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Published on: June 28, 2019
Coronary angiography- or fractional flow reserve-guided complete revascularization in multivessel disease STEMI: A
Federico Archilletti1, Fabrizio Ricci2, Francesco Pelliccia3
1Institute of Cardiology, "G. d'Annunzio" University, 66100 Chieti, Italy; William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London, UK.
Insights
Complete revascularization (CR) significantly reduces mortality and myocardial infarction (MI) in ST-elevation myocardial infarction (STEMI) patients with multi-vessel disease (MVD). Angiography-guided CR offers the lowest risk, questioning the role of fractional flow reserve (FFR) guidance.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- ST-elevation myocardial infarction (STEMI) with multi-vessel disease (MVD) requires optimal revascularization strategy.
- Complete revascularization (CR) aims to restore blood flow to all diseased coronary arteries.
- The optimal guidance strategy for CR in MVD-STEMI remains debated.
Approach:
- Systematic review and meta-analysis of randomized controlled trials (RCTs).
- Comparison of infarct-related artery (IRA)-only percutaneous coronary intervention (PCI) versus CR.
- Evaluation of CR guided by angiography versus fractional flow reserve (FFR).
- Frequentist and Bayesian network meta-analysis to assess treatment efficacy and hierarchy.
Key Points:
- CR significantly reduced the composite endpoint of all-cause death and new myocardial infarction (MI) compared to IRA-only PCI.
- No significant difference was observed between angiography-guided and FFR-guided CR in reducing the primary endpoint.
- Bayesian analysis indicated angio-guided CR as the superior strategy with the lowest risk of adverse events.
Conclusions:
- Complete revascularization (CR) is superior to infarct-related artery (IRA)-only PCI in MVD-STEMI patients.
- Angiography-guided CR demonstrates the lowest risk profile for mortality and new MI.
- The utility of FFR-guided CR in this patient population warrants further investigation.
Aims:
To identify the best strategy to achieve complete revascularization (CR) in patients with ST-elevation myocardial infarction (STEMI) and multi-vessel disease (MVD).
Methods And Results:
We systematically reviewed the literature for randomized controlled trials (RCTs) comparing IRA-only PCI and CR guided by angiography or fractional flow reserve (FFR) in MVD-STEMI. Both frequentist (classical) and Bayesian network meta-analysis were performed, including a comparative hierarchy estimation of the probability to reduce the primary composite endpoint of all-cause death and new myocardial infarction (MI). We identified 11 RCTs, including 8193 STEMI patients. Compared with IRA-only strategy, CR significantly reduced the primary endpoint (OR: 0.73; 95%CI0.55-0.97). We observed non-significant difference between angiography and FFR guidance in reducing the primary endpoint (OR: 0.73, 95% CI 0.35-1.57). The Bayesian probability analysis ranked angio-guided CR as the best intervention yielding lowest risk of all-cause death or new MI (SUCRA92%).
Conclusions:
In patients with MVD-STEMI, CR is associated with a reduction in all-cause mortality and new MI compared with IRA-only PCI. Angio-guided CR is associated with the lowest risk of all-cause death or new MI, therefore the role of FFR-guidance in this setting is questionable.
Condensed Abstract:
Both frequentist and Bayesian network meta-analysis were performed to compare infarct-related artery (IRA)-only percutaneous coronary intervention (PCI) and complete revascularization (CR) guided by angiography or fractional flow reserve (FFR) in multivessel disease (MVD) and acute ST-elevation myocardial infarction (STEMI). Eleven randomized controlled trials were identified, including 8193 STEMI patients. Compared with IRA-only strategy, CR significantly reduced the incidence of the composite endpoint of all-cause death and new myocardial infarction without significant difference in angio-guided and FFR-guided CR. The Bayesian probability analysis ranked angio-guided CR as the best intervention yielding lowest risk of the composite endpoint and, therefore the role of FFR-guidance in this setting is questionable.
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