CABG vs PTCA using drug eluting stents for the treatment of left main coronary artery disease

This research compares the effectiveness of CABG and PTCA using drug eluting stents for the treatment of left main coronary artery disease. The study aims to evaluate the procedure used in both methods and analyze the outcomes, including mortality rate and re-vascularization. The research questions whether CABG is more effective than PTCA using drug-eluting stents for the treatment of left main coronary artery diseases. The alternative hypothesis suggests a predominant change in efficacy and outcome between the two procedures, while the null hypothesis suggests no predominant change.

CABG (surgical procedure) vs PTCA
DRUG ELUTING STENTS FOR THE
TREATMENT OF LEFT MAIN
CORONARY ARTERY DISEASE

Table of Contents
LIST OF FIGURE AND TABLES..................................................................................................1
LIST OF ABBREVIATIONS..........................................................................................................2
ACKNOWLEDGEMENT...............................................................................................................3
ABSTRACT.....................................................................................................................................4
Background.............................................................................................................................4
Methods..................................................................................................................................4
Results....................................................................................................................................4
Conclusion..............................................................................................................................4
TITLE..............................................................................................................................................5
INTRODUCTION...........................................................................................................................5
What is left main coronary artery disease?.............................................................................5
Why left main coronary artery disease is researched?...........................................................5
Causes of left main coronary artery disease...........................................................................6
CABG for the treatment of left main coronary artery disease................................................7
PTCA drug eluting stents for treatment of left main coronary artery disease........................7
Aim.........................................................................................................................................7
Objective.................................................................................................................................8
Research questions.................................................................................................................8
Alternative hypothesis............................................................................................................8
Null hypothesis.......................................................................................................................8
METHODOLOGY..........................................................................................................................9
Criteria for eligibility..............................................................................................................9
Screening of studies..............................................................................................................13
Quality assessment along with data extraction.....................................................................14
Heterogeneity.......................................................................................................................17
Statistics................................................................................................................................17
RESULTS......................................................................................................................................20
PRISMA flowchart...............................................................................................................20
Quality assessment...............................................................................................................22

Data extraction table.............................................................................................................25
DISCUSSION................................................................................................................................29
Risk of bias: ethics................................................................................................................29
Summary of finding..............................................................................................................29
Raw data...............................................................................................................................31
Similar studies......................................................................................................................31
Follow up period...................................................................................................................32
Method based on follow up..................................................................................................33
Limitation.............................................................................................................................34
Future research implication..................................................................................................34
CONCLUSION..............................................................................................................................35
REFERENCES..............................................................................................................................37
APPENDICS..................................................................................................................................41
APPENDIX A: MeSH term..................................................................................................41
APPENDIX B: Data extraction process...............................................................................41

