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Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
Complete versus culprit-only revascularization in patients with ST-segment elevation myocardial infarction and
Haiyan Xu1, Xiwen Zhang1, Jiangjin Li1
1Department of Cardiology, The affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 6 Beijing Road West, Huai'an, 223300, Jiangsu, China.
Insights
Complete revascularization in ST-elevation myocardial infarction (STEMI) patients with multivessel disease did not reduce all-cause mortality. However, immediate complete revascularization may be beneficial when feasible.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Optimal treatment strategy for non-infarct arteries in ST-elevation myocardial infarction (STEMI) with multivessel disease (MVD) undergoing primary percutaneous coronary intervention (PCI) remains undefined.
- Multivessel disease is common in STEMI patients, necessitating decisions on revascularizing non-culprit lesions.
Purpose of the Study:
- To compare complete revascularization (CR) versus infarct-related artery (IRA) only revascularization in STEMI patients with MVD.
- To evaluate the impact of CR on clinical outcomes, including mortality, major adverse cardiac events (MACE), and repeat revascularization.
Main Methods:
- Systematic literature search for randomized controlled trials (RCTs) comparing CR with IRA-only revascularization in hemodynamically stable STEMI patients.
- Meta-analysis using random-effect risk ratios (RRs) to assess clinical outcomes.
Main Results:
- Nine RCTs involving 2989 patients were analyzed. No significant difference in all-cause mortality was observed between CR and IRA-only groups (RR=0.74; p=0.08).
- Complete revascularization significantly reduced MACE (RR=0.53; p<0.001), cardiac death (RR=0.48; p=0.004), and repeat revascularization (RR=0.38; p<0.001) compared to IRA-only.
- Immediate complete revascularization (ICR) showed a trend towards reduced all-cause mortality (RR=0.62; p=0.04), while staged complete revascularization (SCR) did not (RR=0.92; p=0.82). No differences in stroke, contrast-induced nephropathy, or major bleeding.
Conclusions:
- Complete revascularization in STEMI patients with MVD undergoing primary PCI does not reduce all-cause mortality based on current RCT evidence.
- Immediate complete revascularization, when feasible, may be a consideration for patients with STEMI and MVD due to potential mortality benefits.
Background:
The best strategy for the treatment of the non-infarct artery in patients with ST-elevation myocardial infarction (STEMI) and multivessel disease (MVD) undergoing primary percutaneous coronary intervention (PCI) is not yet defined.
Methods:
We searched the literature for randomized controlled trials (RCTs) that compared complete revascularization (CR) with infarct-related coronary artery (IRA) only revascularization in hemodynamically stable patients with STEMI. Random effect risk ratios (RRs) were calculated for clinical outcomes.
Results:
Nine RCTs with 2989 patients were included. No significant difference in all-cause mortality emerged between CR and IRA-only groups (relative risk [RR] = 0.74; 95% confidence interval [CI]: 0.52 to 1.04; p = 0.08). Compared with IRA-only, CR was associated with significantly lower rates of major adverse cardiac events (MACE) (RR = 0.53; 95% CI: 0.41 to 0.68; p < 0.001), cardiac death (RR = 0.48; 95% CI: 0.29 to 0.79; p = 0.004) and repeat revascularization (RR = 0.38; 95% CI: 0.30 to 0.47; p < 0.001). In subgroups analysis, immediate complete revascularization (ICR) reduced the risk of all-cause mortality (RR = 0.62; 95% CI: 0.39 to 0.97; p = 0.04), whereas staged complete revascularization (SCR) did not show any significant benefit in all-cause mortality (RR = 0.92; 95% CI: 0.46 to 1.86; p = 0.82). Stroke, contrast-induced nephropathy and major bleeding were not different between CR and IRA-only.
Conclusions:
For patients with STEMI and multivessel disease undergoing primary PCI, complete revascularization did not decrease the risk of all-cause mortality in current evidence from randomized trials. When feasible, immediate complete revascularization might be considered in patients with STEMI and multivessel disease.
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