Timing of Complete Revascularization in Patients with STEMI and Multivessel Disease: A Systematic Review and
Giuseppe Panuccio1, Nadia Salerno1, Salvatore De Rosa1
1Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy.
Insights
For ST-segment Elevation Myocardial Infarction (STEMI) patients with multivessel coronary artery disease (MVD), immediate complete revascularization showed similar overall outcomes but a higher risk of cardiovascular death compared to staged revascularization. Personalized treatment is recommended.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Multivessel coronary artery disease (MVD) affects approximately half of ST-segment Elevation Myocardial Infarction (STEMI) patients.
- Optimal revascularization strategy in STEMI with MVD remains an area of active investigation.
Purpose of the Study:
- To quantitatively compare single-stage immediate complete revascularization versus deferred staged complete revascularization in STEMI patients with MVD.
- To assess the impact of revascularization timing on clinical outcomes.
Main Methods:
- Systematic review and meta-analysis of all relevant studies.
- Inclusion criteria: STEMI patients with MVD.
- Primary endpoint: composite of all-cause death, myocardial infarction, and repeat revascularization.
- Secondary endpoints: cardiovascular death, acute kidney injury, and major bleeding.
Main Results:
- Eight studies involving 2256 patients were analyzed.
- No significant difference in the primary composite endpoint between immediate and staged complete revascularization (RR 0.95; 95% CI 0.71-1.27; p = 0.74).
- Higher rates of cardiovascular death observed with immediate complete revascularization (5.0% vs 2.6%; RR 0.39; 95% CI 0.25-0.62; p < 0.01).
- Meta-regression indicated a significant interaction with drug-eluting stent (DES) use.
Conclusions:
- Similar clinical outcomes were observed for both single-stage immediate and delayed staged complete revascularization strategies.
- Immediate complete revascularization may be associated with an increased risk of cardiovascular death.
- Personalized revascularization, considering clinical setting, patient factors, and logistics, is advised pending further trial data.
Background:
About half of patients with ST-segment Elevation Myocardial Infarction (STEMI) have multivessel coronary artery disease (MVD). Our aim was to provide a quantitative comparison of single-stage complete revascularization during the index revascularization versus deferred staged complete revascularization in STEMI patients with MVD.
Methods:
All studies evaluating patients with STEMI and MVD were included. The primary endpoint was a composite of all-cause death, myocardial infarction and repeat revascularization. Secondary endpoints were cardiovascular death, acute kidney injury and trial defined major bleeding.
Results:
Eight studies and 2256 patients with STEMI and MVD were included. No difference was evident in the rate of the primary composite endpoint among the study group (Risk Ratio 0.95; 95% CI 0.71-1.27, p = 0.74), while meta-regression showed a significant interaction with drug eluting stent (DES) use (Coefficient -0.005; 95% CI -0.01 to -0.001; p = 0.007). Higher rates of cardiovascular (CV) death were found in the immediate complete revascularization group (5.0% vs 2.6%; Risk Ratio 0.39; 95% CI 0.25-0.62; p 0.01).
Conclusions:
Our analysis documented similar clinical outcomes with either single-stage immediate complete revascularization and delayed staged complete revascularization. Secondary analyses suggest that an increase in cardiovascular death might be expected with single-stage percutaneous coronary intervention (PCI). While new randomized trials on the topic are ongoing, revascularization can be personalized and guided by the acute clinical setting, patients'-related factors and workflow logistics.
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