LIST OF FIGURE AND TABLES
Table 1 Eligibility criteria
Table 2 PICO search term which are used to search on
PubMed, EMBASE along with Cochran.
Table 3 Inclusion along with exclusion key terms
which are associated with Covidence
Table 4 Data extraction process of included studies
Table 5 Analysis and comparison between CABG and
PTCA drug eluting method used in treatment
of left main coronary artery disease in given
studies
Table 6 Data extraction table
Figure 1 CABG versus PTCA.
Chart 1 PRISMA flowchart
Chart 2 CABG VS PTCA
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LIST OF ABBREVIATIONS
CABG Coronary artery bypass graft.
PTCA Percutaneous transluminal coronary
angioplasty.
AF Atrial fibrillation.
LMCAD Left main coronary artery disease
RCT Randomised controlled trial
LDL Low density lipoprotein.
HDL High density lipoprotein
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ACKNOWLEDGEMENT
I would like to express my special thank of gratitude to my teacher………. who gave may a
golden opportunity to do such wonderful project that support my academic journey. The project
is comparative study between CABG and PTCA drug eluting stent in term of effectiveness
for treatment of left main coronary artery disease. I came to know about new thing I really
thankful to them. Apart for this, I would also like to thank my parents and friends who help me to
finalise the project within the limited and proper timeline or timeframe.
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ABSTRACT
Background
The safety and effectiveness of percutaneous coronary intervention along with drug
eluting stent is high debated upon comparison to CABG (coronary artery graft surgery) for a long
period of time.
Methods
Evidence based studies were chosen by surfing PubMed, Cochrane Library and
EMBASE for up to 16th July, 2022. Primarily observed endpoint was myocardial infarction and
stroke during the follow up procedures. Some of the secondary outcomes observed were death,
cardiac death and repeated vascularization.
Results
Four randomized controlled trails and twelve observational studies including 100 patients
per trail. In context with the primary end point, comparing DES and CABG, the confidence
interval or CI was found to be 95%. The incidence of Myocardial infraction was found to be
higher in DES as compared to CABG.
Conclusion
Although it is not cost effective, CABG appears to be safer than PCI with DES for
treatment of left main coronary artery disease for long term follow up. A significant damage is
associated to the artery where stents are inserted in the form of an allergic reaction or direct
damage to the heart. Also, there is a high risk of adverse effects during angioplasty followed by
stent placement along with cognitive impairment including loss of memory and thinking skills.
On the other hand, CABG is associated with lower death rate and less requirement for blood
transfusion.
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TITLE
CABG vs PTCA using drug eluting stents for the treatment of left main coronary artery disease.
INTRODUCTION
What is left main coronary artery disease?
LMCA or left main coronary artery disease is the highest form of lesion which occurs as a
result of ischaemic heart disease. This disease is associated with narrowing of the vessel of the
artery by 50%. Some of the symptoms of LMCAD are heaviness, chest tightness, persistent pain
in heart spreading to arms, legs etc. The left main coronary artery transports blood to the left part
of cardiac muscles. The LMCA further divides into two main branches- The left anterior
descending artery (supplying blood to front-left side of the heart) and The circumflex artery
(transporting blood to the lateral and back side of the heart). There is significant study which is
taken in order to determine the prevalence of unprotected left main coronary artery that is also
known as ULMCA disease which is showing their presence of 5 to 7 percent that is undergoing
within coronary angiography. The left main coronary artery disease is related with heart disease
in simple term the blockage of artery is analysed due to the blood clot. In this, blood clotting is
major issue that is evaluated under the coronary disease especially left main coronary artery
disease. Therefore, left main coronary artery supplies to the left side of heart muscle (the left
auricle and left ventricle). The left main coronary artery is categories into the two branches. The
left anterior descending artery branches off left coronary artery and supplies the blood to front of
the left side of the heart. In this disease the left artery is blocked and inhibit the flow of blood
from one region to another (Bhatt, 2018).
Why left main coronary artery disease is researched?
The left main coronary artery is well discussed above that show clear indication where
appropriate information is evaluated that state the blood clot is major reason that affect the blood
flow or inhibit the blood flow that create complication with patient. The left coronary artery
crucial to be researched as LMCA carries blood to the left atrium and the left ventricle of the
heart. The left side of the heart receives oxygenated blood from the lungs from where the blood
is transported to the rest of the body. If the LMCA is blocked, the supply of blood to the whole
body will be restricted. Therefore, in order to treat this conditions, medical professionals suggest
undergoing coronary artery bypass graft (CABG) for removing blockage and restoration of blood
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flow. The potential risk which is evaluated due to inhibition of blood in artery are heart stroke,
heart attack, myocardial infarction, atherosclerosis and so on. The mortality rate is increase due
to this disease where 10 of people die from 100 (Lee and et. al., 2018). The recorded death which
is analysed in UK due to heart and circulatory disease cause more than 160,000 deaths each year,
in context to average death it is counted 460 deaths each day or one every three minute in UK.
There are around 7.6 million of people living with heart or circulatory disease in the UK that is 4
million men and 3.6 million of women (British heart foundation, 2019). In order to treat such
condition, especially left main coronary artery disease that is related with blockage of artery.
They are treated with tow method named CABG and PTCA drug eluting stent. The CABG is
surgical procedure that allow the blood to move freely. In other hand, PTCA drug eluting is also
used which is drug coated approach where stent is fitted into the artery for proper flow of blood.
The research is about comparison of these two method to know that which one is more effective.
The death is occurring due to disease which must be intervene with such method. The reason of
choosing this topic to make investigation regarding effect of CABG and PTCA drug eluting for
the left main coronary artery disease (Pavlovsky and et. al., 2019).
Causes of left main coronary artery disease
Blockage in the left coronary artery occurs as a result of plaque build-up from cholesterol.
This condition is commonly called as atherosclerosis or “hardening of the arteries”. The
deposition of plaque causes blood clots because of which the walls of the arteries are obstructed.
Left main coronary artery disease have number of causes that is associated with daily lives. In
this, some of the causes are based on lifestyle such as smoking, tobacco use and many more that
is also responsible to lead to coronary artery disease. Unhealthy lifestyle practices, physical
inactivity and prolonged exposure to stress can induce high cholesterol levels in the body which
facilitates deposition of plaque. The blood flow in the arteries is decreased and causes chest pain
along with shortness of breath leading to the possibility of heart attack. Plaque is a fatty
substance made up of cholesterol, waste products, calcium deposits which can stiffen the arteries.
Due to this build-up, supply of oxygenated blood to the heart is restricted. In addition, other
causes are high LDL cholesterol level, high triglyceride level and low high density lipoprotein.
Moreover, hypertension, physical inactivity, obesity and high saturated fat diet. It is also seen at
various of time that the family history is also act as causes that lead to create the issue of left
main artery disease with context of hereditary (Serruys and et. al., 2022).
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CABG for the treatment of left main coronary artery disease
The coronary artery bypass grafting which is well known as CABG that refer as surgical
procedure which is used to treat coronary heart disease. It is usually show the mechanism with
the help of surgical procedure that divert blood around narrowed or clogged part of major arteries
to improve the flow of blood and also initiate the supply of oxygen in heart. CABG includes
removing a blood vessel from person's leg, arm or chest which is used to reroute blood around
the coronary artery which is clogged. CABG does not successfully treat the disease. However, it
helps in relieving the symptoms of chest pain and shortness of breath. The blood is diverted
around the narrowed arteries which leads to improved blood flow and facilitation of oxygen
supply to the heart. The coronary artery bypass graft that show the involvement which is all
about taking the blood vessel form another part of body and show attachment to make it coronary
above below the narrowed or blockage. The divert blood flow with the new blood vessel is
known as graft. The number of graft is well needed that depend on severe the disease that is
related with coronary heart disease.
PTCA drug eluting stents for treatment of left main coronary artery disease
PTCA is refer as percutaneous trans-luminal coronary angioplasty. Stent implantation is
defined as procedure where the treatment is used to opt which is based on stenotic coronary
arteries. In comparison to uncoated, bare metal stent, drug eluting stent reduce risk of restenosis
which is occur in previous treated section that is in stent restenosis. In addition, the stent is used
in order to remove the blockage of blood by putting the stent on artery (Tanaka and et. al., 2019).
Overall, research focus on the comparison in term of effectiveness between CABG or
PTCA drug eluting stent for treatment of left coronary artery disease. In addition, the study is
well related with new concept that is based on comparison between two methods which is used
to treat the coronary disease. Therefore, two methods are useful but the research work is usually
focus on creating the better understanding regard with effective one. The research work well
shows the context where appropriate comparison and evaluation is used to take place that is
related with mechanism of procedure and effectiveness with the analysis of review from the
various source.
Aim
The main aim of this is to compare the efficacy and outcome CABG and PTCA drug
eluting stent in treatment of left main coronary artery disease (outcome include less mortality
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rate and less re-vascularisation after the procedure whether surgical or stents). A meta-analysis of
randomised clinical trials.
Objective
 To compare and analyse the effectiveness of CABG and PTCA drug eluting stent in
treatment of left main coronary artery disease.
 To evaluate and compare the procedure that used in CABG and PTCA using drug eluting
stent in treatment of left main coronary artery disease
Research questions
Is CABG is more effective than PTCA using drug-eluting stents for the treatment of left main
coronary artery diseases?
Alternative hypothesis
There is a predominant change in the efficacy and outcome between the CABG and PTCA
procedure in the treatment of left main coronary artery disease.
Null hypothesis
There is no predominant change in the efficacy and outcome between the CABG and PTCA
procedure in the treatment of left main coronary artery disease.
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METHODOLOGY
Criteria for eligibility
Within research eligibility criteria can be effective and can help in defining protocol that
are generally used by the researcher who conduct research. Within reference to the clinical trials,
it is necessary to meet the person requirement which are included within the trail. In context to
the research process, systematic analysis along with meta-analysis can be effective and must
configure the essential component which are related with the research work. Moreover, there is
review of the protocol that are followed inappropriately and lead to create the ethical
consideration for data along with information selection. Eligibility criteria may also include the
exclusion along with inclusion criteria which are also present some details about selection along
with qualification for the research work (Gallo and et. al., 2022). There is discussion about the
inclusion as well as the exclusion criteria which can be effective in elaborating the qualified
context that are considered within the research procedure or process. Inclusion and exclusion
criteria are described through the table below.
Table 1: Eligibility criteria
Inclusion criteria Exclusion criteria
 English language has been used which
is mandatory and help in taking about
the study or review which are based on
the meta-analysis of the randomised
controlled trial.
 Meta-analysis refers to the key
component which are effective and
about the evidence-based healthcare.
This includes the randomised controlled
trials that help to estimate the effect of
the intervention through effective
consideration. It also offers different
potential advantages (Milojevic and et.
al., 2019).
 Rather than English language that are
undertaken within study for the
research work. Due to this, other
languages are excluded.
 There are some of the studies which are
freely available that needs money along
with other funds that can exclude about
the study and are available through
reviewer.
 In this research work, the PCI is
excluded from the process where bare
metal is also excluded from study.
 There is exclusion of meta-analysis
along with systematic review.
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 All the randomised trials comparing
surgery which include angioplasty and
can show both equivalent or modalities
with the term which is survival or
infarct about the free survival.
 Therefore, left main coronary artery
disease is common among mean age
group which is about 50 years. There is
major data which are associated with
the data along with information which
can include the collection through
different articles or reviews from the
study.
 There is intervention which are taken
and includes the Coronary Artery
Bypass Crafting and Percutaneous
transluminal coronary angioplasty.
 Disease among people can lead to
create within last 10 to 15 years which
are associated with the mortality rate
along with complications. There is
population with stroke that are
participated with study of basic
mechanism which include the function
that are render during artery disease.
 There is study through the secondary
sources which include the article,
journals along with peer reviewed
paper with the grey literature which are
outlined through the published 10 years
to ensure about the data along with
 There is mechanism which can follow
non-pharmacological method or any
intervention which are not taken in the
consideration about the research work.
 There is published literature which are
above 10 years which related with topic
which are undertaken within the review
process.
 The coronary artery disease rather than
left main coronary artery disease is
excluded from study.
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information with appropriate tools that
are implemented with the treatment of
coronary artery disease.
 Then it includes the information along
with data that are related with the PICO
framework that are implemented within
review.
From the above discussion, it can help to understand to create some relevance about
understanding about the inclusion along with exclusion criteria which can be effective for
gathering attention towards the research information which are also included during conducting
the research. Although, it can be also helpful in getting better information using the eligibility
criteria that enable researcher to maintain protocol through conducting research process that are
also associated with avoiding gathering of that data that are not relevant towards the research
questions along with topic that are selected for the research work (Cassim, Godahewa,
Paviththiran, and Wijeyaratne, 2020).
Source of information
For the research work, it is essential to use the reliable source of information which can
be effective and may help to provide different data or information that can be effective to provide
better response towards the research work. Reliable source of information can be effective and
may help in getting better and effective response that are effective and may help to ensure about
use of correct data or information that can help to deliver quality of information towards the
research work (Sabatine and et. al., 2021). Through using the research work which are effective
and may help in getting better response towards the search fraction and allow to obtain validated
article through using the systematic review. Here, database can include Cochrane, PubMed along
with EMBASE. These are some of the reliable sources of information or data which can be
effective to gather data or abstract data which are specially help for the medical research. During
information or data collection through using the PubMed, it can allow to filter associated with
published article within last 10 years along with also about the RCT. It is necessary to apply the
filter which can be effective to deliver better response toward the research criteria about
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inclusion criteria part (Jeong and et. al., 2022). Above 10 years published article should be
excluded to gather data or information through it. Filter should be applied to follow the inclusion
criteria which enable in providing better opportunity for the data along with information
collection. This can be relevant to the study and allow for the comprehensive information that are
evidence based and elucidation from the PubMed. Similarly, Cochran can also be used as the
database for data or information extraction that may include the reliable present articles. Alike
PubMed, filter is also applied to get the article from the range or years (Farina and et. al., 2020).
This can help to get that information which are included in some specific time range and allow to
get relevant information that are under trail section. While conducting the screening process,
where major of the studies refers the RCT which is included. Along with this, EMBASE is
another data base which is appropriate for the data or information collection and are linked with
the topic for information or data collection. Here, filter is applied that can help to get access to
the research article which are effective and may help in getting better information about the
research article and help to gather various data or information which are associated with research
work (Serruys and et. al., 2022).
The last search on PubMed, EMBASE and Cochran are usually occurred in 30 July 2022.
Here, PICO term include the major configuration which are diabolical search which include two
databases which are illustrated in Table 2. The MeSH term is also created and effectively
searched within PubMed for gather or proper data or information collection along with selection.
Table 2: PICO search term which are used to search on PubMed, EMBASE along with Cochran.
Patient Patient with mean age of 50 years suffering
from left main coronary artery disease.
Intervention Coronary Artery Bypass Crafting
Comparison Percutaneous transluminal coronary
angioplasty
Outcome Coronary Artery Bypass Crafting is more
effective than Percutaneous transluminal
coronary angioplasty.
Screening of studies
Afterward searching through different determined source that are effective and may help in
predominately can be identifies as the database that include the PubMed, EMBASE, Cochran.
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So, it can say that research result is imported with using the paid systematic review software
which is named Covidence (Takahashi and et. al., 2020). Additionally, during data elucidation
where duplication is removed, title screening is done along with staring of abstract can also help
to review the reviewer work independently about all the result. Moreover, there is a table 3
which include keyword which have potential to configure information along with data with the
help of using keyword that are identified below. Therefore, Covidence also include about the
potential ability which highlights the word that can help to read faster and can applied in better
manner and efficiently.
Table 3: Inclusion along with exclusion key terms which are associated with Covidence.
Inclusion criteria Exclusion criteria
 Coronary artery bypass crafting
 Percutaneous transluminal coronary
angioplasty
 Left main coronary artery disease
 Treatment
 Adults
 Older people
 Methods
 Non pharmacological
 Drug
 Medication
Here, title and abstract is reviewed and it also show the relevancy that are assessed. Here, full
text screening also began with starting the studies. While research work, methods along with
outcomes also focuses about the suitability order which include proper studies for elucidation of
information and data. Additionally, trial is also requiring some report which are associated with
effectiveness of CABG along with PTCA drug eluting stent within treatment of left main
coronary artery disease (Su and et. al., 2019). There is also some bias requirement that are
effective and may help in getting better response towards the inclusion about research work
which are studies for it. It can also help in providing some experience about the data extraction
section that are relevant and help to provide proper information about the research study. It also
helps to allow about the data extraction section which are included within the study and can
identified to meet the inclusion criteria or may include in the exclusion criteria. When it comes
13

