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Complete or Culprit-Only Revascularization for Patients With Multivessel Coronary Artery Disease Undergoing
Islam Y Elgendy1, Ahmed N Mahmoud1, Dharam J Kumbhani2
1Department of Medicine, University of Florida, Gainesville, Florida.
Insights
Complete revascularization in STEMI patients with multivessel disease reduces major adverse cardiac events (MACE) by lowering urgent revascularization needs. All-cause mortality and reinfarction risks were similar across strategies.
Area of Science:
- Cardiology
- Interventional Cardiology
Background:
- ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease requires revascularization.
- Complete revascularization may improve outcomes, but optimal timing for non-culprit lesions is unclear.
Purpose of the Study:
- To compare the effectiveness of different revascularization strategies in STEMI patients with multivessel disease undergoing primary percutaneous coronary intervention (PCI).
Main Methods:
- Network meta-analysis of 10 randomized trials involving 2,285 patients.
- Comparison of four strategies: complete revascularization (index procedure or staged) versus culprit-only revascularization.
Main Results:
- Complete revascularization, whether at index or staged, significantly reduced major adverse cardiac events (MACE) (RR: 0.57) primarily due to decreased urgent revascularization.
- No significant differences in all-cause mortality or spontaneous reinfarction were observed among strategies.
- MACE reduction was consistent regardless of the timing of non-culprit artery revascularization.
Conclusions:
- Complete revascularization in STEMI multivessel disease patients reduces MACE, with no significant difference in mortality or reinfarction compared to other strategies.
- The timing of non-culprit revascularization (index, during hospitalization, or post-discharge) did not impact MACE reduction.
- Further research is needed to clarify the impact on mortality and reinfarction outcomes.
Objectives:
The authors sought to compare the effectiveness of the different revascularization strategies in ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease undergoing primary percutaneous coronary intervention (PCI).
Background:
Recent randomized trials have suggested that multivessel complete revascularization at the time of primary percutaneous coronary intervention (PCI) is associated with better outcomes, however; the optimum timing for nonculprit PCI is unknown.
Methods:
Trials that randomized STEMI patients with multivessel disease to any combination of the 4 different revascularization strategies (i.e., complete revascularization at the index procedure, staged procedure during the hospitalization, staged procedure after discharge or culprit-only revascularization) were included. Random effect risk ratios (RRs) were conducted. Network meta-analysis was constructed using mixed treatment comparison models, and the 4 revascularization strategies were compared.
Results:
A total of 10 trials with 2,285 patients were included. In the pairwise meta-analysis, complete revascularization (i.e., at the index procedure or as a staged procedure) was associated with a lower risk of major adverse cardiac events (MACE) (RR: 0.57; 95% confidence interval [CI]: 0.42 to 0.77), due to lower risk of urgent revascularization (RR: 0.44; 95% CI: 0.30 to 0.66). The risk of all-cause mortality (RR: 0.76; 95% CI: 0.52 to 1.12), and spontaneous reinfarction (RR: 0.54; 95% CI: 0.23 to 1.27) was similar. The reduction in the risk of MACE was observed irrespective of the timing of nonculprit artery revascularization in the mixed treatment model.
Conclusions:
Current evidence from randomized trials suggests that the risk of all-cause mortality and spontaneous reinfarction is not different among the various revascularization strategies for multivessel disease. Complete revascularization at the index procedure or as a staged procedure (either during the hospitalization or after discharge) was associated with a reduction of MACE due to reduction in urgent revascularization with no difference between these 3 strategies. Future trials are needed to determine the impact of complete revascularization on the risk of all-cause mortality and spontaneous reinfarction.
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