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

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• Picked for Cardiology and Cardiovascular Medicine (paper of the day, 24 October 2026): Randomized-trial meta-analysis of revascularization before TAVI

Abstract

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).

Abstract as published, via PubMed.