under the exclusion criteria then it should be excluded and should show reason that can provide
hypothesis for the topic and are essential to prove.
Quality assessment along with data extraction
Quality assessment which includes the tools or technique that are consider to show devise
structure which are diabolical within terms and should be support information or data which are
adequate about the evaluating the quality after review. Here, review also include the initiated
literature along with article which are articulated with gathering data or information. Extraction
process along with quality assessment are relevant with the data which also began with screening
of studies which are completed (Sá and et. al., 2019). There is also use of another software that
are associated with screening along with another tactic which are used through using the
software that also include Covidence. There is also evaluation that use PubMed along with
Cochran can be more reliable that shows the risk which are associated and formulated from the
Cochran by bias criteria. Therefore, quality study about the research work can also be assessed.
This can help to provide some outline that are associated with whole complete assessment that is
transmitted to revie manager. It also includes the formulation of summarised figure that are well
demonstrated with the colour context that provides instruction for bias. (Here, green indicate
about the low risk, yellow indicates about unsure along with red indicates about the high risk). In
this, data extraction process can find through the elucidate articles through database i.e.,
PubMed, EMBASE and Cochran. Here, data extraction process can also be found in Appendix B
(Holm and et. al., 2020).
In Table 4, there is information about the data extraction process with selected study which
are also include taking into consideration about the outcomes along with data plotted. Moreover,
there is also indication about the data which include review of data that can help to analyse
missing information or data which are lacked during conducting review process. The assessment
of the study helps to provide the proper indication of the strength of evidence that is well
provided to the review. It is also determining that the studies that is based on various of guide
treatment, prevention and policy decision. Therefore, it is also analysed that the quality
assessment of any kind of studies is likely taken into the consideration which is showing
appropriate objective that support the behaviour of objective which is design under the research
questions. In addition, the risk of bias is used to undertaken within the study which is measure
with the various of ways. The other issue which is well related with the study of quality that used
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to follow in order to make the proper study that is based on quality (Göksel, Karpuzoğlu, İşsever,
and Çınar, B., 2018). It includes:
 Choice of result measure.
 Statistical issue and their background.
 Quality of reporting that is also an aspect which is undertaken within research to make
the better choice of working within the research work that is easy to make proper
understanding (Baber, and Dangas, 2018).
 Quality of intervention that is must focus on current context which support the
environment of research work which feasible and create ethical working. In context to
research work, it is majorly analysed that with the help of all randomised control trial that
show the comparison with CBAG and angioplasty that is PTCA have shown that both
modalities that is equivalent in term of survival or infract free survival but they also show
that patient treated with the PTCA that require many more admission for additional
revascularisation process during the period of follow up. Hence, with the various of
study, among the both intervention PTCA is not effective as comparison with CABG.
 Whereas, the main motive to create proposal for the research work in term of quality
evaluation and framework to measure the strength of evidence provided by the review. It
also helps to determine whether the studies are vigorous enough to make the proper
aspect to consideration of outcome when it is perceived.
Table 4: Data extraction process of included studies.
General Cheol and et, al., 2016. Country chosen for study is United states.
Participants Different patient with left main coronary artery disease.
Intervention/comparison Coronary artery bypass grafting and percutaneous transluminal
coronary angioplasty
Outcome Rate of primary outcomes was observed significantly lower with
CABG instead of PCI.
General Gregg and et. al., 2019
Participants 22 percent patient of CABG and 19 percent of patient CABG with
difference of 3 percentage point with 95 percent CI.
Intervention/comparison The PTCA and CABG is evaluated for the study in term of
15

