Meta-Analysis of Complete versus Culprit-Only Revascularization in Patients with ST-Segment Elevation Myocardial
Jeremy Y Levett1, Sarah B Windle2, Kristian B Filion3
1Center of Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital/McGill University, Montreal, Quebec, Canada; Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
Insights
Complete revascularization significantly reduces major adverse cardiovascular events and repeat myocardial infarction in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD). This approach is recommended over culprit-only PCI for better patient outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Many ST-segment elevation myocardial infarction (STEMI) patients have multivessel coronary artery disease (CAD).
- The optimal revascularization strategy for STEMI patients with multivessel CAD remains debated.
- Culprit-only PCI is standard, but complete revascularization is an alternative.
Purpose of the Study:
- To compare major cardiovascular outcomes and procedural complications between complete revascularization and culprit-only PCI in STEMI patients with multivessel CAD.
- To evaluate the efficacy and safety of complete revascularization versus single-lesion intervention.
Main Methods:
- Systematic review and meta-analysis of 9 randomized controlled trials (RCTs) involving 6,751 patients.
- Pooled count data using DerSimonian and Laird random-effects models.
- Analyzed relative risks (RRs) and 95% confidence intervals (CIs) for various outcomes.
Main Results:
- Complete revascularization significantly reduced major adverse cardiovascular events (RR: 0.54; 95%CI: 0.43-0.66) and repeat myocardial infarction (RR: 0.64; 95%CI: 0.48-0.84).
- Repeat revascularization rates were substantially lower with complete revascularization (RR: 0.33; 95%CI: 0.25-0.44).
- Effects on mortality were suggested but not conclusive; stroke, bleeding, and AKI findings were inconclusive.
Conclusions:
- Complete coronary artery revascularization offers significant benefits over culprit-only PCI in STEMI patients with multivessel CAD.
- Complete revascularization should be considered a primary strategy for these patients.
- Further research may clarify effects on mortality and other complications.
Abstract:
Approximately half of patients with ST-segment elevation myocardial infarction (STEMI) present with noninfarct related multivessel coronary artery disease (CAD) during primary percutaneous coronary intervention (PCI). However, questions remain concerning whether patients with STEMI and multivessel CAD should routinely undergo complete revascularization. Our objective was to compare the risks of major cardiovascular outcomes and procedural complications in patients with STEMI and multivessel CAD randomized to complete revascularization versus culprit-only PCI. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing complete revascularization to culprit-only PCI. RCTs were identified via a systematic search of MEDLINE, Embase, and Cochrane CENTRAL. Count data were pooled using DerSimonian and Laird random-effects models with inverse variance weighting to obtain relative risks (RRs) and 95% confidence intervals (CIs). A total of 9 RCTs (n = 6,751) were included, with mean/median follow-up times ranging from 6 to 36 months. Compared with culprit-only PCI, complete revascularization was associated with a substantial reduction in major adverse cardiovascular events (13.1% vs 22.1%; RR: 0.54; 95%CI: 0.43 to 0.66), repeat myocardial infarction (4.9% vs 6.8%; RR: 0.64; 95%CI: 0.48 to 0.84), and repeat revascularization (3.7% vs 12.3%; RR: 0.33; 95%CI: 0.25 to 0.44). Complete revascularization may have beneficial effects on all-cause and cardiovascular mortality, but 95%CIs were wide. Findings for stroke, major bleeding, and contrast-induced acute kidney injury were inconclusive. In conclusion, complete coronary artery revascularization appears to confer benefit over culprit-only PCI in patients with STEMI and multivessel CAD, and should be considered a first-line strategy in these patients.
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