Non-infarct-related artery revascularization during primary percutaneous coronary intervention for ST-segment...

In patients with ST-elevation myocardial infarction (STEMI) and multivessel disease, guidelines recommend infarct-related artery (IRA) only intervention during primary percutaneous coronary intervention (PCI) except in patients with hemodynamic instability. To assess the available evidence, we performed a systematic review and meta-analysis comparing outcomes of non-IRA PCI as an adjunct to primary PCI (same sitting PCI [SS-PCI]) with IRA only PCI (IRA-PCI) in the setting of STEMI.

A comprehensive search identified 14 studies [11 cohort, 3 randomized controlled trials] comprising of 35,239 patients. For cohort studies, patients undergoing SS-PCI had higher rate of anterior infarction (48% vs. 45%, P = .04) and cardiogenic shock (11% vs. 9%, P = .0001) at baseline compared with IRA-PCI. The primary composite end point of death, myocardial infarction and revascularization was higher in the SS-PCI group in the short term (OR, 1.63; CI, 1.12-2.37) and long term (OR, 1.60; CI, 1.18-2.16). However, after excluding patients with shock, there was no difference in primary endpoint for the short (OR, 1.33; CI, 0.67-2.63) and long term (OR, 1.39; CI, 0.80-2.42) follow-up. In analyses limited to randomized controlled trials, primary end point was similar during short term (OR, 0.79; CI, 0.19-3.28) and significantly lower for SS-PCI group in the long term (OR, 0.55; CI, 0.34-0.91).

There is paucity of randomized data to guide management of STEMI patients with multivessel disease. SS-PCI group in cohort studies has higher baseline risk compared to IRA-PCI. The primary end point is higher for SS-PCI in observational cohort studies but this difference did not persist after exclusion of shock patients and for analysis limited to randomized controlled trials. These findings underscore the need of a large randomized controlled trial to guide therapy for a commonly encountered clinical situation.