effectiveness and long term therapeutic effect.
Outcome In patient with left main coronary artery disease of low or
intermediate anatomical complexity, there was no any significant
difference is analysing that is based on PCI and CABG with context
to composite outcome of death, stroke or myocardial infraction at
the 5 years.
General Duk woo park et. al., 2020. The study is conducted in China
Participants Patient with taking CABG is taking n=100 and PCI is also taking
which is about n=100. The primary outcome was showing the
incidence of major adverse cardiac or cerebrovascular events
(composite of death from the any cause, myocardial infraction,
strokes and so on)
Intervention/comparison The analysis and comparison is based on ten years’ outcome after
the use of drug eluting stent versus coronary artery bypass grafting
for left main coronary disease.
Outcome The report of ten year follow up provide the better combat to make
the use of trial of patient with left main coronary artery disease
randomised control to PCI or CABG which did not elaborate the
significant cardiac cerebrovascular events.
Overall, study present data extraction process which is reliable along with validated with the
study. Additionally, this process also helps to provide detailed structure about the research topic
where age, mean age, participants, diabolical age, constructed age along with many more. there
can be risk of biasness which is one of the major threats during conducting the research. There is
also data extraction process which is also reliable that can provide data regarding with bias
studies. This can be outline within the study which also include overall process of the research
work. Additionally, it can also help to provide context which can allow to get better aspect in
relation to biasness which also linked with the hypothesis and majorly the alternative hypothesis
in comparison to null hypothesis (Trasca and et. al., 2018).
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Heterogeneity
This is the study which are undertaken within the process which include the aspect that are
important for the left main coronary artery disease. therefore, initial result includes the evaluation
of process which can be useful. This include the risk of stroke which are associated with ensuring
about the effective response about the CABG. Moreover, there are also some of the associated
information which can also help in getting better response towards the treatment for left main
coronary artery disease (Park and et. al., 2019).
Table 5: Analysis and comparison between CABG and PTCA drug eluting method used in
treatment of left main coronary artery disease in given studies.
Participants Coronary Artery Bypass
Crafting
Percutaneous transluminal
coronary angioplasty
There were 1905 participants
in the trial in CABG.
There were 2775 patient were
included in the study.
There were 2775 patient were
in which 1874 patient were
treated with PCI and have no
differences at the adjusted
analysis.
There was more death to the
patient who uses the PCI and
less number of died patient
who uses the CABG.
Statistics
Using forest plot is main action which is used in order to provide the difference that arise
between the CABG which is surgical process and PTCA drug eluting stent used for the treatment
in left main coronary artery disease. The well show the confidence level that determine approx. P
value that is 0.05 that is deemed significant and anything over the 0.05 was said to have any
statistical significance (Kawashima and et. al., 2020). The position that is analysed which is well
related with diamond that is also considered when it is produced the overall conclusion of report.
There are some of the information about the research topic that can be effective and may help in
getting better response towards the research. This can also associate with focusing on importance
of left main coronary artery disease.
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Figure 1 PTCA versus CABG
Source: PTCA versus CABG, 2020. Access through: https://heart.bmj.com/content/82/4/413
As per hypothesis which state about the measurement of effectiveness as comparison
with CABG to PTCA. In addition, study have major focus to elucidate the data which is well
related CABG and PTCA drug eluting stent that must be investigated with the help of forest plot.
As per the above chart or figure which is well analyse that it indicates the difference between
CABG and PTCA. For PTCA, 75 percent of ad hoc and 25 percent of subsequent admission is
used to taken for the PTCA which is taking the under evaluation for the report. Therefore, 54
percent of re-intervention is used to taken and also it shows calculation that is 40 percent.
Moreover, the data is suffered, it is well analysed that 65.5 percent of patient require at least 1
further hospital stay after their initial stay for the diagnostic coronary angiography. In other hand,
the CABG is also undertaken within evaluation that may provide statistic which is based on 10
percent of hospital stay and 90 percent of subsequent stay. Overall, the re-intervention is used to
taken that indicate 8 percent with the desired outcome for CABG that is 90.8 percent of patient at
least showing the further hospital stay after the initial for diagnostic coronary disease
angiography.
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At last, after taking evaluating part of statistic as per using of forest plot and figure interpretation,
it is analysed that CABG is more effective as taking comparison PTCA drug eluting stent for the
treatment of left main coronary artery disease. The hypothesis is well focus on CABG and PTCA
where comparison is used to made with therapeutic as well statistical level to determine the
effectiveness.
Study ID RR (95%) CABG PTCA Weight
Syntax 1.66 14/117 10/139 24.11
Cardia 1.02 15/151 16/160 29.5
Subtotal 1.24 29/268 26/300 53.5
Syntax 0.54 13/87 13/88 20.6
Cardia 0.59 14/97 16/92 25.5
Subtotal 1.13 27/184 29/180 46.3
Overall 0.67 47/452 56/480 100
Figure 2 CABG VS PTCA
19

