Culprit versus multivessel coronary intervention in ST-segment elevation myocardial infarction: a meta-analysis of
Satyanarayana R Vaidya1,2, Arman Qamar3, Sameer Arora1,4
1Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville.
Insights
Complete multivessel percutaneous coronary intervention (CMV PCI) in ST-segment elevation myocardial infarction (STEMI) patients reduces major adverse cardiac events and cardiac death but not all-cause mortality. CMV PCI is safe and decreases repeat revascularization needs.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- The 2015 ACC/AHA guidelines suggest percutaneous coronary intervention (PCI) for non-infarct arteries in ST-segment elevation myocardial infarction (STEMI) patients.
- The benefit of complete revascularization on mortality in STEMI remains uncertain.
Purpose of the Study:
- To compare complete multivessel PCI (CMV PCI) with infarct-artery-only PCI in STEMI patients.
- To evaluate the efficacy and safety of complete revascularization.
Main Methods:
- Systematic review and meta-analysis of randomized controlled trials (RCTs).
- Included 9 RCTs with 2991 STEMI patients.
- Assessed major adverse cardiac events, cardiovascular mortality, all-cause mortality, repeat revascularization, contrast-induced nephropathy, and major bleeding.
Main Results:
- CMV PCI significantly reduced major adverse cardiac events (RR=0.54), cardiovascular mortality (RR=0.48), and repeat revascularization (RR=0.38).
- No significant reduction in all-cause mortality (RR=0.75) or nonfatal myocardial infarction (RR=0.69) was observed.
- Rates of contrast-induced nephropathy and major bleeding were comparable between groups.
Conclusions:
- Complete revascularization in STEMI patients with multivessel disease is safe.
- CMV PCI reduces MACE, cardiac death, and need for repeat revascularization.
- CMV PCI does not improve all-cause mortality or reduce nonfatal myocardial infarction.
Background:
The 2015 American College of Cardiology/American Heart Association update on primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) recommended PCI of the non-infarct-related artery at the time of primary PCI (class IIb recommendation). Despite evidence supporting complete revascularization in STEMI, its benefit on mortality rates is uncertain.
Methods:
We searched all available databases for randomized controlled trials comparing complete multivessel percutaneous coronary intervention (CMV PCI) with infarct-artery-only revascularization in patients with STEMI. Summary risk ratios and 95% confidence intervals (CIs) were calculated for both the efficacy and safety outcomes.
Results:
Nine randomized controlled trials fulfilled the inclusion criteria, yielding 2991 patients. Follow-up periods ranged from 6 to 36 months. Compared with infarct-related artery-only PCI, CMV PCI was associated with significantly lower rates of major adverse cardiac events [relative risk (RR)=0.54, 95% CI=0.41-0.71; P<0.00001], cardiovascular mortality (RR=0.48, 95% CI=0.28-0.80; P=0.005), and repeat revascularization (RR=0.38, 95% CI=0.30-0.47; P<0.00001). Although, contrast-induced nephropathy and major bleed rates were comparable between both groups, CMV PCI failed to show any reduction in all-cause mortality (RR=0.75, 95% CI=0.53-1.07; P=0.11) and nonfatal myocardial infarction (RR=0.69, 95% CI=0.43-1.10; P=0.12).
Conclusion:
Our results suggest that in patients with STEMI and multivessel disease, complete revascularization is safe, and is associated with reduced risks of major adverse cardiac events and cardiac death along with a reduced need for repeat revascularization. However, it showed no beneficial effect on all-cause mortality and nonfatal myocardial infarction.
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