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Culprit-Only Revascularization, Single-Setting Complete Revascularization, and Staged Complete Revascularization in
Muhammad Haisum Maqsood1, Jacqueline E Tamis-Holland2, Sunil V Rao3
1Department of Cardiology, DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, TX (M.H.M.).
Insights
Single-setting complete revascularization offers the best outcomes for acute myocardial infarction (MI) patients with multivessel disease. This approach reduces cardiovascular events more effectively than staged complete or culprit-only revascularization.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Complete revascularization improves outcomes in acute myocardial infarction (MI) with multivessel coronary artery disease.
- The optimal timing for complete revascularization (single-setting vs. staged) remains uncertain.
Purpose of the Study:
- To compare the cardiovascular outcomes of single-setting complete, staged complete, and culprit vessel-only revascularization in acute MI patients with multivessel disease.
Main Methods:
- A systematic review and meta-analysis of 16 randomized controlled trials involving 11,876 patients.
- Databases searched included PubMed, EMBASE, and clinicaltrials.gov.
Main Results:
- Both single-setting and staged complete revascularization significantly reduced major adverse cardiovascular events, MI, and repeat revascularization compared to culprit-only treatment.
- Single-setting complete revascularization demonstrated superior outcomes over staged complete revascularization for cardiovascular mortality/MI and major adverse cardiovascular events.
- Single-setting complete revascularization was ranked as the optimal strategy, followed by staged complete, then culprit-only revascularization.
Conclusions:
- Single-setting complete revascularization may provide the greatest reduction in cardiovascular events for acute MI patients with multivessel disease.
- Further large-scale randomized trials are needed to definitively establish the optimal timing for complete revascularization.
Background:
Complete revascularization improves cardiovascular outcomes compared with culprit-only revascularization in patients with acute myocardial infarction ([MI]; ST-segment-elevation MI or non-ST-segment-elevation MI) and multivessel coronary artery disease. However, the timing of complete revascularization (single-setting versus staged revascularization) is uncertain. The aim was to compare the outcomes of single-setting complete, staged complete, and culprit vessel-only revascularization in patients with acute MI and multivessel disease.
Methods:
PubMed, EMBASE, and clinicaltrials.gov databases were searched for randomized controlled trials that compared 3 revascularization strategies.
Results:
From 16 randomized controlled trials that randomized 11 876 patients with acute MI and multivessel disease, both single-setting complete and staged complete revascularization reduced primary outcome (cardiovascular mortality/MI; odds ratio [OR], 0.52 [95% CI, 0.41-0.65]; OR, 0.74 [95% CI, 0.62-0.88]), composite of all-cause mortality/MI (OR, 0.52 [95% CI, 0.40-0.67]; OR, 0.78 [95% CI, 0.67-0.91]), major adverse cardiovascular event (OR, 0.42 [95% CI, 0.32-0.56]; OR, 0.62 [95% CI, 0.47-0.82]), MI (OR, 0.39 [95% CI, 0.26-0.57]; OR, 0.73 [95% CI, 0.59-0.90]), and repeat revascularization (OR, 0.30 [95% CI, 0.18-0.47]; OR, 0.46 [95% CI, 0.30-0.71]) compared with culprit-only revascularization. Single-setting complete revascularization reduced cardiovascular mortality/MI (OR, 0.70 [95% CI, 0.55-0.91]), major adverse cardiovascular event (OR, 0.67 [95% CI, 0.50-0.91]), and all-cause mortality/MI driven by a lower risk of MI (OR, 0.53 [95% CI, 0.36-0.77]) compared with staged complete revascularization. Single-setting complete revascularization ranked number 1, followed by staged complete revascularization (number 2) and culprit-only revascularization (number 3) for all outcomes. The results were largely consistent in subgroup analysis comparing ST-segment-elevation MI versus non-ST-segment-elevation MI cohorts.
Conclusions:
Single-setting complete revascularization may offer the greatest reductions in cardiovascular events in patients with acute MI and multivessel disease. A large-scale randomized trial of single-setting complete versus staged complete revascularization is warranted to evaluate the optimal timing of complete revascularization.
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