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Complete vs culprit-only revascularization for patients with multivessel disease undergoing primary percutaneous
Kevin R Bainey1, Shamir R Mehta2, Tony Lai2
1Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
Insights
Staged multivessel percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients improves survival and reduces repeat procedures. Immediate multivessel PCI increases hospital mortality, while staged procedures show better outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease often receive culprit-lesion-only percutaneous coronary intervention (PCI).
- The superiority of complete revascularization strategies in these patients remains unclear.
- This meta-analysis compares routine culprit-only PCI versus multivessel PCI in STEMI.
Purpose of the Study:
- To compare the benefits and risks of routine culprit-only PCI versus multivessel PCI in patients with STEMI and multivessel coronary artery disease.
- To evaluate the impact of different PCI strategies on mortality and repeat procedures.
Main Methods:
- A comprehensive literature search of MEDLINE, EMBASE, ISI Web of Science, and Cochrane Register was conducted from 1996 to January 2011.
- Conference abstracts from January 2002 to January 2011 were also searched.
- Data from 26 studies (3 randomized, 23 nonrandomized) involving 46,324 patients were combined using a fixed-effects model, with long-term mortality as the primary endpoint.
Main Results:
- Overall, multivessel PCI did not significantly differ in hospital mortality compared to culprit-only PCI.
- However, immediate multivessel PCI during the index catheterization increased hospital mortality, whereas staged multivessel PCI was associated with lower hospital mortality.
- Staged multivessel PCI significantly reduced long-term mortality and the need for repeat PCI.
Conclusions:
- Staged multivessel PCI demonstrates improved short- and long-term survival and reduced repeat PCI in STEMI patients with multivessel disease.
- Further large randomized trials are necessary to definitively confirm the benefits of staged multivessel PCI in this patient population.
Background:
Patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease who undergo primary percutaneous coronary intervention (PCI) are most commonly treated with PCI to the culprit lesion only. Whether a strategy of complete revascularization in these patients is superior is unknown. We performed a meta-analysis comparing the benefits and risks of routine culprit-only PCI vs multivessel PCI in STEMI.
Methods:
MEDLINE, EMBASE, ISI Web of Science, and The Cochrane Register of Controlled Trials were searched from 1996 to January 2011. Relevant conference abstracts were searched from January 2002 to January 2011. Studies included STEMI with multivessel disease receiving primary PCI. The primary end point was long-term mortality. Data were combined using a fixed-effects model.
Results:
Of 507 citations, 26 studies (3 randomized, 23 nonrandomized; 46,324 patients, 7886 multivessel PCI and 38,438 culprit-only PCI) were included. There was no significant difference in hospital mortality with multivessel PCI vs culprit-only PCI (odds ratio [OR] 1.11, 95% CI 0.98-1.25, P = .10 [randomized OR 0.24, 95% CI 0.06-0.91, P = .04; nonrandomized OR 1.12, 95% CI 1.00-1.27, P = .06]). However, if multivessel PCI during index catheterization was performed, hospital mortality was increased (OR 1.35, 95% CI 1.19-1.54, P < .001). When multivessel PCI was performed as a staged procedure, hospital mortality was lower (OR 0.35, 95% CI 0.21-0.59; P < .001; P interaction < .001). Reduced long-term mortality (OR 0.74, 95% CI 0.65-0.85, P < .001[randomized OR 0.61, 95% CI 0.28-1.33, P = .22; nonrandomized OR 0.75, 95% CI 0.65-0.86, P < .001]) and repeat PCI (OR 0.65; 95% 0.46-0.90, P = .01[randomized OR 0.31, 95% CI 0.17-0.57, P < .001; nonrandomized OR 0.88, 95% CI 0.59-1.31, P = .54]) were observed with multivessel PCI.
Conclusion:
Overall, staged multivessel PCI improved short- and long-term survival and reduced repeat PCI. Still, large randomized trials are required to confirm the benefits of staged multivessel PCI in STEMI.
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