Timing of multivessel revascularization in stable patients with STEMI: a systematic review and network meta-analysis
Felix Voll1, Constantin Kuna1, Maria Scalamogna2
1Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.
Insights
Multivessel percutaneous coronary intervention (MV-PCI) during the index hospitalization for ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease (CAD) reduces death and revascularization. This approach is safer and more effective than culprit-only PCI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease (CAD) often requires intervention.
- Current guidelines recommend multivessel percutaneous coronary intervention (MV-PCI) in STEMI patients without cardiogenic shock.
- The optimal timing for MV-PCI in this patient population remains under investigation.
Purpose of the Study:
- To determine the optimal timing of MV-PCI in patients with STEMI and multivessel CAD without cardiogenic shock.
- To compare the efficacy and safety of different MV-PCI timing strategies against culprit vessel-only PCI.
Main Methods:
- A network meta-analysis of 11 randomized trials involving 10,507 patients.
- Patients were assigned to MV-PCI (same sitting, staged during index hospitalization, or staged during subsequent hospitalization) or culprit vessel-only PCI.
- Primary outcome was all-cause death; secondary outcomes included cardiovascular death, myocardial infarction, and unplanned revascularization.
Main Results:
- MV-PCI staged during the index hospitalization significantly reduced all-cause death compared to culprit vessel-only PCI (RR 0.73; P=.008).
- MV-PCI, regardless of timing, reduced cardiovascular mortality.
- MV-PCI within the index hospitalization (single or staged) significantly reduced myocardial infarction and unplanned revascularization.
Conclusions:
- MV-PCI performed during the index hospitalization (single or staged) is the safest and most effective strategy for STEMI patients with multivessel CAD without cardiogenic shock.
- Timing of MV-PCI did not significantly impact all-cause death rates.
- This approach improves outcomes by reducing major adverse cardiac events.
Introduction And Objectives:
Multivessel percutaneous coronary intervention (MV-PCI) is recommended in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD) without cardiogenic shock. The present network meta-analysis investigated the optimal timing of MV-PCI in this context.
Methods:
We pooled the aggregated data from randomized trials investigating stable STEMI patients with multivessel CAD treated with a strategy of either MV-PCI or culprit vessel-only PCI. The primary outcome was all-cause death. The main secondary outcomes were cardiovascular death, myocardial infarction, and unplanned ischemia-driven revascularization.
Results:
Among 11 trials, a total of 10 507 patients were randomly assigned to MV-PCI (same sitting, n=1683; staged during the index hospitalization, n=3460; staged during a subsequent hospitalization within 45 days, n=3275) or to culprit vessel-only PCI (n=2089). The median follow-up was 18.6 months. In comparison with culprit vessel-only PCI, MV-PCI staged during the index hospitalization significantly reduced all-cause death (risk ratio, 0.73; 95%CI, 0.56-0.92; P=.008) and ranked as possibly the best treatment option for this outcome compared with all other strategies. In comparison with culprit vessel-only PCI, a MV-PCI reduced cardiovascular mortality without differences dependent on the timing of revascularization. MV-PCI within the index hospitalization, either in a single procedure or staged, significantly reduced myocardial infarction and unplanned ischemia-driven revascularization, with no significant difference between each other.
Conclusions:
In patients with STEMI and multivessel CAD without cardiogenic shock, multivessel PCI within the index hospitalization, either in a single procedure or staged, represents the safest and most efficacious approach. The different timings of multivessel PCI did not result in any significant differences in all-cause death. This study is registered at PROSPERO (CRD42023457794).
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