TUGAS PAPER

MATA KULIAH METODELOGI PENELITIAN DAN STATISTIKA

TOPIK:
METAANALISIS

Dosen Pengajar:
Dr. Budi Utomo, dr., M.Kes

Oleh:
Kelompok 5
Melia Bogari 012118246306
Karisma Septari Idamusaga 012118026318
Nurun Nabilla Junaedy 012118026311
Nuril Sudiyatma 012118026309
Isna Mahmudah 012118026314
Aldira Rasthy Krisdania 012118026316
Willy Gunawan 012118066305
Wisnu Wahyu Nugroho 012118066312
Nanda Daiva Putra 012118046302
Dinda Rozita Maharani 012118046303

MATA KULIAH DASAR UMUM

PROGRAM PENDIDIKAN DOKTER SPESIALIS-I
FK UNAIR-RSUD Dr. SOETOMO SURABAYA
2021
IDENTIFIKASI

Title Perbandingan angka kematian pasien penyakit jantung koroner

yang menjalani coronary artery bypass graft (CABG) dan
percutaneous coronary intervention (PCI)
Comparison of mortality rates of patients with coronary artery
disease undergoing coronary artery bypass graft (CABG) and
percutaneous coronary intervention (PCI)
Objective Mengidentifikasi, menggambarkan, mengevaluasi, dan
mensintesis semua bukti untuk tingkat kematian pasien dengan
penyakit jantung koroner yang menjalani CABG dan PCI.
Identifying, describing, evaluating, and synthesising all evidence
for the mortality rates of patients with coronary artery disease
undergoing CABG and PCI.
Participants/population Pasien dengan penyakit jantung koroner
Patients with coronary artery disease
Intervention(s), Pasien dengan penyakit jantung koroner yang menjalani prosedur
exposure(s) CABG
Patients with coronary artery disease undergoing a CABG
procedure
Comparator(s)/control Pasien yang menjalani prosedur PCI pada pasien penyakit arteri
koroner
Coronary artery disease patients who undergo the PCI procedure
Outcome Tingkat Kematian
Mortality rate
Keywords (coronary artery disease) AND (coronary artery bypass graft OR
CABG) AND (percutaneous coronary intervention OR PCI) AND
mortality rate OR mortality)
Protocol guideline PRISMA checklist and flowchart
STRATEGI PENCARIAN

Penelitian ini merupakan penelitian systematic review dan meta-analisis yang membahas
Perbandingan angka kematian pasien penyakit jantung koroner yang menjalani coronary artery
bypass graft (CABG) dan percutaneous coronary intervention (PCI). Penelitian systematic
review dapat memberikan informasi yang beragam antar beberapa studi yang dilakukan
sebelumnya. Penelitian juga dapat memberikan informasi baru dari beberapa artikel. Penelitian
juga dapat digunakan sebagai rekomendasi untuk pengembangan ilmu pengetahuan di dunia
medis terkait angka kematian pasien penyakit jantung koroner yang menjalani coronary artery
bypass graft (CABG) dan percutaneous coronary intervention (PCI),

Data yang dibutuhkan dalam penelitian ini merupakan data dari dalam beberapa artikel
ilmiah. Penelitian menggunakan literatur berupa artikel yang dipublikasikan selama lima tahun
terakhir yaitu tahun 2016 sampai 2021. Sumber data diawali dengan melakukan pencarian
jurnal akademik dalam basis data jurnal. Basis data jurnal yang digunakan adalah PubMed dan
Scopus. Dalam melakukan pencarian data jurnal yang sesuai dengan penelitian ini, maka kami
menggunakan kata kunci sebagai berikut:

a. coronary artery disease

b.CABG
c. PCI
d.Mortality rate

Dalam pencarian artikel, kata kunci digabungkan dengan Boolean yaitu AND and OR.
Penggunaan dari Boolean memiliki tujuan untuk memperluas pencarian artikel. Selanjutnya,
dapat memfokuskan pencarian pada artikel-artikel secara spesifik.

