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Does multivessel revascularization fit all patients with STEMI and multivessel coronary artery disease? A systematic
Meng-Jin Hu1, Xiao-Song Li1, Chen Jin1
1State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China.
Insights
For ST-segment elevation myocardial infarction (STEMI) with cardiogenic shock, culprit-only PCI is preferred over immediate multivessel PCI to avoid renal failure. For STEMI with chronic total occlusion (CTO), staged multivessel PCI is recommended over culprit-only PCI to reduce long-term adverse events.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Multivessel percutaneous coronary intervention (PCI) shows promise for ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease.
- Previous trials excluded patients with cardiogenic shock or chronic total occlusion (CTO).
Purpose of the Study:
- To compare revascularization strategies in STEMI patients with multivessel disease complicated by cardiogenic shock or CTO.
- To assess the relative merits of immediate or staged multivessel PCI versus culprit-only PCI.
Main Methods:
- Systematic review and meta-analysis of 16 studies (8695 patients) for cardiogenic shock and 8 studies (2259 patients) for CTO.
- Compared culprit-only PCI (CO-PCI) with immediate or staged multivessel PCI (MV-PCI).
- Calculated random odd ratios (OR) and 95% confidence intervals (CI).
Main Results:
- In cardiogenic shock patients, CO-PCI showed lower short-term renal failure risk versus immediate MV-PCI, with no significant differences in other major adverse cardiovascular events (MACE).
- In CTO patients, CO-PCI had higher long-term risks for MACE, all-cause mortality, cardiac death, heart failure, and stroke compared to staged MV-PCI.
- No significant differences in re-infarction or bleeding were observed in either group.
Conclusions:
- Immediate MV-PCI is not recommended for STEMI with cardiogenic shock due to increased renal failure risk.
- Staged MV-PCI is recommended for STEMI with CTO to improve long-term outcomes and reduce mortality.
- Culprit-only PCI strategies have different implications based on patient complications (cardiogenic shock vs. CTO).
Objective:
We sought to assess the relative merits of different revascularization strategies in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease complicated by cardiogenic shock or chronic total occlusion (CTO).
Background:
Recent randomized trials and meta-analysis have suggested that multivessel percutaneous coronary intervention (PCI) is associated with better outcomes in patients with STEMI and multivessel coronary artery disease, however, patients complicated by cardiogenic shock or CTO were excluded.
Methods:
Studies that compared multivessel PCI (immediate or staged) with culprit-only PCI in patients with STEMI and multivessel coronary artery disease complicated by cardiogenic shock or CTO were included. Random odd ratio (OR) and 95% confidence interval (CI) were conducted.
Results:
Sixteen studies with 8695 patients complicated by cardiogenic shock and eight studies with 2259 patients complicated by CTO were included. In patients complicated by cardiogenic shock, a strategy of CO-PCI was associated with lower risk for short-term renal failure (OR: 0.75; 95% CI: 0.61-0.93; I2 = 0.0%), with no significant difference in MACE, all-cause mortality, re-infarction, revascularization, cardiac death, heart failure, major bleeding, or stroke compared with an immediate MV-PCI strategy. In patients complicated by CTO, a strategy of CO-PCI was associated with higher risk for long-term MACE (OR: 2.06; 95% CI: 1.39-3.06; I2 = 54.0%), all-cause mortality (OR: 2.89; 95% CI: 2.09-4.00; I2 = 0.0%), cardiac death (OR: 3.12; 95% CI: 2.05-4.75; I2 = 16.8%), heart failure (OR: 1.99; 95% CI: 1.22-3.24; I2 = 0.0%), and stroke (OR: 2.80; 95% CI: 1.04-7.53; I2 = 0.0%) compared with a staged MV-PCI strategy, without any difference in re-infarction, revascularization, or major bleeding.
Conclusions:
For patients with STEMI and multivessel coronary artery disease complicated by cardiogenic shock, an immediate multivessel PCI was not advocated due to a higher risk for short-term renal failure, whereas for patients complicated by CTO, a staged multivessel PCI was advocated due to reduced risks for long-term MACE, all-cause mortality, cardiac death, heart failure, and stroke.
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