Complete versus culprit only revascularization in ST-elevation myocardial infarction-a perspective on recent trials
Gabriela Andries1, Sahil Khera1,2, Robert J Timmermans1
1Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA.
Insights
Multivessel coronary artery disease (CAD) increases risks, yet guidelines caution against complete revascularization during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). Evidence suggests multivessel PCI may reduce major adverse cardiac events (MACE).
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Multivessel coronary artery disease (CAD) is linked to worse outcomes than single-vessel CAD, including higher mortality and major adverse cardiac events (MACE).
- Patients with ST-elevation myocardial infarction (STEMI) and multivessel CAD face increased risks, posing a therapeutic challenge.
- Current guidelines often do not recommend percutaneous coronary intervention (PCI) for non-culprit lesions during primary PCI in stable STEMI patients.
Purpose of the Study:
- To evaluate the impact of multivessel PCI versus culprit-lesion-only PCI in STEMI patients with multivessel CAD.
- To assess the safety and efficacy of complete revascularization strategies in this patient population.
Main Methods:
- Review of randomized controlled trials (RCTs) and meta-analyses comparing multivessel PCI with single-vessel PCI in STEMI patients.
- Analysis of outcomes including MACE, mortality, myocardial infarction (MI), and repeat revascularization.
Main Results:
- Meta-analyses suggest multivessel PCI may lower the risk of MACE and repeat revascularization.
- The risk of recurrent MI and mortality appears similar between strategies.
- Existing RCTs may lack sufficient power to definitively assess hard clinical outcomes like death and MI.
Conclusions:
- While evidence trends towards improved MACE outcomes with multivessel PCI, definitive conclusions on hard endpoints are limited by trial power.
- The optimal revascularization strategy for STEMI patients with multivessel CAD remains an area for further investigation.
Abstract:
The presence of multivessel coronary artery disease (CAD) is strongly associated with higher 30-day mortality, reduced myocardial reperfusion success, reinfarction, and occurrence of major adverse cardiac events (MACE) at 1 year compared with single-vessel CAD. Despite higher morbidity and mortality in patients with ST-elevation myocardial infarction (STEMI) and coexistent multivessel CAD, major guidelines recommended against percutaneous coronary intervention (PCI) on non-culprit lesions at the time of primary PCI in patients with STEMI who are hemodynamically stable. The presence of multivessel CAD often poses a therapeutic dilemma for interventional cardiologists. A few larger scale randomized controlled trials (RCTs) and meta-analyses have been conducted. The conclusions regarding multivessel PCI generally trend towards lower risk of MACE, repeat revascularization, with similar risks of recurrent myocardial infarction (MI) and mortality. However, none of the RCTs were adequately powered for hard outcomes of death and MI.
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