RESULTS
PRISMA flowchart
Within the research, the PRISMA flow diagram is help to visualise that is based on the
screening process. In this, they initially show the number of records which is based on article that
found and makes the selection process more transparent by reporting the decision which is
associated with various stage of the review which may be a meta-analysis of systematic review
(Codner and et. al., 2019). There are number of article which is recorded at various stage which
is helpful to research to show the various aspect of screening and process of data retrieval. In
context to this research work, the main aim to choose the PRISMA flowchart is to improve the
author reporting which is linked with their study which is systematic review of meta-analysis.
PRISMA may also useful in order to make the critical appraisal that is published with systematic
review that is not based on quality assessment that is focus on the instrument to make the gauge
where quality of systematic review is taken and underlying (Rajachandran, and Makhija, 2022).
In this, the PRISMA flowchart starting a comparative screening which is based on hypothesis
that is CABG is more effective as compared with PTCA drug eluting stent for treatment of left
main coronary artery disease. The PRISMA flowchart include screening process that is related
with hypothesis that is above mentioned.
20

Chart 1: PRISMA flowchart
21
Records identified from*:
Databases (n = 240)
Registers (n = 120)
Records removed before
screening:
Duplicate records removed (n
= 110)
Records marked as ineligible
by automation tools (n = 90)
Records removed for other
reasons (n = 45)
Records screened
(n = 60)
Records excluded**
(n = 60)
Reports sought for retrieval
(n = 20) Reports not retrieved
(n = 50)
Reports assessed for eligibility
(n = 25)
Reports excluded:
Reason 1 (n = 30)
Reason 2 (n = 25)
Reason 3 (n = 10)
etc.
Studies included in review
(n = 20)
Reports of included studies
(n = 60)
Identification of studies via databases and registers
Identification
Screening
Included

Quality assessment
With the initial, it is important to known about quality assessment and their relevance in
the research work. In this, the assessment study quality gives the proper indication of strength of
evidence that is well provided by taking the review of study that is associated with article. It is
also determining that studies are vigorous enough to make the proper guide treatment, prevention
and decision that is related with policy. Assessing the quality of evidence contained within the
aspect of systematic review is as important as analysing the data (Lee and et. al., 2018). The
result and outcome poorly conducted can be skewed by biases from the research methodology
and interpreted with caution. Therefore, in this research work, the assessing the quality of
evidence within systematic review is an essential as analyse the data within. The result that is
poorly conducted can be skewed with the biases from research methodology. The such studies
which is acknowledge as such as in the systematic review or outright excluded that is undertaken
within the study. Selecting appropriate tool in order to analyse strength of evidence and biases
such as imbedded with each paper is also important. In the systematic review show the
manuscript development tool that is showing the checklist that is built into the software. In this,
the other software such as Rayyan that may help to provide the proper screening search result
and exclude the unnecessary studies that is include in the study. Therefore, in context with topic,
the CABG and PTCA drug eluting stent where the bare metal is not included within the study.
The topic is broad but the information is narrow show quality assessment help to allow the reader
to generate proper understanding that is related with the topic. There are some of method which
is feasibly use under various circumstance. The discussion follows some of tool that support
study is based on quality of assessment (Cui and et. al., 2018). It includes:
 Assessing the methodological quality of systematic review is act as tool which is used for
quality assessments which have major focus to critical appraise the systematic review. In
the context to the topic. It shows that CABG is more effective as compared with PTCA
drug eluting stent for the left main coronary artery disease. The outcome is deriving as
per use of systematic review tool.
 Cochrane risk of bias that is RoB 2 that is work as tool which is well recommended tool
for assessing quality and manage the risk of bias and offer wide range of appraisal
checklist for the wide range of study type. In reference to topic, the major of study is
22

