Meta-Analysis Comparing Culprit-Only Versus Complete Multivessel Percutaneous Coronary Intervention in Patients With
Waqas Ullah1, Salman Zahid2, Nayab Nadeem1
1Abington Jefferson Health, Abington, Pennsylvania.
Insights
Multivessel revascularization (MVR) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease significantly reduces major adverse cardiovascular events, angina, and revascularization compared to culprit-only revascularization (COR). MVR is a superior strategy for these complex STEMI patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Surgery
Background:
- ST-segment elevation myocardial infarction (STEMI) in patients with multivessel coronary artery disease (CAD) presents a significant prognostic challenge.
- The optimal revascularization strategy, culprit-only revascularization (COR) versus multivessel revascularization (MVR), remains a critical clinical question.
Purpose of the Study:
- To compare the clinical outcomes of COR versus MVR in patients with STEMI and multivessel CAD.
- To determine the impact of each revascularization strategy on major adverse cardiovascular events (MACE), angina, mortality, and other cardiac events.
Main Methods:
- A systematic review and meta-analysis of 28 studies involving 26,892 patients (18,377 in COR, 8,515 in MVR) was conducted.
- Random-effect models were used to calculate unadjusted odds ratios (OR) and relative risks for various clinical outcomes.
- Follow-up duration was a median of 1 year.
Main Results:
- MVR was associated with a significantly lower incidence of MACE (OR 1.36), angina (OR 2.28), and need for revascularization (OR 1.76) compared to COR.
- All-cause mortality, cardiovascular mortality, heart failure, need for CABG, repeat MI, and stroke rates were similar between the groups in the pooled analysis.
- Subgroup analysis of RCTs showed a significantly lower risk of repeat MI with MVR (OR 1.46).
Conclusions:
- Multivessel revascularization (MVR) is associated with improved outcomes in STEMI patients with multivessel CAD, demonstrating significant reductions in MACE, angina, and repeat revascularization.
- While mortality and other key events were similar in the overall analysis, MVR showed a benefit in reducing repeat MIs in randomized controlled trials.
- The findings support MVR as a preferred strategy over COR for selected STEMI patients with multivessel disease.
Abstract:
ST-segment elevation myocardial infarction (STEMI) in patients with concomitant multivessel coronary artery disease is associated with poor prognosis. We sought to determine the merits of percutaneous coronary intervention of the culprit-only revascularization (COR) compared with multivessel revascularization (MVR) approach. Multiple databases were queried to identify relevant articles. Data were analyzed using a random-effect model to calculate unadjusted odds ratio (OR) and relative risk. A total of 28 studies comprising 26,892 patients, 18,377 in the COR and 8,515 in the MVR group were included. The mean age of patients was 63 years, comprising 72% of male patients. The baseline characteristics of the 2 treatment groups were comparable. On a median follow-up of 1-year, COR was associated with a significantly higher odds of major adverse cardiovascular events (MACE; OR 1.36, 95% confidence interval [CI] 1.10 to 1.70, p = 0.005), angina (OR 2.28, 95% CI 1.83 to 2.85, p ≤ 0.00001) and revascularization (OR 1.76, 95% CI 1.22 to 2.54, p = 0.002) compared with patients undergoing MVR for STEMI. The all-cause mortality (OR 1.18, 95% CI 0.91 to 1.53, p = 0.22), cardiovascular mortality (OR 1.30, 95% CI 0.98 to 1.72, p = 0.07), rate of heart failure (OR 1.17, 95% CI 0.86 to 1.59, p = 0.31), need for coronary artery bypass graft (CABG) (OR 1.47, 95% CI 0.82 to 2.64, p = 0.19), repeat myocardial infarction (MI) events (OR 1.23, 95% CI 0.93 to 1.64, p = 0.15) and risk of stroke (OR 1.27 95% CI 0.68 to 2.34, p = 0.45%) were similar between the two groups. A subgroup analysis based on follow-up duration and study design mostly followed the results of the pooled analysis except that the risk of repeat MI events were significantly lower in the MVR group across RCTs (OR 1.46, 95% CI 1.10 to 1.94, p = 0.009). In contrast to the culprit-only approach, MVR in patients with STEMI is associated with a significant reduction in MACE, angina and need for revascularization.
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