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Complete revascularization for patients with multivessel coronary artery disease and ST-segment elevation myocardial
Gani Bajraktari1,2,3, Ibadete Bytyçi1,2, Michael Y Henein1
1Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
Insights
Complete revascularization significantly reduces major adverse cardiac events and cardiovascular mortality in ST-segment elevation myocardial infarction patients with multivessel coronary artery disease. This strategy is safe and effective, offering improved outcomes without increased adverse events.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials & Meta-Analysis
Background:
- ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease (MVD) presents complex treatment challenges.
- The COMPLETE trial indicated benefits of complete revascularization for major adverse cardiac events (MACE) but not mortality.
- Existing evidence requires further synthesis to clarify the role of complete revascularization in STEMI with MVD.
Purpose of the Study:
- To conduct a meta-analysis evaluating the efficacy of complete revascularization versus culprit-lesion-only percutaneous coronary intervention (PCI).
- To specifically assess the impact on cardiovascular and total mortality in hemodynamically stable STEMI patients with MVD.
- To synthesize data from randomized controlled trials (RCTs), including the COMPLETE trial.
Main Methods:
- A comprehensive literature search was performed across multiple databases (PubMed, MEDLINE, Embase, Scopus, Google Scholar, CENTRAL, ClinicalTrials.gov).
- Ten RCTs involving 7033 patients (3420 complete revascularization, 3613 culprit-only PCI) were included.
- Random effects risk ratios were calculated for efficacy and safety outcomes with a median follow-up of 27.7 months.
Main Results:
- Complete revascularization significantly reduced MACE (10.4% vs. 16.6%), cardiovascular mortality (2.87% vs. 3.72%), reinfarction (5.1% vs. 7.1%), urgent revascularization (7.92% vs. 17.4%), and cardiovascular hospitalizations (8.68% vs. 11.4%).
- No significant differences were observed in all-cause mortality, stroke, major bleeding, or contrast-induced nephropathy.
- Risk ratios demonstrated substantial risk reductions for key adverse events with complete revascularization.
Conclusions:
- Complete revascularization is superior to culprit-only PCI in reducing MACE and cardiovascular mortality in STEMI patients with MVD.
- The strategy does not increase the risk of adverse safety outcomes, including major bleeding and nephropathy.
- This meta-analysis supports complete revascularization as a beneficial treatment approach for selected STEMI patients with MVD.
Background:
The recently published COMPLETE trial has demonstrated that patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD), who underwent successful percutaneous coronary intervention (PCI) of both culprit and non-culprit (vs. culprit-only) lesions had a reduced risk of major adverse cardiac events (MACE), but not of cardiovascular or total mortality. The aim of this meta-analysis was to assess the efficacy of complete revascularization on cardiovascular or total mortality reduction using available randomized controlled trials (RCTs) including the COMPLETE trial, in hemodynamically stable STEMI patients with MVD.
Methods:
PubMed, MEDLINE, Embase, Scopus, Google Scholar, CENTRAL and ClinicalTrials.gov databases search identified 10 RCTs of 7033 patients with STEMI and MVD which compared complete (n = 3420) vs. only culprit lesion (n = 3613) PCI for a median 27.7 months follow-up. Random effect risk ratios were used to estimate for efficacy and safety outcomes.
Results:
Complete revascularization reduced the risk of MACE (10.4% vs.16.6%; RR = 0.59, 95% CI: 0.47 to 0.74, p < 0.0001), CV mortality (2.87% vs. 3.72%; RR = 0.73, 95% CI: 0.56 to 0.95, p = 0.02), reinfarction (5.1% vs. 7.1%; RR = 0.67, 95% CI: 0.52 to 0.86, p = 0.002), urgent revascularization (7.92% vs.17.4%; RR = 0.47, 95% CI: 0.30 to 0.73, p < 0.001), and CV hospitalization (8.68% vs.11.4%; RR = 0.65, 95% CI: 0.44to 0.96, p = 0.03) compared with culprit only revascularization. All-cause mortality, stroke, major bleeding events, or contrast induced nephropathy were not affected by the revascularization strategy.
Conclusion:
The findings of this meta-analysis suggest that in patients with STEMI and MVD, complete revascularization is superior to culprit-only PCI in reducing the risk of MACE outcomes, including cardiovascular mortality, without increasing the risk of adverse safety outcomes.
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