Tabel 1. Pencarian Literatur

Database Keyword

PubMed “coronary artery disease” AND “coronary

artery bypass graft OR CABG” AND
“percutaneous coronary intervention” OR
PCI” AND “mortality rate” OR mortality”
Scopus “coronary artery disease” AND “coronary
artery bypass graft OR CABG” AND
“percutaneous coronary intervention” OR
PCI” AND “mortality rate” OR mortality”

PubMed SCOPUS

Hasil artikel yang ditemukan
Kriteria Inklusi:
1.Artikel terpublikasi 5
tahun terakhir.
2.Artikel dimuat dalam
jurnal internasional
3.Artikel dalam Bahasa
Inggris

Kriteria Eksklusi :
Screening
1.Artikel yang membahas tentang pasien dengan
coronary artery disease yang tidak berhubungan
tingkat kematian antara pemberian intervensi
CABG dan PCI

Artikel Akhir yang

dikaji
PRISMA FLOW DIAGRAM

Identification of studies via databases and registers

Records identified from: Records removed before

Databases (n = 2) screening:
Identification

Duplicate records removed (n

= 200)
PubMed (n=1439) & Scopus (n=956) Records marked as ineligible
by automation tools (n = 50)
Records removed for other
Registers (n = 2404) reasons (n = 673)

Records screened Records excluded

(n = 1481) studies irrelevant (n = 806)

Reports sought for retrieval Reports not retrieved

(n = 675) (n = 635)
Screening

Reports assessed for eligibility

(n = 40) Reports excluded:
25 Wrong outcomes
4 Wrong intervention
5 Wrong study design

Studies included in review

Included

(n = 6)
Reports of included studies
(n = 6)
DATA EKSTRAKSI

Authors Ramanathan K, Hideyuki Daniel J F M Gennaro Giustino, Park D, et al Ori Ben-Yehuda, et

et al Kawashima, MD, Thuijs, et al et al al
et al
Tahun 2017 2021 2019 2020 2020 2019

