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Percutaneous Coronary Revascularization Strategies After Myocardial Infarction: A Systematic Review and Network
Rohin K Reddy1, James P Howard1, Yasser Jamil2
1National Heart and Lung Institute, Imperial College London, London, United Kingdom.
Insights
Complete revascularization after myocardial infarction (MI) significantly reduces all-cause mortality and other adverse events. Immediate complete revascularization appears more beneficial than staged approaches for patients with multivessel coronary artery disease.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Percutaneous coronary intervention (PCI) strategies following myocardial infarction (MI) in patients with multivessel coronary artery disease are debated.
- Complete revascularization (CR) has shown outcome improvements over culprit revascularization (Culprit-R), but a reduction in all-cause mortality has not been definitively demonstrated.
- Optimal timing (immediate vs. staged) and non-culprit lesion evaluation methods (angiography vs. physiology) for CR remain subjects of ongoing discussion.
Conclusions:
- Complete revascularization following MI is associated with a significant reduction in all-cause mortality, cardiovascular mortality, MI, and major adverse cardiac events.
- Immediate complete revascularization may offer advantages over staged approaches, although further head-to-head trials are warranted to confirm these findings.
- This meta-analysis provides robust evidence supporting CR as a superior revascularization strategy in MI patients with multivessel coronary artery disease.
Background:
Complete revascularization with percutaneous coronary intervention improves outcomes compared with culprit revascularization following myocardial infarction (MI) with multivessel coronary artery disease. An all-cause mortality reduction has never been demonstrated. Debate also remains regarding the optimal timing of complete revascularization (immediate or staged), and method of evaluation of nonculprit lesions (physiology or angiography).
Objectives:
This study aims to perform an updated systematic review with frequentist and Bayesian network meta-analyses including the totality of randomized data investigating revascularization strategies in patients presenting with MI and multivessel coronary artery disease.
Methods:
The primary comparison tested complete vs culprit revascularization. Timing and methods of achieving complete revascularization were assessed. The prespecified primary outcome was all-cause mortality. Outcomes were expressed as relative risk (RR) (95% CI).
Results:
Twenty-four eligible trials randomized 16,371 patients (weighted mean follow-up: 26.4 months). Compared with culprit revascularization, complete revascularization reduced all-cause mortality in patients with any MI (RR: 0.85; 95% CI: 0.74-0.99; P = 0.04). Cardiovascular mortality, MI, major adverse cardiac events and repeat revascularization were also significantly reduced. In patients presenting with ST-segment elevation myocardial infarction, the point estimate for all-cause mortality with complete revascularization was RR: 0.91 (95% CI: 0.78-1.05; P = 0.18). Rates of stent thrombosis, major bleeding, and acute kidney injury were similar. Immediate complete revascularization ranked higher than staged complete revascularization for all endpoints.
Conclusions:
Complete revascularization following MI reduces all-cause mortality, cardiovascular mortality, MI, major adverse cardiac events, and repeat revascularization. There may be benefits to immediate complete revascularization, but additional head-to-head trials are needed.
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