Meta-Analysis of Randomized Controlled Trials Comparing Multivessel Versus Culprit-Only Revascularization for
Georges E El-Hayek1, Anthony H Gershlick2, Mun K Hong1
1Department of Cardiology, Mount Sinai Saint Luke's Hospital, New York, New York.
Insights
Multivessel percutaneous coronary intervention (MV PCI) significantly reduces mortality and recurrent myocardial infarction in ST-elevation myocardial infarction (STEMI) patients with multivessel coronary disease. This approach offers improved outcomes compared to culprit vessel-only revascularization.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Research
Background:
- Current guidelines advise against non-infarct artery revascularization in ST-segment elevation myocardial infarction (STEMI) patients, primarily based on observational data.
- Recent randomized controlled trials (RCTs) suggest potential benefits of a multivessel revascularization strategy in STEMI.
- Existing evidence from RCTs on this topic is limited, necessitating further synthesis.
Purpose of the Study:
- To conduct a meta-analysis of RCTs comparing multivessel percutaneous coronary intervention (MV PCI) with culprit vessel-only revascularization (COR).
- To evaluate the impact of MV PCI versus COR on mortality and myocardial infarction in STEMI patients with multivessel coronary disease (MVCD).
- To synthesize current RCT evidence regarding revascularization strategies for STEMI with MVCD.
Main Methods:
- Systematic search of Medline, PubMed, and Scopus databases for relevant RCTs.
- Inclusion criteria focused on RCTs comparing MV PCI versus COR in STEMI patients with MVCD.
- Extraction of data on all-cause mortality, cardiac death, recurrent myocardial infarction, and revascularization rates.
Main Results:
- Four RCTs involving 566 patients (MV PCI) and 478 patients (COR) were analyzed.
- MV PCI demonstrated a significant reduction in all-cause mortality (RR 0.57) and cardiac death (RR 0.38).
- Patients undergoing MV PCI also experienced significantly lower rates of recurrent myocardial infarction (RR 0.41) and future revascularization (RR 0.37).
Conclusions:
- Meta-analysis of RCT data indicates that MV PCI improves clinical outcomes in STEMI patients with MVCD.
- MV PCI is associated with reduced mortality, cardiac death, recurrent MI, and need for revascularization.
- These findings suggest a potential shift in guidelines regarding revascularization strategies for STEMI with MVCD.
Abstract:
Current guidelines recommend against revascularization of the noninfarct artery during the index percutaneous coronary intervention (PCI) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI). This was based largely on observational studies with few data coming from randomized controlled trials (RCTs). Recently, several small-to-moderate sized RCTs have provided data, suggesting that a multivessel revascularization approach may be appropriate. We performed a meta-analysis of RCTs comparing multivessel percutaneous coronary intervention (MV PCI) versus culprit vessel-only revascularization (COR) during primary PCI in patients with STEMI and multivessel coronary disease (MVCD). We searched Medline, PubMed, and Scopus databases for RCTs comparing MV PCI versus COR in patients with STEMI and MVCD. The incidence of all-cause death, cardiac death, recurrent myocardial infarction, and revascularization during follow-up were extracted. Four RCTs fit our primary selection criteria. Among these, 566 patients underwent MV PCI (either at the time of the primary PCI or as a staged procedure) and 478 patients underwent COR. During long-term follow-up (range 1 to 2.5 years), combined data indicated a significant reduction in all-cause mortality (relative risk [RR] 0.57, 95% confidence interval [CI] 0.36 to 0.92, p = 0.02) and in cardiac death (RR 0.38, 95% CI 0.20 to 0.73, p = 0.004) with MV PCI. In addition, there was a significantly lower risk of recurrent myocardial infarction (RR 0.41, 95% CI 0.23 to 0.75; p = 0.004) and future revascularization (RR 0.37, 95% CI 0.27 to 0.52; p <0.00001). In conclusion, from the RCT data, MV PCI appears to improve outcomes in patients with STEMI and MVCD.
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