Judul Surgical Versus Mortality 10 Years Percutaneous Mortality After Ten-Year Impact of Large
Percutaneous After Percutaneous coronary Repeat Outcomes After Periprocedural
Coronary or Surgical intervention versus Revascularization Drug-Eluting Myocardial Infarction
Revascularization Revascularization coronary artery Following PCI or Stents Versus on Mortality after
in Patients with in Patients with bypass grafting in Coronary Artery Coronary Artery Percutaneous
Diabetes and Total Coronary patients with Bypass Grafting for Bypass Grafting Coronary Intervention
Acute Coronary Artery Occlusions three-vessel or Left Main Disease for Left Main and Coronary Artery
Syndromes left main Coronary Disease Bypass Grafting for
coronary artery Left Main Disease : an
disease: Analysis from the
10-year follow-up EXCEL Trial
of the
multicentre
randomised
controlled
SYNTAX trial
Metode population-based, Randomized Randomized Randomized Randomized Randomized
penelitian retrospective Controlled Trial Controlled Trial Controlled Trial Controlled Trial Controlled Trial
cohort study
British Columbia North American North American and North American and Korea USA
and European European countries European countries
countries
Population all patients older A total of 1,800 Patients aged 21 All patients were Patients were Patient with LM
than patients with years or older with required to have low eligible for diameter stenosis of
20 years of age de novo 3VD de-novo three- or intermediate participation in the >70% as estimated
with DM and and/or LM, who vessel disease and anatomic complexity trial if they had de visually or a stenosis
angiographically were deemed left main coronary of coronary artery novo stenosis of of 50%
confirmed MV- eligible artery disease disease, as defined the LMCA of more to <70% if determined
CAD (stenosis of for both PCI and by a site- determined than 50% (as by means of non-
>70% in 2 or CABG based on SYNTAX (Synergy estimated visually) invasive or invasive
more clinical judgment Between PCI With and had received a testing to be
major epicardial and Taxus and Cardiac diagnosis of stable haemodynamically
vessels, excluding the consensus of a Surgery) score of angina, unstable significant, a site-
the left main Heart Team <32 angina, silent assessed SYNTAX
coronary artery) ischemia, or non– score <32, and a
who underwent ST segment consensus among the
either PCI or elevation MI, in 13 members of the heart
isolated hospitals in Korea team regarding
CABG between from April 2004 to eligibility
October 1, 2007 August 2009. for revascularization
and January 31, Clinical and with either PCI or
2014 anatomic eligibility CABG
in British of all participants
Columbia had to be
considered by the
cardiologists and
surgeons at each
hospital to be
equivalently
suitable for both
PCI and CABG.
Jumlat total 4819 1800 1800 1905 600 1858
sample
Jumlah 1931 897 897 957 300 935
sample
CABG
Jumlah 2888 903 903 948 300 923
sample PCI
Variable The primary The primary The prespecified The primary The primary The primary endpoint
Outcome outcome was endpoint of this primary endpoint of endpoint of this outcome was a of the original study
yang diteliti the first study was all-cause the SYNTAXES study is to composite of major was the rate of a
occurrence of a mortality at 10 study was all-cause investigate the adverse cardiac and composite of death
major adverse years. The death at 10 years in incidence and cerebrovascular from any cause,
cardiac or secondary patients randomly impact on mortality events. Major stroke, or MI at 3
cerebrovascular endpoint was all- assigned to PCI of repeat secondary years, analysed by
event (MACCE), cause mortality at with drug-eluting revascularization outcomes included intention-totreat.
defined as a maximum stents versus after index the individual
composite available follow-up CABG. The percutaneous components of the
of all-cause secondary endpoint coronary primary composite
mortality, was all-cause death intervention (PCI) or outcome; a
nonfatal MI at maximum coronary artery composite of death,
(International available follow-up bypass grafting MI, or stroke, any
Classification of in patients randomly (CABG) for left revascularization
Disease-Tenth assigned to PCI main coronary artery and definite stent
Revision [ICD- with drug-eluting disease (LMCAD). thrombosis or
10] stents versus symptomatic graft
codes I21, I22) CABG. occlusion. All
and nonfatal participants in this
stroke (ICD-10 trial were invited to
codes I60 participate in 10-
to I64, H356, year follow-up
H341, The evaluations.
primary endpoint
of this
 study was all-
cause mortality at
10 years. The
secondary
endpoint was all-
cause mortality at
maximum
available follow-
up H342, and
H348) after
revascularization.
Secondary
outcomes
included the
individual
components of
MACCE, repeat
revascularization
postdischarge
(RR), and a
composite of
MACCE and
repeat
revascularization
(MACCE[r])
Hasil At 30-days post- Of 1,800 From March, 2005, During 3-year At 10 years, a Periprocedural MI was
penelitian revascularization, randomized to April, 2007, 1800 follow-up, there primary outcome associated with
for ACS patients patients to the PCI patients were were 346 repeat event occurred in SYNTAX score,
the odds ratio for or CABG arm, 460 randomly assigned revascularization 29.8% of the PCI COPD, cross-clamp
MACCE favored patients had at least to the PCI (n=903) procedures among group and in 24.7% duration and total
CABG 0.49 (95% 1 lesion of TO. In or CABG (n=897) 185 patients. PCI of the CABG procedure duration,
confidence patients with group. Vital status was associated with group (hazard ratio and not using
