Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials for Multivessel PCI Versus Culprit Artery
Insights
Multivessel (MV) percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients without shock reduces cardiac events and revascularization. However, MV PCI did not show a benefit in all-cause mortality compared to culprit-only PCI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- ST-elevation myocardial infarction (STEMI) with multivessel coronary artery disease is typically treated with percutaneous coronary intervention (PCI) to the culprit lesion only.
- The clinical benefit of multivessel (MV) PCI in STEMI patients without cardiogenic shock remains uncertain.
Purpose of the Study:
- To evaluate the efficacy and safety of MV PCI compared to culprit-only PCI in STEMI patients without cardiogenic shock.
- To compare outcomes including mortality, reinfarction, revascularization, and major adverse cardiovascular events (MACE).
Main Methods:
- A systematic search of PubMed, EMBASE, and Cochrane Database (1996-2019) identified relevant randomized controlled trials (RCTs).
- Nine RCTs with 6930 patients were included for pairwise meta-analysis comparing MV PCI versus culprit-only PCI.
- Trial sequential analysis (TSA) was performed to assess the robustness of the evidence.
Main Results:
- Multivessel PCI was associated with a significantly lower risk of cardiac mortality, reinfarction, MACE, and repeat revascularization compared to culprit-only PCI.
- No significant difference was observed in all-cause mortality between the two strategies.
- TSA indicated futility for detecting all-cause mortality benefit and lacked firm evidence for cardiac mortality and reinfarction benefits, but confirmed benefits for revascularization and MACE.
Conclusions:
- MV PCI strategy demonstrates significant benefits in reducing cardiac mortality, reinfarction, repeat revascularization, and MACE in STEMI patients without cardiogenic shock.
- No improvement in all-cause mortality was found with MV PCI compared to culprit-only PCI.
- The evidence supporting MV PCI for cardiac mortality and reinfarction benefits requires further robust confirmation.
Background:
Traditionally ST-elevation myocardial infarction (STEMI) with multivessel coronary artery disease is treated with percutaneous coronary intervention (PCI) to culprit lesion only. The benefit of multivessel (MV) PCI among STEMI patients without cardiogenic shock is unclear.
Methods:
PubMed, EMBASE, and Cochrane Database were searched from 1996 to 2019, for studies of patients with STEMI without cardiogenic shock, who underwent PCI. Only randomized controlled trials comparing culprit PCI to MV PCI vs culprit vessel PCI were included for pairwise meta-analysis. All-cause mortality, cardiac mortality, reinfarction, revascularization and major adverse cardiovascular events (MACE) were compared. Trial sequential analysis (TSA) was performed for outcome variables.
Results:
Nine randomized controlled trials contributed 6930 patients meeting inclusion criteria. Three thousand three hundred seventy-six underwent MV PCI, and 3554 underwent culprit PCI. Our analysis demonstrated no significant difference in all-cause mortality. MV PCI had a lower risk of cardiac mortality, reinfarction, MACE and repeat revascularization compared to culprit PCI (P values <0.05). TSA showed futility for further trials to detect all-cause mortality benefit and lack of firm evidence of benefit in cardiac mortality and re-infarction, but firm evidence of benefit in revascularization and MACE.
Conclusions:
In conclusion, MV PCI strategy was beneficial in reducing cardiac mortality, reinfarction, repeat revascularization, and MACE but there was no all-cause mortality benefit when compared to culprit only PCI strategy. Evidence for benefit in cardiac mortality and re-infarction is not robust per TSA.
Related Concept Videos
01:30Acute Coronary Syndrome I: Introduction
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:28Acute Coronary Syndrome IV: Interprofessional Care
01:27Coronary Artery Disease V: Interprofessional Care
01:19Acute Coronary Syndrome II: Pathophysiology and Clinical Manifestations