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.

BACKGROUND

The optimal management of coronary artery disease in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) remains uncertain.

AIMS: We aimed to compare clinical outcomes between routine coronary revascularisation and conservative management in patients undergoing TAVI and to assess the relative effectiveness of individual revascularisation strategies by performing a meta-analysis of randomised trials.

METHODS

We conducted a pairwise meta-analysis comparing percutaneous coronary intervention (PCI) with conservative treatment and a network meta-analysis comparing the relative effectiveness of individual strategies, including angiography-guided and physiology-guided PCI. The primary outcome was a study-defined composite endpoint of major adverse cardiovascular events (MACE). Secondary endpoints included the individual outcomes of all-cause death, cardiovascular death, myocardial infarction, stroke, unplanned revascularisation, and major bleeding.

RESULTS

Five trials (N=1,644 patients) were included in the systematic review, and four were included in the primary quantitative synthesis (N=1,476). Compared with conservative treatment, routine PCI was associated with lower risks of MACE (risk ratio [RR] 0.80, 95% confidence interval [CI]: 0.65-0.98) and unplanned revascularisation (RR 0.30, 95% CI: 0.11-0.83) and an increased risk of major bleeding (RR 1.57, 95% CI: 1.07-2.32). In the network meta-analysis, physiology-guided PCI significantly reduced MACE, stroke, and unplanned revascularisation compared with conservative treatment and ranked highest for all ischaemic outcomes among revascularisation strategies.

CONCLUSIONS

Among patients referred for TAVI, routine revascularisation reduces the risk of ischaemic outcomes compared with conservative treatment. In this setting, physiology-guided PCI may be associated with the most favourable efficacy profile across available strategies. (PROSPERO: CRD420261330194).