Complete versus culprit-only revascularization for ST-segment-elevation myocardial infarction and multivessel
Sripal Bangalore1, Bora Toklu2, Jørn Wetterslev2
1From the Division of Cardiology, New York University School of Medicine, New York, NY (S.B., B.T.); and Division of Cardiology, The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (J.W.). sripalbangalore@gmail.com.
Insights
Complete revascularization in ST-segment-elevation myocardial infarction significantly reduces major adverse cardiovascular events, primarily by decreasing repeat procedures. However, firm evidence for reduced death or myocardial infarction is lacking.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Current guidelines recommend against nonculprit artery intervention during primary percutaneous coronary intervention for ST-elevation myocardial infarction.
- This recommendation is based on older observational data, with recent trials suggesting a potential benefit for complete revascularization.
Purpose of the Study:
- To evaluate the efficacy and safety of complete versus culprit-only revascularization in patients with ST-segment-elevation myocardial infarction.
- To synthesize evidence from randomized controlled trials on revascularization strategies.
Main Methods:
- Systematic search of PubMed, EMBASE, and CENTRAL databases for relevant randomized trials.
- Inclusion criteria focused on trials comparing complete versus culprit-only revascularization in ST-elevation myocardial infarction patients.
- Efficacy outcomes included major adverse cardiovascular events, death, myocardial infarction, and repeat revascularization; safety outcomes included contrast-induced nephropathy, contrast volume, and procedure time.
Main Results:
- Five trials with 1165 patients were analyzed.
- Complete revascularization significantly reduced major adverse cardiovascular events, cardiovascular death, and repeat revascularization.
- Trial sequential analysis confirmed firm evidence for reduced major adverse cardiovascular events, driven by decreased repeat revascularization, but not for reduced death or myocardial infarction.
- Complete revascularization increased contrast volume and procedure time without increasing contrast-induced nephropathy.
Conclusions:
- Complete revascularization, whether immediate or staged, significantly lowers major adverse cardiovascular events in ST-elevation myocardial infarction patients.
- The benefit is largely attributed to a reduction in repeat revascularization procedures.
- There is currently insufficient firm evidence to support a reduction in death or myocardial infarction with complete revascularization compared to culprit-only revascularization.
Background:
The 2013 American College of Cardiology Foundation/American Heart Association guidelines for patients with ST-segment-elevation myocardial infarction gives a class III indication for nonculprit artery percutaneous coronary intervention at the time of primary percutaneous coronary intervention, driven by data from observational studies. However, more recent trials suggest otherwise.
Methods And Results:
We conducted PUBMED, EMBASE, and CENTRAL searches for randomized trials comparing complete versus culprit-only revascularization in patients with ST-segment-elevation myocardial infarction. Efficacy outcomes were major adverse cardiovascular events, as well as death, cardiovascular death, myocardial infarction, and repeat revascularization. Safety outcomes were contrast-induced nephropathy, contrast volume used, and procedure time. Five trials with 1165 patients fulfilled the inclusion criteria. Complete revascularization (68% during index percutaneous coronary intervention) was associated with significant reduction in major adverse cardiovascular events (rate ratio =0.48; 95% confidence interval =0.37-0.61), death (rate ratio =0.60; 95% confidence interval =0.38-0.97), cardiovascular death (rate ratio =0.38, 95% confidence interval =0.20-0.73), and repeat revascularization (rate ratio =0.42; 95% confidence interval =0.31-0.57) when compared with culprit-only revascularization. However, trial sequential analyses (similar to interim analysis of a randomized trial) powered for a 25% relative reduction showed firm evidence (cumulative z-curve crossed the monitoring boundary) only for major adverse cardiovascular events driven by a decrease in repeat revascularization with no firm evidence for reduction in death and myocardial infarction. Moreover, there was a significant increase in contrast volume use (mean difference 85.12 [70.41-83.00] ml) and procedure time (mean difference 16.42 [13.22-19.63] mins) with complete revascularization without increase in contrast-induced nephropathy.
Conclusions:
In patients with ST-segment-elevation myocardial infarction, immediate or staged complete revascularization results in significant reduction in major adverse cardiovascular events driven largely by reduction in repeat revascularization with no firm evidence for the reduction in death or myocardial infarction when compared with culprit-only revascularization.
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