therapy versus medical therapy alone in chronic coronary syndrome: A hierarchical win-ratio analysis from SCAAR

Abstract Background Revascularization of patients with chronic coronary syndrome (CCS) using percutaneous coronary intervention (PCI) is frequently done. However, the role of a PCI in this subgroup of patients with coronary artery disease remains controversial. Purpose The objective is to determine whether PCI plus medical therapy is associated with better outcomes for patients with CCS, compared to medical therapy only. Methods We conducted a population-based nationwide observational study. Using the Swedish Coronary Angiography and Angioplasty registry (SCAAR) we identified all patients with CCS undergoing coronary angiography between 2010-2020. Patients with obstructive coronary artery disease, defined as having at least one stenosis with ≥50% luminal obstruction were included. Patients were stratified into two groups according to their received treatment with PCI plus medical therapy or medical therapy only. Propensity score (PS) matching was used to match the two groups on their baseline characteristics. Outcome was assessed with win-ratio and the primary endpoint was net adverse clinical event (NACE) within 5-years. In the win-ratio analysis, the components of NACE were ranked (1) all-cause mortality, (2) stroke, (3) bleeding and (4) myocardial infarction. Subgroup analysis was also performed. Results After propensity score matching, two groups comprising 16,937 patients each, were formed. Baseline characteristics were comparable between the two groups (Table 1). However, patients who underwent PCI were more likely to receive dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, while those treated with medical therapy were more commonly prescribed nitrates. Additionally, statins were prescribed more frequently to patients treated with PCI. The hierarchical outcome analysis showed no statistically significant difference between the two groups (win-ratio: 0.98; 95% confidence interval: 0.94-1.02; p=0.345). Subgroup analyses of men, women, patients aged 75 years and older, diabetic patients, and non-diabetic patients showed no significant differences in outcome between the two groups. Conclusion In this study, which aimed to assess the outcomes of patients with CCS using a hierarchical approach, revascularization with PCI did not result in better outcomes when compared to medical therapy alone. These findings suggest that for patients with CCS, medical therapy may be just as effective as PCI in improving outcomes.Baseline characteristicsWin-ratio