Sabatine MS, Bergmark BA, Murphy SA, et al. - In order to ascertain the optimal revascularization strategy for patients with left main coronary artery disease, researchers herein examined long-term outcomes for patients treated with percutaneous coronary intervention (PCI) with drug-eluting stents vs coronary artery bypass grafting (CABG).

• A literature search in MEDLINE, Embase, and the Cochrane database yielded 1,599 results; of these, four RCTs—SYNTAX, PRECOMBAT, NOBLE, and EXCEL—met the inclusion criteria for the meta-analysis.

• Random assignment of a total of 4,394 patients, with a median SYNTAX score of 25·0 (IQR 18·0–31·0), was made to PCI (n = 2,197) or CABG (n = 2,197).

• No statistically significant difference appeared in terms of 5-year all-cause death between patients receiving PCI vs CABG, although a Bayesian approach suggested the existence of a difference (more likely than not <0·2% per year) favoring CABG.

• Trade-offs were recorded in terms of the risk of myocardial infarction, stroke, and revascularization.

• There appears a possible value of the heart team approach to communicate expected outcome disparities to aid patients in reaching a treatment decision.