based on the randomised control trial where patient are selected with the aspect of
prospective randomised study and outcome is derive that is appropriate for the topic.
 Centre for evidence based medicine that usually contain the collection of critical
appraisal tool that is useful in order to analyse and evaluate the article review where aim,
objective and study design that is suitable for the research topic. In critical appraisal,
different article is well selected and analysis is used to taken that is based on study
design, outcome and many more that support the quality assessment (Macovei and et. al.,
2020).
Assessment of study quality gives the indication of the proper strength of the proper evidence
that is suffix with the help of study. In addition, there are some of aspect which is undertaken
within the study. For example, there are some of the selected tool which is well suitable in order
to make the study quality assessment. The tool which is used for quality assessment tool are
Cochran manual, JAMevidence and so on which is showing the context of evaluation. The
quality tool is well discussed and used for further implication which follow the context such as
https://med.mercer.edu/library/systematic-review-quality-assessment.htm. This is referring as
link which is provide the better instruction which is well suitable to make the better assessment
for the tool which is comprehensive and showing the phenomena which is helpful to appraise the
work on the basis of quality. It helps to provide wide range of data implementation which is
required for the research to make appropriate data and information. The CABG and PTCA drug
eluting stent are well investigated in term of their effectiveness that support for treatment of left
coronary artery disease. In this, it is also analysing that the data have proper set which is well
focus on the research question and hypothesis which is formulated in order to make proper
investigation (Stefanos Giannopoulos and et. al., 2022).
While taking the contrast of quality assessment, as above discussed the tool are used to
undertaken that provide assistance to measure the quality of work. In the present review the term
of quality, quality assessment and assurance are well used which may help to provide the
attempted which is defined and described the to assess the proper standard that is primary in
order to fill the proper aspect and division that is based on central level. For the quality review,
various indicator is used which help to established the variable that reflect the deviation in
quality. There are various of criteria that is used to reflect and provide proper determinant that
have optimal level of care while making the proper standard of care that is well illustrated. The
23

quality of work is initiated when proper quality assurance is used to taken with the continuous
process which help to determine the standard which is related with the relation to this. In this,
quality assessment is referring as context of data collect and analysis through which the degree of
conformity to refer the unsatisfactory, attempts are used to made to discover the reason for this
(Strauss and et. al., 2021).
24

Data extraction table
Table 6: Data extraction
Title Author Year Country Patient age Study
design
Sample size Result
Coronary
artery bypass
grafting
versus
percutaneous
coronary
intervention
for
unprotected
left main
disease
Edward 2020 United
state
40 to 60
years old.
Systematic
review
Unknown Coronary artery
bypass grafting
is more effective
for unprotected
left main disease
as comparison
with
percutaneous
coronary
intervention.
Drug-eluting
stent
placement
versus
coronary
artery bypass
surgery for
unprotected
left main
coronary
artery
disease: A
meta-
analysis of
randomized
controlled
Sunil et.
al.,
2017 Michigan Unknown Meta-
analysis
The total
sample size
is 4595
CABG result is
fewer and need
to repeat the
revascularisation
process then
PCI
25

trials
Meta-
Analysis of
Comparison
of 5-Year
Outcomes of
Percutaneous
Coronary
Intervention
Versus
Coronary
Artery
Bypass
Grafting in
Patients
With
Unprotected
Left Main
Coronary
Artery in the
Era of Drug-
eluting
Stents
Mahin
et. al.,
2017 United
kingdom
Older people
(Age not
defined)
Meta-
analysis
Sample size
is unknown
PCI is
comparative
CABG is
effective.
Coronary
Artery
Bypass
Surgery
Versus
Drug-Eluting
Stent
Implantation
Cheol
et. al.
2016 Unknown 50 and
above with
initial
complication
of left main
coronary
artery
disease.
Meta-
analysis
Patient who
is taking
CABG and
PCI with
DES is
randomly
selected.
The CABG is
more
advantageous as
compared to
PCI with DES.
26

for Left
Main or
Multivessel
Coronary
Artery
Disease: A
Meta-
Analysis of
Individual
Patient Data
Drug-eluting
stent for left
main
coronary
artery
disease. The
DELTA
registry: a
multicenter
registry
evaluating
percutaneous
coronary
intervention
versus
coronary
artery bypass
grafting for
left main
treatment.
Alaide
et. al.,
2012 Milan,
Italy
Unknown Systematic
study
design
The sample
size is 2775
patient with
left main
coronary
artery
disease.
CABG is more
effective as
comparison with
PTCI
27

28

DISCUSSION
Risk of bias: ethics
There is different ethical consideration which leads to impact the research outcomes and
should be taken in consideration and should avoid the risk of biasness. It is also essential to take
care of better and effective response which are associated with ensuring about the ethical concern
where informed consent is highly important. Before research, it is essential to take consent from
the participants who are involved in the research process. Here, getting consent is the ethical
concern and should not be biased that can help to provide creditably of the research. There is also
need to take care that every participant should get consent and have all the information which is
necessary to have. During research, it is also need to ensure about taking care of each and every
element. In this, it is essential to ensure about taking care of effective response towards the
participant’s involvement in the research. Here, it is essential to ensure about taking care of each
and every element that are included in delivery of better knowledge and ensure about using that
information to get better outcomes. Here, risk of bias in the research can misled to the correct
research outcomes and may create research problem. Here, it is also needed to ensure about
taking care of better and effective response which are associated with ensure about gathering
correct information which are essential and should provide effective response. During research,
there is need to ensure that research design or data gathering should not be biased and have
correct information that can be effective and may help in getting positive research outcome that
can be used for the further research or practices. Researchers should ensure that research ethics
should not be bias which can mislead to research response and may lead to create false outcome.
There is also need to take care about the effective response where risk of bias can lead to change
the research result. During the research all the ethical consideration has been followed that help
to get the correct information and allow to provide better response towards the research.
Research has also taken care of the research response which are also associated with ensuring
about following the ethics that may have positive result.
Summary of finding
Through research it has been found that left main coronary artery refers to the disease that
lead to create negative health impact to people and may lead to create negative health impact on
individual who are suffering from it. It leads to create the blockage of the artery due to blood
29