interval [CI]: 0.34 TOs, the status of information at 10 higher rates of any [HR] with PCI vs antegrade
to 0.71), whereas TO recanalization years was complete repeat CABG, 1.25 [95% cardioplegia. By
among SIHD or revascularization for 841 (93%) revascularization CI, 0.93–1.69]). multivariable analysis,
patients MACCE was not associated patients in the PCI (12.9% vs. 7.6%; The 10-year PMI was associated
was not affected with 10-year all- group and 848 hazard ratio: 1.73; incidence of the with cardiovascular
by cause mortality, (95%) patients 95% confidence composite of death, death and all-cause
revascularization irrespective of in the CABG group. interval: 1.28 to myocardial death at 3 years
strategy (odds the assigned At 10 years, 244 2.33; p 1 4 0.0003). infarction, or [adjusted hazard ratio
ratio: 1.46; 95% treatment (PCI (27%) patients had Need for repeat stroke (18.2% vs (HR) 2.63, 95% CI
CI: 0.71 to 3.01; p arm: 29.9% vs. died after PCI and revascularization 17.5%; HR 1.00 1.19–5.81; P = 0.02
interaction 29.4%; adjusted 211 (24%) after was independently [95% CI, 0.70– and adjusted HR 2.28,
<0.01). With a hazard ratio [HR]: CABG (hazard associated with 1.44]) and all- 95% CI 1.22–4.29; P =
median follow-up 0.992; 95% ratio 1·17 [95% CI increased risk for 3- cause mortality 0.01, respectively].
of 3.3 years, the confidence interval 0·97–1·41], year all-cause (14.5% vs 13.8%; The effect of PMI was
late (31-day to 5- [CI]: 0.474 p=0·092). Among mortality (adjusted HR 1.13 [95% CI, consistent for PCI and
year) benefit of to 2.075; p = 0.982; patients with three- hazard ratio: 2.05; 0.75–1.70]) were CABG for
CABG over PCI and CABG arm: vessel disease, 151 95% confidence not significantly cardiovascular death
no longer varied 28.0% vs. 21.4%; (28%) of 546 had interval: 1.13 to different between (P interaction = 0.56)
by acuity of adjusted HR: died after 3.70; p 1 4 0.02) and the PCI and CABG and all-cause death (P
presentation, with 0.656; 95% CI: PCI versus 113 cardiovascular groups. Ischemia- interaction = 0.59).
a hazard ratio for 0.281 to 1.533; p = (21%) of 549 after mortality (adjusted driven target-vessel Peak post-procedure
MACCE in ACS 0.330). When TOs CABG (hazard ratio hazard ratio: 4.22; revascularization CK-MB >_10x URL
patients of 0.67 existed in left main 1·41 [95% CI 1·10– 95% confidence was more frequent strongly predicted
(95% CI: 0.55 to and/or left anterior 1·80]), and among interval: 2.10 to after PCI than after mortality, whereas
0.81) and the descending artery, patients with left 8.48; p < 0.0001) CABG (16.1% vs lesser degrees of
hazard ratio for the status of TO main consistently after 8.0%; HR 1.98 myonecrosis were not
SIHD patients of recanalization or coronary artery both PCI and CABG [95% CI, 1.21– associated with
0.55 (95% CI: revascularization disease, 93 (26%) of (pint 1 4 0.85 for 3.21). prognosis.
0.40 to 0.74; did not have 357 had died after both endpoints).
pinteraction = an impact on the PCI versus 98 Although target
0.28). mortality (34.5% (28%) of 348 after vessel
vs. 26.9%; adjusted CABG (0·90 [0·68– revascularization
 HR: 0.896; 95% 1·20], and target lesion
CI: 0.314 to 2.555; p revascularization
p = 0.837). interaction=0·019). were both associated
There was no with an increased
treatment-by- risk for mortality,
subgroup interaction target vessel non–
with diabetes (p target lesion
interaction=0·66) revascularization
and no linear trend and non–target
across SYNTAX vessel
score tertiles (p revascularization
trend=0·30). were not.
Kesimpulan In diabetic "1. Among patients At 10 years, no In the EXCEL trial, In this 10-year In the EXCEL trial,
penelitian patients with MV- with TOs (n = significant repeat follow-up of the PMI was more
CAD, CABG was 460), there were no difference existed in revascularization PRECOMBAT common after CABG
associated with a significant all-cause death during follow-up trial that enrolled than PCI, and was
lower rate of differences in the between PCI using was performed less patients with strongly associated
long-term all-cause mortality first-generation frequently after LMCA disease, with increased
MACCE relative at paclitaxel-eluting CABG than PCI and there was no 3-year mortality after
to PCI for both 10 years between stents and CABG. was associated with significant controlling for
ACS and SIHD. patients with However, CABG increased mortality difference between potential confounders.
successfully provided a after both PCI and CABG in Only extensive
recanalized or significant survival procedures. the incidence of myonecrosis was
revascularized TOs benefit in patients Reducing the need major adverse prognostically
and those with three-vessel for repeat cardiac or important.
without, disease, but not in revascularization cerebrovascular
irrespective of the patients with left may further improve events, composite
assigned treatment main coronary long-term survival of death, MI, or
(PCI or CABG) artery disease. after percutaneous or stroke, and all-
and location of surgical treatment of cause mortality.
TOs (left main LMCAD. However, the study
coronary had insufficient
artery and/or LAD statistical power to
or other vessels). allow for a firm
2. When patients conclusion, hence
with TO were further research is
stratified according needed in this area.
to
the type of disease
(3VD or LM),
there was no
difference
between the PCI
and CABG arm in
terms of
the 10-year
mortality."
PRISMA CHECKLIST
Mengevaluasi setiap studi literatur yang digunakan dengan Prisma Checklist
Sebagai contoh pengisian adalah sebagai berikut;

