Complete vs Culprit-Lesion-Only Revascularization for ST-Segment Elevation Myocardial Infarction: A Systematic Review
Kevin R Bainey1, Thomas Engstrøm2, Pieter C Smits3
1Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
Insights
Complete revascularization in ST-elevation myocardial infarction (STEMI) patients with multivessel disease reduces cardiovascular death and new myocardial infarctions (MI). Both fractional flow reserve (FFR)- and angiography-guided strategies showed similar benefits, indicating effective treatment for hard clinical outcomes.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Clinical Trials and Meta-Analysis
Background:
- The COMPLETE trial indicated complete revascularization reduces adverse events in ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease.
- Uncertainty remains regarding complete revascularization's impact on cardiovascular (CV) mortality and consistency across fractional flow reserve (FFR)- and angiography-guided strategies.
Purpose of the Study:
- To determine if complete revascularization decreases CV mortality in STEMI patients with multivessel disease via systematic review and meta-analysis.
- To assess if FFR- and angiography-guided PCI strategies for nonculprit lesions influence the association between complete revascularization and hard clinical outcomes.
Main Methods:
- Systematic search of multiple databases (MEDLINE, Embase, Web of Science, CENTRAL) and conference proceedings up to September 2019.
- Inclusion of 10 randomized clinical trials comparing complete revascularization versus culprit-lesion-only PCI in 7030 STEMI patients with multivessel disease.
- Meta-analysis using random-effects models to calculate odds ratios (OR) for CV death and the composite of CV death or new MI.
Main Results:
- Complete revascularization was associated with reduced CV death (OR, 0.69; P=.05) and a significantly lower composite of CV death or new MI (OR, 0.69; P=.001) compared to culprit-lesion-only PCI.
- No significant heterogeneity was observed in the composite outcome between FFR-guided (OR, 0.78) and angiography-guided (OR, 0.61) strategies.
- All-cause mortality showed a non-significant trend towards reduction with complete revascularization (OR, 0.84; P=.13).
Conclusions:
- Complete revascularization significantly reduces CV mortality and the composite of CV death or new MI in STEMI patients with multivessel disease.
- The benefits of complete revascularization on major CV outcomes are consistent regardless of whether FFR- or angiography-guided strategies are employed for nonculprit lesions.
- These findings support complete revascularization as a beneficial strategy for improving hard clinical outcomes in this patient population.
Importance:
Recently, the Complete vs Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI (percutaneous coronary intervention) for STEMI (ST-segment elevation myocardial infarction [MI]) (COMPLETE) trial showed that angiography-guided PCI of the nonculprit lesion with the goal of complete revascularization reduced cardiovascular (CV) death or new MI compared with PCI of the culprit lesion only in STEMI. Whether complete revascularization also reduces CV mortality is uncertain. Moreover, whether the association of complete revascularization with hard clinical outcomes is consistent when fractional flow reserve (FFR)- and angiography-guided strategies are used is unknown.
Objective:
To determine through a systematic review and meta-analysis (1) whether complete revascularization is associated with decreased CV mortality and (2) whether heterogeneity in the association occurs when FFR- and angiography-guided PCI strategies for nonculprit lesions are performed.
Data Sources:
A systematic search of MEDLINE, Embase, ISI Web of Science, and CENTRAL (Cochrane Central Register of Controlled Trials) from database inception to September 30, 2019, was performed. Conference proceedings were also reviewed from January 1, 2002, to September 30, 2019.
Study Selection:
English-language randomized clinical trials comparing complete revascularization vs culprit-lesion-only PCI in patients with STEMI and multivessel disease were included.
Data Extraction And Synthesis:
The combined odds ratio (OR) was calculated with the random-effects model using the Mantel-Haenszel method (sensitivity with fixed-effects model). Heterogeneity was measured using the I2 statistic. Publication bias was evaluated using the inverted funnel plot approach. Data were analyzed from October 2019 to January 2020.
Main Outcomes And Measures:
Cardiovascular death and the composite of CV death or new MI.
Results:
Ten randomized clinical trials involving 7030 unique patients were included. The weighted mean follow-up time was 29.5 months. Complete revascularization was associated with reduced CV death compared with culprit-lesion-only PCI (80 of 3191 [2.5%] vs 106 of 3406 [3.1%]; OR, 0.69 [95% CI, 0.48-0.99]; P = .05; fixed-effects model OR, 0.74 [95% CI, 0.55-0.99]; P = .04). All-cause mortality occurred in 153 of 3426 patients (4.5%) in the complete revascularization group vs 177 of 3604 (4.9%) in the culprit-lesion-only group (OR, 0.84 [95% CI, 0.67-1.05]; P = .13; I2 = 0%). Complete revascularization was associated with a reduced composite of CV death or new MI (192 of 2616 [7.3%] vs 266 of 2586 [10.3%]; OR, 0.69 [95% CI, 0.55-0.87]; P = .001; fixed-effects model OR, 0.69 [95% CI, 0.57-0.84]; P < .001), with no heterogeneity in this outcome when complete revascularization was performed using an FFR-guided strategy (OR, 0.78 [95% CI, 0.43-1.44]) or an angiography-guided strategy (OR, 0.61 [95% CI, 0.38-0.97]; P = .52 for interaction).
Conclusions And Relevance:
In patients with STEMI and multivessel disease, complete revascularization was associated with a reduction in CV mortality compared with culprit-lesion-only PCI. There was no differential association with treatment between FFR- and angiography-guided strategies on major CV outcomes.
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