Immediate Versus Staged Complete Revascularization in Patients With Acute Coronary Syndrome: A Systematic Review and
Huzaifa Ahmad Cheema1, Karan Bhanushali2, Aruba Sohail3
1Department of Cardiology, King Edward Medical University, Lahore, Pakistan.
Insights
Immediate complete revascularization (ICR) in acute coronary syndrome (ACS) with multivessel disease (MVD) reduces myocardial infarction and repeat procedures. However, ICR showed no difference in mortality compared to staged revascularization.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Complete revascularization (CR) is recommended for acute coronary syndrome (ACS) with multivessel disease (MVD).
- The optimal timing for CR, specifically immediate versus staged procedures, remains debated.
- This meta-analysis addresses the timing question by comparing immediate CR (ICR) with staged CR.
Approach:
- A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted.
- Searched major databases (MEDLINE, Embase, Cochrane Library, ClinicalTrials.gov) for relevant RCTs.
- Pooled data from 9 RCTs involving 7,506 patients, primarily those with ST-segment elevation myocardial infarction (STEMI) and MVD.
Key Points:
- Immediate CR (ICR) significantly reduced the rate of myocardial infarction compared to staged CR.
- ICR also decreased the need for repeat revascularization procedures at 6 months and beyond.
- No significant differences were observed in all-cause or cardiovascular mortality between ICR and staged CR at any time point.
- Rates of cerebrovascular events and stent thrombosis were similar between the two strategies.
Conclusions:
- An immediate complete revascularization strategy in patients with STEMI and MVD leads to fewer myocardial infarctions and repeat procedures.
- Mortality rates remain comparable between immediate and staged complete revascularization.
- Further research is warranted to explore CR strategies in broader ACS populations.
Abstract:
A strategy of complete revascularization (CR) is recommended in patients with acute coronary syndrome (ACS) and multivessel disease (MVD). However, the optimal timing of CR remains equivocal. We searched MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing immediate CR (ICR) with staged CR in patients with ACS and MVD. Our primary outcomes were all-cause and cardiovascular mortality. All outcomes were assessed at 3 time points: in-hospital or at 30 days, at 6 months to 1 year, and at >1 year. Data were pooled in RevMan 5.4 using risk ratios as the effect measure. A total of 9 RCTs (7,506 patients) were included in our review. A total of 7 trials enrolled patients with ST-segment elevation myocardial infarction (STEMI), 1 enrolled patients with non-STEMI only, and 1 enrolled patients with all types of ACS. There was no difference between ICR and staged CR regarding all-cause and cardiovascular mortality at any time window. ICR reduced the rate of myocardial infarction and decreased the rate of repeat revascularization at 6 months and beyond. The rates of cerebrovascular events and stent thrombosis were similar between the 2 groups. In conclusion, the present meta-analysis demonstrated a lower rate of myocardial infarction and a reduction in repeat revascularization at and after 6 months with ICR strategy in patients with mainly STEMI and MVD. The 2 groups had no difference in the risk of all-cause and cardiovascular mortality. Further RCTs are needed to provide more definitive conclusions and investigate CR strategies in other ACS.
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