clot. Here, blood clotting can lead to create high impact and may lead to major issue specially
within the left main coronary artery disease. There is another finding that left main artery disease
is highly responsible to impact individual life which should be taken in care and research should
be done to provide better and effective positive response towards reducing the cases of the such
disease and may help to humanity to serve better and provide better quality of life. It has been
found that to treat left main coronary artery disease, there is need to ensure about reducing the
cases of blockage of artery. Here, different method can be used to reduce such cases in which
CABG along with PTCA drug eluting stent can provide better response and help to delivery
better health to patient with left main coronary artery disease. CABG includes the surgical
procedure which is effective and help to provide better response to through allow blood to move
freely within artery. It provides diversion to blood which can help to provide better path for
flowing and may help in getting better response towards the body function. This helps to reduce
the blood pressure on the artery where bypass grafting help to improve the blood flow through
initiating the oxygen within heart (Thuijs and et. al., 2019). Here, the diverted blood flow
through the new blood vessel are known as the graft. Here, number of graft can be depending on
the seriousness of the disease. It has been found that number of blood vessels needs to be treated
for proper blood circulation where using of CABG and PTCA help to reduce the death rates or
risk of myocardial infarction than treatment with the drug-eluting stent. It has found that patients
who has three vessel disease has been treated with the CABG and patient who received the
treatment of stent had about 0.80 hazard ration and survival rate was 94%. Patient with two
blood vessel were treated with the CABG had the 0.71% hazard ration and has the adjusted
survival rate about 96%. This represent that CABG and PTCA both are effective and have about
equivalent response which result also depends on associated factor. Here, it can also reduce the
mortality rate and help to avoid such stoke in future. Research also includes different response
where CABG and PTCA treatment both are effective and have about equal response and
difference varies due to different factors It is also found that PTCA drug eluting can be used that
includes the drug coated approach and stent is fitted within the artery which can allow to flow
blood properly. Here, research includes the comparison about the CABG along with PTCA
which include about getting better positive response in the left main coronary artery disease.
30

Raw data
To perform the research in better way, extracting data or information is one of the
important task which are highly effective and may lead to provide better response for effective
outcomes. This can also help in getting better care and allow to improve the research area in
better way. Here, while conducting the research there was need for various resources that can be
authenticating and have better result in gathering quality information for better positive result.
Here, raw data was needed to collect which was further interpreted to get better response and
allow to get effective information through those collected raw data. There was also needed to
take care about the positive result that also help in getting better care and allow to provide more
positive outcomes in the research process and result. Different source was visited where internet
and online platform were highly effective and allow to provide large number of information or
data. PubMed, Cochran and EMBASE has main role in proving large number of data regarding
the research topic. There were different journals, articles which were available on the internet
that allow to provide various information about the research topic and help in performing the
research in better way (Park and et. al., 2020). There was also needed to ensure about taking care
of better and effective response which are effective and needed to take care through using
internet, e-mail and other source that allow to gather more information through taking care of the
better and effective response and help to improve the research outcomes.
Similar studies
There were different similar studies in which one has better information and provide high
data that allow researcher to conduct their research in better way. This include better and
effective response towards the treatment which include different strategies for the left main
coronary artery disease that was also associated with the acute coronary syndromes. Here, in this
article it includes various information related with the left main coronary artery stenosis which is
not rare in nature and are reported about 3 to 10 %. Here, unprotected LMCA intervention can be
clinical challenges which include the traditional management of the cardiac centres. Here, article
provide various information about effective prevention and intervention towards the care and
help in prevention from the left main coronary artery disease. This is effective and allow to
provide better response through using the setting of acute coronary syndromes which include the
cardiogenic shock along with hemodynamic instability. It also defines about the cardiac events
which are more frequent and allow surgery for the selecte3d stable patient with multi vessel
31

diseases (Treatment strategies in the left main coronary artery disease associated with acute
coronary syndromes, (2015)). Through this study, it helps research to get various knowledge and
data that are effective and allow to provide better response towards the collection of data. It also
allows research to perform well and help in getting better care and support which are associated
with improving knowledge that can contribute in the research study and improve the research
outcome in better way (Gomes and et. al., 2020).
Follow up period.
Activities/Months February March April May June July August
Introduction
Aim and
objective
Literature review
Methodology
Results
Discussion
Conclusion
Submission
The time plan generally involve solving the similar scheduling issues, but more
additionally the choices of specific activities is left open and it must be chosen with their
scheduling, mainly provided of the actions as well as their effects. the research of the topic
provided mainly starts in the month of February with having introduction about the concept of
CABG vs PTCA using drug eluting stents for the treatment of left main coronary artery disease.
It can be effectively described such as the optimal care treatment of the CAD (Ischemic coronary
artery illness) is generally at the point of a discussion of several people across countries. while
doing research over the provided topic, there are some of its standpoints like greater risk of the
repeat revascularization as well as the cardiovascular events within the DES-PCI can remain
consistent via throughout the study (Navalta and et. al., 2019). Within this, the research aims and
objectives have been set out in the march and April that can take a huge step towards the
investigation. The literature review is being taken under consideration within the month of
32

March and April that has effectively provides an information about the specific topic. By
considering the viewpoints of various authors, the concept is now much more clear and
acknowledgeable. It can provide knowledge about the topic which is CABG and PTCA drug
eluting stent in treatment of left main coronary artery disease. It is also determined that the
Percutaneous coronary intervention is effectively considered as a reasonable alternative towards
the coronary artery bypass surgery for various patients with having left or multivessel coronary
artery illness (Soratto and et. al., 2020).
Method based on follow up
The methods which are being used within the research over the chosen topic are such as
Criteria for eligibility, Screening of studies, Quality assessment along with data extraction,
Heterogeneity and Statistics as well. Each of the investigation generally includes a guidelines
known as eligibility criteria, specifically illustrates the features which should be shared by all the
effective participants. Within this, a follow-up study specifically occurs after the investigation or
a care treatment that has been presented towards the participants or the vulnerable patients as
well. There is also a meta-analysis which was effectively achieved by using various random
effect model with aid of the review leader for the statistical analysis. In addition to this, the
categorical variables were mainly pooled as an odd ratio with involving about 95% of the
confidence interval (Fedushko and et. al., 2019). Furthermore, the crude events from the
discussion were mainly used to effectively calculate the odds ratio with involving the confidence
intervals when suitable. Moreover, within the research, there is being used a Cochrane
collaboration tool for effectively assessing the risk of bias to significantly identify the quality of
involved Randomized Control Trials. The tool mainly assesses the possible risk of selection
biasness, the performance bias, detection bias, attrition bias, reporting bias as well as the other
bias. Moreover, the review was mainly conducted as per the preferred reporting items for the
systematic reviews as well as the meta-analysis like PRISMA guidelines for both the systematic
review and meta-analysis. For the investigation, there are various databases searched like
PubMed, MEDLINE, Scopus, EMBASE and Cochrane Library in order to gather all the effective
data. Within this, the database searched with the help of keyword such as left main coronary
disease OR “Unprotected left main coronary disease” AND “Drug eluting Stent” and many
more. It can also include the MeSH term in order to search the study topic (Ntoumanis and et. al.,
2021).
33