PRISMA 2009 Checklist for systematic review

Section/topic # Checklist item Reported on page #

TITLE
Title 1 Identify the report as a systematic review. Describe in the title
ABSTRACT
Structured summary 2 Provide a structured summary including, as applicable: background; The eligibility criteria and limitations of the
objectives; data sources; study eligibility criteria, participants, and study are not well describe in abstract
interventions; study appraisal and synthesis methods; results; limitations; section.
conclusions and implications of key findings; systematic review registration Background, objective, data source, study
number. appraisal, and conclusion have described
well.
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of what is already known. Well describe,
However in introduction section the authors
wrote “Susie Linder-Pelz (1982, p. 580)
defines patient satisfaction as positive
evaluations of distinct dimensions of health
care” but in reference there is no article
authored by Susie Linder-Pelz.
Objectives 4 Provide an explicit statement of questions being addressed with reference to Not clearly
participants, interventions, comparisons, outcomes, and study design
(PICOS).
METHODS
Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Well describe in method section
Web address), and, if available, provide registration information including
registration number.
Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report Well describe
characteristics (e.g., years considered, language, publication status) used as
criteria for eligibility, giving rationale.
Information sources 7 Describe all information sources (e.g., databases with dates of coverage, Not clearly describe in method section
contact with study authors to identify additional studies) in the search and
date last searched.
Search 8 Present full electronic search strategy for at least one database, including Well describe
any limits used, such that it could be repeated.
Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in Well describe
systematic review, and, if applicable, included in the meta-analysis).
Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, The data collection process was clearly
independently, in duplicate) and any processes for obtaining and confirming describe
data from investigators.
Data items 11 List and define all variables for which data were sought (e.g., PICOS, Not clearly
funding sources) and any assumptions and simplifications made.
Risk of bias in individual 12 Describe methods used for assessing risk of bias of individual studies NA
studies (including specification of whether this was done at the study or outcome
level), and how this information is to be used in any data synthesis.
Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means). NA
Synthesis of results 14 Describe the methods of handling data and combining results of studies, if Method of handling data was done by 1)
done, including measures of consistency (e.g., I2) for each meta-analysis. Grouping the effective factors which
included, 2) Extracting main findings
Section/topic
Risk of bias across studies
Additional analyses
RESULTS
Study selection
Study characteristics
Risk of bias within studies
Results of individual studies
Synthesis of results
Risk of bias across studies
Additional analysis
DISCUSSION
Summary of evidence
# Checklist item Reported on page #
15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., NA
publication bias, selective reporting within studies).
16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta- Not clearly
regression), if done, indicating which were pre-specified.
17 Give numbers of studies screened, assessed for eligibility, and included in the review, Flow diagram is well
with reasons for exclusions at each stage, ideally with a flow diagram. describe
18 For each study, present characteristics for which data were extracted (e.g., study size, Describe systematically in
PICOS, follow-up period) and provide the citations. the table 1.
19 Present data on risk of bias of each study and, if available, any outcome level Not clearly
assessment (see item 12).
20 For all outcomes considered (benefits or harms), present, for each study: (a) simple Well describe in the section
summary data for each intervention group (b) effect estimates and confidence and table 2
intervals, ideally with a forest plot.
21 Present results of each meta-analysis done, including confidence intervals and The main finding from each
measures of consistency. study is well describe,
however the authors did not
describe about the
confidence interval.
22 Present results of any assessment of risk of bias across studies (see Item 15). NA
23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, Not clearly
meta-regression [see Item 16]).
24 Summarize the main findings including the strength of evidence for each main Well describe in discussion
outcome; consider their relevance to key groups (e.g., healthcare providers, users, section and summarize in
and policy makers). the table 2 – table 9.
In most of paragraph of
discussion section, the
authors wrote %x (e.g.,
%20, %45), but that all
 have been repaired

Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level The outcome level review-
(e.g., incomplete retrieval of identified research, reporting bias). level, and study implication
are well describe, but the
limitation is not clearly
describe
Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and Well describe
implications for future research.
FUNDING
Funding 27 Describe sources of funding for the systematic review and other support (e.g., supply Well describe
of data); role of funders for the systematic review.

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7):
e1000097. doi:10.1371/journal.pmed1000097