Coronary artery disease management in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis of randomised controlled trials.
Kamil Bujak, Daniele Giacoppo, Claudio Laudani et al.
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In 30 seconds
This systematic review and meta-analysis of randomised trials compared coronary revascularisation strategies in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). Five trials included 1,644 patients; four trials with 1,476 patients contributed to the primary quantitative synthesis. Compared with conservative management, routine percutaneous coronary intervention (PCI) was associated with lower risks of major adverse cardiovascular events (MACE; RR 0.80, 95% CI: 0.65-0.98) and unplanned revascularisation, but a higher risk of major bleeding. Network analysis ranked physiology-guided PCI highest for ischaemic outcomes.
Key findings
- Routine PCI was associated with lower MACE risk than conservative treatment (RR 0.80, 95% CI: 0.65-0.98).
- Unplanned revascularisation was less frequent with routine PCI (RR 0.30, 95% CI: 0.11-0.83).
- Routine PCI was associated with increased major bleeding risk (RR 1.57, 95% CI: 1.07-2.32).
- Physiology-guided PCI significantly reduced MACE, stroke, and unplanned revascularisation versus conservative treatment and ranked highest for ischaemic outcomes.
Why it matters
Coronary disease management around TAVI involves balancing prevention of ischaemic events against procedural harm. These pooled randomised-trial findings suggest routine PCI may reduce MACE and subsequent revascularisation, while increasing major bleeding. The network analysis also indicates that the choice of PCI guidance strategy may affect the balance of outcomes, although comparative estimates should be interpreted in light of the available trial evidence.
What to keep in mind
The quantitative synthesis included four trials and 1,476 patients; MACE was a study-defined composite endpoint. Network comparisons depend on the available randomised-trial evidence.