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Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
Complete revascularization for patients with ST-segment elevation myocardial infarction and multivessel coronary
Gani Bajraktari1,2,3, Haki Jashari1,2, Pranvera Ibrahimi1,2
1Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
Insights
Complete revascularization (CR) in ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease reduces major adverse cardiac events and cardiac death. However, CR does not significantly impact all-cause mortality or PCI-related complications compared to infarct-related artery-only treatment.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Contradictory data exist regarding complete revascularization (CR) versus infarct-related artery (IRA) only in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI).
- Existing randomized clinical trials (RCTs) have had limited sample sizes, necessitating further investigation.
Purpose of the Study:
- To conduct a meta-analysis of RCTs to evaluate the efficacy and safety of CR compared to IRA-only revascularization in STEMI patients with multivessel disease (MVD).
Main Methods:
- Systematic literature search of multiple databases (PubMed, Embase, Scopus, etc.) for relevant RCTs.
- Inclusion criteria: STEMI patients with MVD undergoing primary PCI, comparing CR with IRA-only.
- Random effect risk ratios (RRs) were calculated for various clinical outcomes.
Main Results:
- Ten RCTs with 3291 patients were analyzed, with a median follow-up of 17.5 months.
- CR significantly reduced major adverse cardiac events (RR=0.57), cardiac mortality (RR=0.52), and repeat revascularization (RR=0.50) compared to IRA-only.
- No significant differences were observed in all-cause mortality, nonfatal myocardial infarction, stroke, major bleeding, or contrast-induced nephropathy.
Conclusions:
- CR in STEMI patients with MVD undergoing primary PCI is associated with reduced risks of major adverse cardiac events, repeat revascularization, and cardiac death.
- The benefits of CR regarding cardiac mortality and safety are supported, but further large-scale trials are needed for definitive guidance on optimal patient management.
Introduction:
Despite the recent findings in randomized clinical trials (RCTs) with limited sample sizes and the updates in clinical guidelines, the current available data for the complete revascularization (CR) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) at the time of primary percutaneous coronary intervention (PCI) are still contradictory.
Aim:
The aim of this meta-analysis of the existing RCTs was to assess the efficacy of the CR versus revascularization of infarct-related artery (IRA) only during primary PCI in patients with STEMI and multivessel disease (MVD).
Patients And Methods:
We searched PubMed, MEDLINE, Embase, Scopus, Google Scholar, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov databases aiming to find RCTs for patients with STEMI and MVD which compared CR with IRA-only. Random effect risk ratios (RRs) were calculated for efficacy and safety outcomes.
Results:
Ten RCTs with 3291 patients were included. The median follow-up duration was 17.5 months. Major adverse cardiac events (RR=0.57; 0.43-0.76; P<0.0001), cardiac mortality (RR=0.52; 0.31-0.87; P=0.014), and repeat revascularization (RR=0.50; 0.30-0.84; P=0.009) were lower in CR compared with IRA-only strategies. However, there was no significant difference in the risk of all-cause mortality, recurrent nonfatal myocardial infarction, stroke, major bleeding events, and contrast-induced nephropathy.
Conclusion:
For patients with STEMI and MVD undergoing primary PCI, the current evidence suggests that the risk of major adverse cardiac events, repeat revascularization, and cardiac death is reduced by CR. However, the risk for all-cause mortality and PCI-related complications is not different from the isolated culprit lesion-only treatment. Although these findings support the cardiac mortality and safety benefit of CR in stable STEMI, further large trials are required to provide better guidance for optimum management of such patients.
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