Limitation
The provided research topic has various limitations such as the heterogeneity in the
definition of specific myocardial infarction by a person investigation. In this, there are small
number of RCTs. The major limitation is that this is generally an observational study. Within
this, the previous Drug Eluting Stent was mainly used in the trails except the best one. It can
remain a controversial whether the information from the other provided article about drug eluting
stent trails are mainly applicable towards the current studies. It can provide a better safety profile
of the newer people Drug eluting stent versus the earlier which has been examined. In addition to
this, the CABG generally seems to maintain its superiority above the Percutaneous Coronary
Intervention even in the time of new people’s Drug Eluting Stent. Within this, the description of
the medical results was quite different within the trails. Therefore, it will not impact the
comparison among the two care treatment strategies since they were randomized. At last, the
antiplatelet agents as well as the statins were more less frequently used within the Coronary
Artery Bypass grafting group of people as comparison with the Percutaneous coronary
interventions group of people, that can be quite disadvantageous for the Coronary Artery Bypass
Grafting groups in order to protect against the cardiovascular events (Monteiro and et. al., 2019).
Nevertheless, the Coronary Artery Bypass Grafting is much better than the Percutaneous
coronary interventions with the drug eluting stent within the prevention of the myocardial
infarction. Furthermore, the early risk of the stroke may be greater within the Coronary Artery
Bypass Grafting group of people with the Percutaneous coronary interventions groups.
Therefore, the long-term risk of stroke is generally associated with the significant risk
components mainly need life style changes as well as an optimal clinical therapy. Within the
study, the Coronary Artery Bypass Grafting generally did not carry a greater risk of developing
stroke as compared with the Percutaneous coronary interventions with the Drug Eluting Stent.
The requirement for repeat revascularization was remarkably reducing after the Coronary Artery
Bypass Grafting, effectively depicting the significant gaps within the repeat revascularization
among the Coronary Artery Bypass Grafting and a percutaneous Coronary Interventions is still a
substantial even within the Drug Eluting Stent era (Powles and et. al., 2020).
Future research implication
The research implications generally refer to an influence which the study may have over
the future study or the policy decision or the relevant field of interest of the research. the
34

vulnerable patients with involving the left main coronary artery illness generally have a poor
prognosis it is because of involving the huge risk of myocardium. the survival within the
vulnerable patients with involving a left main coronary artery illness is longer after the
revascularization with either the Coronary Artery Bypass Grafting or the Percutaneous Coronary
Interventions than with the clinical therapeutic alone. In addition to this, the conflicting long
term findings from these specific trails that generally have reported. Therefore, to accomplish an
adequate power, these specific trails mainly relied over the differences within the incidents of
repeat revascularization a result of less necessity towards healthcare professionals and vulnerable
patients than stroke, death and a myocardial infarction as well (Schmid and et. al., 2020).
CONCLUSION
From the above research work, it can be concluded that the choice between CABG and stent
depends on various factors such as the onset and intensity of disease. Upon comparison, it is
proved that the recovery period for drug eluting stent is shorter as compared to coronary artery
bypass graft surgery. Coronary artery disease is characterized by build-up of plaque inside the
arteries which cause restricts the supply of blood in the heart. CABG is a surgical procedure
which is used in the treatment of coronary left artery disease which causes the blood vessels to
restrict the supply of oxygen and nutrients to the cardiac muscles. The bypass graft surgery is
considered a primary therapy for improving the quality of life in individuals prolonging their
survival. In contrast to percutaneous coronary angioplasty, it was researched that patients with
PCA surgery are five times more likely to undergo re vascularisation after the surgery. However,
it was observed that PCA surgery is less expensive compared to bypass surgery. Both these
surgeries ensure protection against risk of strokes, myocardial infraction and even death. There is
a greater need for vascularisation with stents which further becomes expensive in the long run.
CABG significantly lowers the risk of heart attacks in future. After successful CABG surgery,
the intensity of symptoms is reduced and the longevity of life is increased for about 10-15 years.
According to evidence-based randomised trails, more than 95% of the high risk patients have not
experienced serious complications. The risk of death after the procedure is about 1-2%. The
survival rate of patients suffering from coronary artery disease, heart failure and left ventricular
dysfunction has significantly improved. The doctor surgically grafts a blood vessel from the
35

body to the narrowed artery which facilitates the flow of blood around the diseased artery.
Ongoing shortness of breath along with angina in heart arteries can be treated effectively with
CABG by elimination of symptoms suffered by the patient. Bypassing of clogged arteries
ensures proper facilitation of blood inside the heart and all around the body. The plaque
deposited inside the walls of arteries ruptures and leads to formation of blood clots which cause
symptoms like chest discomfort and pain. Therefore, it is crucial for the blocked arteries to be
treated, otherwise the damage of heart can go undiagnosed and lead to fatal consequences.
36

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40

APPENDICS
APPENDIX A: MeSH term
Population “Patient” [MeSH Terms] OR “patient” [All Fields] OR “Participants” [All
Field] OR “Participant” [All Field]
“coronary” [MeSH Terms] OR “coronary” [All Fields] OR “coronary” [All
field]
Intervention “Coronary Artery Bypass Crafting ” [MeSH Terms] OR “Coronary Artery
Bypass Crafting ” [All Field] “Percutaneous transluminal coronary
angioplasty” [MeSH Terms] OR “Percutaneous transluminal coronary
angioplasty” [All Field]
Comparison “Percutaneous transluminal coronary angioplasty” [MeSH Terms] OR
“Percutaneous transluminal coronary angioplasty” [All Field]
Outcome “Provide relief” [MeSH Terms] OR “Provide relief” [All Field] OR “Patient
recovery” [All field] OR “patient recovery” [All field] OR “Comfort patient”
[All field] OR “comfort patient” [All field]
APPENDIX B: Data extraction process
Criteria/Author Gregg et. al.,
2019
Donald et. al.,
2014
Alaide et. al.,
2012
Cheol et. al.,
2020
Is aim clear? ✓ ✓ ✓ ✓
Is purpose or
report is clear?
✓ ✓ ✓ ✓
Is exclusion and
inclusion criteria
being clear?
✓ ✖ ✖ ✓
Is source of
information is
appropriate?
✓ ✖ ✓ ✖
Are outcomes ✓ ✓ ✓ ✓
41

being relevance?
Is there any
potential risk?
✓ ✓ ✓ ✓
42