Background: Nowadays the optimal strategy for patients with chronic total occlusion (CTO) has not been well established. This meta-analysis aims to evaluate effect of PCI and optimal medical therapy (OMT) on clinical outcomes in these patients. Methods: Pubmed, Embase and Cochrane Library were searched for studies about patients who had CTO and received PCI or medical therapy as initial strategy, from inception to February 2020. Results of pooled analysis were expressed by risk ratios (RR) and

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... 5% confidence intervals (CI), which were calculated by random effects or fixed effects model according to heterogeneity. Sensitivity analysis was performed by removing one study a time. Funnel plot and Egger's value were used to appraise publication bias. All analysis were calculated by Revmen5.0 and Stata15.0 software.Results: Total 11studies were included in our meta-analysis, 4 RCTs and 7 observation studies using PSM. Total 5664 patients with CTO were enrolled. 2904 patients underwent PCI and 2760 patients received OMT. Pooled analysis indicated that compared with OMT, PCI was associated with lower risk of cardiac death (RR 0.59,95%CI 0.45-0.77, P<0.001). However, there was no significant discrimination in MACE (RR 0.83, 95% CI 0.64-1.06, P=0.14), myocardial infarction (RR 0.98, 95%CI 0.78-1.24, P=0.86), repeat revascularization (RR 0.95, 95%CI 0.71-1.25, P=0.71), and stroke (RR 0.62, 95%CI 0.29-1.34, P=0.22). Sub-analysis by ethnicity showed that PCI was associated with lower incidence of MACE compared with OMT in West European (RR 0.48, 95% CI 0.28-0.84, P=0.01), but not in East Asian (RR 0.94,95% CI 0.77-1.16, P=0.58). Conclusions: Compared with OMT, PCI is associated with lower risk of cardiac death. However, there was no significant difference in MACE, MI, repeated revascularization and stroke. Sub-analysis indicates that PCI is favor of West European.